Assessing the characteristics of postoperative pain and its quality of management

among patients underwent surgery: A cross-sectional study from North Wales, UK

Abstract

Background

Quality pain management (QPM) focuses on patient-centered, safe, effective, timely,

efficient, and equitable care, aiming to reduce pain severity, provide relief, minimize

functional interference, and ensure satisfaction. Despite improvement efforts and guidelines,

pain prevalence in hospitals remains high (48%-88% in the past 24 hours), negatively

impacting well-being and increasing costs. Encouraging patient involvement yields positive

outcomes in acute and chronic pain scenarios. This study examines pain experienced by

surgical patients three days post-operation and evaluates pain management quality.

Methods

A cross-sectional study conducted at a tertiary care hospital in North Wales, UK for one year

among 261 surgical patients who underwent elective procedures. A validated questionnaire,

Strategic and Clinical Quality Indicators Postoperative Pain (SCQIPP), comprising three

subscales (pain management, nursing intervention, and environment) with 14 items, was

utilized. Participants rated each item on a 5-point Likert-type scale. Descriptive statistics

summarized participant demographics, pain intensity scores, and satisfaction levels using

means, standard deviations, frequencies, and percentages.

Results

Tingling was the most commonly experienced sensation, reported by 83.5% of patients.

Pulsating pain was also prevalent, reported by 61.7% of patients. The most frequently

reported factor was movement, with 84.7% of patients experiencing increased pain when

moving. Loss of the painkiller's effect was also a significant factor, reported by 33.3% of

patients. The mean score for pain management was 14.01±1.34, indicating the participants'
satisfaction with pain management. The mean score for nursing/staff intervention was

26.91±2.34, reflecting positive perceptions of the assistance provided by healthcare

professionals. Overall, the total mean score for the SCQIPP questionnaire was 48.96±4.08,

suggesting a generally high level of satisfaction with pain management, nursing intervention,

and the environment.

Conclusion

This study identified areas for improvement in postoperative pain management, emphasizing

patient-centered care. Active patient participation, individualized approaches, and effective

communication are crucial for enhancing care quality. Findings stress the importance of

prioritizing patient preferences, shared decision-making, and comprehensive education to

optimize pain management, improve experiences, and enhance outcomes.

Keywords: Pain, surgery, nursing, postoperative, management

INTRODUCTION

Pain management is a significant concern for patients, and the perception of care plays a

crucial role in evaluating the quality of healthcare institutions [1]. Quality pain management

(QPM) encompasses the structure, process, and outcomes of care, focusing on patient-

centered, safe, effective, timely, efficient, and equitable services. QPM aims to reduce pain

severity, provide adequate pain relief, minimize functional interference, minimize adverse

effects from pain or its treatment, and ensure patient satisfaction with the pain treatment [2].

Despite numerous quality improvement initiatives and the existence of clinical guidelines and

treatment protocols, pain remains prevalent in hospital settings, with reported prevalence

rates ranging from 48% to 88% within the past 24 hours [3]. Approximately 30% of patients

experience severe pain, which negatively impacts their physical, psychological, and social

well-being. Additionally, pain can increase hospital costs due to delayed recovery and pain-

related readmissions [4].

Research has shown a correlation between patient satisfaction and pain severity.

Paradoxically, patients often report high satisfaction levels despite experiencing severe pain

[5,6]. This contradiction can be explained by the importance of effective communication and

trust between patients and healthcare professionals [7,8]. The collaboration and trust

established in this relationship are vital components of patient participation, shared decision

making, and access to comprehensive information [9]. Encouraging patient participation as a

means to enhance pain management is advocated, although the specific effectiveness of

including patients in decision making within a hospital setting is still relatively unknown

[10]. However, in both acute postoperative and chronic pain scenarios, increased patient

participation has been associated with positive pain-related outcomes. Studies indicate that
patients who feel in control of their pain experience better outcomes compared to those with

limited control.

This study aimed to examine the pain encountered by surgical patients on the third day after

their operation, as well as to evaluate the quality of the pain management provided.
METHODS and MATERIALS

Study Design, Sample, Setting

This study employed a cross-sectional research design to investigate surgical patients' pain

experience and the quality of care provided for pain management on the third postoperative

day. The study was conducted at a tertiary care hospital in North Wales, UK, which

specializes in various surgical procedures, for 1 year (June 2022 to May 2023).

Study Participants

The sample consisted of 261 surgical patients who had undergone operations (general

surgery, orthopaedics and gynaecology) at the hospital during study period. The inclusion

criteria for participation were as follows: adult patients (age 18 and above) who underwent

elective surgical procedures (being available on the third postoperative day), were capable of

providing informed consent, and were able to communicate their pain experience. Patients

with cognitive impairments or language barriers were excluded from the study. A

convenience sampling method was employed to recruit participants.

Data Collection Tool

A standardized and validated questionnaire, and Strategic and Clinical Quality Indicators

Postoperative Pain (SCQIPP), was utilized to collect data regarding patients' pain experience

and the quality of pain management. The measurement instrument comprised three subscales:

pain management, nursing intervention, and environment, and consisted of a set of 14 items.

Participants were asked to rate each item on a 5-point Likert-type scale, ranging from 1

(strongly disagree) to 5 (strongly agree). The total score on the SPPM scale could range from

14 to 70, with higher scores indicating a higher level of satisfaction with postoperative

management. Interpreting the scores, a mean score < 4 for an item suggested a low quality of
health care, while a mean score between 4 to 4.5 indicated an acceptable quality, and a mean

score > 4.5 indicated a high quality of health care [11].

Data Collection Procedure

Prior to data collection, ethical approval was obtained from the Institutional Review Board of

the hospital. Participants were approached individually by trained research assistants who

explained the study's purpose, procedures, and potential risks and benefits. Informed consent

was obtained from each participant who agreed to participate voluntarily. Participants were

assured of the confidentiality and anonymity of their responses.

The research assistants administered the SCQIPP questionnaire to participants on the third

postoperative day during one-on-one interviews. The research assistants provided assistance

if participants faced difficulties in completing the questionnaire due to physical discomfort or

comprehension issues. The interviews were conducted in a private and comfortable

environment to ensure participants' privacy and encourage open communication. Descriptive

statistics, including means, standard deviations, frequencies, and percentages, were calculated

to summarize the demographic characteristics of the participants, pain intensity scores, and

satisfaction levels.

Ethical Consideration

The study was conducted in compliance with ethical guidelines and principles, ensuring the

protection of participants' rights and welfare. Informed consent was obtained from all

participants, and their confidentiality and anonymity were strictly maintained throughout the

study. Participants were informed of their right to withdraw from the study at any time

without facing any negative consequences. The study protocol was reviewed and approved by

the Institutional Review Board of the hospital, ensuring that the research adhered to ethical

standards.
RESULTS

The study included a total of 261 participants with diverse demographic and clinical

characteristics. In terms of age distribution, the majority of participants fell into the 31-60

years age group, with 26.4% aged 31-45 years, 31.8% aged 46-60 years, and 20.7% aged less

than 31 years or over 60 years. Gender distribution was nearly balanced, with 52.9% male

and 47.1% female participants. Regarding education, the highest proportion (31.8%) had

completed primary/middle school, followed by high/senior secondary school (29.9%),

graduate or above (23.4%), and illiterate (14.9%). In terms of inpatient department (IPD), the

largest group was from general surgery (46.0%), followed by orthopedics (36.4%) and

gynaecology (17.6%). The duration of surgery varied, with 46.4% of surgeries lasting less

than 2 hours, 37.5% lasting 2-4 hours, and 16.1% lasting over 4 hours. The majority of

participants received general anesthesia (60.2%) compared to regional/local anesthesia

(39.8%). Regarding postoperative pain management, nonsteroidal anti-inflammatory drugs

were the most commonly used approach (100%), while a smaller percentage received opioid

analgesics (4.2%) or other methods (3.4%). The expected time for pain management was

predominantly less than 11 minutes (94.3%), with only a small percentage reporting an

expected time of 11-20 minutes (5.7%) (Table 1).

Table 1. Baseline characteristics of the patient (N = 261).

Variables Frequency %

Age group (in years)

<31 54 20.7

31–45 69 26.4

46–60 83 31.8

>60 55 21.1
Gender

Female 123 47.1

Male 138 52.9

Education

Illiterate 39 14.9

Primary/Middle school 83 31.8

High/Senior Secondary school 78 29.9

Graduate or above 61 23.4

IPD

Orthopedics 95 36.4

General surgery 120 46.0

Gynaecology 46 17.6

Duration of surgery (in hours)

<2 121 46.4

2-4 98 37.5

>4 42 16.1

Type of anaesthesia

General 157 60.2

Regional/Local 104 39.8

Postoperative pain management*

Nonsteroidal anti-inflammatory drug 261 100.0

Opioid analgesics 11 4.2

Other 9 3.4

Expected time for pain management (minutes)

<11 246 94.3

 11–20 15 5.7

*Multiple responses

Among the pain patients included in the study, various characteristics of pain experiences

were reported. Tingling was the most commonly experienced sensation, reported by 83.5% of

patients. Pulsating pain was also prevalent, reported by 61.7% of patients. Other sensations

included pressing/tugging/pulling (13.4%), pricking/crushing (13.4%), burning (11.9%),

formication (4.2%), and cramp-like pain (3.4%). It is important to note that patients could

report multiple types of pain sensations (Figure 1).

Characteristi cs of Pain*
Cramp like 3.4 (9)

Formication 4.2 (11)

Burning 11.9 (31)

Pricking/crushing 13.4 (35)

Pressing/tugging/pulling 13.4 (35)

Pulsating 61.7 (161)

Tingling 83.5 (218)

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Figure 1. Characteristics of pain experienced by patients (N = 261).

*Multiple responses

Several factors contributing to increased postoperative pain were identified among the study

participants. The most frequently reported factor was movement, with 84.7% of patients

experiencing increased pain when moving. Loss of the painkiller's effect was also a

significant factor, reported by 33.3% of patients. Other contributing factors included activities

such as dressing of the incision site, coughing, and flatulence (4.2%), as well as long-term
physical inactivity (3.1%). It should be noted that patients could report multiple factors

contributing to their postoperative pain (Figure 2).

Factors increasing postoperative pain*

Long-term physical inactivity 3.1 (8)

Dressing of the incision site/coughing/ flatulence 4.2 (11)

Loss of the effect of the painkiller 33.3 (87)

Moving 84.7 (221)

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0

Figure 2. Factors increasing postoperative pain among patients (N = 261).

*Multiple responses

Various factors that were found to reduce postoperative pain among the participants were

identified. The most commonly reported factor was resting, with 59.0% of patients

experiencing pain reduction when they rested. Taking analgesics was another significant

factor, reported by 56.3% of patients. Lying in the appropriate position was mentioned by

18.4% of patients as a pain-reducing factor. Other reported factors included moving or going

to the bathroom (3.4%), diverting attention to something else (2.7%), and reading books

(2.3%). It is important to note that patients could report multiple factors contributing to the

reduction of their postoperative pain (Figure 3).

 Factors reducing postoperati ve pain*
Reading books 2.3 (6)

Drawing attention to something else 2.7 (7)

Moving/going to the bathroom 3.4 (9)

Lying in the appropriate position 18.4 (48)

Taking analgesics 56.3 (147)

Resting 59.0 (154)

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0

Figure3. Factors reducing postoperative pain among patients (N = 261).

*Multiple responses

The results of the SCQIPP questionnaire, completed by 261 participants, revealed various

aspects of pain management in the healthcare setting. Participants reported low levels of

active participation in deciding how their pain should be managed (mean=2.11±0.61) and

receiving pain medication without explicit requests (mean=3.58±0.92). However, the medical

staff assisted in finding comfortable positions to alleviate pain (mean=3.81±0.53) and

consistently inquired about pain during specific movements (mean=4.04±0.67). Participants

also reported prompt and efficient responses to pain relief requests (mean=3.98±0.82). The

room ambiance was perceived as pleasant (mean=4.03±0.56), and the staff demonstrated

expertise in pain alleviation (mean=3.83±0.54). Participants felt believed when

communicating their pain experiences (mean=3.95±0.35), and the staff collaborated

effectively in providing comprehensive pain management (mean=3.87±0.65). However, the

level of care regarding active participation and receiving detailed information about pain

treatment options was perceived as low (mean=2.12±0.66 and mean=1.93±1.22,

respectively). Overall, the level of care for most items fell within near acceptable range

(Table 2).
Table 2. Mean Scores for the 14 Items in the SCQIPP questionnaire among patients (N =

261).

Items in the SCQIPP questionnaire (N = 261). Mean±SD

I had the opportunity to actively participate in deciding how my 2.11±0.61*

pain should be managed

The medical staff assisted me in finding a comfortable position in 3.81±0.53*

bed to alleviate pain

My room provided a peaceful and quiet environment during the 4.01±0.53

night

Pain medication was administered to me, even without explicit 3.58±0.92*

requests

Throughout the day, the staff consistently inquired about any pain 4.04±0.67#

experienced during deep breaths, sitting up, or movement

I was regularly asked to rate my pain level on a scale of 0 to 10 or 1.93±1.22*

mark it on a straight line

The healthcare professionals ensured my pain treatment continued 3.75±0.73*

until I was fully satisfied with the relief

The room where my bed was located created a pleasant ambiance 4.03±0.56#

Whenever I requested pain relief, the response was prompt and 3.98±0.82*

efficient

The medical team possessed accurate knowledge regarding the 3.96±0.46*

severity of my pain and the treatments administered

The staff demonstrated expertise in effectively alleviating my pain 3.83±0.54*

 I felt completely believed by the staff when I communicated my 3.95±0.35*

pain experiences

The staff collaborated seamlessly to provide comprehensive pain 3.87±0.65*

management

Prior to my surgery, I received detailed information about the pain 2.12±0.66*

treatment options available post-operation

*Level of care “low”; #Level of care “acceptable”

The mean scores for the SCQIPP questionnaire and its subscales were calculated. The mean

score for pain management was 14.01±1.34, indicating the participants' satisfaction with pain

management. The mean score for nursing/staff intervention was 26.91±2.34, reflecting

positive perceptions of the assistance provided by healthcare professionals. The mean score

for the environment subscale was 8.04±1.06, indicating a positive perception of the room

ambiance. Overall, the total mean score for the SCQIPP questionnaire was 48.96±4.08,

suggesting a generally high level of satisfaction with pain management, nursing intervention,

and the environment (Table 3).

Table 3. Total and subscale mean score for the SCQIPP questionnaire among patients (N

= 261).

Total and subscale mean score for the SCQIPP questionnaire Mean±SD

Pain management 14.01±1.34

Nursing/staff intervention 26.91±2.34

Environment 8.04±1.06

Total 48.96±4.08
DISCUSSION

The assessment of pain and the quality of postoperative pain management are critical aspects

of healthcare for surgical patients. In this study, a diverse sample of 261 participants with

varying demographic and clinical characteristics was included to evaluate these important

factors. The findings of the SCQIPP questionnaire provided valuable insights into the

participants' perceptions and experiences regarding pain management in the healthcare

setting.

The mean scores for the SCQIPP questionnaire and its subscales provided a comprehensive

assessment of pain management and patient satisfaction. The mean score for pain

management indicated a high level of satisfaction among participants, suggesting that the

pain management strategies employed were generally effective. The positive mean score for

nursing/staff intervention reflected participants' positive perceptions of the assistance

provided by healthcare professionals. Additionally, the favorable mean score for the

environment subscale indicated that the room ambiance was conducive to patient comfort.

Collectively, these findings highlight the overall high level of satisfaction with pain

management, nursing intervention, and the environment.

In the existing literature, studies by Gunningberg et al., Frödin et al., Patanwala et al.,

Vatansever et al., Magidy et al., Subramanian et al., and Juszczak et al., consistently indicate

a high level of patient satisfaction with pain management [12,13,14,15,16,17,18].

Interestingly, our current study yielded contrasting findings, suggesting a lower quality of

postoperative pain management (POPM) and was comparable to the results of Wadensten et

al., Carr et al, and Idvall et al., [19,20,21].

One notable finding was the relatively low levels of active participation reported by

participants in deciding how their pain should be managed. This indicates a potential area for

improvement in patient-centered care, where patients should be empowered to have a more

active role in decision-making processes concerning their pain management. Similarly,

participants reported receiving pain medication without explicit requests, suggesting a lack of

individualized and tailored approaches to pain management. This highlights the need for

healthcare providers to engage in effective communication with patients to understand their

unique pain management needs and preferences and it was supported in the studies by

Subramanian et al., Best et al., and O'Donnell et al., [17,22,23] Furthermore, the pleasant

room ambiance and the staff's demonstrated expertise in pain alleviation were perceived

positively by the participants which was also reported in the studies by Harris et al., and

Williams et al., [24,25].

In our study, the tingling was the most commonly reported sensation (83.5%), followed by

pulsating pain (61.7%). Determining the characteristics of pain is crucial as it plays a

significant role in guiding treatment approaches [26]. Postoperative pain experienced by

patients encompasses various sensations including pulsating, tingling, burning, blunt, sharp,

and pressuring [27]. A study by Büyükyilmaz et al., found that 78% of the patients reported

experiencing pulsating pain, while 52.7% experienced tingling pain [28]. Study by Akyol et

al., revealed that 32.5% of the patients reported pulsating pain, with 76.7% of them feeling

pain at the incision site [29].

In our study, factors contributing to increased postoperative pain were identified among the

participants. The most frequently reported factor was movement, with 84.7% of patients

experiencing increased pain during movement. Loss of the painkiller's effect was also a

significant factor (33.3%), indicating the need for optimized pain medication regimens and

monitoring. Patanwala et al., Ramia et al., and Yılmaz et al., studies have highlighted those
activities such as getting out of bed, coughing, positioning, movement, and dressing of the

incision site after surgery can elicit pain [14,30,31].

Limitations

It is important to acknowledge some limitations of the study. First, the study was conducted

in a specific setting and may not be generalizable to other healthcare contexts. Second, the

data relied on self-report measures, which are subject to recall and response biases. Future

research could include objective measures of pain and pain management outcomes to

complement self-report data.

CONCLUSION

In conclusion, this study identified areas for improvement in postoperative pain management

and highlighted the importance of patient-centered care. Active patient participation,

individualized pain management approaches, and effective communication were identified as

crucial factors in enhancing the quality of care. The findings emphasize the need for

healthcare providers to prioritize patient preferences, promote shared decision-making, and

ensure comprehensive patient education. By addressing these areas, healthcare providers can

optimize postoperative pain management, improve patient experiences, and enhance overall

patient outcomes.
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