Original Article
Postoperative Pain:
From the *Mount Sinai Medical
Center, New York, New York; †Frances
Payne Bolton School of Nursing, Case
Western Reserve University,
Cleveland, Ohio.
Address correspondence to Lavonia
Francis, DNP, RN, NEA-BC, Senior
Director of Nursing, Mount Sinai
Medical Center, One Gustave Levy
Place, New York, NY 10029. E-mail:
lavonia.francis@mountsinai.org
Received June 25, 2011;
Revised May 2, 2012;
Accepted May 24, 2012.
1524-9042/$36.00
Ó 2013 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2012.05.002
Nurses’ Knowledge and
Patients’ Experiences
--- Lavonia Francis, DNP, RN, NEA-BC,*
and Joyce J. Fitzpatrick, PhD, RN, FAAN†
- ABSTRACT:
The aim of this study was to determine nurses’ knowledge and
attitudes regarding postoperative pain and identify postoperative pa-
tients’ pain intensity experiences. The assessment and management of
acute postoperative pain is important in the care of postoperative
surgical patients. Inadequate relief of postoperative pain can con-
tribute to postoperative complications such as atelectasis, deep vein
thrombosis, and delayed wound healing. A pilot study with an
exploratory design was conducted at a large teaching hospital in the
eastern United States. The convenience samples included 31 nurses
from the gastrointestinal and urologic surgical units and 14 first- and
second-day adult postoperative open and laparoscopic gastrointesti-
nal and urologic patients who received patient-controlled analgesia
(PCA). The Knowledge and Attitudes Survey Regarding Pain was
used to measure nurses’ knowledge about pain management. The
Short-Form McGill Pain Questionnaire (SF-MPQ) was used to measure
patients’ pain intensity. The nurses’ mean score on the Knowledge and
Attitudes Survey Regarding Pain was 69.3%. Patients experienced
moderate pain, as indicated by the score on the SF-MPQ. There is
a need to increase nurses’ knowledge of pain management.
Ó 2013 by the American Society for Pain Management Nursing
The assessment and management of acute postoperative pain is an important as-
pect in the care of surgical patients. Pain management is a vital component in the
recovery of postoperative patients. Pain can diminish a patient’s ability to partic-
ipate in postoperative interventions such as coughing, deep breathing, and am-
bulating. These interventions are key elements in preventing postoperative
complications. Challenges such as lack of patient assessment in managing pain
and lack of appropriate use of analgesics have been reported (Gunningberg &
Idvall, 2007; Idvall & Berg, 2008; White & Kehlet, 2010). Pain management is
multifaceted and requires a multidisciplinary approach in improving patient
outcomes.
BACKGROUND
Owing to the subjective nature of pain, assessment and management of pain can
be a complex process. Timing, route, and appropriate use of analgesics need to
Pain Management Nursing, Vol 14, No 4 (December), 2013: pp 351-357
352 Francis and Fitzpatrick
be considered in the management of pain. Despite ad-
vances in pain management, such as patient-controlled
analgesia (PCA) and multimodal analgesia, patients
continue to experience moderate to severe pain
(Bedard, Purden, Sauve-Larose, Certosini, & Schein,
2006; Brown, Constance, Bedard, & Pruden, 2011;
Niemi-Murola, Poybia, Onkinen, Rhen, Makela, &
Niemi, 2007). The role of the nurse is pivotal in the as-
sessment and management of postoperative pain.
Nurses need to understand the pathophysiology of
pain and recognize that pain management is vital in
the recovery of postoperative patients. Pain assess-
ment and reassessment are components of the nurse’s
role that are key in pain management. Therefore, the
purpose of this pilot study was to determine nurses’
knowledge and attitudes regarding postoperative
pain and identify patients’ level of pain intensity.
PAIN MANAGEMENT AND
ASSESSMENT
The most reliable indicator of pain is the patient’s self-
report (Institute for Clinical Systems Improvement,
2008). Patients communicate pain verbally and
through body and facial expressions. Therefore, pa-
tient observation and the use of pain assessment tools,
such as the visual analog scale (VAS) need to be used in
the assessment of postoperative pain. Nurses’ and pa-
tients’ assessment of pain has been documented
(Gunningberg & Idvall, 2007; Sloman, Rosen, Rom, &
Shin, 2005). Sloman et al. (2005) studied nurses’ rat-
ings of pain intensity and suffering compared with pa-
tients’ own ratings of these variables in adult surgical
patients. Patients completed the Short-Form McGill
Pain Questionnaire (SF-MPQ), VAS, and demographic
questionnaire. Nurses assessed their assigned patients
and then completed the same questionnaires. The find-
ings indicated that nurses significantly underrated pain
compared with patients on pain sensation (t ¼ 3.131;
p ¼ .002), pain affect (t ¼ 4.410; p ¼ .0001), present
pain intensity at rest (t ¼ 3.498; p # .001), present
pain intensity on movement (t ¼ 6.278; p # .0001),
overall pain intensity (t ¼ 2.235; p ¼ .028), and patient
suffering due to pain (t ¼ 3.774; p # .0001). There
were no statistically significant effects found for demo-
graphic or cultural data.
Gunningberg and Idvall (2007) used a descriptive
and comparative design to study the quality of postoper-
ative pain management. Paired patient and nurse assess-
ments of patients’ pain management were conducted in
general and thoracic surgery services. The Strategic and
Clinical Quality Indicators in Postoperative Pain Man-
agement questionnaire was completed by patients and
nurses. Audit of patient records was also completed.
The findings revealed that the mean score for four ques-
tion items in general surgery and five items in thoracic
surgery was >4.5, which indicated high quality of pa-
tient care. Patients in general surgery experienced
more pain than patients in thoracic surgery. Patients in
general surgery assessed their worst pain to be signifi-
cantly higher than the nurses did. The mean score for
the patients’ worst pain during the past 24 hours was
5.7 and the nurses’ score was 4.5 on a scale range of
0-10. A significant difference was found in both services
in the assessments of worst pain during the past 24
hours between patients, nurses, and documentation in
the patient record. Pain intensity assessment was docu-
mented significantly more often in general surgery
(41%) than in thoracic surgery (6.7%).
Idvall, Berg, Unosson and Brudin (2005) investi-
gated the differences between nurse and patient as-
sessments of postoperative pain management in two
hospitals with the use of the Strategic and Clinical
Quality Indicators in Postoperative Pain Management
questionnaire. The findings revealed that the correla-
tion between patient and nurse ratings for both hospi-
tals regarding worst pain during the past 24 hours was
statistically significant (r ¼ 0.57-0.59). Patients rated
their worst pain during the past 24 hours higher than
the nurses’ rating (p < .05). Idvall and Berg (2008)
also used the Strategic and Clinical Quality Indicators
in Postoperative Pain Management questionnaire in
their study of how orthopedic patients assessed the
quality of care they received. One of the question items
rated highest was that pain relief was addressed
promptly when requested. The item rated lowest
was the regular use of a pain assessment instrument.
Eid and Bucknall’s (2008) retrospective audit of
patients’ medical records demonstrated that nurses’
documentation of pain assessment and management
was insufficient in their study of postoperative pain
management in older patients (n ¼ 43) with hip frac-
tures. The study findings indicated that there was no
documentation of pain intensity rating using the VAS
in 77% of the reviewed medical records and no docu-
mentation of pain assessment in 65% of the records.
Neither nonpharmacologic intervention nor pain man-
agement education was documented.
Lin and Wang (2005) examined the effects of post-
operative nursing intervention for pain related to ab-
dominal surgical patients’ preoperative anxiety, pain
attitude, and postoperative pain. A questionnaire and
the Brief Pain Inventory were used. The findings re-
vealed that there was a statistically significant differ-
ence (F ¼ 174.03; p < .001) in the mean anxiety
scores after the preoperative nursing intervention for
pain between the experimental group and the control
group. Additionally, there was a statistically significant
 Postoperative Pain and Patients’ Experiences
difference (F ¼ 260.58; p < .001) in pain attitude and
pain scores between the two groups. The researchers
suggested that preoperative nursing intervention for
pain has positive effects on preoperative pain anxiety
and attitude and pain perception.
NURSES’ KNOWLEDGE OF PAIN
MANAGEMENT
Matthews and Malcolm (2007) surveyed two groups of
nurses with the Nurses’ Knowledge and Attitudes Sur-
vey Regarding Pain. The nurses in group 1 worked at
an orthopedic center and completed a knowledge
and competency program in pain management. Group
2 nurses attended a pain conference but did not com-
plete the knowledge and competency program. The
nurses in group 2 worked in a variety of clinical areas.
The overall mean score on the survey for both
groups was 73.8%. The findings showed that there
was no significant difference in the total of correct re-
sponses between the two groups. However, there was
a severe deficit in knowledge related to questions re-
garding nonpharmacologic interventions and opioid
use in chronic pain conditions. Another finding
was that group 1 had a higher correct response rate
(p ¼ .001) than group 2 for the scenario questions.
Wilson (2007) studied nurses’ knowledge of pain
management among 35 oncology nurse specialists and
37 general nurses with the use of a revised version of
the Knowledge and Attitudes Survey Regarding Pain.
Wilson reported that the oncology nurse specialists’
mean score (79.42%) was higher than the mean score
(64.86%) of the general nurses; however, the nurse
specialists’ knowledge scores were not consistent
with their years of experience. Abdalrahim, Majala,
Stomberg and Bergdam (2010) explored nurses’
knowledge and attitudes toward pain on surgical units
before and after implementation of a postoperative
management program. A 21-item questionnaire was
used and patient records audited. The overall score
for correct answers on the questionnaire during the
preintervention phase was 45.7%. The score in-
creased to 75% after implementation of the program.
Improvement was also noted in documentation of
pain management in the patients’ records after imple-
mentation of the postoperative pain management
program.
Wang and Tsai (2010) studied nurses’ knowledge
and barriers regarding pain management among 370
intensive care unit nurses in 16 hospitals. The findings
indicated that the overall average of correct response
rate for the Nurses’ Knowledge and Attitudes Survey
was 53.4%. The researchers also reported that nurses’
knowledge of pain management was significantly and
353
negatively related to perceived barriers to pain man-
agement (r ¼ 0.12; p < .01).
METHODS
Design and Setting
A descriptive exploratory design was used. The pilot
study was conducted at a large full-service teaching
hospital in the eastern United States.
Samples
Thirty-one registered nurses from the gastrointestinal
and urologic surgical units participated. Newly hired
nurses with <3 months’ experience on their unit
were excluded. These nurses were in the orientation
phase and may not have completed the educational
component for pain assessment and management. The
nurses were not paired with the patient participants.
Fourteen first- and second-day adult postoperative
open and laparoscopic gastrointestinal and urologic
procedure patients receiving PCA participated in the
study. The sample consisted of patients who spoke
and understood English. Cognitively impaired patients
were excluded from the study, as were patients with
a history of past or active substance abuse or long-
term opioid treatment.
Measures
Nurses’ Knowledge of Pain Management. The
Knowledge and Attitudes Survey Regarding Pain devel-
oped by Ferrell and McCaffery (2005) was used. This
instrument consists of 21 true/false and 17 multiple
choice questions. The last two items of the multiple
choice questions have two parts. Ferrell and McCaffery
recommended not distinguishing items as measuring
either knowledge or attitude, because many of the
items measure both knowledge and attitude, but rather
analyzing data in terms of the percentage of correct
scores as well as analyzing individual items. For the
present study, items 1-36 were each assigned 1 point
and items 37 and 38 were each assigned 2 points for
scoring. The data were analyzed by percentage of cor-
rect scores.
The Knowledge and Attitudes Survey Regarding
Pain has been tested for evidence of validity and reli-
ability. Content validity has been established by review
of pain experts (Ferrell & McCaffery, 2005). The con-
tent is based on standards of pain management devel-
oped by the American Pain Society, the World Health
Organization, and the Agency for Health Care Policy
and Research. Construct validity has been established
by comparing scores of nurses at various levels of ex-
pertise. Test-retest reliability has been established by
repeated testing in a continuing education class of staff
354 Francis and Fitzpatrick
nurses (r > 0.80). Internal consistency reliability was
established with items reflecting both knowledge and
attitude (r > 0.70) (Ferrell & McCaffery).
Postoperative Pain Intensity. Patients’ pain inten-
sity was measured by three scores on the SF-MPQ.
The SF-MPQ provides quantitative measures of clinical
pain (Melzack, 1975). The SF-MPQ was developed
from the long-form McGill Pain Questionnaire
(Melzack, 1987). The SF-MPQ consists of three sec-
tions. The first section of the questionnaire consists
of 15 adjectives that describe sensory and affective di-
mensions of pain. Eleven items represent sensory de-
scriptors of pain and four items represent affective
descriptors of pain. Each descriptor has four responses
as follows: 0 ¼ none; 1 ¼ mild; 2 ¼ moderate; and 3 ¼
severe. Subjects respond by rating each descriptor of
their pain ‘‘now.’’ Three pain scores are derived from
the sum of the intensity values of the descriptors cho-
sen for sensory, affective, and combined scores of the
patient’s chosen descriptors. The range of possible
scores for each descriptor is 0-3 and range of possible
combined scores is from 0 to 45. The higher the score,
the greater the intensity of pain.
The second section of the SF-MPQ consists of
a VAS. The VAS scale ranges from no pain to worst pos-
sible pain. Subjects are shown the scale and are in-
structed to place a mark on the scale indicating their
pain level. The third section of the SF-MPQ consists
of the present pain intensity (PPI) index. The ratings
for the PPI are 0 ¼ no pain; 1 ¼ mild pain; 2 ¼ discom-
forting pain; 3 ¼ distressing pain; 4 ¼ horrible pain;
and 5 ¼ excruciating pain. A separate score is reported
for each section. The higher the score, the greater the
intensity of pain.
The SF-MPQ has been tested for evidence of reliabil-
ity and validity. A study was conducted to compare the
long form and short form of the McGill Pain Question-
naire (Melzack, 1987). The first section of the SF-MPQ
was compared to the long form with 90 patients. The
study groups included patients in postsurgical and ob-
stetrical units and patients with musculoskeletal pain
in a physiotherapy department. The findings of the study
revealed that the sensory, affective, and total scores from
the short and long forms of the McGill Pain Question-
naire were significantly correlated. Correlation coeffi-
cients were r ¼ 0.88 (p ¼ .001) (Melzack, 1987).
Procedure
Institutional Review Board approval was obtained be-
fore data collection. Patients were approached on the
first and second postoperative days. The researcher in-
terviewed the patients using the SF-MPQ and demo-
graphic questionnaire after obtaining signed consent.
Face-to-face recruitment of nurses was done by
attending unit staff meetings. The investigator de-
scribed the study and explained the purpose of the
study. Research packets containing a cover letter, de-
mographic questionnaire, the Knowledge and Atti-
tudes Survey Regarding Pain, and return envelope
were distributed to the nurse participants.
RESULTS
Sample
There were two samples for this pilot study, a conve-
nience sample of 31 nurse participants and a conve-
nience sample of 14 patient participants from three
surgical units at a large teaching hospital in the eastern
United States. Sixty nurse questionnaires were distrib-
uted; 31 (51.6%) nurse participants returned com-
pleted questionnaires. Seventy-two patients were
approached; 14 patients agreed to participate in the
study, for a response rate of 19%. Patients who were
not willing to participate were either not interested
or requested that the investigator come back on an-
other day. For logistical reasons it was not possible to
contact them on another day. The nurses were not
paired with the patient participants.
Characteristics of Nurse Participants
The nurses’ ages ranged from 22 to 62 years. The mean
age for the nurse participants was 36 years (SD 12.1).
Twenty five (80.6%) were female and 6 (19.4%) male.
The educational characteristics of the nurse par-
ticipants included education level and pain manage-
ment education. Twenty-eight nurse participants
(90.3%) received a Bachelor of Science in Nursing
(BSN) as their basic nursing preparation and one
(3.2%) received an Associate degree. Two participants
(6.5%) received a Master of Science in Nursing. Eleven
of the nurse participants (44%) had not attended a pain
management education session outside the study facil-
ity. Seven (28%) had attended a half-day pain manage-
ment educational session and seven (28%) had
attended a full-day pain educational session.
The work-related characteristics examined were
years of nursing experience, years working on current
unit, and years of other surgical experience. Years of
nursing experience ranged from 1 to 40 years with
a mean of 7.9 years (SD 9.1). Fourteen nurse partici-
pants (48.3%) had <5 years of nursing experience, 8
(27.6%) had 5-10 years, 3 (10.3%) had 11-15 years, 2
(6.9%) had 16-20 years, and 2 (6.9%) had >20 years
of experience.
Years of other surgical experience ranged from
1 to 28 years with a mean of 8.1 years (SD 8.2). Six
nurse participants (20.7%) had surgical experience
of 1-5 years; 2 (6.9%) had 6 to 10 years; 1 (3.4%) had
 Postoperative Pain and Patients’ Experiences 355

11 to 15 years, 1 (3.4%) had 16-20 years, and 1 (3.4%)

had >20 years of other surgical experience. Sample TABLE 2.
characteristics of the nurses are included in Table 1. Nurse Participants (n ¼ 31): Knowledge and
The mean score on the Knowledge and Attitudes Attitudes Survey Regarding Pain
Survey Regarding Pain was 69.3%. These results are in-
Mean (%) SD
cluded in Table 2. There were no significant differ-
ences found between the mean scores and the Overall Score 69.3 4.9
demographic variables of the nurse participants. Score by age (y)
<40 69.1 4.1
40 to <60 73.0 6.6
Characteristics of Patient Participants $60 70.5 2.1
The patients’ ages ranged from 28 to 71 years. The Scores by educational level
mean age was 51 years (SD 12.9). Six (42.9%) were fe- Bachelors 69.1 3.9
male and 8 (57.1%) male. Eleven (78.6%) patients were Masters 69.0 15.6
white, 2 (14.3%) were black, and 1 (7.1%) was of an-
other racial background. Twelve patients’ birth place
was the United States (85.7%), and 2 (14.3%) were were interviewed on the first postoperative day and
born outside of the United States. three (21.4%) were interviewed on the second postop-
Four of the patient participants (28.6%) com- erative day. Nine first-day postoperative patients
pleted high school, 3 (21.4%) received a bachelor de- (64.3%) had open procedures and two (14.3%) had lap-
gree, 3 (21.4%) received a master degree, and 4 aroscopic procedures. Two second-day postoperative
(28.6%) had other educational background. Sample patients (14.3%) had open procedures and one
characteristics of the patients are included in Table 3. (7.1%) had a laparoscopic procedure. These results
Fourteen postoperative day 1 and day 2 gastroin- are included in Table 4.
testinal and urologic patients participated in the study. All of the patient participants received PCA. Thir-
The operative procedures were as follows: one (7.1%) teen patients (92.9%) received peripheral PCA and one
open urologic procedure; one (7.1%) laparoscopic uro- (7.1%) received epidural PCA. Six patients (42.8%) re-
logic procedure, ten (71.4%) open gastrointestinal pro- ceived fentanyl PCA and eight (57.1%) received mor-
cedures; and two (14.3%) laparoscopic gastrointestinal phine PCA. One (7.1%) patient received epidural
procedures. Eleven of the patient participants (78.6%) fentanyl PCA. These results are included in Table 4.
The SF-MPQ was used to measure the postopera-
tive patients’ pain intensity. The SF-MPQ consists of
TABLE 1. three sections. A separate score was calculated for
each section. The results were analyzed as follows:
Characteristics of Nurse Participants (n ¼ 31)
n %

Age (y) TABLE 3.

22-35 15 53.5 Characteristics of Patient Participants (n ¼ 14)
36-55 10 35.7
56-62 3 10.7 n %
Sex
Female 25 80.6 Age (y)
Male 6 19.4 28-40 4 28.6
Education 41-60 6 42.8
MSN 2 6.5 >60 4 28.6
BSN 28 90.3 Sex
Associate 1 3.2 Female 6 42.9
Pain management education Male 8 57.1
None 11 44 Race
Half day 7 28 White 11 78.6
Full day 7 28 Black 2 14.3
Nursing experience (y) Other 1 7.1
<5 14 48.3 Education
5-10 8 27.6 High school diploma 4 28.6
11-15 3 10.3 Bachelor degree 3 21.4
16-20 2 6.9 Master degree 3 21.4
>20 2 6.9 Other 4 28.6
356 Francis and Fitzpatrick

perception of pain management and insufficient docu-

TABLE 4. mentation of pain assessment have been reported (Eid
Clinical Characteristics of Patient Participants & Bucknall, 2008; Gunningberg & Idvall, 2007; Idvall &
(n ¼ 14) Berg, 2008; Idvall et al., 2005; Sloman et al., 2005). In-
tervention processes for improving postoperative pain
n %
management also have been documented (Abdalrahim
Procedure et al., 2010; Lin & Wang, 2005). Based on the reported
Urologic findings, there is a need to improve pain management.
Open 1 7.1 The mean score on the Knowledge and Attitudes
Laparoscopic 1 7.1
Survey Regarding Pain for the present pilot study was
Gastrointestinal
Open 10 71.4 69.3%. Similar mean score findings, ranging from
Laparoscopic 2 14.3 45.7% to 73.8%, have been reported (Abdalrahim
Procedures by postoperative day et al. 2010; Matthews & Malcolm, 2007; Wang & Tsai,
Day 1 11 78.6 2010; Wilson, 2007). The mean score for the knowl-
Day 2 3 21.4
edge questions in the present study was lower than
Open procedures
Postoperative day 1 9 64.3 the mean score for the attitude questions. All of the
Postoperative day 2 2 14.3 nurse participants correctly answered item no. 30
Laparoscopic procedures (the most accurate judge of the intensity of the patient’s
Postoperative day 1 2 14.3 pain is the patient). This response indicates that the
Postoperative day 2 1 7.1
nurse participants in this pilot study understand the
PCA method
Peripheral 13 92.9 concept that pain is subjective and that the patient’s
Epidural 1 7.1 pain is whatever the patient indicates. There were no
Analgesic significant differences in the mean scores between
Fentanyl the three units nor significant differences between
Peripheral PCA 5 35.7
the mean scores and the nurses’ demographic variables.
Epidural 1 7.1
Morphine The sample size of this pilot study was small and limited
Peripheral PCA 8 57.1 to specific clinical services. The findings can not be
generalized to other units at the study facility.
The results of the SF-MPQ indicated that the pa-
overall scores; scores by unit, postoperative day, proce- tient participants experienced moderate pain intensity
dures, and analgesics; and scores by age, sex, race, and based on the mean score of the descriptors of pain and
educational level. VAS sections. This finding was consistent with other re-
The mean scores for each section of the SF-MPQ ported findings regarding patients’ pain experiences
were as follows: descriptors of pain (section 1), 13.9 (Bedard et al., 2006; Brown et al., 2011; Neimi-
(SD 7.9); VAS (section 2), 4.6 (SD 1.9); and present Murola et al., 2007). Pain management is an important
pain intensity index (section 3), 2.2 (SD 1.3). These re- aspect of care for postoperative patients. Adequate
sults are included in Table 5. There were no significant pain relief allows patients to participate in activities
differences found between the mean scores and demo- that can prevent postoperative complications. Effec-
graphic variables of the patient participants. tive pain management requires the intervention of mul-
tiple disciplines.
DISCUSSION
Study Limitations
Pain assessment and nurses’ knowledge regarding pain The limitations of this pilot study were the small sample
management have been studied. Nurse and patient size and the limited surgical services. There were only
two patients from the urologic surgical service. Thus,
all of the patient variables could not be compared
TABLE 5.
with the patients on the urologic service. The results
Short-Form McGill Pain Questionnaire: Patient
of the study can not be generalized in similar settings.
Participants’ Scores (n ¼ 14)
Mean SD Implications for Practice
Pain management is an important aspect in the recov-
Descriptors of pain 13.9 7.9 ery of postoperative patients. Nurses have a vital role
Visual analog scale 4.6 1.9
in promoting positive patient outcomes. Therefore,
Present pain intensity index 2.2 1.3
nurses need to be knowledgeable about pain
 Postoperative Pain and Patients’ Experiences
assessment and management. The nurses’ mean score
on the Knowledge and Attitudes Survey Regarding
Pain in this study was within the range of mean scores
reported in other studies. The consistent findings sug-
gest that improvement is needed in nurses’ knowledge
regarding pain management. Also, the results in this
study indicated that patients experienced moderate
pain intensity. This finding was also consistent with
findings in other studies.
A multidisciplinary approach is essential in the
management of patients’ postoperative pain.The provi-
sion of pain management educational programs for dis-
ciplines involved in the management of patients’ pain
is essential in improving staff knowledge. Integration
of evidence-based practice from all disciplines involved
in pain management is integral in improving patient
outcomes.
Recommendations for Future Research
Recommendations for future research include replica-
tion of this study with a larger sample and other
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