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stoperative pain assessment based on numeric ratings is not the same r patients and professionals: A cross-sectional study queline F.M. van Dijk a,*, Albert J.M. van Wijck a, Teus H. Kappen a, Linda M. Peelen a,b, r J. Kalkman a, Marieke J. Schuurmans c iversity Medical Centre Utrecht, Department of Perioperative Care and Emergency Medicine, The Netherlands iversity Medical Centre Utrecht, Julius Centre for Health Sciences and Primary Care, The Netherlands iversity Medical Centre Utrecht, Department of Nursing Science, The Netherlands What is already known about the topic? ain assessment is the foundation of pain management hen a patient is experiencing postoperative pain. A frequent and thorough assessment of patients’ pain by registered nurses provides information to achieve optimal pain relief. ? Clinical guidelines are developed for postoperative pain management based on the patient’s pain score. In these guidelines different cut-off points are used to treat the pain. What this paper adds ? Patients and professionals do interpret the numeric rating scores for postoperative pain differently. T I C L E I N F O le history: ived 27 December 2010 ived in revised form 7 July 2011 pted 16 July 2011 ords: lgesics eline measurement operative pain A B S T R A C T Background: Numeric pain scores have become important in clinical practice to assess postoperative pain and to help develop guidelines for treating pain. Professionals need the patients’ pain scores to administer analgesic medication. However, do professionals interpret the pain scores in line with the actual perception of pain by the patients? Objective: The study aim was to assess which Numerical Rating Scale (NRS) pain score was considered bearable on a Verbal Rating Scale (VRS) by patients and professionals. Methods: This prospective study examined the relationship between the Numerical Rating Scale and a Verbal Rating Scale. The patients (n = 10,434) rated their pain the day after surgery on the 11-point NRS (0 = no pain and 10 = worst imaginable pain) and a VRS comprising five descriptors: ‘‘no pain’’; ‘‘little pain’’; ‘‘painful but bearable’’; ‘‘considerable pain’’; and ‘‘terrible pain’’. The first three categories together (‘‘no pain’’, ‘‘little pain’’ and ‘‘painful but bearable’’) were considered ‘‘bearable’’ and the last two categories (‘‘considerable pain’’ and ‘‘terrible pain’’) were deemed as ‘‘unbearable’’ pain. The professionals (n = 303) were asked to relate the numbers of the NRS to the words of the VRS. Results: Most patients considered NRS 4–6 as ‘‘bearable’’ pain. Among professionals, anesthesiologists, Post Anaesthesia Care nurses, and ward nurses interpreted NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently; they considered NRS of 5 and higher to be not bearable. Conclusions: Some care providers and patients differ in their interpretation of the postoperative NRS scores. A risk of overtreatment might arise when health care providers rigidly follow guidelines that prescribe strong analgesics for pain scores above 3 or 4 without probing the patient’s preference for pharmacological treatment. ? 2011 Elsevier Ltd. All rights reserved. Corresponding author at: University Medical Centre Utrecht, Pain ic L02.502, Department of Perioperative Care and Emergency icine, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. +31 88 75 56163; fax: +31 88 75 55511. E-mail address: j.f.m.vandijk@umcutrecht.nl queline F.M. van Dijk). Contents lists available at ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0-7489/$ – see front matter ? 2011 Elsevier Ltd. All rights reserved. 10.1016/j.ijnurstu.2011.07.009
J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–7166 ? The findings suggest a potential risk of overtreatment if the pain is assessed by the Numeric Rating Scale (NRS) only. 1. Introduction According to the American Pain Society guidelines (APS, 1995) for pain management, postoperative pain should be assessed regularly and documented carefully. The inten- sity of pain should be evaluated and recorded at intervals depending on the severity of pain and the clinical situation. Pain assessment and management is a significant part of nursing care and the pain is mostly assessed through verbal communication with the patient. The Numeric Rating Scale (NRS) is frequently used for this purpose: the patient is asked to score the pain on an 11 point scale, where 0 indicates no pain and 10 indicates the worst imaginable pain. The NRS is considered a valid and reliable pain assessment tool (Breivik et al., 2000; DeLoach et al., 1998; Good et al., 2001). The patient’s NRS score is a leading indicator in the postoperative pain treatment. Many guidelines for pain management recommend prescription of analgesics on the basis of the patients’ NRS pain score (APS, 1995; Gordon et al., 2005; VMS, 2009). However, the NRS threshold for prescribing analgesics varies: some guidelines for acute and cancer pain chose an NRS cut-off >4 (APS, 1995; Gordon et al., 2005) while at least in one other, also for acute and cancer pain, an NRS cut-off >3 is the criterion for administering analgesics (VMS, 2009). Furthermore, in clinical practice not all patients with an NRS pain score above the treatment threshold are willing to accept the analgesic treatment offered mostly because they still consider the pain as ‘‘bearable’’. This suggests that professionals and patients might perceive the necessity for pain treatment differently. If so, health care providers who strictly follow current guidelines could be at risk of overtreating some patients. The aim of the study was to investigate how post- operative NRS pain scores of the patients relate to the presence of ‘‘bearable’’ versus ‘‘unbearable’’ pain. In a prospective study, the postoperative NRS pain scores were compared with the same patients’ adjectival descriptions of pain on a Verbal Rating Scale (VRS). The agreement between patients and professionals on the relationship between the NRS and VRS was then studied on the basis of comparisons between the two scales. We hypothesized that patients and professionals might differ in their interpretation of NRS scores. 2. Methods 2.1. Study design We describe a cross-sectional study of a large sample of patients admitted for elective surgery. The current study was part of a large cluster-randomized study, implement- ing a prediction rule for improving the treatment of postoperative nausea and vomiting. In this study, 23,000 in- and out-patients participated. The study was approved by the institutional Ethics Committee of the University Medical Centre in Utrecht. It was not necessary to obtain informed consent from the patients because pain mea- surement is part of clinical care. Informed and voluntary consent of the health care professionals was assumed by return of a completed questionnaire. 2.2. Subjects Between March 16th, 2006 and December 21st, 2007, all adult patients scheduled for elective surgery at the University Medical Centre of Utrecht were recruited. The following patients were excluded: those who were trans- ferred directly to an intensive care unit; who needed postoperative ventilatory support; who had complications followed by a second operation; who did not understand the verbal questions of the research nurse; or who underwent ambulatory surgery. All patients received a written bro- chure preoperatively giving information about postopera- tive pain measurement and treatment, in accordance with the protocol of the hospital’s Acute Pain Service. Furthermore, we conducted a national survey in which 303 professionals participated: anesthesiologists, Acute Pain Nurses, nurses working on the Post Anaesthesia Care Unit (PACU), student PACU-nurses and ward nurses. The health professionals were a convenience sample. During one week in May, 2008 the PACU nurses and nurses on the surgical wards of the UMC Utrecht were visited and invited to participate in the study. In addition, the nurses in training in the UMC Utrecht for PACU-nurse and working in different hospitals in the Netherlands were invited to participate. The anesthesiologists were randomly selected from a national anaesthesia congress. The Acute Pain Nurses, registered as members of the Dutch association for pain nurses in 2008, were approached by email. All health professionals were personally informed and invited to participate by the pain nurse who was not involved in patient care. 2.3. Data collection Trained research nurses who were not involved in the postoperative care asked the patients about their pain at rest on the day after surgery. The 11 point NRS was used, where 0 indicates no pain and 10 the worst pain imaginable. The VRS used in this study gives five expressions on a scale of increasing burden: ‘‘no pain’’ (VRS 0), ‘‘little pain’’ (VRS 1), ‘‘painful but bearable’’ (VRS 2), ‘‘considerable pain’’ (VRS 3) and ‘‘terrible pain’’ (VRS 4). The first three categories together (‘‘no pain’’, ‘‘little pain’’ and ‘painful but bearable’) were considered ‘bearable’ and the last two categories together (‘considerable pain’ and ‘terrible pain’) were deemed as ‘unbearable’ pain. Further- more, information concerning gender, age, surgical pro- cedure and type of anaesthesia was gathered. The professionals were invited to relate the NRS to the VRS; they received a hand-delivered questionnaire with the five descriptions constituting the aforementioned VRS and were asked to relate the numbers 0–10 of the NRS to these words. The questionnaires were hand-collected when once completed. No demographic data from the health profes- sionals were collected.
2.4. com exp foll tive Cor Spe for Wh Sen ‘un VRS we (RO NR val exa pat bet did ana ver con tha 3. R 3.1. in elig und inc obt one ma sco unc Tab Dem Ag Ge Ty Ty ENT Valu J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–71 67 Statistical analyses Data were analyzed using descriptive statistics on plete cases. Results for continuous variables were ressed as mean (SD) or as median for variables owing normal and non-normal distributions, respec- ly. Categorical data were expressed as frequencies. relations between NRS and VRS were calculated by the arman rank correlation coefficient. Statistical testing non-normally distributed variables used the Mann– itney test, and for categorical values the x2 test. sitivity and specificity of the NRS in detecting bearable’ pain were calculated using cut-off points ?2 (bearable pain) and VRS >2 (unbearable pain) and re represented by a Receiver Operator Characteristic C) curve. To analyze the relationship between VRS and S scores, we used the modal score (the most frequent ue) of the numbers of the NRS per VRS category and mined whether this relationship differed between ients and professionals. To be able to detect differences ween males and females and different age groups we subgroup analyses for gender and age. Statistical lyses were performed using SPSS Statistical Software, sion 15.0 (SPSS Inc., Chicago, IL). The results were sidered statistically significant if the p-values were less n 0.05. esults Patients The demographic and perioperative data are presented Table 1. Data from 10,576 surgical inpatients were ible for the current study; the other 12,424 patients erwent ambulatory surgery or did not meet the lusion criteria. An NRS and VRS pain score pair was ained 24 h after surgery from 10,434 patients. Data on or both scales were incomplete for 142 patients, inly because they were too sick to determine the pain re; failed to understand; were confused; or were ooperative. Fig. 1 shows the distribution of the NRS scores of actual pain at rest 24 h after the operation. The median NRS score was 2. Twenty-four percent of the patients scored an NRS >4; this is the threshold value for pain treatment according to various guidelines (APS, 1995; Gordon et al., 2005). In general, women reported higher pain scores than men (median 3 versus 2, respectively; p < 0.001). Older patients (aged 65 and older) reported lower pain scores than younger patients (median 2 versus 3; p < 0.001) (Table 2). Fig. 2 shows the distribution of the VRS scores of actual pain at rest 24 h after surgery. Both the median and the mode of the VRS scores were 1 (little pain). In total, 22.7% of the patients reported ‘no pain’ (VRS 0), 38.9% reported ‘little pain’ (VRS 1), 29.4% reported ‘painful but bearable’ (VRS 2), 8.3% reported ‘considerable pain’ (VRS 3) and 0.7% reported ‘terrible pain’ (VRS 4). Women consistently reported more severe pain scores than men (p < 0.001). Older patients reported less severe pain scores than younger patients (p < 0.001) (Table 3). 3.2. Professionals One hundred and forty anesthesiologists participated (response rate 100%), along with 50 Acute Pain Nurses (response rate 94%); 33 PACU nurses (response rate 100%); 16 nurses in training for PACU-nurse (response rate 100%); and 67 nurses on the ward (response rate 100%). le 1 ographic and perioperative data (n = 10,434 patients). e, mean ? SD (range) 52 ? 17 (18–98) nder, n (%) Female 5348 (51) Male 5086 (49) pe of surgery, n (%) General 2097 (20) ENT/faciomaxillary 1988 (19) Orthopedic 1058 (10) Neurosurgery 974 (9) Urology 965 (9) Gynecologic 868 (8) Plastic surgery 838 (8) Vascular surgery 676 (6) Eye surgery 593 (6) Cardiothoracic 226 (2) Other 151 (1) pe of anaesthesia, n (%) General 9182 (88) Locoregional 1252 (12) NRS 109876543210 Pe rc en t 20% 15% 10% 5% 0% Fig. 1. Pain scores on the Numeric Rating Scale 24 h after surgery in percentages. Table 2 Differences in NRS pain scores. Median pain score p-Value Gender (n) Male (5086) 2 <0.001a Female (5348) 3 Age (n) ?65 years (7760) 2 <0.001a <65 years (2674) 3 : ear, nose and throat surgery.es are numbers (%). a Mann–Whitney test.
J.F.M. van Dijk et al. / International Journal of Nursing Studies 49 (2012) 65–7168 3.3. The relation of the NRS to the VRS The VRS and NRS scores of the patients were significantly correlated (Spearman correlation coefficient r = 0.84, p < 0.001). Twenty-four percent of the post- operative patients reported an NRS pain score >4, while 9% reported ‘considerable’ or ‘terrible pain’ on the VRS. The patients associated NRS 0 with VRS ‘no pain’; NRS 1–3 with VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’; NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’. As different guidelines show various NRS cut-off points to determine the need for treatment with analgesics, the sensitivity and specificity of the NRS scores and VRS ‘bearable’ and ‘unbearable’ were calculated for different NRS cut-off points. Fig. 3 shows an ROC curve depicting the sensitivity and 1 ? specificity for these cut-off points. Using an NRS cut-off point of 4, 17% of the patients considered NRS >4 to be ‘bearable’ pain (1 ? specificity) and 5% considered it as ‘unbearable’ pain (1 ? sensitivity). So using an NRS cut-off value >4 for analgesic adminis- tration, 17% of the patients would be incorrectly classified as having unbearable pain, possibly resulting in over- treatment, while 5% would be undertreated. With a cut-off point of NRS >3, 30% of the patients would be overtreated and 3% would be undertreated. Fig. 4 shows the distribution of the relationship between the NRS and VRS according to the patients and the professionals. The PACU and ward nurses interpreted the NRS and VRS scores in the same way: NRS 0 equated with VRS ‘no pain’; NRS 1-3 with VRS ‘little pain’; NRS 4–5 with VRS ‘painful but bearable’; NRS 6–8 with VRS ‘considerable pain’; and NRS 9–10 with VRS ‘terrible pain’. The anesthesiologists interpreted NRS 1 as ‘no pain’ but their other ratings were identical to those of the PACU and ward nurses. The Acute Pain Nurses interpreted the scores differently: NRS 1–2 ‘little pain’; 3–4 ‘painful but bearable’; 5–7 ‘considerable pain’; and 8–10 ‘terrible pain’. The distribution of the NRS scores over the VRS categories given by the Acute Pain Nurse was shifted to the left in comparison with those of the other professionals and patients, because they assigned lower NRS scores to the VRS categories. 4. Discussion The present study distinguishes ‘bearable’ from ‘unbearable’ postoperative pain and analyzes the relation- ship between NRS and VRS scores as assessed by post- operative patients and professionals. We found that most patients (65%) with NRS 4–6 considered their pain bearable. Among the professionals, the anesthesiologists, PACU and ward nurses interpreted the NRS scores in the same way as the patients. Only the Acute Pain Nurses interpreted the scores differently. In previous studies, different descriptions of pain have frequently been used: no; mild; moderate; and severe pain. In a recent study on pain after orthopedic surgery, the patients related NRS 1–3 to mild; 4–5 to moderate; and 6– 10 to severe pain (Dihle et al., 2006). After coronary artery bypass grafting, NRS 1–3 was related to mild; 4–6 to moderate; and 7–10 to severe pain (Mendoza et al., 2004). These studies show that in postoperative pain the upper boundary for mild pain is NRS 3 and for moderate pain NRS 5 or 6. These results are comparable to the findings of the VRS


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