Evaluation of a Pain Management Education Program and Operational Guideline on Nursing ... .

Duke University Hospital, Durham, N.C.



Pain management is a vital component in the care of postoperative patients recovering on inpatient surgery units. Nationally, 43 million surgical patients experience postoperative pain annually, with upwards of 40% of patients reporting severe pain beyond hospitalization (Institute of Medicine, 2011; Schreiber et al., 2014). In a national survey of postoperative patients, 80% reported postoperative pain, less than 50% achieved adequate pain relief, and 10% to 50% of postoperative patients developed chronic pain (Institute of Medicine, 2011). Inadequate pain management may lead to issues of chronic pain, delayed mobility leading to delayed wound healing, feelings of isolation, and increased risk of complications such as pneumonia, pressure ulcers, and pulmonary embolism (Crawford, Armstrong, Boardmen, & Coulthard, 2011; Schreiber et al., 2014).

Nursing students often receive inadequate pain management education and, as a result, lack knowledge of pain management basics, such as how individual pain medications work, routes of administration available, and potential issues, such as oversedation, to watch for (Romero-Hall, 2015). This lack of adequate pain management education may lead to fear of addiction, lack of pharmacology knowledge, and incorrect beliefs about pain medication. Perceived barriers to quality pain management practice include a lack of education, fears of contributing to addiction, and a lack of familiarity with evidence-based practice utilization, which contributes to inadequate pain management (Salinas & Abdolrasulnia, 2011). Nurses also have little knowledge of nonpharmacological pain management techniques and report that they are not confident in their abilities to manage patients' pain (Rognstad et al., 2012). On our surgical oncology unit, providing adequate pain management is a challenge for nurses because of multiple surgical oncologic services on the unit, lack of nursing knowledge and comfort with pain management practice, high nursing turnover rates, minimal continuing education offerings, and inexperience of nursing staff. As a result, patient satisfaction with pain management has been consistently low, and many patients have ongoing pain issues as they recover from surgery at home.

Literature Review

Pain management education programs for nurses have been shown to be effective in addressing the aforementioned challenges. Programs should provide education about pain pathways, impact of medications on pain pathways (Salinas & Abdolrasulnia, 2011), and the purpose and benefits of nonpharmacological pain management as an adjunct to the pain regimen (Rognstad et al., 2012; Tracy, 2010). Interventions should also provide guidance in terms of pain assessment skills, parameters for monitoring pain, education about hospital protocols for pain management, and methods for educating patients about pain (Crawford, Armstrong, Boardman, & Coulthard, 2011). In addition, effective programs provide advice on multimodal pain management that incorporates opioid and nonopioid approaches, as well as nonpharmacological approaches to pain management. Studies have shown that acute pain management education programs have a positive effect on pain control and patient satisfaction, yet weaknesses in nursing knowledge, practices, and attitudes due to inadequate pain management education remain (McNamara, Harmon, & Saunders, 2012). Thus, targeted pain management education for nurses has the potential to improve pain management and increase confidence in managing pain.

In addition to continuing education, pain management can be improved through development and implementation of clinical pathways, also known as operational guidelines, combined with targeted nursing pain education. An operational guideline is a means to establish standardized care practice, which improves patient outcomes and staff efficiency while lowering overall costs of care and improving quality (Lawal et al., 2016). Although there is little consensus on a standardized definition for operational guidelines, most researchers agree on four key components: (a) a structured multidisciplinary care plan; (b) translation of evidence into local practice; (c) an “inventory of actions” which is a detailed layout of steps needed for the plan of care; and (d) a goal to provide standardized care to a specific population (Lawal et al., 2016).

The purpose of this quality improvement (QI) project was to design, implement, and evaluate a pain management continuing education program and operational guideline for nurses in surgical oncology, focusing on improving practice, attitudes, and pain management. Specific aims were to evaluate:

  1. Differences in nurses' practice and attitudes related to pain management after attending a pain management curriculum for postoperative surgical oncology patients.
  2. Nurse satisfaction with the educational program and associated operational guideline.
  3. Changes in the administration of intravenous (IV) pain medication in the 24 hours prior to discharge.
  4. Changes in patient readmissions due to uncontrolled pain.
  5. Changes in levels of surgical oncology patient satisfaction related to pain, as reported in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.


This QI project used a pretest–posttest design using surveys and chart reviews to evaluate the effectiveness of a pain management continuing education program and operational guideline. The surgical oncology unit serves ear, nose, and throat (ENT); colorectal; gastrointestinal; urologic; and cardiothoracic surgery patients. The medical center's institutional review board approved this QI project.

Setting and Sample

The setting is the 40-bed surgical oncology unit located within an 885-bed academic medical center. There are 35 nurses on the unit and, on average, approximately 1,054 patients are discharged from the unit each month. To answer Aims 1 and 2, a convenience sample of staff nurses who work solely in surgical oncology was recruited. Recruitment was conducted through face-to-face discussions of the project between the project coordinator and the staff nurses. To answer Aims 3, 4, and 5, a convenience sample of patient charts over the 3 months preintervention and over the 3 months postintervention were reviewed. To be included in the review, the patient could not have a history of chronic pain, sickle cell disease, or drug addiction, and the patient must have been admitted for surgical intervention by ENT, colorectal, gastrointestinal, cardiothoracic, or urology surgery.

Theoretical Framework

The current QI project was guided by the Knowledge-to-Action (KTA) Framework (Figure). The KTA Framework is intended to bring clarity to the process of knowledge translation, with the goal of creation of evidence-based interventions that are usable and can be sustained (Field, Booth, Ilott, & Gerrish, 2014). The two components of this framework, knowledge creation and the action cycle, were used by the project coordinator to develop the educational intervention. Knowledge creation involves inquiring about knowledge, synthesizing the information, creating tools, and tailoring the knowledge to an issue (Field et al., 2014). The components of the action cycle involved problem identification, selection of knowledge to use, adaptation of knowledge to the situation, assessment of barriers to knowledge use, selection and implementation of interventions, monitoring knowledge use, and outcomes evaluation (Field et al., 2014).

Knowledge-to-Action Cycle. From “Lost in Knowledge Translation: Time for a Map?” by I. Graham, J. Logan, M. Harrison, S. Straus, J. Tetroe, W. Caswell, and N. Robinson, 2006, Journal of Continuing Education in the Health Professions, 26, p. 19. Copyright 2006 by John Wiley and Sons. Adapted with permission.


Knowledge-to-Action Cycle. From “Lost in Knowledge Translation: Time for a Map?” by I. Graham, J. Logan, M. Harrison, S. Straus, J. Tetroe, W. Caswell, and N. Robinson, 2006, Journal of Continuing Education in the Health Professions, 26, p. 19. Copyright 2006 by John Wiley and Sons. Adapted with permission.

The project coordinator used knowledge creation by questioning the evidence for postoperative pain management and seeking input from nursing staff regarding information valuable to their understanding of pain management. This information was synthesized and tailored to meet the needs of the surgical oncology nursing staff and the patient population. The project coordinator used the action cycle when she identified pain knowledge deficiencies, adapted new knowledge to the patient population, and selected the approach to knowledge translation—in this case, an educational program and operational guideline.


The project coordinator, in collaboration with a nurse educator, developed the operational guideline based on the hospital-wide pain management policy. Vital components of the policy were used to create the operational guideline, which offered an easy-to-follow guide to pain management, and were divided into columns: (a) patient and family education and collaboration; (b) pain assessment; (c) pain medication administration; (d) pain reassessment; (e) documentation; (f) nonpharmacological pain management; and (g) discharge planning. These columns were on one side of a flowsheet, and the flipside had service-specific columns with pain management standards derived from discussions with providers from surgical oncology, urology, colorectal, and cardiothoracic surgery. The flowsheet was placed at nurses' stations and nurses were encouraged to use it to guide the care of their patients.

Nursing staff were asked to complete preintervention pain management practice and attitudes surveys prior to viewing a 20-minute online pain education module. Topics covered in the online module included pain pathways, impact of medications on pain pathways, opioid and nonopioid medication use, pain assessment and monitoring, nonpharmacologic interventions, the hospital-wide pain protocol, and introduction to the pain management operational guideline. They then attended a 30-minute live education session, where they reviewed pain management and learned about the operational guideline. The live education session included a summary of the online module, discussion of the operational guideline, and a real-life surgical oncology case scenario to analyze in tandem with the operational guideline. The educational material was developed based on the American Pain Society postoperative pain guidelines (Chou et al., 2016), pain management modules addressing pain pathways (University of Wisconsin School of Medicine and Public Health, 2010), equianalgesic calculators, and opioid conversion charts. Six weeks after the live education session, nurses completed postintervention pain management practice, attitudes, and satisfaction surveys.

Data Collection Tools

The demographic tool collected data on surgical oncology nurses, including age, gender, race, level of education, years of experience, years worked on the unit, and shift worked. To answer Aim 1, a 19-item practice survey, which required nurses to provide a rating on a 5-point Likert-scale (1 = never, 5 = always) was used to measure pain-related practice. Similarly, a 14-item attitudes survey, which required nurses to provide a rating on a 5-point Likert-scale (1 = strongly disagree, 5 = strongly agree) was used to measure pain-related attitudes. Questions sought to evaluate nursing attitudes surrounding patient pain behaviors, views of age or sex in terms of pain, and attitudes about pain medications in general. The Alliance of State Pain Initiatives, in association with the University of Wisconsin, developed these surveys as part of their Pain Improvement Partnership program. The hospital where the QI project was completed received approval to use these surveys in future projects from a conference in which the surveys were introduced. In using these surveys, the data could be compared to previous initiatives at the hospital. Neither the practice or attitudes surveys were tested for reliability or validity; therefore, we are unable to speak to the reliability or validity of the data. However, construct validity was established by evaluating previous use of the surveys at this hospital. A previous QI project at this hospital, which has not been published, used the practice and attitudes surveys with nurses who trained in a pain resource nurse program. That QI project showed similar results in terms of practice and attitudes, indicating some consistency in ability to measure change in practice and attitudes.

To answer Aim 2, nursing satisfaction was measured through an 11-item survey developed by the project coordinator. This survey was based on the Pain Management RN Needs Assessment created by the University of Wisconsin Hospital and Clinics (1996). Questions centered on satisfaction with the education and operational guideline. Nurses answered on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). To answer Aim 3, pain management data were collected by chart review, which included patients' discharge date and time, age, sex, surgical service, and IV narcotic administrations. To answer Aim 4, readmissions attributed to pain for all surgical oncology patients read-mitted during both the pre- and postintervention periods were examined through evaluation of readmissions forms that included the patient's medical record number, as well as their reason for readmission, date of discharge, and date of readmission. Finally, to answer Aim 5, patient satisfaction was measured by HCAHPS scores of always on the question “During this hospital stay, how often was your pain well controlled?” Data for Aims 3, 4, and 5 were collected for 3 months before and 3 months after the intervention.


Significance was set at α = .05. SPSS® version 24.0 for Windows was used for data analysis. Demographic data revealed that 26 staff nurses completed the prepractice and preattitudes surveys, whereas 25 nurses completed the postpractice and postattitudes surveys. The mean age of surgical oncology nurses was 36.76 years; level of nursing education was distributed as 13 associate degrees (52%) and 11 bachelor degrees (44%). Twenty percent were nurses for less than 1 year, 28% were nurses for 1 to 5 years, and 20% were nurses for 11 to 15 years. Thirty-six percent of nurses had worked on the surgical oncology unit for less than 1 year, 56% of nurses had worked on the unit for 1 to 5 years, and 8% had worked on the unit for 5 to 10 years. Twenty-five of the 26 participants were female, and nearly 70% worked day shift.

To measure part 1 of Aim 1, nursing pain management practice, descriptive statistics, and paired t tests were performed. Results are presented in Table 1. There were significant improvements, as evidenced in questions 2, 4, 5, 6, 7, 14, and 19. The second part of Aim 1, nursing attitudes about pain (Table 2), did not significantly change.

Changes in Nursing Pain Management Practice after the Educational Intervention and Operational Guideline (N = 25)

Table 1:

Changes in Nursing Pain Management Practice after the Educational Intervention and Operational Guideline (N = 25)

Changes in Attitudes about Pain Management after the Educational Intervention and Operational Guideline (N = 25)

Table 2:

Changes in Attitudes about Pain Management after the Educational Intervention and Operational Guideline (N = 25)

Aim 2 was analyzed using descriptive statistics, frequency, mean, and percentage. Nurses were highly satisfied with the intervention and were also satisfied with information provided about the operational guideline during the education sessions (mean = 4.48, SD = .510), support and resources offered to aid in implementation of the operational guideline in patient care (mean = 4.40, SD = .577), and overall satisfaction with the education session (mean = 4.40, SD = .500). The pain guideline meets the pain needs of patients (mean = 4.08, SD = .862) was the area in which nurses were least satisfied.

Aim 3, intravenous narcotic administrations 24 hours before discharge, was analyzed using Fisher's exact test. Of the patients in the preintervention group (N = 44), six patients (13.6%) received one dose of narcotic, two patients (4.5%) received three doses of narcotic, and one patient (2.2%) received six doses of narcotic in the day before discharge. During the postintervention period, only three of 44 patients (6.8%) received one dose of narcotic and one of 44 patients (2.2%) received three doses of narcotic in the 24 hours before discharge. A 2-sided Fisher's exact test revealed p = .008, φ = −.306, and 95% CI [.080, .652], indicating a statistically significant change in nursing administration of IV narcotics in the 24 hours prior to discharge.

Aim 4, readmissions attributed to pain, was analyzed using Fisher's exact test. In the 3 months prior to the educational intervention, there were 16 readmissions, of which nine (56%) were attributed to poorly controlled postoperative pain. In the 3 months postintervention, there were 33 readmissions, of which eight (24%) were attributed to poorly controlled pain. A 2-sided Fisher's exact test revealed p = .053, φ = −.315, and 95% CI [.070, .885], which is not statistically significant but does indicate that as one variable increased, the other decreased.

Aim 5, patient satisfaction, was analyzed using descriptive statistics and the Mann-Whitney U test to analyze ratings of always on the HCAHPS item “During this hospital stay, how often was your pain well controlled?” Patients' scores did not significantly improve from pre- (median = 70.4) to postintervention (median = 65.25), Mann-Whitney U = 3.00, n1 = n2 = 8, p = .200.


Although there were no significant changes from preto postintervention scores in terms of nursing attitudes about pain, some items demonstrated important changes. One valuable area of improvement was question 14, which indicates a nonsignificant improvement in perception of managing pain in those who are uncomfortable, perhaps related to discussion of pain pathways and opioid, nonopioid, and nonpharmacologic management of pain. An area of concern, although still nonsignificant, was a greater agreement with question 10, indicating nurses were more likely, postintervention, to answer that patients who are ambulating are not in pain. Clearly, nursing attitudes about pain are difficult to change and may take more than a brief educational intervention and operational guideline to improve. However, the improvements in nursing practice demonstrate it is possible to improve the way nurses manage pain through further education and tailoring of education to specific patient populations or areas of focus that the nurses involved find valuable.

Despite the lack of change in nurses' attitudes, nursing practice scores improved from pre- to postintervention, particularly related to educating patients, pain assessments, and equianalgesic conversions, indicate nursing staff feel better educated about the concept of pain management in postoperative patients. These improvements in practice are similar to those of a quasi-experimental study of surgical nurses at a teaching hospital in Jordan that demonstrated improvement in nurses' knowledge and attitudes after attending an education session (Abdalrahim, Majali, Stomberg, & Bergbom, 2011). The Abdalrahim et al. (2011) study, like this QI project, demonstrated that despite improvements, deficiencies in knowledge remain. This result could indicate that, even with targeted education, ingrained attitudes and misconceptions about pain management are strong enough to interfere with full understanding of the concept of pain.

Although it is important that the focus of educational interventions target knowledge improvement, a much larger change is necessary within our clinical culture to make lasting changes to attitudes, which will result in high-quality pain management (Carr & Watt-Watson, 2012). It is important that not only pain specialists take interest in this but that all health care professionals, from nurses to providers, have a role and a vested interest. When health care professionals view high-quality pain management as an attainable expectation, the environment will be one in which health care professionals, patients, and policy makers can “campaign for the policy and social environment where knowledge becomes practice, skills become habit, and excellence becomes the norm” (Ellis, Johnson, & Taylor, 2012, p. 57).

Although the Abdalrahim et al. (2011) study showed improvement in nursing practice, it did not focus on patient outcomes related to pain. In the current QI project, intravenous narcotic administrations in the 24 hours before discharge decreased significantly and readmissions due to pain had a nonsignificant reduction. Given the improvement in nursing practice posteducation and the decrease in IV narcotic administrations and readmissions due to pain, there may be a link between targeted education, operational guidelines, improved practice, and overall pain management. Although there was no change in HCAHPS scores in this QI project, the findings are consistent with a recent study of postoperative pain in surgical patients, which demonstrated that 66% of patients answered always on the question “During this hospital stay, how often was your pain well controlled?” on HCAHPS surveys (Buvanendran et al., 2015).

In the current QI project, educational support for nurses is being sustained through a “Pain Corner” on the unit-based website, which includes the online module, voiceover PowerPoint® of the live education session, operational guideline and hospital pain policy, and various evidence-based pain management materials, such as the American Pain Society postoperative pain guidelines (Chou et al., 2016), the University of Wisconsin pain module (University of Wisconsin School of Medicine and Public Health, 2010), and equianalgesic calculators (i.e., http://clincalc.com/opioids/). Sustainability of this project would be best evaluated by repeating the surveys of staff, reevaluating readmissions and HCAHPS scores, and an assessment of whether nursing staff have continued to use the tools provided.


There are several limitations of the QI project. First, the sample size was small due to high nursing turnover and lacked diversity due to the largely female nursing population in the unit. Another limitation was that the ENT service was not agreeable to participation in the operational guideline. They did not give feedback on their pain management preferences and, therefore, nurses still have uncertainties about how to manage pain in the ENT population. In this QI project, the practice and attitudes surveys used were different than more common surveys used, such as the Knowledge and Attitudes Survey Regarding Pain (City of Hope, 2014), making it difficult to compare results from this QI project to results of other studies. Of note, providers that knew of the initiative began to discontinue IV narcotic medications prior to discharge. Although this is a positive provider practice development, it makes it challenging to determine whether this is the reason fewer IV narcotics were administered prior to discharge or whether the education and operational guideline led to less use by nurses.

Future studies should include multiple surgical nursing units to ensure a larger sample size and more diversity. Studies should also incorporate the commonly used Knowledge and Attitudes Survey Regarding Pain (City of Hope, 2014), which allows for greater comparison among studies. Greater attention must be paid to the best way to influence nursing attitudes. Future studies should investigate the effects of increased education and operational guidelines on the quality of patient care delivered, as well as safety and patient outcomes.


Despite the limitations, this QI project has important implications for continuing nursing education and professional practice development. A strength of the project is that it not only investigated nursing practice and attitudes but also patient readmissions attributed to pain, IV narcotic administrations in the 24 hours before discharge, and HCAHPS scores. By incorporating these components, there is a clearer picture of the potential positive influence of further nursing education and tools, such as operational guidelines, on pain-related patient outcomes as nursing practice improves.


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Changes in Nursing Pain Management Practice after the Educational Intervention and Operational Guideline (N = 25)

ItemPreintervention, Mean ± SDPostintervention, Mean ± SDt (p)
1. I screen for pain in all my patients every shift or visit.4.76 ± 0.444.72 ± 0.460.327 (.746)
2. I perform a pain assessment on every patient who tells me he or she has pain.4.60 ± 0.504.88 ± 0.33−2.585 (.016)
3. When I call a physician to discuss a pain problem, I provide a summary of the current pain assessment.4.24 ± 0.834.52 ± 0.59−1.319 (.200)
4. I develop recommendations for treatment before I contact a physician to discuss a patient who is in pain.3.58 ± 0.784.33 ± 0.64−3.892 (.001)
5. I teach patients who are taking opioids the facts about addiction.3.08 ± 0.983.84 ± 0.99−2.618 (.015)
6. I teach patients who are taking opioids the facts about physical dependence.2.84 ± 0.943.84 ± 0.99−3.536 (.002)
7. I teach patients who are taking opioids the facts about tolerance.3.38 ± 0.973.96 ± 0.99−2.119 (.045)
8. I teach patients whom to contact if they have unrelieved pain.4.48 ± 0.824.68 ± 0.56−1.000 (.327)
9. I teach patients how to decide when they should contact their health care provider if they have unrelieved pain.4.24 ± 0.834.56 ± 0.65−1.877 (.073)
10. I teach patients how to decide when they should contact their provider if they have unacceptable side effects.4.12 ± 0.974.28 ± 0.74−0.723 (.476)
11. Before I give a patient a PRN analgesic, I assess the intensity of the pain.4.76 ± 0.444.84 ± 0.37−0.625 (.538)
12. Before I give a patient a PRN analgesic, I assess the quality of the pain.4.60 ± 0.654.84 ± 0.37−1.541 (.136)
13. Before I give a patient a PRN analgesic, I assess the location of the pain.4.48 ± 0.654.80 ± 0.41−1.995 (.058)
14. I reassess patient's pain within 90 minutes of giving an analgesic.4.00 ± 0.784.42 ± 0.58−2.632 (.015)
15. I reassess patient's pain within 2 hours of a report of pain of moderate or greater intensity.3.84 ± 0.904.20 ± 0.87−1.616 (.119)
16. I assess cognitively impaired patients for the presence of behaviors that indicate discomfort.4.36 ± 0.574.48 ± 0.59−0.768 (.450)
17. I include nonpharmacologic interventions in my care of patients in pain.4.00 ± 0.514.00 ± 0.660.000 (1.000)
18. I make certain that patients who are taking opioids are on a bowel regimen.3.76 ± 0.664.20 ± 0.58−2.400 (.024)
19. When a patient is changed to a different opioid, I do an equianalgesic calculation to determine whether the dose of the new drug is likely to provide the same amount of pain relief.2.08 ± 1.023.42 ± 1.25−3.936 (.001)

Changes in Attitudes about Pain Management after the Educational Intervention and Operational Guideline (N = 25)

ItemPreintervention, Mean ± SDPostintervention, Mean ± SDt (p)
1. Older people can bore you to death talking about pain.1.76 ± 0.881.68 ± 0.630.358 (.703)
2. I like to be known as a person who doesn't complain about pain.3.08 ± 0.932.75 ± 0.991.356 (.188)
3. Older women complain about pain more than older men.2.32 ± 0.752.28 ± 0.980.143 (.888)
4. Men are supposed to be brave and not let anybody know if they have pain.1.48 ± 0.511.72 ± 0.84−1.297 (.207)
5. Some patients exaggerate their pain as a way of getting attention.2.96 ± 1.022.76 ± 0.830.667 (.511)
6. Patients are often embarrassed to tell their nurse that they're hurting.3.24 ± 1.012.68 ± 1.111.713 (.100)
7. Learning to live with pain builds character.1.68 ± 0.691.72 ± 0.68−0.296 (.770)
8. Life is painful. There is no getting around that.2.08 ± 1.152.00 ± 1.000.267 (.792)
9. By suffering in this life, we are purifying ourselves for life to come.1.68 ± 0.751.76 ± 0.72−0.492 (.627)
10. If patients can still get around or do things, I have to wonder if they are in that much pain.2.08 ± 0.812.32 ± 0.90−0.923 (.365)
11. Good patients avoid talking about pain.1.56 ± 0.651.72 ± 0.68−0.891 (.382)
12. It's better to put up with pain than to deal with the side effects of the pain medicines.1.68 ± 0.691.80 ± 0.82−0.681 (.503)
13. Pain medicines should be given only when pain is severe.1.64 ± 0.861.84 ± 0.62−1.000 (.324)
14. Patients should experience discomfort prior to receiving the next dose of pain medicine.2.00 ± 0.911.76 ± 0.521.141 (.265)