Patient’s perception of acute post-operative pain and satisfaction with pain
management undergoing abdominal surgeries in an academic medical
institute: a cross-sectional study.
Dr N K Jaiswal,
Abstract:
1. Introduction:Persistent pain after major abdominal surgery can lead to discomfort to
the patients. Ineffective postoperative pain management has physiological,
psychological, ethical, and financial consequences. The degree of patient satisfaction
could simply be a reflection of the performance of the health care providers and not an
indication of the efficaciousness of pain management. There is a paucity of data
regarding this aspect in Indian post -surgical patients. Objectives:To find out the
prevalence of acute post-operative painand level of patient’s satisfaction regarding
nurse’s and doctor’s response for pain managementin patients of elective abdominal
surgeries. Material and methods: Observational study using questionaire ,visual
analogue scale . Results:At 5th post –operative hour, the pain was mild with 35 patients
having a score of 2, 128 patients had a score of 3 and 36 patients had a score of 4 with a
mean score of 2.9 ± 0.61. Worst possible pain within 24 hours was found with a score of
8 in 46 patients ,score of 9 in 125 patients and score of 10 in 28 patients with a mean of
8.9 ± 0.61.Average pain of score 6 was found in 146 patients and score of 7 was found in
45 patients with a mean of 6.1 ± 0.46. 79% and 83% of respondents reported that they
were “satisfied” with how their nurses and physicians, respectively, responded to their
complaints regarding pain.Conclusions : Majority of the patients felt the post operative
pain in 24 hours of the surgery with mild pain initially worst possible pain later on .79%
and 83% of respondents reported that they were “satisfied” with how their nurses and
physicians manage their pain.63% participants suggested that time lag for receiving the
pain relief medication in the study population is 0 to 10 minutes
Key words: Visual analogue scale(VAS), questionnaire based study, post-operative pain
Introduction:
The World Health Organization defines pain as “an unpleasant sensory or emotional
experience associated with actual or potential tissue damage, or described in terms of such
damage”.1
Pain is a subjective experience, which cannot be easily measured. It requires
consciousness.2Pain is the result of a complex interplay between signaling systems, modulation
from higher centers and the unique perception of the individual.3
Acute pain is almost always self-limited.4When the condition that produces the pain
resolves, or when the nociceptive input is blocked by a local anaesthetic or altered by a
peripheral or central analgesic medication, the pain leaves.
Major abdominal surgical operations ideally require the Acute Pain Management Service
(APMS) for regular pain assessment and timely management of breakthrough pains and
complications in the postoperative period5. Evidence has suggested that APMS has improved
morbidity and reduced the duration of hospital stay. 6
The American Pain Society Quality of Care Committee designated pain as the fifth vital
sign, since then the health care professionals have become increasingly aware of proper pain
management policies and the need to assess pain management outcomes.7
Persistent pain after major abdominal surgery can lead to shallow breathing which
facilitates retention of secretion with eventual development of pneumonia contributing to organ
dysfunction and prolonged convalescence.Therefore, ineffective postoperative pain management
has physiological, psychological, ethical, and financial consequences. 8
The degree of patient satisfaction could simply be a reflection of the performance of the
health care providers and not an indication of the efficaciousness of pain management.9 There is
a paucity of data regarding this aspect in Indian post -surgical patients.10
The rationale of this study is to assess pain management practices and their effectiveness
after abdominal surgery in a tertiary care hospital .
Aimand objectives
2. To evaluate the prevalence of acute post-operative pain in patients of elective abdominal
surgeries.
3. To find out the level patient’s satisfaction regarding nurse’s and doctor’s response for
pain management
Material and Methods:
Study design: Cross- sectional observational study.
Study group:Patients admitted in the wards of surgery department in the tertiary Health Care
Teaching Institute for major/minor abdominal surgeries. (n=200)
Study duration: Two months from 1st May to 30th June 2019.
Study site: Department of Surgery in collaboration with department of Pharmacology in a
tertiary care teaching institute.
Inclusion criterion:Men and women in age group 18 -60yrs undergoing abdominal surgeries
were included in the study.
Exclusion criteria:Patients undergoing surgeries other than abdominal surgeries, patients
undergoing surgery for malignant disorder and trauma,patients receiving antipsychotic
drugspregnant women were excluded from the study.
Ethics and consent:Prior permission of Institutional Ethics Committee (Reg. no. ECR /1033
/Inst /MH /2018) was taken for conducting the study. Written informed consent was obtained
from each participant after explaining them the study protocol. The study team did not interfere
with any of the treatment aspects of the patients.
Study tools:
1.Questionnaire :A predesigned & pre-validated questionnaire was used in the study to assess
the post-operative pain status of the patients. The patients were made to understand the study
survey in the language they understand. They were given 11 questions survey, modified from the
American Pain Society’s Patient Outcome Questionnaire and the Patient Opinion of Pain
Management Tool.11
2.Visual Analogue Scale (VAS):
A Visual Analogue Scale was used to quantify the pain status of the patient and their pain
perception was assessed on the numeric 0-10, indicating the strength of pain perceived from no
pain to worst possible pain. This scale does not take into justification multi-dimentional
approaches to pain management, which should not only include the concept of adequate pain
control but also ‘patient satisfaction with pain control.’ 12
Acute post-operative pain at rest was evaluated within 24 hrs of surgery, by visual analogue scale
(VAS).For further analysis, pain was classified as mild (VAS 1–3.5), moderate (VAS 4–6.5) and
severe (VAS >6.5). The two questions (question numbers 6 and 7) were put to patients to rate
their satisfaction required them to report satisfaction on a six-point likert scale.The treating
physician and nursing staff were not aware of the study hypothesis or outcome measures.The
second author who is 2nd MBBS student collected the data and was not a part of the team that
provided perioperative care to the patients
Scoring and assessment:
The assessment of pain outcomes has been conducted by measuring each patients
subjective level of pain control using pain intensity scales, most commonly the 0-10 numerical
scale (0 being no pain and 10 being the worst pain imaginable).
This survey also examined different aspects of pain intensity and satisfaction. Pain
intensity was measured by asking each patient to evaluate their present, most severe, and average
pain levels within the last 24 hours (questions 5–7), and patient satisfaction was also measured
(questions 7–11).
Statistical Analysis:
All completed questionnaires were cross checked to ensure data consistency and completeness.
All recorded data were coded and entered in the MS Excel 2019.
Analysis were performed using Statistical Package for the Social Sciences(SPSS) version for
Windows software full version 23. Descriptive statistics and bivariate analysis were used for the
analysis. And the relationship between the patient’s level of pain and satisfaction with pain
control has been calculated.
Results:
A total of 200 patients participated in this study, 160 (80%) of the respondents were males and
40 (20%) were females. The mean age of respondents was 37.43± 10.32 years but the highest
number of participant were found in the age group of 31-50 years (64%). [fig.1: a, b]
11-30 years [52=26%]
31-50 years
[128=64%]
51-70 years [20=10%]
Male [160=80%]
Female [40=20%]
All the patients enrolled in the study had experienced pain in past 24 hours. Hence the patients
were asked questions 4-6, which were qualitative questions designed to assess each patient’s
postoperative 5th hour pain , average and worst levels of pain control over the previous 24 hours.
Responses of the patients on the Visual Analogue Scale are shown in Table 1 and fig.3.The
mean scores of all the 3 questions are tabulated in Table 2. At 5th post –operative hour, the pain
was mild with 35 patients having a score of 2, 128 patients had a score of 3 and 36 patients had a
score of 4 with a mean score of 2.9 ± 0.61. Worst possible pain within 24 hours was found with a
score of 8 in 46 patients ,score of 9 in 125 patients and score of 10 in 28 patients with a mean of
8.9 ± 0.61.
Average pain of score 6 was found in 146 patients and score of 7 was found in 45 patients with a
mean of 6.1 ± 0.46
Table 1: Respondents response of pain on Visual Analogue Scale (VAS) [n=200]:
Pain Response on Visual Analogue Scale
0 1 2 3 4 5 6 7 8 9 10
Pain at 5th 0 1 35 128 36 0 0 0 0 0 0
postoperative
hour
Worst 0 0 0 0 0 0 0 1 46 125 28
possible pain
within 24
hours of
surgery
Average pain 0 0 0 0 0 6 149 45 0 0 0
during the
postoperative
24hrs
Table 2 : Levels of pain score in past 24 hrs (n=200)
Pain status Mean score ± S.D(0-10 VAS)
Pain at 5th postoperative hour 2.9 ± 0.61
Worst possible pain within 24 hours of surgery 8.9 ± 0.61
Average pain during the postoperative 24hrs 6.1 ± 0.46
80%
70%
% of respondents
60%
50%
40%
30%
20%
10%
0%
1 2 3 4 5 6 7 8 9 10
Responses on visual analogue scale
Pain status at 5th hour
Worst pain status in last 24
hours
Average pain status in past 24
hours
Table 3 : Responses regarding pain management and patient satisfaction(n=200)
Level of satisfaction Patients satisfaction regarding Patients satisfaction regarding
nurse’s response for pain doctor’s response for pain
management. n (%) management. n (%)
Very dissatisfied 0 0
Slightly satisfied 32 (16) 21 (10.5)
Dissatisfied 10 (5) 8 (4)
Satisfied 158 (79) 166 (83)
Slightly dissatisfied 0 0
Very satisfied 0 4 (2)
Table 4:Patients satisfaction regarding nurse’s response for pain management (n=200)
Level of satisfaction Satisfied 158
Gender Males 126
Females 32
Age group 11-20yrs 06
21-30yrs 35
31-40yrs 55
41-50yrs 46
Table 5:Patients satisfaction regarding doctor’s response for pain management (n=200)
Level of satisfaction Satisfied 166
Gender Males 133
Females 33
Age group 11-20yrs 08
21-30yrs 38
31-40yrs 54
41-50yrs 48
Questions 7-10 were designed to assess patient satisfaction with pain control and evaluate the
various factors that contribute to patient satisfaction. Table 3 shows that in total, 79% and 83%
of respondents reported that they were “satisfied” with how their nurses and physicians,
respectively, responded to their complaints regarding pain. Table 4 and 5 depicts patients
satisfaction regarding nurse’s response and treating doctor’s response for pain managementThe
question regarding waiting time for the administration of pain medication demonstrated varying
results (question 9). Among respondents who requested pain medication, 26 (63%) received
medication within 10 minutes of asking, 56 (28%) within 11–20 minutes and 18 (9%) within 21–
30 minutes. [fig. 4]
0-10 mins [126 = 63%]
11-20 mins [56 = 28%]
21-30 mins [18 = 9%]
Number of respodents
YES NO
Experience of any pain after medication
Spearman’s rank correlation coefficients were calculated to determine the relationship between
each patient’s level of pain and their satisfaction with pain control. Based on the 200 participants
who answered questions, the correlation coefficient was determined to be r = 0.117 (95%
confidence interval =0.096 to 0.139). A slight, but non-significant, upward trend line was
observed (i e, satisfaction increased as the level of pain increased). This positive correlation was
not significantly different from 0, as implied by the 95% confidence interval, indicating the
insignificance of the trend line.
8
7
6
5
Pain score
4
3
2
1
0
0.5 1 1.5 2 2.5 3 3.5 4 4.5
Mean score of level of satisfaction
Figure 6. Relationship between patient satisfaction and pain control (n = 200).
Note: Spearman correlation (95% CI): 0.117 (0.096 to 0.139)
Discussion:
In the present cross- sectional ,observational study, total of 200 patients undergoing abdominal
surgeries participated, their perception of acute post-operative pain and satisfaction with pain
management status was assessed using a questionnaire ,VAS, 6 point likert scale .This tool not
only assesses pain control but also patient satisfaction with pain control.12
In the present study it was seen that acute post-operative pain at 5th hour and upto 24 hours is
prevalent in patients undergoing elective abdominal surgeries. Many studies in literature report
prevalence of postoperative pain ,13,14,15,16,17,18
In the present study patients reported mild pain in early hours after surgery and worst possible
pain after some hours of surgery which was very severe and overall average pain was severe .
These findings coincides with findings from other studies.19,20,21
In the present study total, 79% and 83% of respondents reported that they were “satisfied”
regarding their care giving nurse’s and treating doctor’s responses for their pain management
respectively .Ingrid Svensson et al. reported that gender, age, pre‐operative expectation and
actual experience of pain relief, and the overall pain experience were the factors associated with
the probability of being satisfied/dissatisfied. 22 In our study maximum respondents to this
question were males but this may be due to more number of males in the study population
Likewise maximum respondents were from age group 31-40yrsTeresa A pellino et al. suggested
no significant effect on gender and perception of pain. 19
In a study conducted by Jorge Malouf et al it was seen that patients were highly satisfied with
pain management, even when they were in pain. Moreover, it establishes that patient
dissatisfaction with treatment was highly related to the satisfaction with caregivers and pain
intensity23
Stahmer et al reported thatthere is a significant association between changes in pain intensity (PI)
and pain relief. Greater reductions in PI are required for patients presenting with more severe
initial pain to achieve relief compared with those who have lesser initial PI. While there is a
linear relationship between increasing pain relief and satisfaction, relief of pain appears to only
partially contribute to overall satisfaction with pain management. Patient satisfaction with pain
management is associated with the amount of pain relief achieved. Considering the overall high
level of satisfaction, it appears that pain relief alone is not the only factor that affects patient
satisfaction with pain management.24
In the present study 63% participants suggested that time lag for receiving the pain relief
medication after complaining of postoperative pain during the 24 hours study period is 0 to 10
minutes and in 28% cases the time lag is 11 to 20 minutes. This finding of the present study
correlates with the finding of the study by shay Phillips et al.25
In the study done by shay Phillips et al. the correlation coefficient was determined to be r =
−0.31 (95% confidence interval = −0.79 to 0.39). This negative correlation was not significantly
different from 0, as implied by the 95% confidence interval, indicating the insignificance of the
trend line. But in contradiction to their study, in the present study spearman’s rank correlation
coefficients was determined to be r = 0.117. It shows the positive co-relation between patient’s
level of pain and their satisfaction with pain control.25
A misunderstanding held by many health care practitioners is that low pain intensity scores are
revealing positive patient satisfaction and that high pain intensity scores are indicative of
negative patient satisfaction. Indeed, there is a remarkable biological, social, psychological
element to pain that should not be unnoticed and could explain why the use of pain severity
scales as the sole measure of clinical outcomes is suboptimal. Physicians and nurses are aware of
the scary task of educating patients about the importance of pain control. The number of
interruptions made by the nursing staff during the night can also influence the patient’s level of
satisfaction (ie, patients who report a high number of interruptions may report low levels of
satisfaction).
While this study demonstrates the importance of addressing patient satisfaction as an
independent variable of pain management, the strength of this study could be limited by the fact
that we used a self-reported survey, therefore, the results are not validated. Like most surveys,
this study is subject to both response and non-response bias. In terms of response bias, patients
may answer survey questions by reporting how they think the questions should be answered
instead of how they truly feel. In addition, some patients may respond to survey questions by
reporting the most extreme response, especially if they experienced a positive or negative
encounter with a health care provider that day. Another factor that cannot be ruled out is the
biases of family members who help the patient complete the survey. Pain is subjective
phenomenon ,not felt by brain but by the person.
Conclusions:
Majority of the patients felt the post operative pain in 24 hours of the surgery with mild pain
initially worst possible pain later on .79% and 83% of respondents reported that they were
“satisfied” with how their nurses and physicians manage their pain.63% participants suggested
that time lag for receiving the pain relief medication in the study population is 0 to 10 minutes.
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