Clinical judgment and management of postoperative pain in critical care patients

Measuring Acute Pain Over Time in the Critically Ill Using the Multidimensional Objective Pain Assessment Tool (MOPAT)

BACKGROUND

A valid and reliable instrument is needed to assess acute pain in critically ill patients unable to self-report and who may be transitioning between critical care and other settings.

AIM

To examine the reliability, validity, and clinical utility of the Multidimensional Objective Pain Assessment Tool (MOPAT) when used over time by critical care nurses to assess acute pain in non-communicative critically ill patients.

METHODS

Twenty-seven patients had pain assessed at two time points (T1 and T2) surrounding a painful event for up to 3 days. Twenty-one ICU nurses participated in pain assessments and completed the Clinical Utility Questionnaire.

RESULTS

Internal consistency reliability coefficient alphas for the MOPAT were .68 at T1 and .72 at T2. Inter-rater agreement during painful procedures or turning was 68% for the behavioral dimension and 80% for the physiologic dimension. Validity was evidenced by decreases (p < .001) in the MOPAT total and behavioral and physiologic dimension scores when comparing T1 and T2. Nurses found the tool clinically useful.

CONCLUSION

The MOPAT can be used in the critical care setting as a helpful tool to assess pain in non-communicative patients. The MOPAT is unique in that the instrument can be used over time and across settings.

Assessment of pain in sedated and mechanically ventilated patients: an observational study

BACKGROUND

Critically ill patients often undergo unpleasant procedures. We quantified the effects of an unpleasant stimulus on physiological and behavioral parameters and evaluated how they are modified by sedation and analgesia.

METHODS

A 6-month study in the 30-bed intensive care unit (ICU) of a university hospital examined 21 sedated patients from various diagnostic groups. Hemodynamic and respiratory parameters, pupil size, facial expression, muscle tone, body movement, and the Richmond Agitation-Sedation Scale (RASS) score were measured before and during intratracheal suctioning, first in sedated patients, after sedation was stopped, and after an opioid bolus.

RESULTS

Before intratracheal suctioning, patients had RASS scores of -1.8 ± 1.2 (mean ± standard deviation; sedation), -0.6 ± 1.7 (sedation stop), and -0.9 ± 1.4 (analgesia) (P = 0.014). Intratracheal suctioning significantly increased RASS during both sedation (to -0.6 ± 1.7) and sedation stop (to 1.0 ± 1.5) (both P < 0.01), but not during analgesia. Systolic blood pressure increased during sedation (by 9 ± 10 mmHg), during sedation stop (by 15 ± 17 mmHg) and during analgesia (by 9 ± 4 mmHg; all P < 0.01), but diastolic pressure only during sedation and sedation stop (both P < 0.01). Facial expression, body movement, and muscle tone changed significantly during the episodes of intratracheal suctioning. Heart rate, tidal volume, and pupil size remained stable under all conditions.

CONCLUSIONS

Intratracheal suctioning evoked significant changes in some physiological and behavioral parameters. Some physiological changes were suppressed by analgesia, but at our ICU's standard doses, neither analgesia nor sedation attenuated changes in behavioral parameters at the intensity tested.

A preliminary validation of the Swedish version of the Critical-Care Pain Observation Tool in adults

BACKGROUND

Assessing pain in critically ill patients can be complicated, especially for those unable to communicate. A recently developed pain assessment tool, the Critical-Care Pain Observation Tool (CPOT), has been shown to be a reliable tool for pain assessment in the Intensive Care Unit (ICU). The aim of the study was to validate the Swedish version of the CPOT.

METHODS

Conscious and unconscious adults were observed during two procedures: one non-nociceptive procedure (NNP) (arm- and face wash) and one nociceptive procedure (NP) (turning). In total, there were 240 patient assessments pre-, per- and post-procedure performed by two independent staff members at rest, during and 15 min after the different procedures. Measures of interrater reliability, internal consistency and discriminant validity of the CPOT were obtained to examine the properties of the Swedish version of CPOT.

RESULTS

The results provide indications of good agreement between the independent raters (ICC=0.84). There was an adequate discriminant validity of the Swedish version of CPOT established by a significant peak for CPOT scores during the NP (per-procedure). There was also a consistent pattern of significant correlations between CPOT and the mean artery pressure (ρ=0.32-0.45).

CONCLUSION

The Swedish version of the CPOT is a suitable instrument for assessing pain in critically ill adults. The overall reliability and validity measures converge with findings from previous studies of the CPOT, but in order to achieve enhanced generalizability of the CPOT, we encourage further evaluation of CPOT in broader groups of critically ill patients.

Survey of assessment and management of pain for critically ill adults

OBJECTIVE

To investigate critical care nurses' current practice and knowledge related to pain assessment and management for critically ill adults able and unable to self-report pain.

DESIGN

Cross sectional self-report survey.

RESULTS

Survey response rate was 57%. Though more respondents used formal pain assessment tools often or routinely for patients able to self-report compared to patients unable to communicate (P<0.0001), there was no difference in perceived importance of pain assessment tools. Nurses were less confident in their ability to accurately assess pain for patients unable to self-report (P<0.0001). Behaviours most frequently considered routinely indicative of pain were grimacing (88/140, 62.9%), vocalisation (78/140, 55.7%) and wincing (73/140, 52.1%). Haemodynamic instability, nursing workload and patient inability to communicate were the barriers considered to interfere with pain assessment and management most frequently. Enablers to effective management included pain prioritisation, and adequate prescription of analgesia. Most respondents (118/140 84.3%) had received continuing education on topics related to pain.

CONCLUSIONS

Though nurses considered pain assessment equally important for patients unable and able to selfreport, formal assessment tools were used less frequently and nurses were less confident in their ability to assess pain for patients unable to self-report.

[Evaluation of pain during posture change in patients with invasive mechanical ventilation]

INTRODUCTION

The evaluation of pain poses special difficulties in critical patients who have altered verbal communication.

OBJECTIVES

Compare the behaviour responses to pain, measured with the Critical-Care Pain Observation Tool (CPOT) scale and the physiological responses before, during and after the posture change procedure in patients with invasive mechanical ventilation. Analyze if there are any differences in the COPT score between medical and surgical patients and between the conscious and unconscious patients in the posture change procedure. Describe the analgesia/sedation administered to the patients 1 hour before and during the posture change procedure.

MATERIAL AND METHODS

This descriptive, prospective study evaluated pain during turning/postural changes in 201 observations performed in 56 patients. Data collection was made 1 minute before, during, and 10 minutes after the procedure using the COPT scale that includes four indicators: facial expression, body movements, muscle tension and adaptation to the ventilator. In the same way, the physiological variables were recorded: mean arterial pressure, heart rate, respiratory rate and arterial oxygen saturation.

RESULTS

Total mean score of the CPOT scale before the procedure of turning was 0.30, during it 2.06 and after the procedure 0.15 with statistically significant differences. Facial expression was the indicator that increased the greatest in relationship with the baseline condition, since it occurred in 55% of the observations body movements increased in more than 40%; adaptation to the ventilator, occurred in 33% and muscular tension had an increase of 22% of the observations. There were also slight variations in the physiological variables during the postural change regarding baseline with statistically significant differences. Total mean score of the CPOT scale during turning of the surgical patients was higher than medical patients (p = 0.018). Patients received analgesia/sedation one hour prior to the procedure in 99.5% of the observation and additional analgesia for the postural change was only administered in 13% of the observations.

CONCLUSIONS

Observation of the patient's behavior during posture change and the physiological changes produced allows the professionals to objectify the pain in the critical patients who can verbal communication problems.

Structured approaches to pain management in the ICU

Pain in patients who are critically ill remains undertreated despite decades of research, guideline development and distribution, and intense educational efforts. By nature of their complex medical conditions, these patients present unique challenges to the delivery of optimal pain treatment. Outdated clinical practices and faulty systems, such as a formulary that allows dangerous prescriptions, present additional obstacles. A multidisciplinary and patient-centered continuous quality improvement process is essential to identifying barriers and implementing evidence-based solutions to the problem of undertreated pain in hospital ICUs. This article addresses barriers common to the ICU setting and presents a number of structured approaches that have been shown to be successful in improving pain treatment in patients who are critically ill.

Effect of acute and chronic alcohol abuse on pain management in a trauma center

The proper management of acute pain has been identified as a primary indicator of quality assurance in US trauma centers. Nearly half of all trauma patients are injured while intoxicated and 75% of these patients have chronic alcohol problems. The management of pain caused by injuries in patients with alcohol problems poses unique challenges. Biases exist regarding the crosstolerance effects of ethanol and opioids and the pain thresholds of patients with substance abuse histories. The purpose of this review is to examine some of the factors that inform our decisions of how to manage acute pain in this population and to review the empirical evidence that exists.

Critical care nurses provide their perspectives of patients' symptoms in intensive care units

BACKGROUND

Patients in intensive care units (ICUs) can be adversely affected by distressing symptoms. When critically ill patients are unable to self-report symptoms, ICU nurses become proxy reporters.

OBJECTIVE

The purpose of this prospective, descriptive study was to explore how ICU nurses assess and treat distressing symptoms in critically ill patients at high risk of dying.

METHODS

Twenty-two nurses participated in this single-site, prospective, descriptive study and described their patients' symptoms and how the symptoms were being managed in response to interviews that used open-ended questions. Taped interviews were transcribed verbatim, and themes were identified.

RESULTS

Three major themes were derived from the data: 1) signs of symptoms, (2) treatment of symptoms, and (3) "symptoms" versus "signs." Most nurses did not make distinctions between the assessment of "signs" of disease and the assessment of "symptoms," and consequently, signs and symptoms were frequently inventoried collectively.

CONCLUSION

Critically ill patients experience a broad range of symptoms. Continued attempts to validate nonverbal measures of symptoms are warranted because lack of such measures may adversely affect symptom treatment for critically ill patients. Furthermore, heightened awareness and increased education of nurses to differentiate between signs and symptoms lay the foundation for increasing attention on symptoms, improving accuracy of symptom assessment, and guiding appropriate symptom management.

Sedation and analgesia in the intensive care unit

PURPOSE OF REVIEW

Sedation and analgesia are important means of providing care for the critically ill patient.

RECENT FINDINGS

It is now clear that posttraumatic stress disorders resulting from an intensive care unit stay may be prevented by the right level of sedation. New drug developments but also recent findings in new ventilation strategies allow for a sedation management that is better tailored to an individual's need. Most importantly, regular definition of the appropriate level of sedation and analgesia as well as monitoring of the desired level will help to avoid over- and undersedation and may ultimately improve the outcome of the patient and reduce costs.

SUMMARY

Sedation and analgesia are now regarded as an integral part of treatment on the intensive care unit instead of being an unpleasant but necessary and minor issue. The importance of monitoring the level of sedation and analgesia has only recently been realized. It remains to be shown that new management strategies including an evaluation of the patient, planned interventions and the choice of drugs will further improve the care for the critically ill.

Self-reported pain scores in the emergency department: lack of association with vital signs

BACKGROUND

Some practitioners and investigators have presumed relationships between pain scores and heart rate, blood pressure, or respiratory rate. Previous literature has not adequately addressed the association of pain and vital signs.

OBJECTIVES

To identify any association between self-reported pain and heart rate, blood pressure, or respiratory rate.

METHODS

In this retrospective, observational study, emergency department patients older than 17 years of age presenting between May 2004 and April 2005 with verifiable painful diagnoses (including nephrolithiasis, myocardial infarction, small bowel obstruction, fracture, burn, crush injury, stab wound, amputation, corneal abrasion, and dislocation) were identified. Data were extracted from the hospital's database, including patients' age, gender, emergency department diagnosis, self-reported pain score, heart rate, blood pressure, and respiratory rate.

RESULTS

Among 1,063 subjects, the most common diagnoses were nephrolithiasis (25%; n = 267) and fracture (23%; n = 249). The mean (+/- SD) triage pain score was 7 (+/- 3). The mean (+/- SD) heart rate was 85 (+/- 16) beats/min, mean (+/- SD) systolic blood pressure was 141 (+/- 23) mm Hg, and mean (+/- SD) respiratory rate was 19 (+/- 3) breaths/min. There were no clinically significant differences in mean vital signs across the individual pain scores, as demonstrated by overlapping confidence intervals across pain scores.

CONCLUSIONS

No clinically significant associations were identified between self-reported triage pain scores and heart rate, blood pressure, or respiratory rate.

Clinical Judgments About Endotracheal Suctioning: What Cues Do Expert Pediatric Critical Care Nurses Consider?

Making accurate and timely judgments based on multiple ways of knowing is an essential skill in critical care nursing practice. Studies have proposed that positive patient outcomes are linked to expert judgments in a variety of critical care situations; however, little is known about clinical judgments related to specific critical care nursing interventions. This article presents a qualitative nursing research study which examined the cues that expert pediatric critical care nurses used in making clinical judgments about suctioning intubated and ventilated, critically ill children. The participants' words and actions attest that the 'sensing' and 'thinking' of the process of cue use, are interwoven with, and integral to, the 'doing,' which is the process of skilled performance.

Pain Assessment and Management in Critically Ill Intubated Patients: a Retrospective Study

• Background Little research has been done on pain assessment in critical care, especially in patients who cannot communicate verbally.

• Objectives To describe (1) pain indicators used by nurses and physicians for pain assessment, (2) pain management (pharmacological and nonpharmacological interventions) undertaken by nurses to relieve pain, and (3) pain indicators used for pain reassessment by nurses to verify the effectiveness of pain management in patients who are intubated.

• Methods Medical files from 2 specialized healthcare centers in Quebec City, Quebec, were reviewed. A data collection instrument based on Melzack’s theory was developed from existing tools. Pain-related indicators were clustered into nonobservable/subjective (patients’ self-reports of pain) and observable/objective (physiological and behavioral) categories.

• Results A total of 183 pain episodes in 52 patients who received mechanical ventilation were analyzed. Observable indicators were recorded 97% of the time. Patients’ self-reports of pain were recorded only 29% of the time, a practice contradictory to recommendations for pain assessment. Pharmacological interventions were used more often (89% of the time) than nonpharmacological interventions (&lt;25%) for managing pain. Almost 40% of the time, pain was not reassessed after an intervention. For reassessments, observable indicators were recorded 66% of the time; patients self-reports were recorded only 8% of the time.

• Conclusions Pain documentation in medical files is incomplete or inadequate. The lack of a pain assessment tool may contribute to this situation. Research is still needed in the development of tools to enhance pain assessment in critically ill intubated patients.

Balancing: a basic process in end-of-life cancer care

In this grounded theory study, the authors interviewed caregivers and patients in end-of-life cancer care and found Balancing to be a fundamental process explaining the problem-solving strategies of most participants and offering a comprehensive perspective on both health care in general and end-of-life cancer care in particular. Balancing stages were Weighing--sensing needs and wishes signaled by patients, gauging them against caregiver resources in diagnosing and care planning; Shifting--breaking bad news, changing care places, and treatments; and Compensating--controlling symptoms, educating and team-working, prioritizing and "stretching" time, innovating care methods, improvising, and maintaining the homeostasis of hope. The Balancing outcome is characterized by Compromising, or "Walking a fine line," at best an optimized situation, at worst a deceit.

Pain Assessment and Management in the Critically Ill: Wizardry or Science?

Assessment and management of patients’ pain across practice settings have recently received the increased attention of providers, patients, patients’ families, and regulatory agencies. Scientific advances in understanding pain mechanisms, multidimensional methods of pain assessment, and analgesic pharmacology have aided in the improvement of pain management practices. However, pain assessment and management for critical care patients, especially those with communication barriers, continue to present challenges to clinicians and researchers. The state of nursing science of pain in critically ill patients, including development and testing of pain assessment methods and clinical trials of pharmacological interventions, is described. Special emphasis is placed on results from the Thunder Project II, a major multisite investigation of procedural pain.

Pain and anxiety management in the postoperative gastro-surgical setting

BACKGROUND

Despite increasing knowledge and technological advances, patients continue to experience pain and anxiety in the postoperative setting.

AIM OF THE STUDY

The aim of this study was to examine how nurses managed patients' pain and anxiety within the gastro-surgical hospital setting.

METHODS

An observational design was selected to examine nurses' management of postoperative patients' pain and anxiety. Six nurses who were involved in direct patient care in one of two gastro-surgical wards in a public teaching hospital in Melbourne, Australia, were randomly selected to participate. The observation period comprised a fixed 2-hour segment, and each nurse was observed on three different occasions.

FINDINGS

Patient assessment was a major concern for participants, which was influenced by the modes of assessment used, patients' medical condition and operation procedure, and their self-reports of pain or anxiety. Communication with health care professionals and policy and protocol concerns also affected nurses' pain and anxiety management decisions. Formal communication through the multidisciplinary ward round tended to be somewhat fragmented, as the medical consultant did not seek out the bedside nurse. Nurses had good knowledge of unit policies and protocols and, while attempting to enforce them, spent considerable time encouraging medical colleagues to abide by these guidelines. Finally, nurses made complex clinical judgements which extended beyond the administration of analgesics or antianxiety drugs.

STUDY LIMITATIONS

It is possible that nurses demonstrated a raised awareness of how they managed patients' pain and anxiety during observation periods.

CONCLUSIONS

The study confirmed the importance of examining the complexities of the clinical context in determining how nurses manage pain and anxiety in the postoperative setting.

Medication trends and documentation of pain management following surgery

The purpose of the present study was to examine prescribing and administering activities for sedative and analgesic medication in postoperative patients, and to describe nurses' documentation practices for pain management in nursing notes. A prospective audit was undertaken of medication order charts and nursing notes of 100 patients on the operation day and over the first four days following surgery. Almost all patients received some form of infusion, while the use of 'as required' analgesics varied from one-third to over two-thirds of patients during the postoperative period. Few patients were prescribed fixed-order analgesics or sedative medications. An audit of nursing entries found that nurses had documented inadequately in four major areas: pain assessment, use of non-pharmacological interventions, use of pharmacological interventions, and outcome of interventions. The findings contribute to improving our understanding of nurses' pain management and identify the need to use clinical judgement that is individualized to patients' needs.

How do intensive care nurses assess patients' pain?

Identification and evaluation of pain in critical care patients may be difficult because of communication problems. Moreover, at present there are very few nursing studies that examine the attitudes of critical care nurses towards the assessment of patients' pain. This study was designed to determine the approach of critical care nurses towards assessing patients' pain levels, and to evaluate the problems in nursing diagnosis of those having difficulty in articulating their pain symptoms. We used a questionnaire to assess nurses attitudes to patients' pain. The study sample consisted of 91 critical care nurses who were recruited between January and February 2002. The results suggest that patient pain was considered undesirable by 44% of nurses. About 70-3% of the nurses reported resorting to administering analgesics to relieve their patients' pain. Some 57.1 % of nurses stated that they would have investigated whether the patients had really been experiencing pain, prior to administering the prescribed analgesics to patients. Some 85.7% of the sample indicated that the patients themselves would make the most accurate evaluation of their pain. The data suggested that 39.6% of nurses did not know how to evaluate pain symptoms in critical care patients suffering from complicated problems, and that 37.4% evaluated pain by monitoring the patients' behaviours. The study demonstrated that most of the critical care nurses did not know how to evaluate pain in patients having communication problems. The paper concludes by suggesting that there is a clear need to address nursing education and training with regard to evaluation and management of patients' pain whilst in critical care environment.

Observation of pain assessment and management--the complexities of clinical practice

Pain assessment and management are complex issues that embrace physiological, emotional, cognitive, and social dimensions. This observational study sought to investigate nurse-patient interactions associated with pain assessment and management in hospitalized postsurgical patients in clinical practice settings. Twelve field observations were carried out on Registered Nurses' activities relating to pain with their assigned patients. All nurses were involved in direct patient care in one surgical unit of a metropolitan teaching hospital in Melbourne, Australia. Six observation times were identified as key periods for activities relating to pain, which included change of shift and high activity periods. Each observation period lasted 2 hours and was examined on two occasions. Four major themes were identified as barriers to effective pain management: nurses' responses to interruptions of activities relating to pain, nurses' attentiveness to patient cues of pain, nurses' varying interpretations of pain, and nurses' attempts to address competing demands of nurses, doctors and patients. These findings provide some understanding of the complexities impacting on nurses' assessment and management of postoperative pain. Further research using this observational methodology is indicated to examine these influences in more depth. This knowledge may form the basis for developing and evaluating strategic intervention programmes that analyse nurses' management of postoperative pain and, in particular, their administration of opioid analgesics.

Use of a pain assessment and intervention notation (P.A.I.N.) tool in critical care nursing practice: nurses' evaluations

BACKGROUND

One of the barriers to effective pain management in critical care is the lack of systematic, comprehensive methods for assessing and treating pain. Use of a printed, standardized pain assessment and intervention tool can stimulate critical thinking and provide a framework for organizing pain assessment and management data.

OBJECTIVES

The objectives of this study were to do the following: (1) describe the Pain Assessment and Intervention Notation (P.A.I.N.) tool, (2) detail critical care nurse participants' evaluations of the P.A.I.N. intervention tool when used during care of postoperative patients in pain, and (3) evaluate the tool's usefulness in practice and education.

METHODS

Eleven intensive care unit (n = 7) and postanesthesia care unit (n = 4) nurses completed a questionnaire after they had used the pain tool in their clinical practices with 31 postoperative patients.

RESULTS

Ten of the 11 nurses who returned an evaluation questionnaire found that the P.A.I.N. tool provided a consistent, systematic method of quantifying their assessment of patient pain and analgesic responsiveness. Five nurse participants believed that the P.A.I.N. tool improved their practice with regard to pain and sedation assessment. Three of the 11 nurses believed that the usefulness of the tool was limited because it was too detailed to be used routinely when caring for critically ill patients. All but 1 of the 11 nurses believed that the tool would have helped them earlier in their practice (ie, when they had less critical care nursing experience).

CONCLUSIONS

The assessment and treatment of pain in critically ill patients are highly complex processes. This study identified many advantages of the use of a standardized, systematic approach to pain assessment and treatment by health professionals.

Acute pain management: implications of scientific evidence for nursing practice in the postoperative context

Unrelieved acute pain remains prevalent in hospitalized patients despite advances in pain management. A decade after the Australian National Health and Medical Research Council called for improved pain management practices by health professionals, it released clinical guidelines to provide clinicians with current scientific evidence to augment their clinical decision-making. This paper examines the implications of national guidelines on nursing practice and highlights the inadequacies of current implementation policies. Pain management guidelines have failed to decrease patients' postoperative pain because organizations and researchers have ignored the impact of contextual influences on clinicians' decision-making. It is recommended that for successful implementation of national guidelines to occur at the local level of practice, organizations must assist clinicians to identify local influences on their decision-making, to address the issues specific to their own work environment and to evaluate any changes in practice.

"Thinking aloud": data collection in the natural setting

Knowledge of how nurses make decisions is a desirable outcome of research. However, there currently exists an inadequacy in the techniques used to examine such decision making. In this article, the authors describe the techniques used in two studies incorporating "thinking aloud" to successfully examine the decision making of expert critical care practitioners in the natural setting. Both techniques of thinking aloud were found to provide useful information regarding decision making in the natural setting. No ethical implications were experienced in conducting these studies in the natural setting. In conclusion, the use of thinking aloud in the natural setting is an effective means of data collection.

Clinical competence in pain assessment

Our knowledge about the content of the clinical knowledge used by nurses in a surgical recovery unit for assessment of postoperative pain is fairly limited. The aim of the present study was to analyse and describe the variations of nurses' conceptions of the impact of clinical experience on competence in post-operative pain assessment. The informants consist of critical care nurses. A phenomenographical approach has been applied to tape-recorded interview data. The results reveal that clinical competence in pain assessment was described in three categories: (a) to be able to see; (b) to be able to differentiate; (c) to be able to give. The observations articulate what nurses perceive that they have learnt from experience in performing many clinical pain assessments and point to some difficulties in using a single-data source for the development of valid and truthful professional knowledge. In the development of professional experience, it is of the utmost importance to be able to change perspective from what is most frequent and general to what is special and unique, to base one's standpoint on the individual patient's experience and integrate this with previous professional experience.

Expert critical care nurses' use of pulmonary artery pressure monitoring

Critical care nurses make numerous complex decisions during their day-to-day practice. General themes in previous decision-making studies have included the influence of knowledge and previous experience, the increasing complexity of decisions made and the change in decision-making processes used as the nurse progresses from a novice to an expert practitioner. This paper reports one component of a study which used a concept attainment framework to determine what data were used by eight expert critical care nurses in relation to haemodynamic monitoring. Results indicated that pulmonary artery pressure monitoring was used to attain the concepts of preload, cardiac output and blood pressure. In addition, participants used few clinical assessment attributes, but collected a large number of attributes which they arranged around three to five central concepts and took a broad view of haemodynamic assessment. One participant did not display many of the decision-making features normally associated with an expert practitioner. In conclusion, expert critical care nurses process an immense amount of data in a short space of time. However, they may not use all available data. Evidence suggests not all nurses who practise in the field for a lengthy period reach the level of an expert.

Strategies used in post-operative pain assessment and their clinical accuracy

Our knowledge about the content of strategies used by staff members in a surgical recovery unit for assessment of post-operative pain is fairly limited. The aim of the present study was to describe variations in the content of strategies used by nurses and physicians in practical clinical pain assessments and to evaluate the clinical accuracy of the strategies used. Critical care nurses (n = 30), physicians (n = 30) and postsurgical patients (n = 180) comprise the respondents. Applying a phenomenographical approach, interview data were tape-recorded during 180 clinical pain assessments. The pain assessments were related to comparative bedside pain ratings (Visual analogue Scale, VAS), both by staff members and post-operative patients. The recorded interviews were analysed to describe variations in ways of assessing pain. Pain assessment strategies were established by combining categories describing the impact of experience and categories of assessment criteria. The present observations, if included in the education of clinical staff members, could increase the understanding and thereby the quality of the pain assessment process.