The role of nurses in ensuring the quality of care for patients with postoperative pain

Introduction

Postoperative pain represents one of the most frequent and burdensome complications following surgical procedures. It significantly affects the patient’s well-being, recovery process, and quality of life. For this reason, proper pain management represents a key element of the postoperative care and requires collaboration within the whole therapeutic team, with particular attention paid to the role of the nurses [1, 2]. According to the definition of the International Association for the Study of Pain (IASP), pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It serves a warning and protective function; however, under clinical conditions – especially after a surgical procedure – it becomes a significant therapeutic problem. It is of a subjective and multidimensional nature, and the way it is perceived depends on physiological, psychological, social, and cultural factors [3]. In clinical practice, pain is classified as acute and chronic. Acute pain usually appears as a result of tissue damage, sudden injury, inflammation, or in the course of the perioperative period. It is transient and serves a warning function, by signalling a threat to the organism. Chronic pain, on the other hand, persists for more than three months, often becoming a disease in itself, with numerous somatic and psychological consequences. In the case of postoperative patients, effective management of acute pain is crucial to prevent its prolongation and the development of undesirable consequences [3]. Postoperative pain arises from tissue damage during surgery and occurs when intraoperative analgesia wears off. It may originate both from surface tissues and deeper structures, including muscles and periosteum. The highest intensity is typically observed in the first 24 hours after surgery, followed by a gradual reduction in symptoms. In the literature, it is emphasised that this phenomenon is largely self-limiting, but individual perception of pain and psychosocial factors can significantly modify its intensity [1, 3, 4]. Many factors affect the level of pain experienced by the patient. These include the following: the extent and location of the procedure, the patient’s mental state, their level of anxiety and neuroticism, experiences related to previous hospitalisations, as well as their awareness of the possibility of pain. The individual pain threshold and subjective perception of suffering are also of significant importance. For this reason, effective pain management requires individualised care and a differentiated approach to each patient [1]. Assessment of pain intensity provides the basis for effective treatment. Self-report scales (numerical, verbal, visual-analogue) are most commonly used, while observational methods are used for unconscious patients or those with cognitive impairments. The combination of the patient’s self-assessment and the nurse’s observations allows for a more complete picture of the clinical situation [4-6]. The objectives of pain management in the postoperative period include eliminating unnecessary suffering, improving comfort, accelerating recovery, and reducing the risk of complications associated with the procedure. Properly administered anaesthesia reduces the body’s stress response, decreases the incidence of respiratory and thromboembolic disorders, and shortens hospitalisation time. From a systemic perspective, effective pain management contributes to reducing the cost of treatment [7, 8]. In practice, pain management should have a comprehensive nature and be based on the principles of the World Health Organisation (WHO) analgesic ladder. The choice of medications depends on the pain intensity and consists of using successively stronger analgesics, with the possibility of combining them with other medications and non-pharmacological methods. Non-pharmacological methods include, among others, cold compresses, appropriate patient positioning, and breathing exercises, which support pharmacotherapy and improve patient comfort [1]. The nurse plays a special role in the treatment of postoperative pain. It is the nurse who spends the most time with the patient and is responsible for the consistent assessment of pain, implementation of medical recommendations, monitoring the effectiveness of the measures taken, and observing any possible adverse effects. The nurse should also have knowledge of the mechanisms of pain development, its assessment, treatment methods, and patient and family education. Their task is to provide holistic care, covering both physical and emotional aspects, as well as to cooperate with the multidisciplinary team to ensure the highest quality of care [1, 2].
The aim of the study was to assess the role of nurses in ensuring the quality of care for patients with postoperative pain. To investigate the research problem, the following research questions were formulated:
1. How do patients assess the quality of nursing care in the management of postoperative pain in the orthopaedic ward?
2. Which socio-demographic factors may influence patients’ assessment of the quality of nursing care after surgery in the orthopaedic ward?
3. Are there significant differences in the assessment of the quality of nursing care in the management of postoperative pain between patients undergoing different types of surgical procedures in the orthopaedic ward?
4. What is the impact of the type of anaesthesia used on patients’ assessment of the quality of nursing care after surgery in the orthopaedic ward?
5. How does the occurrence of postoperative adverse effects correlate with selected aspects of patients’ assessment of the quality of nursing care in the management of postoperative pain?
6. How do respondents assess nursing care in the individual subscales (communication, performance, trust, environment) of the Scale of Clinical Indicators of Quality of Postoperative Pain Management?
Research hypotheses:
1. Patients assess the quality of nursing care in the management of postoperative pain in the orthopaedic ward positively, although some areas – particularly patient education – require improvement.
2. Socio-demographic factors such as age, gender, place of residence, and professional activity significantly influence patients’ assessment of the quality of nursing care after surgery in the orthopaedic ward.
3. There are no significant differences in the assessment of the quality of nursing care in the management of postoperative pain between patients undergoing different types of surgical procedures in the orthopaedic ward.
4. The type of anaesthesia used does not significantly affect patients’ assessment of the quality of nursing care after surgery in the orthopaedic ward.
5. The occurrence of postoperative adverse effects significantly reduces patients’ assessment of the quality of nursing care in the management of postoperative pain.
6. Patients differentiate their assessment of nursing care in the individual subscales of the Scale of Clinical Indicators of Quality of Postoperative Pain Management, rating nurses’ knowledge and competence the highest, and communication and patient education the lowest.

Material and methods

Organisation of the study

The study was conducted in the Department of Orthopaedics and Traumatology of the Musculoskeletal System with the Spinal Surgery Subdivision at one of Krakow’s hospitals between January and June 2024. The study group consisted of adult patients hospitalised after surgery, who gave their informed consent to participate in the study and were in a state of health that allowed them to complete the questionnaire on their own.
The study involved a diagnostic survey using a questionnaire technique. Two research tools were applied: 1) A proprietary questionnaire containing 21 questions concerning patients’ socio-demographic data, the intensity of pain experienced, as well as overall satisfaction with pain management and nursing care; and 2) The Clinical Indicators of Quality of Postoperative Pain Management Scale (Polish: Skala Klinicznych Wskaźników Jakości Postępowania z Bólem Pooperacyjnym – SKWJPzBP), containing 14 questions in 4 categories: Communication, Action, Trust, and Environment. The answers were rated on a 5-point Likert scale (1 – strongly disagree, 5 – strongly agree).
The questionnaires were given to the patients on the second day after surgery, usually just before they were discharged from hospital. The respondents were informed about the purpose of the study and the need to complete the questionnaire on their own. If necessary, they were provided with explanations or support in answering the questions. The questionnaires were planned to take about an hour to complete, after which they were collected by the author of the study. The study involved 81 patients aged between 18 and 82 years. According to the authors of the scale, high quality of care corresponds to a score of ≥ 4.5 points for each statement. Results below this threshold point to the need for quality improvement. Patients who rated care at 1-2 points were classified as requiring significant care improvement. The minimum threshold scores are as follows: 63 points for the entire scale and, respectively: Communication – 13.5 points, Environment – 13.5 points, Action – 18 points, and Trust – 18 points. The theoretical overall range of the scale falls within the range 14-70 points.
Approval for the study was obtained from the Scientific Research Ethics Committee of the Jagiellonian University Medical College (No. 118.6120.182.2023) and the directors of the facilities where the research was conducted.

Statistical analysis

The statistical analysis was performed using STATISTICA version 14.0, from TIBCO Software. Descriptive statistics such as means, medians, standard deviations, and percentages were used to describe the study groups and the characteristics of the variables. Pearson’s correlation coefficient and the chi-squared test were used to assess the relationship between dichotomous variables, assuming a significance level of p ≤ 0.05.

Results

The study involved 81 patients, most of whom (56.79%, n = 46) were women. The most numerous groups of respondents were over 60 years of age (38.27%, n = 31) and between 46 and 60 years of age (33.33%, n = 27). The 18-30 age group represented 14.81% (n = 12), and the 31-45 age group represented 13.58% (n = 11). 37.04% (n = 30) of the respondents had higher education, 33.33% (n = 27) had secondary education, 23.46% (n = 19) had vocational education, and 6.17% (n = 5) had primary education. City residents accounted for 59.26% (n = 48). Over half of the respondents (50.62%, n = 41) were professionally active, while 39.51% (n = 32) were on disability or retirement. In addition, a small percentage of participants were students (6.17%, n = 5) or part-time workers (3.70%, n = 3). 59.26% (n = 48) of the respondents admitted to having chronic diseases. The most common comorbidities among the respondents were hypertension (45.68%, n = 37), type 2 diabetes (25.93%, n = 21), and hypothyroidism (14.81%, n = 12) (Table 1).
Most respondents underwent hip replacement surgery (38.27%, n = 31) or knee replacement surgery (32.10%, n = 26). In 29.63% (n = 24) of the respondents, the surgery was the result of an injury. The predominant anaesthesia method used was neuraxial blockade (74.07%, n = 60). Peripheral nerve block was reported by 27.16% (n = 22) of patients and general anaesthesia by 22.22% (n = 18). Most of the respondents experienced the most intense postoperative pain on day zero (69.14%, n = 56). On the first day, 30.86% (n = 25) reported the highest intensity of pain, while no one reported the highest pain on the second day. On the NRS scale, the values most often ranged from 6 to 10 points. Levels 7 (20.99%, n = 17) and 8 (18.52%, n = 15) were indicated most frequently, while levels 2 (1.23%, n = 1) and 3 (2.47%, n = 2) were indicated least frequently. The type of pain experienced was most often described by the patients as shooting (56.79%, n = 46) and sharp (46.91%, n = 38). These were followed by burning pain (18.52%, n = 15), dull or stinging pain (16.05%, n = 13), and paralysing pain (12.35%, n = 10). Most of the respondents (87.65%, n = 71) were informed about the methods of postoperative pain management, most often by nurses (82.72%, n = 67). Information was also provided by physicians (19.75%, n = 16) and medical carers (2.47%, n = 2).
Almost all respondents (93.83%, n = 76) confirmed that personnel asked them about pain – in the vast majority of cases, these were nurses (91.36%, n = 74), and less frequently physicians (18.52%, n = 15) and medical carers (1.23%, n = 1). Analgesic agents were administered to 97.53% (n = 79) of the respondents, regardless of pain level; only 2.47% (n = 2) did not receive pharmacotherapy. The satisfaction with pain management was mostly rated very highly: 29.63% (n = 24) rated it 9 on a 10-point scale, 25.93% (n = 21) rated it 7 and 8, and 13.58% (n = 11) rated it at 6 points. Lower ratings (5 points) were given by 4.94% (n = 4). More than half of the respondents (55.56%, n = 45) did not experience any adverse effects after taking analgesic agents. Among the 44.44% (n = 36) who reported them, nausea was the most common (37.04%, n = 30). There were also cases of vomiting (18.52%, n = 15), dizziness (13.58%, n = 11), drowsiness (11.11%, n = 9), and nightmares (1.23%, n = 1). Over two-thirds of the respondents (70.37%, n = 57) confirmed that personnel members had suggested non-pharmacological methods of pain management, while 29.63% (n = 24) had not received such suggestions.
The average score for the entire scale in the group of respondents was 59.33 points, which did not reach the desired value of 63 points. In terms of individual subscales, the desired minimum score was also not achieved in the areas of communication (13.23), environment (15.07), and trust (12.70). The required threshold was exceeded only in the case of action (18.32). In terms of communication, the lowest score was obtained for informing patients about the pain management that would be offered after the procedure (4.21). In turn, the highest rating was given to the aspect of cooperation between physicians and nurses in the management of patients’ pain (4.51). In terms of the environment, the highest rated item was help in finding a comfortable position in bed to avoid or reduce pain (4.15). The lowest rating was given to the request of personnel members to rate the level of pain at any time of the day on a scale of 1-10 (2.88). In the action subscale, the highest score was given to the statement concerning nurses’ knowledge of pain management (4.72), and the lowest to the statement concerning nurses’ assistance in pain management until relief is achieved (4.43). In the category of trust, the respondents gave the highest rating to the statement concerning having a friendly room (4.31) and the lowest rating to ensuring peace and quiet for a good night’s sleep (4.17) (Table 2).
Over one-third of the respondents (35.80%, n = 29) felt that the overall level of care was adequate in terms of clinical indicators of the quality of postoperative pain management. In the communication subscale, 56.79% (n = 46) of the respondents reported an adequate level. In terms of the environment, this percentage was 16.05% (n = 13), action – 61.73% (n = 50), and trust – 39.51% (n = 32).
The conducted analysis did not reveal any statistically significant differences in the respondents’ assessment of the level of nursing care and the quality of postoperative pain management in terms of communication with respect to any socio-demographic factor (p > 0.05). In the environment category, statistically significant correlations were observed for gender (p = 0.0387) and place of residence (p = 0.0422). Men (Cramér’s V = 0.181) and respondents living in cities (p = 0.0422) experienced greater satisfaction in this subscale. In the case of the action subscale, statistically significant correlations were observed for the age (p = 0.0371) and professional activity (p = 0.0319) of the respondents. The respondents aged 31-45 years rated nursing care highest in this respect, while those over 60 years old rated it lowest (r = 0.1817). Respondents who were professionally active also experienced higher satisfaction in this area (r = 0.2383). The assessment of care in the area of trust differed in a statistically significant manner only in relation to the professional activity of the respondents (p = 0.0291), with professionally active patients declaring higher satisfaction in this area (Cramér’s V = 0.167). Overall satisfaction with the level of nursing care depended on the age of the respondents (p = 0.0498) and their professional activity (p = 0.0034). The lowest satisfaction was reported by the oldest respondents (r = –0.2341) and those who were not professionally active (Cramér’s V = 0.224) (Table 3).
Statistical analysis did not reveal any significant correlations between the assessment of the proper level of nursing care in the management of postoperative pain and the type of surgical procedure performed (p > 0.05). Similarly, there were no significant differences in the respondents’ assessments with regard to the type of anaesthesia used (p > 0.05). Statistically significant correlations in the assessment of the proper level of nursing care in the management of postoperative pain were noted only in the “Environment” subscale, depending on the occurrence of adverse effects after surgery (p = 0.0213). Higher satisfaction levels in this category were achieved by patients who did not report any negative symptoms after surgery (r = 0.2557).

Discussion

Modern healthcare places great emphasis on the effectiveness of pain management, which is a clinical priority in orthopaedics and a key factor influencing the quality of life of patients. The results of our own study show significant challenges related to the quality of nursing care for patients after orthopaedic procedures. The analysis demonstrated that only a few respondents rated the care as high, especially in the areas of environment and trust, indicating the need for further action to improve the quality of postoperative care. In the communication subscale, the percentage of positive ratings was higher, but in other aspects, the values remained low. Similar results were obtained by Juszczak, whose study using the Clinical Indicators of Quality of Postoperative Pain Management Scale showed that the average overall score did not reach the minimum value, and the lowest scores were given for informing patients about the methods of pain management and quantitative assessment of pain by personnel members. Almost half of the respondents had encountered quantitative pain assessment, but the overall score was low. Also in the area of trust in the personnel and environmental aspects (including insufficient numbers of nurses), the results were unsatisfactory, which made it difficult to respond quickly to patients’ needs. In addition, some of the respondents were convinced that pain had to be present after the surgery, which explains the percentage of patients who believed that they had not received analgesics [9].
Both our own study and those of other authors confirm the hypothesis that most patients negatively assess the quality of nursing care in the management of postoperative pain. Therefore, there is an urgent need for measures to improve the quality of postoperative care in orthopaedic wards. The next phase of our own research did not reveal any significant differences in the assessment of nursing care quality in terms of communication based on any of the socio-demographic factors. However, statistically significant correlations were observed in relation to gender and place of residence in the environment category, and in relation to age and professional activity in the action subscale. Furthermore, it was demonstrated that the assessment of care in the area of trust differed significantly only in relation to the respondents’ professional activity, and the overall satisfaction with the level of nursing care depended on the age and professional activity of the respondents. In the context of the second hypothesis, the results of our own study partially confirm this assumption, as there are certain socio-demographic factors, such as gender, age, and in particular professional activity, which have a significant impact on the level of satisfaction of patients in the orthopaedic wards with the quality of nursing care. However, other factors, such as educational level or the presence of chronic diseases, did not have a significant impact on patient satisfaction in any area. Comparing the results of our own study with the analyses of other authors, the study by Wójcik-Brylska et al. also showed significant correlations between the age, education, and economic status of patients and their level of satisfaction, which is consistent with our own results, where age and professional activity had a significant impact on patient satisfaction [10]. Therefore, it should be concluded that there are certain socio-demographic factors that may influence the level of patient satisfaction with nursing care in orthopaedic wards. Our own study showed that the type of surgical procedure of patients does not have a significant impact on their assessment of the quality of nursing care in the management of postoperative pain. Most of the respondents had undergone hip or knee replacement surgery, as well as surgery due to injury. Despite the diversity of these procedures, no statistically significant correlations were observed in the respondents’ assessment of the appropriate level of nursing care. In the context of studies by other authors, El-Badry Ali and Abdel Fattah assessed patient satisfaction with postoperative pain management by nurses, taking into account different types of surgical procedures. The results of the study showed that the effectiveness of postoperative pain management is a key factor influencing the assessment of nursing care quality, regardless of the type of surgery [9]. The findings suggest that, regardless of the type of surgery, patients give similar ratings of the quality of nursing care in the context of postoperative pain. This is an important observation for clinical practice, suggesting that effective nursing care can be applied in various surgical procedures with the aim of alleviating pain and improving the patient’s experience. The study conducted in the further part of the paper also did not reveal any statistically significant correlations between the type of anaesthesia used and the patients’ assessment of the quality of nursing care in the management of postoperative pain. Almost three-quarters of the respondents received neuraxial blockade, while a smaller group received peripheral nerve block or general anaesthesia. Based on the results obtained, no significant difference was found in the assessment of nursing care quality depending on the type of anaesthesia used. This means that the method of anaesthesia did not affect the patients’ perception of the quality of nursing care in terms of postoperative pain. Supporting our conclusions, Small and Laycock’s study showed that the type of anaesthesia used has no significant impact on the assessment of nursing care quality in the context of postoperative pain management. Other factors, such as the organisation of care, access to information, and the overall quality of the healthcare provided, are more important for the patients’ assessments. These results are consistent with our own findings, which additionally emphasises the consistency of the results in this field [11]. The results of both studies suggest that the type of anaesthesia used does not significantly affect the patients’ perceptions of the quality of nursing care in terms of postoperative pain. The conclusions from both analyses may be relevant to clinical practice, suggesting that the effectiveness of nursing care in this area does not depend on a specific method of anaesthesia. Therefore, the choice of anaesthesia type can be made mainly on the basis of other clinical criteria, without the need to worry about its impact on patients’ assessment of the quality of care. The final phase of our own study focused on analysing the relationship between the occurrence of adverse effects and the assessment of the quality of nursing care in the context of postoperative pain management. Most respondents did not experience any adverse effects after the use of analgesics, but nearly half of the respondents reported various complaints. Statistically significant correlations were observed only in terms of the environment, where patients who did not report any negative symptoms after surgery expressed greater satisfaction. In the context of a hypothesis-supporting study, the work of Ataro et al. examined how serious postoperative complications correlate with lower patient satisfaction with nursing care and the overall hospital experience. The occurrence of adverse events, such as complications, significantly lowered the ratings of nursing care quality [12]. These results emphasise the importance of adverse effects as a factor influencing the assessment of nursing care quality in the management of postoperative pain. Both our own study and other reports indicate the need for a comprehensive approach, encompassing not only pharmacotherapy, but also nursing support and the adaptation of care to the individual and socio-demographic needs of patients. The results suggest that the type of procedure or anaesthesia used does not affect the assessment of the quality of care, whereas the occurrence of adverse events is of significant importance. This represents a significant step forward in improving orthopaedic care and highlights the need to develop treatment strategies that effectively reduce pain and increase patient satisfaction with the treatment process.

Limitations of the study

The study was limited by the small and homogeneous group of patients hospitalised in a single hospital ward, which may limit the possibility of generalising the results to other facilities and diverse patient populations. Additionally, the study did not include long-term follow-up of the patients after discharge, which could have contributed to a more comprehensive assessment of the durability of satisfaction with care and the effectiveness of applied pain management strategies. Another limitation was the possibility of subjective factors, such as individual pain perception, influencing the results. In future, it would be worthwhile to conduct studies on a larger sample covering several wards and to introduce the assessment of pain management at specific intervals, which would ensure a more reliable and comprehensive analysis of the quality of care.

Conclusions

The negative assessment of most patients after orthopaedic surgery indicates an urgent need to improve the quality of nursing care in terms of managing postoperative pain by implementing more effective pain management strategies and a more individualised approach.
The identified socio-demographic factors influencing patient satisfaction confirm the validity of personalised care, which may contribute to increased patient satisfaction and improved treatment effectiveness.
The lack of correlation between the type of surgical procedure and the assessment of nursing care quality demonstrates the universality of effective care in various orthopaedic procedures, which provides important guidance for clinical practice and healthcare organisation.
The irrelevance of the type of applied anaesthesia method in assessing the quality of care suggests that decisions regarding its selection may be made on the basis of clinical criteria, without concern for the impact on patient experience.
The impact of adverse effects on the assessment of the quality of care, particularly in the environmental aspect, emphasises the need for a comprehensive approach to postoperative pain management, including both pharmacological measures and nursing support.

Disclosures

This research received no external funding.
The study was approved by the Bioethics Committee of the Jagiellonian University Medical College (Approval No. 118.6120.182.2023).
The authors declare no conflict of interest.

References