Abstract
Poor management of post-operative cardiac surgery can contribute to medical complications
including pneumonia, deep vein thrombosis, infection and delayed healing, as well as the
development of chronic pain. It is therefore important that all patients undergoing surgery should
receive adequate pain management. There are key priorities for improving post-operative pain
management that has been identified in four different areas. Firstly, patients should be more
involved in decisions regarding their own treatment, particularly when fateful alternatives are
being considered. For this to be meaningful, relevant information should be provided so that
they are well informed about the various options available. Secondly, better professional
education and training of the various members of the multidisciplinary pain management team
would enhance their skills and knowledge, and thereby improve patient care. Thirdly, there is
scope for optimizing treatment. Examples include the use of synergistic analgesia to target pain
at different points along pain pathways, more widespread adoption of patient-controlled
analgesia, and the use of minimally invasive rather than open surgery. Fourthly, organizational
change could provide similar benefits; introducing acute pain services and increasing their
availability towards the 24 hours in a day ideal, greater adherence to protocols, increased use of
patient-reported outcomes, and greater receptivity to technological advances would all help to
enhance performance and increase patient satisfaction
Keywords:
Postoperative pain, Patients controlled analgesia, post-operative acute pain
3
What Improves Outcomes when Patients Control their own analgesia Post Cardiac Surgery?
Chapter 1: Introduction
Background
Post-operative pain is one of the consequences of surgeries and the fear of such pain is one of
the main concerns of many patients who undergo surgery. This is a well-justified fear and post-
operative pain has been accepted as a foreseeable part of post-surgery experienced by
patients. However, even when unrelieved pain is reported, it may not result in corrective
measures or many patients may not receive adequate postoperative pain relief because of staff
failures to routinely assess pain and prescribed pain relief and physicians are not held
accountable for poor analgesia. Another factor in inadequate pain relief is the fear of the
possibility of the development of physical dependence, tolerance, addiction, and side effects
which could prevent physicians from prescribing analgesic especially opioid ones.
According to Malek et al. (2017), immediately after an operation, the pain can be expected to be
severe and may need controlling with strong parenteral opioids in combination with local
anesthetic blocks and peripherally acting drugs. Normally, postoperative pain should decrease
with time and the need for drugs to be given by injection should cease. There is then a step
down to oral opioids and finally to non-steroidal anti-inflammatory drugs and acetaminophen on
its own. As the experience of pain varies between patients and opioid effects vary between
individuals, so the dosage of opioids need to be assessed for each individual in order to achieve
adequate pain control. Analgesics or compounds with less pronounced dependency or
tolerance should be used, if possible, and finally, analgesic therapy and the patient’s need for
opioids should be evaluated frequently.
Research Objective
To determine the strategies associated with the positive outcomes/Effects of using
analgesics to control postoperative pain in adult patients?
To investigate the effects of patients controlled analgesia among adult postoperative
pain patients.
5
Research Questions
What strategies are associated with the positive outcomes/Effects of using analgesics to
control postoperative pain in adult patients?
What are the effects of patients controlled analgesia among adult postoperative pain
patients?
Chapter 2: a Literature review
Cardiac surgery has been associated with a significant amount of postoperative pain (Malek,
Sevcik & Bejsovec, 2017). This has prompted the patients to participate in their own analgesia
administration during their postoperative pain (Malek, Sevcik & Bejsovec, 2017). After a surgical
procedure, patients can experience pain originating from rib retraction, median sternotomy or
thoracotomy incisions, presence and removal of the chest drains, harvesting of vessels from the
forearm or legs for grafting, and many more ( Hooten, 2013) . The severity of postoperative pain
is determined by the surgical procedure used. For example, when a port-access coronary artery
bypass (PACAB) which is a less invasive cardiac procedure is used, there is less tissue injury
and less postoperative pain is experienced (Zubrzycki et al, 2018).
The common type of pain experienced after a surgical procedure is acute pain. According to
Malek, Sevcik & Bejsovec (2017), post-operative pain is still not managed well in the 21 st
Century in more than half of the patients undergoing surgical procedures. The researchers used
the case of the Czech Republic as evidence where 18% of the patients who underwent surgical
procedures mentioned the pain to be a stressful experience after an operation. Moreover, the
study further revealed that 36% of post-surgical complaints were as a result of pain. A review
conducted by Maier in the management of postoperative pain in Germany gave common
occurrences of postoperative pain among patients, specifically pain.
Patients Controlled Analgesics is extensively used in post-operative care. PCA has been found
to be a more feasible option for clinician-driven titration and re-dosing. According to Bijur et al
(2017), analgesics in 2011 were prescribed to approximately 97 million patients visiting the ED
in the United States alone. However, the use of PCA requires a lot of time and may not be
feasible in highly populated ED.
There is a growing concern of over-prescription of opioids in post-operative pain controlled
analgesia, leading to addiction. According to Zhao et al (2019), 80% of patients who undergo a
6
surgical procedure are given opioid analgesics to eliminate pain. Unfortunately, there is a great
concern about the irrational use of opioids leading to dependence on the drugs and abuse
(Zhao et al, 2019). This has contributed to a high mortality rate and burden to the economy
(Zhao et al, 2019). In the United States alone, there are 33, 000 deaths per year as a result of
opioid addiction, and as said above, the economy is burdened since the addicted persons will
have to be treated (Zhao et al, 2019). From the year 2004 to 2012, 80% of patients who
underwent a surgical procedure filled in the prescription of opioid analgesics (Bui et al, 2019).
This is a concern because these rates have been increasing over time, and they were
established inappropriate or excessive than the required dose (Bui et al, 2018). Statistics
revealed by the United States in 2013 indicated that $78.5 billion was used to treat opioid
addiction and overdose (Zhao et al 2019).
There are several postoperative pain management interventions and strategies in use. A good
example is an intervention that was initiated by the American Pain Society in collaboration with
the American Society of Anesthesiologists (ASA). The postoperative pain management
guidelines and procedures were commissioned by the two bodies purposively to encourage
evidence-based, safer, and effective postoperative pain management in adults and children
(Chou et al 2016). The procedures and guidelines captured the use of different pharmacological
modalities, postoperative education, planning of postoperative pain management, the transition
to outpatient care, and organizational procedures and policies. In 2012, a practice guideline
containing procedure and processes was published by the ASA and later reviewed for approval
by the American Society of Regional Anesthesia and Pain Medicine.
Understanding the use of analgesics to manage postoperative pain is very crucial in nursing
practice, patient care, and management of health care organizations. When it comes to a
patient’s outcome, Glowacki (2015) revealed that postoperative pain management done
effectively improves early mobility and reduces the complications of ileus, myocardial infarction,
and urinary retention. In addition, effective post-surgical pain management is associated with
reduced pulmonary complications, reduced stress, earlier overall recovery, reduced rates of
readmission, and improved quality of life. Just as earlier discussed, the healthcare system
incurs losses associated with postoperative pain, nonetheless, adequate and earlier
management of postoperative pain will ensure that financial resources that would otherwise be
used to take care of the patients channeled to other economic sectors or improvement of the
health care system. In 2013, the American Nurse Credential Center revealed that only 1672 of
the registered nurses in the US had accredited pain management qualifications (Glowacki
7
2015). This, therefore, means that more nurses are needed in this field, hence, a suggestion by
the Nurse Practitioner Healthcare Foundation which proposed the development of a
standardized curriculum in pain management. This impacts nursing practice positively because
they will have an increasing role to play in future postoperative pain management.
Some of the possible outcomes of using PCA may include; reduced postoperative
complications, patients’ satisfaction, improved quality of life, prevention of pain development,
and improved knowledge regarding pain management.
Acute Pain in Post-Surgery Patient
One of the most common symptoms before and after surgery or any medical intervention is
acute pain. Weinrib et al. (2017) indicate that the presence of acute pain is sure evidence that
the beholder has tissue insult that might be present due to injury, surgical operative procedure,
disease, or childbirth that aims at preventing further damage. In the presence of acute pain,
there is an unpleasant emotional and mental sensation that occurs in association with
vegetative signs, psychological reactions, and behavior change (Noel et al. 2017) . In essence,
acute pain lasts several hours to days and barely a month but to makes the patient seek
medical attention within minutes, hours, or a few days after its onset. Moreover, identifiable
stimuli acute pain provokes acute pain and the pain disappears ones the injured tissue heals or
the cause is removed. However, if it is ignored, acute pain can turn chronic, that is, the pain can
be lasting more than months and the intensity might be similar or increasing intensity with time
(Weinrib et al. 2017). Postoperative pain is a perfect example of acute pain and apparently, all
surgical procedures lead to various levels of postoperative pain on the patient, which call for
pain management. Weinrib et al. (2017) adds that as a concern, most patients undergoing
surgical operation worry about postoperative pain and a number of studies including those
conducted in nations with advanced health care systems reveal that even at the initial decade of
the 21 st century, close to one-third to half of the postoperative pain in patients had not been
managed properly. The concern in pain poor management of postoperative pain depends on
various factors that range from the intensity of the pain as the patient can reveal to healthcare
provider facts.
Analgesia in Pain Management
Analgesia is drugs whose actions interfere with the pathophysiology of pain and ensures that
pain is minimal on the patients. However, according to Hooten et al. (2013) , the medical care
8
provider should know the cause or origin of the pain, the sight of pain, aggravating, and relieving
factors to the pain because this helps in knowing the divisions the pain affects in the patients.
Moreover, pain assessment helps in grading and characterization of the pain, and its
classification according to duration.
Patient-Controlled Analgesia
Patient-controlled analgesia (PCA) is a method used in pain management in which the patient
decides when to get the dose of pain medication (Hübner et al. 2015) . In most situations, PCA
seems the best way to pay relief than involving another person such as a nurse who helps the
patient in pain medication. In this type of pain management, the patient waits for the
uncomfortable levels of pain and he/she presses a button on a computerized device that is
attached to a central venous cannula that passes the analgesia from the computerized device
that measures doses of the drug (Aloia et al. 2017) . Currently, PCA is used in pan crises such
as those encountered in pancreatitis and sickle cell crisis where excruciating pain needs
management with opioid analgesia, but it is also used in postoperative acute pains. Additionally,
PCA is also applicable in-home care of patients in hospice or those nursing moderate to severe
pain due to cancer and those who cannot take per oral medications. Children young as 7 years
old can be beneficiaries of the treatment using PCA if only they understand the instructions
used in PCA and the principal idea (Aloia et al. 2017) . However, the use of PCA is
contraindicated and inapplicable in people who are disoriented, confused, or unconscious.
Effects of Patient-Controlled Analgesia
Benefits of Using Patient Controlled Analgesia in Postoperative Patients
The benefits are with the patient than with the medical provider because it gives positive results
compared to other medical provider controlled analgesia. Foremost, the equipment allows the
patient to take the lowest quantities of the analgesia that is effective in pain management as per
the condition of the patient. The low doses prevent the patient from adverse effects of an
overdose of the drug such as nausea, vomiting, and bowel disturbances amongst others (Martin
R. Tramer & Bernhard Walder 1999) . Additionally, the low dose prevents the patient from
developing tolerance to high doses of the drug, which can result in another medical condition
secondary to pain management with opioid drugs (Choiniere et al. 1998) . Ideally, the aim of the
administration of the drugs is to get the lowest dosage that can relieve pain and prevent the
tolerance and adverse effects of the drug. Moreover, the patient gains wellness or becomes
stable such that he/she can walk or move limbs, which allow them to start physiotherapeutic
exercise and movement. Ability to move and exercise helps in preventing conditions associated
9
with debilitation such as stasis of blood that can lead to venous thrombosis and later
thromboembolism that predisposes the patient to other adverse conditions that are life-
threatening (B. Walder et al. 2001) . Such conditions include myocardial infarction secondary to
thromboembolism in the coronary artery, stroke secondary to blockage vessels of the circle of
Willis by an embolus, or deep venous thrombosis (B. Walder et al. 2001) . In essence,
myocardial infarction and stroke can result in death because myocardial infarction limits the
amount of blood pumped from the heart to tissues, which leads to hypoxia and ischemia to
tissues. Moreover, stroke can result in impaired function of the sympathetic system thus
reducing the performance of the structures in the brain stem that control breathing and heart
rate (Chelly et al. 2004) . Thus, using patient-controlled analgesia reduces the chances of
encountering adverse effects of analgesia related to using opioid drugs, tolerance to the drug,
and improved condition of the patient that eliminates dangers that are associated with
debilitation.
Also beneficial in patient-controlled analgesia is the ability of the patient to monitor his condition
and only use the drug when it is necessary, which eliminates the regular input of a medical
provider that sees the patient takes unnecessary levels of the analgesia that can cause adverse
effects (Martin R. Tramer & Bernhard Walder 1999) . Conversely, patient-controlled analgesia
ensures that the patient is only getting very low amounts of the analgesic, which means that
they cannot stimulate the nervous response that stimulates the chemoreceptor trigger zone,
which is responsible for emesis (Martin R. Tramer & Bernhard Walder 1999) .
However, medical providers also benefit from the efficiency of patient-controlled analgesia in a
number of ways. The patent is in charge of the management of his/her pain, which means that
follow up on the performance of the analgesia allows the practitioner to assess and grade the
quality of pain more effectively (Varrassi et al. 1999) . Additionally, the equipment ensures that
the patient is getting low doses of the drug, which eliminates medical provider errors such as
overdosage and delivery of high doses that might induce tolerance and adverse effects that
worsens the quality of life of the patient (Chelly et al. 2004) . While the medical care provider has
an active involvement in the management of pain, the error associated with the delivery of
dosage and adverse effects are eliminated, which gives the patient a better quality of life.
Chapter 3: Methodology
The study employed a qualitative research method, specifically a literature review method.
According to Rothstein & Borenstein (2006), a systematic review basically uses explicit methods
10
to establish relevant studies or literature to the research question and then summarizes them.
Generally, the aim of this literature search was to establish a solution to the research question
using keywords to search the online databases for relevant literature. The purpose of this
literature review was to come up with six relevant published research studies and then do a
CASP to prove their credibility, and compare the themes of the six studies as the central part of
the methodology that gives answer to the research question; What actions can nurses take to
increase the effectiveness of analgesics to control postoperative pain in adult patients?
According to Djikers (2017), CASP tool is very crucial because it focuses on assisting the
researchers to decide whether the study will be helpful in answering the research question.
Information sources
Data was collected by searching electronic databases, scanning reference lists of articles and
consulting with experts in the field. No limits were applied for languages and foreign papers
were translated. This search was applied to Medline (1966 – present), Pre-Medline electronic
sources and also Cochrane and Database of Abstracts of Reviews of Effectiveness (DARE)
databases were reviewed.
Search Strategy
The literature search was conducted in PubMed, Medline, Cochrane library, and CINAHL
databases. The search involved keywords post-operation, pain, analgesics, post-cardiac
surgery, and outcome. The databases were searched for relevant works of literature including
Random Controlled Trials, Systematic Reviews, cross-sectional studies, and meta-analysis
studies. Below is a Boolean search table that summarizes the search strategy that was used.
Moreover, an advanced search was done to narrow down the results to fit in the inclusion
criteria as discussed below. PubMed and Cochrane library gave a large number of articles, and
therefore, an advanced search was conducted in the two databases to determine articles with
free full texts and eliminate those with previews. A literature search in Medline combined the
words patients, improved, and outcomes and use of “adults” eliminated literature that would be
discussing children. A literature search in CINAHL was modified by using keywords “cardiac
surgery”, “pain”. AND “analgesia to give articles that are more specific to post-cardiac operative
patients.
DATABASE KEYWORDS USED
PubMed Analgesia AND Postoperative
11
Medline Patients AND Improved AND Outcome AND
Adults
Cochrane Library Analgesia AND Postoperative AND Outcome
CINAHL Post-cardiac surgery AND Analgesia AND
Patients.
The strength of using the different search terms for the different databases search as in the
table above was necessary to give a variety of published articles the study could select from.
Inclusion Criteria and Exclusion Criteria
The inclusion strategy was based on the year of article publication, language used and
relevance to the research question. The first consideration was that all the articles were written
in the English language. Secondly, the year of publication was a factor to consider and, articles
published from 2009 up to date were included, and It was important to use articles not older
than 10 years because they are not up to date. Using updated articles is important because they
capture recent adjustments information, improvements and modifications in nursing practice. To
determine the relevancy, the abstract of the identified articles was read and the relevant ones
were included in the study.
Articles focusing on children's patients were excluded. Moreover, reading of the abstracts was
sententious to screen the most relevant articles that apply in this case. Once the articles were
retrieved from the electronic databases, each article’s abstract was read to determine their
relevance to the research question, irrelevant articles, reports, conference abstracts, and
protocols were all excluded.
The table below shows the summary of the literature search from various databases
Database Key terms Results Selected
based on
the title
Selected
based on
abstract
Free
literature
could be
accessed
Relevant
Literature
PubMed “Analgesia”
AND
“Postoperative
”
450 12 5 4 2
Cochrane “Analgesia”
AND
375 10 6 3 2
12
“Postoperative
” AND
“Outcome”
CINAHL “Cardiac
Surgery” AND
“Pain” AND
“Analgesia”
250 7 4 3 1
Medline “Adult
Patients” AND
“Improved”
AND
“Outcome”
125 7 2 2 1
As shown in the table above, the literature results were searched based on the relevancy of the
title. For instance, PubMed had a large number of literature totaling to 450, 12 were selected
based on the relevancy to the title. Once the abstracts were read, 5 articles were extracted. Out
of these, only 4 could be freely accessed and only 2 found to be more relevant to the research
question. Cochrane library gave the second largest number of articles totaling to 375, 10 were
selected based on title 6 based on abstract, and only 3 could be accessed to get the 2 relevant
literature. CINAHL database gave the least literature totaling to 250. Their titles were screened
and 7 selected, out of these, only 2 had relevant abstracts. The accessible articles were 2
hence 1 relevant article that was used. Finally, out of 125 works of literature that were identified
in Medline, only 7 were selected based on the title, 2 based on the abstract. These two were
accessible but only 1 was relevant to the study.
Below is a PRISMA flow diagram that shows the number of identified studies, excluded studies,
and included studies (Liberati et al, 2009).
13
PRISMA 2009 Flow Diagram
Records identified through database
searches
(n = 1200 )
Additional records identified through
other sources
(n = 5 )
Records after duplicates removed
(n = 500)
Records screened
(n = 485)
Records excluded
(n = 450)
Full-text articles assessed for
eligibility
(n = 35 )
Full-text articles excluded,
with reasons
(n = 29)
Studies included in
quantitative synthesis
(Systematic Review)
(n =6 )
14
Ethical Implications
Ethical considerations during systematic reviews are of great importance. According to Vergnes
et al (2010), there is adequate evidence showing that the methodology used in conducting the
literature search does not prevent unethical studies inclusion. Vergnes (2010) further adds that
it is ironic that the inclusion of unethical studies is made easy and even supported by the need
to provide more information. All data was anonymized locally and input into a preformed
encrypted spreadsheet to be given to the study leads. No identifiable patient data are to leave
the respective trust and all published data will be anonymized with respect to the patient and the
trust. Individual trust data or consultant names were also not be published in an identifiable
manner. To ensure ethical acceptability, credibility, and reliability of this thematic analysis, the
research was conducted by taking into consideration the ethical guidelines included in the works
of literature. Furthermore, the guidelines for the responsible systematic reviews and conduct
incorporating legislation and self-regulation were applied by ensuring only articles that had
adequate ethical consideration of their participants were used.
Chapter 4: Results
The table below is a summary of the result articles retrieved from the electronic databases, with
a focus on the aim of the studies, type of study, main findings and conclusion, and strengths
and limitations of the articles.
Author/Date Aim of the Study Type of Study Main
findings/Conclusio
n
Strengths &
Limitations
Yong &
Coulthard
(2010)
To determine
whether there is
a difference
between the
protective
analgesia
groups
compared with
conventional
analgesia
groups with the
aim of improving
postoperative
pain experience
RCT Patients in the
protective
analgesia group
experienced
severe pain as
compared to the
patients in the
conventional
group.
The study used
an adequate
sample size of
122 that gave a
reasonable
result worth
using as a
literature source.
However, the
research only
used ibuprofen
for protective
analgesia and
conventional
analgesia hence
the result may
not be
conclusive.
Vitile et al To establish Cross-Sectional After 24 hours from The sample size
15
(2019) pain
management
practices and
describe patient
satisfaction
measurements
for intensive
care patients
after cardiac
surgery with a
sternotomy
approach at a
hospital in the
University of
Riga, Latvia.
surgery, patients’
pain management
satisfaction was
high, despite the
fact that the
nurses’ knowledge
was average, and
this further
classified
communication
and attitude as two
main factors
affecting patients’
satisfaction.
of 72 used was
small hence
cannot be used
to generalize the
effect on the
general
population.
Therefore, more
research is
needed.
Nachiyunde &
Lam (2018)
To determine
the efficacy of
different modes
of analgesia in
postoperative
pain
management
and early
mobilization in
postoperative
cardiac surgical
patients.
Systematic
Review
The use of
combined
techniques
including PCA with
Opioids and local
anesthetic
subcutaneous
infusions are the
best pain
management
strategies,
especially in post-
cardiac surgery.
This will assist in
avoiding vomiting
and excessive
nausea.
The inclusion
and exclusion
criteria used is
so strict hence
there were a
limited number
of literature used
for analysis
Van Dijk et al
(2010)
To describe the
knowledge of
the patients and
nurses and
beliefs
concerning pain
management. In
addition, the
researchers
wanted to
establish the
effects
education has
on patients and
nurses' beliefs
on postoperative
pain.
RCT The study revealed
outstanding
results, for
instance, the
intervention group
that consisted of
patients who were
actively involved in
their postoperative
pain control posted
an increase in their
level of knowledge
The article used
an adequate
sample size on
the nurses;
hence the
results can be
considered
valid. However,
there are many
postoperative
patients
experiencing
pain.
Shah, Wong &
Wong (2015)
To determine
patient
Systematic
Review
A combination of
multimodal
The study only
used two
16
satisfaction and
positive
outcomes in
pain
management
after an
ambulatory
surgery
analgesia and local
anesthetics
technique will
assist to improve
the quality of pain
relief. However,
the study was not
able to prove
whether the
patients treated
through this
technique gets
satisfied since
patient satisfaction
is a complex
concept entailing
cognitive, social,
and cultural issues.
databases, that
is MEDLINE and
Embase to
retrieve their
literature,
therefore, the
researchers had
limited options
to get relevant
information to
answer the
research
question.
Mitsiou &
Mitsiou (2013)
To establish the
satisfaction of
patients with
their
postoperative
pain
management
using strategies
such as
analgesics while
identifying the
characteristics of
their pain and
exploring any
possible gaps in
post-operative
pain
management in
Armed Forces’
Hospitals in
Anthems.
Survey The findings of this
survey established
that 90.7% of
patients were
generally satisfied
with how their
post-surgical pain
was being
managed. On the
other hand, 53.3%
of the patients
were fully satisfied
with their post-
surgical pain
management.
Generally, the
study
demonstrated that
all patients who
underwent major
surgery were
satisfied with their
pain management
owing to the fact
that they were
involved in their
pain management
The patients’
expectations
about their post-
operative pain
level and pain
relief were not
investigated.
The previous
patients’ pain
experience was
not investigated
and this might
have affected
their pain
assessment.
Again, this study
is valid because
a sample of 150
patient
respondents
was used and
this gives the
general view of
the entire
population of
postoperative
pain patients.
The study
contributed to
answering the
research
question owing
to the fact that
17
one of the
factors that
contribute to
improved
outcomes of
postoperative
patients is that
they are
involved in their
analgesics use.
Summary of Critical Appraisal
Critical appraisal is a process used to determine the strengths and weaknesses of research in a
systematic way. According to Young & Solomon (2009), the most sententious aspect of the
critical appraisal process is the evaluation of validity, appropriateness, and relevance of the
study design and the research question. Moreover, the methodological design used in the study
should be carefully evaluated. Therefore, a Critical Appraisal Skills Program (CASP) tool was
used to evaluate the validity and relevance of the systematic review articles. CASP suggests ten
checklist questions that can help in critically appraising a research study. In this case, the
Critical Appraisal of the six articles was conducted based on three questions, that is; do the
studies answer and focus on a valid research question? Do the studies use an adequate sample
size? Do the studies have valid results?
All the articles focused on valid research questions with specific research designs to answer the
research questions. To begin with, Yong & Coulthard (2010) focused on a valid research
question of whether there is a difference between the protective analgesia groups compared
with conventional analgesia groups with the aim of improving postoperative pain experience.
This research question is almost similar to what Nachiyunde & Lam (2018) were addressed,
which was to determine the efficacy of different modes of analgesia in postoperative pain.
Similarly, Shah, Wong & Wong (2015) and Mitsiou & Mitsiou (2013) also addressed similar
research questions that focused on determining patients’ satisfaction with their postoperative
pain management.
18
Among the six articles presented above, only Yong & Coulthard (2010) and Van Dijk (2019)
adopted Random Controlled trial designs, whereas Nachiyunde & Lam (2018) and Shah, Wong
& Wong (2015) used systematic reviews. On the other hand, the article by Vitile et al (2019) and
Mitsiou & Mitsiou (2013) employed cross-sectional studies and survey designs respectively.
When it comes to the sample size, the article by Yong & Coulthard (2010) clearly addressed a
focused issue; for example, it focused on a sample of 122 postoperative patients’ population,
and a protective and a conventional analgesia intervention given. However, the sample size
used was by Vilite et al (2019) is 72 which is quite small considering a large number of patients
experiencing postoperative pain in the general population. Van Dijk et al (2010) and Mitsiou &
Mitsiou also used an adequate sample size that gave the hypothesized findings, whereas Shah,
Wong & Wong (2015) limited their review in only two databases, that is; MEDLINE and
EMBASE.
Finally, based on the question of the validity of the findings of the articles, the findings of Yong &
Coulthard (2010) can be considered valid because of the adequate sample size used to give the
findings that Patients in the protective analgesia group experienced severe pain as compared to
the patients in the conventional group. However, the research only used ibuprofen for protective
analgesia. Similarly, Van Dijk et al (2010) and Mitsiou & Mitsiou (2013) produced vali results
that can be applied in the general population owing to the adequate sample size used and the
design. On the other hand, the findings by the article Vilite et al (2019) may not be valid due to
the small sample size of 72 which is quite small considering a large number of patients
experiencing postoperative pain in the general population hence the findings may not be valid.
19
Analysis
Theme 1 Theme 2 Theme 3 Theme 4
Patients’
Satisfaction
and Improved
quality of life.
Characteristics
of Postoperative
pain
Patient-
Controlled
analgesia and
opioids.
Nurses and
Patient’s
knowledge
regarding pain
management
Article 1 √ √ √
Article 2 √ √
Article 3 √ √
Article 4 √ √
Article 5 √ √
Article 6 √ √ √ √
The connection between the Themes
From the themes table above, the main four themes identified in the six articles are satisfaction
and improved quality of life among patients, characteristics of post-operative pain, patients
controlled analgesia and opioids, and finally nurses' knowledge regarding pain management.
Theme 1 appeared in all the six articles, theme 2 in only two articles, theme 3 in four of the
articles, and theme 4 in only two articles. Therefore, the most common theme is “patients’
satisfaction and improved quality of life.” This theme is closely connected to theme 3 “patients
controlled analgesia (PCA).” The connection between these two themes answers the research
question in that; for postoperative patients to realize an improved outcome and quality of life,
20
strategies such as patients controlling their analgesia administration. This agrees with the
findings by Martin, Tramer & Bernhard Walder (2009) that PCA allows the administration of low
doses of analgesia hence preventing the patient from adverse effects of overdose such as
vomiting, bowel disturbances, nausea, and many more. Moreover, this finding is also in
agreement with a study by Choiniere et al (1998) that the administration of low doses prevents
the patient from developing tolerance to high doses of the drug which can lead to other
dangerous medical conditions. PCA will ensure quick recovery after surgery because the patient
has the ability to monitor their condition and use the drug when it is needed, hence satisfaction
and improved quality of life.
Secondly, theme 1, theme 2, and theme 4 are also connected and answer the research
question. The central theme is theme 1; “patients’ satisfaction and improved quality of life”.
According to a study conducted by Karaca & Durna (2019), patients who were attended to by
knowledgeable and skilled nurses who understood their sickness reported a high satisfaction
rate. Furthermore, this study revealed that patients who were treated at the surgery and
obstetric gynecology units were highly satisfied with their nursing care and had fewer
readmission rates. Therefore, this means that nurses have a great role to play when it comes to
helping postoperative pain patients heal. For instance, nurses have to understand the nature
and characteristics of postoperative pain and have the necessary knowledge regarding pain
management. It can only be concluded that the connection between the above themes clearly
answers the research question.
Chapter 4: Discussion
Surgeries are extremely stressful events and post-operative pain control is one of the greatest
concerns for both physicians and patients. Patients' postoperative experiences influence their
existential aspects of lifelong after surgery. They can avoid adverse effects associated with
postoperative pain such as pneumonia, thrombosis, and the development of other conditions
such as anxiety and psychological distress. Therefore, this study is very significant because
nurses can apply their findings when managing postoperative pain patients to avoid the
occurrence of the aforementioned effects. Postoperative pain management requires
collaboration between nurses, patients, and surgeons.
In summary, the main findings of this research are that postoperative patients who participate or
have control of their pain management using analgesics have high satisfaction and improved
quality of life. More importantly, this study has proven that this can be achieved when nurses
21
are knowledgeable about the characteristics of postoperative pain. Through this, they will know
the right medication for the patient. The study retrieved a total of 6 articles from PubMed,
CINAHL, Cochrane Library, and Medline. Out of the 6 articles retrieved, article 6 written by
Mitsiou & Mitsiou (2013) which talks about patients’ satisfaction was the most relevant and cuts
across all the 6 themes. Article 1 written by Yong & Coulthard (2010) and answers the question
as to whether protective analgesia can reduce postoperative pain was the second most relevant
article. This was a randomized controlled trial, and its findings cuts across the three themes
stated in the analysis section. However, articles 2, 3, 4, and 5 only had two common themes
relating to each other. This is one of the limitations of the study owing to the fact that the
information retrieved from these pieces of literature does not answer the research question
completely. The second limitation of this research is the small number of articles used. A
sample of 6 articles used in this systematic review limited the number of literature that could
have been explored and included in the study.
It is possible that varying misconceptions may deter professionals and patients from providing
adequate pain relief. The fear of the possibility of developing physical dependence, tolerance,
addiction, and side effects especially respiratory depression could prevent physicians from
prescribing it and make patients anxious about its usage. It is certainly important to consider the
risk of dependence when using these drugs therapeutically. Despite this risk, under no
circumstances should adequate pain relief ever be withheld because an opioid exhibits the
potential for abuse or because legislative controls complicate the process of prescribing
narcotics. However, certain principles can be observed by the clinicians to minimize problems
presented by tolerance and dependence when managing pain with opioid analgesics.
Undertreated severe pain may have physiological consequences increasing the stress response
to surgery, seen as a cascade of endocrine-metabolic and inflammatory events that ultimately
may contribute to organ dysfunction, morbidity, increased hospital stays, and mortality. The pain
often causes the patient to remain immobile, thus becoming vulnerable to deep venous
thrombosis, pulmonary atelectasis, muscle wasting and urinary retention.
The experience of pain varies between patients and various factors cause opioid effects to vary
between individuals, therefore, the dosage of morphine and other opioids need to be assessed
for each individual in order to achieve adequate pain control. Some even suggest pain
assessment as the fifth vital sign. Analgesics or compounds with less pronounced dependency
or tolerance should be used, if possible, and finally, analgesic therapy and the patient’s need for
opioids should be evaluated frequently.
22
According to Corke (2013), acute postoperative pain can develop into chronic pain, and the
prevalence of chronic postoperative pain is approximated to be averagely 10-50%. Moreover,
chronic pain can be severe and disabling in 6% of the patients. Despite the fact that the
experienced pain was mostly moderate, still, patients reported satisfaction from their pain
management. This could be the result of the belief that pain is an inevitable part of the post-
surgery experience.
Moreover, nurses have the responsibility of educating the patients on how to manage their pain
after an operation because poor management of pain can result in adverse physical and
physiological effects on the patient and those taking care of them. It is undeniable that nurses
have ethical and professional responsibility to ensure effective patients’ pain relief (Mahama &
Ninnoni, 2019). This is a theme discussed in the two articles retrieved from the databases,
theme 4 “Nurses and Patient’s knowledge regarding pain management” is an important aspect
of pain management. This is clearly highlighted in one of the 6 articles by van Dijk et al (2017),
in their research; they described the knowledge and beliefs of patients and nurses about the
management of postoperative pain. Their study established that patients had a high level of
knowledge in the intervention group as compared to the control group. On the nurses’ side, no
differences were found in their beliefs, however, they were knowledgeable about postoperative
pain management and lower pain management obstacles as compared to the patients.
Therefore, the knowledge possessed by nurses and patients is a very important strategy in pain
management. The findings from this study are applicable to nursing practice and the nursing
profession. From this study, professional nurses can deduce what is required for effective
postoperative pain management, that is; the characteristics of pain must be understood first and
knowledge and beliefs of patients must also be taken into consideration. Undoubtedly, patients
will be satisfied and a nurse attending to the particular patient will also be happy. This review
has answered the research question and also provides the basis for future research in the same
area for conclusive findings.
Chapter 5: Conclusion and Recommendations
In conclusion, the literature review of this paper focused on postoperative pain, patients
controlled analgesia and the effects of PCA on the patients. However, upon searching the
databases with the key terms, another important aspect of patients' and nurses’ knowledge and
beliefs were noted. Patients’ satisfaction and improved quality of life was the dominant theme in
all the 6 articles, and it implies that for that the main goal of managing postoperative pain is to
23
satisfy the patients and ensure they have improved quality of life even after the surgery. For this
to be achieved, nurses must have the necessary knowledge and skills to effectively manage
pain and pass the same knowledge to their patients during care, and this is one of the main
strategies. The other themes or rather strategies included understanding the nature or
characteristics of postoperative pain, patients controlled analgesia. These themes are related
and interconnected, and for postoperative patients using controlled analgesia to have an
improved outcome, nurses must be knowledgeable about the pain, they have to understand
patients’ beliefs, and educate them on pain management.
First, it is recommended that nurses and anesthetists to consider using different modes of
analgesia in post-cardiac surgery pain management. This is very important in preventing acute
pain from progressing to chronic pain. A systematic review study conducted by Nachiyunde &
Lam (2018) provided that combining PCA with opioids together with local subcutaneous
anesthetic continuous infusion is very effective compared to using PCA alone. However, this
study warns that there is a need to be careful with the use of ketamine in post-surgery pain
management since the study in this area is not conclusive.
Secondly, Nurses need to be well equipped with the necessary knowledge and skills needed for
postoperative pain management and how to handle physical and psychological conditions.
Samarkandi (2018) conducted a study on the level of knowledge and attitude nurses had
towards pain management; the study revealed that nurses’ respondents had less knowledge of
pain management and negative attitude towards pain management.
Finally, a proper guideline and policies need to be put in place to ensure the right pain patients
are given the right dosage of opioids analgesia to curb the menace of its abuse. Arnold &
Childers (2017) talked about the problem of opioid addiction in their study about “management
of acute pain in the patient chronically using opioids”. Their study revealed that acute pain may
develop from patients using opioids in opioid chronic pain management therapy due to
addiction. This can be prevented with appropriate prescriptions and guidelines for the use of
opioids to manage pain.
24
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