Documentation of postoperative pain by nurses in surgical wards

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1 Acute Pain (2008) 10, Documentation of postoperative pain by nurses in surgical wards Maysoon S. Abdalrahim a,, Sawsan A. Majali b, Ingegerd Bergbom c,1 a Faculty of Nursing, University of Jordan, Amman, Jordan b Dar Al Hekma College, Jeddah, Saudi Arabia c The Sahlgrenska Academy at Gothenburg University, Faculty of Health and Caring Sciences, Institute of Nursing, Box 457, SE Göteborg, Sweden Received 3 September 2007; received in revised form 27 March 2008; accepted 18 April 2008 KEYWORDS Postoperative pain; Audit; Nursing documentation; Pain assessment; Pain management Summary Purpose: To describe nursing documentation of pain assessment and management in the first 72 h postoperatively in surgical wards. Methods: A retrospective approach was used to collect data on nurses documentation from patients records. A total sample size of 322 records at six hospitals in Jordan were audited using three audit instruments; Pain and Anxiety Audit Tool, the North American Nursing Diagnosis Association (NANDA) form for characteristics of acute pain, and comprehensiveness assessment tool. Results: There was no evidence of pain assessment documentation on the first day of surgery in 113 (35%) of patient s records. Pain location was the most recorded information for pain assessment in 197 (61%) notes, and only 14 (4.3%) nurses used a pain scale. More than 53% of the records lacked information about medication for pain management. There was a significant difference (p < 0.05) in all the categories of pain documentation between the first day and the subsequent days. Nurses documented patients self-report of pain [297 (92.3%)], and patients crying [200 (62.1%)]. More than 80% (273) of the records were ranked below the minimum score for a satisfactory documentation. Conclusion: The results indicate the need to improve postoperative pain assessment and documentation, and the establishment of acute pain service Elsevier B.V. All rights reserved. Corresponding author at: Faculty of Nursing, University of Jordan, Amman, Jordan. Tel.: ; fax: addresses: maysoona@ju.edu.jo (M.S. Abdalrahim), smajali@dah.edu.sa (S.A. Majali), ingegerd.bergbom@fhs.gu.se (I. Bergbom). 1 Tel.: ; fax: /$ see front matter 2008 Elsevier B.V. All rights reserved. doi: /j.acpain

2 74 M.S. Abdalrahim et al. 1. Introduction Pain is the most common symptom reported by patients in surgical wards. Nevertheless, the patient should receive substantial relief from pain [1,2]. Successful postoperative pain (POP) management requires health team cooperative efforts in proper assessment, management, and documentation of pain [3]. Pain assessment and management following surgery are central to the care of postoperative patients. Postoperative pain management should be based on a well-organized health care system that emphasizes documentation of the management outcome for each individual patient [4,5]. There is good evidence that careful and regular assessment of pain improves the perception of nurses and physicians concerning the impact of pain on their patients lives, and enhances the quality of its management [6,7]. Unfortunately, studies revealed that pain documentation by nurses and physicians in different healthcare settings is infrequent, and the use of pain scales is limited [8]. Also, there are many barriers to analgesic outcomes in patients suffering from pain such as; inadequate knowledge and skills, and inappropriate attitudes of the health care providers [9]. The primary purpose of documentation of clients care is communication amongst health team members. The content of the documentation consists of information about the patients condition, responses to illness, and the care that is provided. The ultimate purpose is promotion of the quality of care [3]. However, communication, assessment, and documentation of pain by nurses are often a problem for hospitalized patients [10]. Additional documentation of patient pain history, clinical problems, treatment, and follow-up actions are needed to improve practice and research [4]. The nurse is responsible for the assessment, analysis, planning, implementation and evaluation of patient s nursing care. For the safety of the patients, the documentation of daily nursing care in patients records is vital [11]. This documentation is facilitated if it is adapted to the steps of the nursing process: assessment, analysis, planning, implementation and evaluation [2]. It has been suggested that the key issue of postoperative management strategies is to make pain visible. This can be done by accurate pain assessment documentation, as well as monitoring the efficacy of pain treatment and the documentation should also include patient satisfaction [12,13] Inadequate POP documentation Approximately 50% of postoperative patients have been inadequately treated for pain [14,15]. In 1991, the Committee on Quality Assurance Standards of the Acute Pain Service (APS) developed quality assurance standards for relief of acute pain to evaluate institutional pain management practices. Guideline on Acute Pain Management Standards emphasized that pain should be assessed and documented on admission, after pain-producing procedures, new complaints of pain, routinely, and at regular intervals that depend on the severity of pain. The documentation should include all assessment and management measures and responses of the patients [8,16]. Dalton et al. [4] audited 787 patient charts at six sites to evaluate documentation of practice provided by a multidisciplinary team of nurses, physicians, and pharmacists who participated in an educational programme on POP management. The results revealed documentation of assessment, treatment, and outcome data was infrequent and inconsistent. They suggested that professional staff must implement and maintain change in POP documentation, and be accountable for action that will produce better outcomes for the patient and for the system that is providing care. A study by Chanvej et al. [8] audited 425 patients records to evaluate the quality of POP documentation in the first 72 h postoperatively. The study revealed that documentation of pain both before and after giving analgesics was scarce, pain assessment items were documented inconsistently and below accepted standards. Similar findings were reported in a qualitative descriptive study. Briggs and Dean [17] analysed the nursing documentation of POP management in an orthopaedic directorate of a large teaching hospital in the north of England. Sixty-five patients were interviewed postoperatively about their pain experience, and pain scores were recorded. Findings indicated that individual assessment of pain was poorly documented, and the nurses scores of the patient s POP differed from the patients reports. Additionally, interventions to help the patients to cope with night time pain were rarely documented. In an attempt to evaluate the adequacy of database documentation of POP management of acute pain service on surgical wards, Stomberg et al. [5] studied 2890 registered cases in the database, a homogeneous 2-year sample of documentation charts. They found that only 58% of the data charts were properly completed and entered into the database. The database documentation routines were not found to function optimally [13].

3 Documentation of postoperative pain by nurses in surgical wards Monitoring of pain management programmes In several studies, the authors discussed the need for intervention programmes in order to improve the quality of pain assessment and documentation. De Rond et al. [10] conducted a study aimed to overcome the main barriers by implementing and evaluating a pain monitoring programme (PMP) for nurses. They discussed factors that influenced communication and documentation of patients pain by health team members. Results showed that the PMP proved to be effective in improving nurses assessment of patients pain and documentation about pain in nursing records.stomberg and Haljamäe [13] surveyed the impact of organizational revision of pain management routines on the audit of pain management and on the attitudes of staff members involved in the acute pain service. The study recommended regular monitoring and documentation of relevant audit variables to use them for a continuous feedback to all staff members on the adequacy of the APS. In a prospective audit study by Manias [18] medication order charts and nursing notes of 100 patients on the operation day and over the first four days following surgery were reviewed. The purpose of the study was to examine prescribing and administering activities for POP sedative and analgesic medication, and to describe nurses documentation practices for pain management. Results of the charts audit showed that nurses had documented inadequately in four major areas: pain assessment, use of nonpharmacological interventions, use of pharmacological interventions, and outcome of interventions. Based on the review of literature, it can be concluded that world wide nursing documentation about pain assessment and management is still inadequate. In Jordan, no previous studies have been found to describe nurses documentation of POP assessment and management. Nevertheless, hospitals seek to optimize the quality of nursing care, and meet the accreditation standards. Accordingly, this study took the initial steps towards improving nursing documentation of POP through evaluation of the current documentation practices of pain assessment and management in surgical wards in Jordan. 2. Aims of the study The overall purpose of this study was to describe and compare nursing documentation of pain assessment and management in the first 72 h postoperatively in the surgical wards. The questions of the study were: 1. How do nurses in the surgical ward document assessment and management of patients POP? 2. Are there any differences in nurses notes of patients POP amongst the three days following the surgery? 3. What are the characteristics of acute pain that nurses in surgical ward document? 4. What are the scores of comprehensiveness nurses get for their documentation of POP management? 3. Materials and method A retrospective quantitative approach was used to collect data on the documentation system, and on the strategies of POP assessment and management in the surgical wards in Jordan Settings and sample Six hospitals of large size ( beds) in Jordan were conveniently assigned to be audited, looking specifically at POP assessment and management documentation in the first 72 h in surgical wards. Data were collected over a six months period, from August 2006 to February The estimated target population was 5800 patients records (30 patients capacity per surgical floor in the eight surgical wards over six months). The inclusion criteria for the selection of the patients whose records to be reviewed were: all the patients over 15 years of age, admitted to the hospital after surgery, and stayed as an inpatient in the surgical ward for at least three days. Exclusion criteria were: patients who received pharmacological interventions for chronic pain management, and patients with neurological, cancer, burn, and skin procedures. Using the hospitals information system, a total number of 2600 records were found to meet the inclusion criteria. An adequate sample size was statistically calculated, and a total of 322 hospital records were randomly assigned for analysis using the systematic random sampling technique [19] Data collection procedure Permission and written approvals for abstraction of records were obtained from the ethical committees and hospitals administrators. All personal

4 76 M.S. Abdalrahim et al. identifications of patients were not viewed in the abstracted records to ensure no violation to their privacy. After obtaining permission, the records were reviewed by three research assistants who were not involved in the documentation of these records, and were not employed at the selected hospitals. They were teaching assistants employed at the faculty of nursing in the University of Jordan, and received training in the documentation process of pain. When examining the nursing notes, the research assistants recorded information relating to assessment of patient s pain, the use of an assessment tool, and the use of pharmacological and nonpharmacological interventions for pain. The nursing notes were examined on the first three days following the operation. It was predicted that nurses would make at least one note relating to the patients pain every eight hours shift. If more than one nursing note was made on the same day, the notes were considered as one note for the purpose of this study. The records review was performed using three audit instruments; the Pain and Anxiety Audit Tool (PAAT) developed by Manias [18], the North American Nursing Diagnosis Association (NANDA) form for the characteristics of acute pain [20], and comprehensiveness was assessed by using a tool developed by Ehnfors and Smedby [21] Pain and Anxiety Audit Tool The PAAT was developed by Manias [18] 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. This tool was tested for validity and reliability and divided into three sections. Section one contains questions about the patients demographic profile, including age, diagnosis, gender, and current surgery. Section two was designed to collect information about the patients infusions, and orders of analgesic and sedative medications. Section three was designed to request details about the nurses documentation of pain management in the nurses notes. For the purpose of this study only section one and three were used to collect data from the patients records. Two research assistants audited a random sample of 32 (10%) patients records, and the agreement was 96% NANDA form for the characteristics of acute pain The records were reviewed by using the North American Nursing Diagnosis Association characteristics of acute pain [20]. The validated characteristics of acute pain according to NANDA are: patients self-report of pain, changes in pulse rate, blood pressure and respiratory pattern, restlessness, sweating, grimacing, increased muscle tension, whining, whimpering and crying. The validity of these characteristics has been tested, and references for each sign and symptom have been presented [18,20] Comprehensiveness measuring instrument Comprehensiveness of nursing records of pain was assessed using an instrument developed by Ehnfors and Smedby [21] based on Swedish regulations for nursing recording. Notes on the pain management process were scored on a five-point scale, with scoring based on the following criteria: 1. The problem is described, or interventions planned or have been implemented. 2. The problem is described, and interventions are planned or have been implemented. 3. The problem is described, and interventions are planned or have been implemented. The nursing outcome is noted. 4. The problem is described, interventions are planned and have been implemented. The nursing outcome is noted. 5. All steps comprising the nursing process are recorded. The recording is of relevance to nursing. A score of 5 indicates optimal comprehensiveness, covering the entire nursing process. A score of three is considered to be the minimum score for satisfactory documentation, encompassing problem description, intervention and outcome. Two research assistants audited a random sample of 32 (10%) patients records, and the agreement was 94% Statistical analysis Descriptive statistics (including frequency distributions and measures of central tendency) were used to organize and summarize the data. SPSS (version 14) was used to analyse the data. Results were recorded as number (percentage), mean and standard deviation. Pair samples test was used to evaluate the differences in nursing documentation amongst the three postoperative days, and a p- value less than 0.05 was taken to be significant.

5 Documentation of postoperative pain by nurses in surgical wards 77 Table 1 Patients demographic information (n = 322) Patient demographic Patients sex Total n (%) Male n (%) Female n (%) Patients age (mean = 46.9 years) (5.6) 16 (5) 34 (10.6) (23.9) 41 (12.7) 118 (36.6) (17.7) 38 (11.8) 95 (29.5) (14.5) 28 (8.8) 75 (23.3) Coexisting conditions Diabetes mellitus 55 (17.1) 32 (9.9) 87(27) Hypertensive 57 (17.7) 50 (15.5) 107 (23.2) Other illnesses 36 (11.2) 18 (5.6) 54 (16.8) Surgeries Intraabdominal 59 (18.3) 45(14) 104 (32.3) Orthopedic 52 (16.1) 26 (8.1) 78 (24.2) Eye, ENT, and neck 25 (7.7) 16(5) 41 (12.7) Renal 46 (14.3) 26 (8.1) 72 (22.4) Intrathoracic 17 (5.3) 10 (3.1) 27 (8.4) Type of anesthesia General 152 (47.2) 100 (31.1) 252 (78.3) Regional 47 (14.6) 23 (7.1) 70 (21.7) Total 199 (61.8) 123 (38.2) 322 (100) 4. Results 4.1. Documentation of POP in the first 72 h Demographic information about the patients sample is presented in Table 1. Documentation of pain management is related to four major areas: pain assessment, use of non-pharmacological interventions, use of pharmacological interventions, and outcome of interventions. The frequencies and percentages of these areas are presented in Table 2. Regarding pain assessment in the first day of surgery, there was no evidence of documentation in 113 (35%) of patient s records. There were 197 (61%) notes concerning the location of pain which was the most frequent information recorded for pain assessment. On the other hand, there were only 14 (4.3%) of nurses that used pain scale. The next frequently documented pain assessment information was verbal statements [64 (20%)], and the duration of pain [68 (21.1%)]. None of the nurses recorded any observation of non-verbal patient s behaviour toward POP. Non-pharmacological interventions, such as coughing and deep breathing, turning, education, positioning for comfort, massage, and relaxation were documented collectively in 78 (24%) of nursing notes of the first day. In relation to the pharmacological interventions, more than half of the patient s records 173 (53.7%) contained no information about the medication administered for pain management, and most of the documented information 101 (31.41%) provided only the quantifiable amount. Although the outcomes of interventions were described in 49 (15.2%) of the first day s nursing notes. they mostly contained quantified evaluation of the pharmacological intervention, and there were no details about the side effects of the analgesics (Table 2). During the second day, 174 (54%) of patients records had no documentation about pain assessment. There were 102 (31.7%) nurses notes that contained a description of the location of pain which was the most frequent information recorded for pain assessment, and 43 (13.4%) notes on its duration. The other pain assessment percentages are presented in Table 2. Records showed evidence of limited nurses documentation of non-pharmacological interventions in the second day of surgery; only 212 (65.8%) nursing notes contained this category. Nonpharmacological interventions were documented collectively in only 26 (8.1%) nurses notes. Similarly, the outcomes of interventions were not documented in 280 (87%) nursing notes; it lacks documentation in all items in this category (Table 2). Examining pain documentation in patients records on the third postoperative day revealed that nursing notes in all the areas were almost

6 78 M.S. Abdalrahim et al. Table 2 Nature of documentation relating to pain management provided in nursing notes on the first three postoperative days (N = 322) Nature of documentation Day 1 n (%) Day 2 n (%) Day 3 n (%) Pain assessment No documentation 113 (35.1) 174 (54) 302 (87.6) Verbal statement about pain 64 (20) 30 (9.3) 7 (2.2) Location 197 (61.2) 102 (31.7) 20 (6.2) Use of pain scale 14 (4.3) 4 (1.2) 0 (0) Duration of pain 68 (21.1) 43 (13.4) 11 (3.5) What improves pain 32 (9.9) 21 (6.5) 4 (1.2) What aggravates pain 30 (9.3) 14 (4.3) 2 (0.6) Quality of pain 28 (8.7) 13 (4) 6 (1.9) Observation of non-verbal behaviour 0 (0) 0 (0) 0 (0) Non-pharmacological interventions No documentation 165 (51.3) 212 (65.8) 312 (96.9) Cough and deep breathing with a towel 11 (3.5) 4 (1.2) 2 (0.6) Turning 16 (4.6) 5 (1.6) 0 (0) Education 13 (4) 2 (0.6) 2 (0.6) Position for comfort 16 (5) 5 (1.6) 2 (0.6) Massage 15 (4.7) 6 (1.9) 0 (0) Relaxation 7 (2.2) 4 (1.2) 0 (0) Pharmacological interventions No documentation 173 (53.7) 204 (63.4) 319 (99.1) Quantifiable amount 101 (31.4) 10 (3.1) 2 (0.6) Non-quantifiable amount 48 (14.9) 8 (2.4) 0 (0) Outcome of interventions No documentation 273 (84.8) 280 (87) 322 (100) Side-effects of analgesics/sedatives 0 (0) 0 (0) 0 (0) Non-quantifiable evaluation of analgesics/sedatives 3 (0.9) 2 (0.6) 0 (0) Quantifiable evaluation of analgesics/sedatives 41 (12.8) 28 (8.7) 0 (0) Non-quantifiable evaluation of non-pharmacological interventions 2 (0.6) 2 (0.6) 0 (0) Quantifiable evaluation of non-pharmacological interventions 3 (0.9) 0 (0) 0 (0) absent mainly in the documentation of pharmacological interventions and of the outcomes. The analysis of nurses notes in the three postoperative days utilizing PAAT tool was represented by the sum of numbers of the items in each category. The results showed a significant difference (p < 0.05) between documentation of pain assessment and non-pharmacological interventions in the first day and the second day. Also, a significant decrease in all the categories of pain documentation on the third day was noted as compared to the first day (p < 0.05). The means of the scores for pain assessment category decreased from the first day to the second and the third day (1.7, 1.25, and 1.09 respectively). A similar pattern was noted for the change in the documentation of the pharmacological interventions amongst the three days, mainly between the first and the third day. The difference in the scores as shown in Table 3 indicated that nurses tend to document POP assessment and interventions less often over time Characteristics of acute pain in nursing documentation Examining the records looking for the characteristic from the NANDA diagnosis of acute pain, it was found that nurses frequently tend to document patients self-report of pain [297 (92.3%)], and the patients crying [200 (62.1%)]. The other pain characteristics such as sweating, whining, and whimpering were rarely documented or absent (Table 4). The words used in the records to describe the characteristics of pain were pressure, sharp, squeezing, spasmodic, and stabbing Comprehensiveness of nursing documentation of POP management Recording of POP management was scored to assess the comprehensiveness of nursing documentation. The mean score was 1.4 (S.D. = 1.1) on a scale ranging from 1 to 5, in which the highest score represented the most comprehensive documentation.

7 Documentation of postoperative pain by nurses in surgical wards 79 Table 3 Differences in documentation of in the first three postoperative days Compared days Categories Means (day x, day y ) S tandard deviation (day x, day y ) Significance (p-value) Day 1 and day 2 Pain assessment (1.70, 1.25) (1.278, 1.168) Non-pharmacological interventions (0.75, 0.74) (1.225, 0.745) Pharmacological interventions (1.00, 0.69) (0.921, 0.566) Outcome of interventions (1.00, 0.98) (0.518, 0.432) Day 1 and day 3 Pain assessment (1.70, 1.09) (1.278, 0.509) Non-pharmacological interventions (0.75, 0.99) (1.225, 0.223) Pharmacological interventions (1.00, 0.02) (0.921, 0.136) Outcome of interventions (1.00, 0.00) (0.518, 0.000) 0 Day 2 and day 3 Pain assessment (1.25, 1.09) (1.168, 0.509) Non-pharmacological interventions (0.74, 0.99) (0.745, 0.223) Pharmacological interventions (0.69, 0.02) (0.566, 0.136) Outcome of interventions (0.98, 0.00) (0.432, 0.000) 0 Table 4 Number and percentages of patients records containing the different characteristics proposed by NANDA Pain characteristics n (%) Patient s self-report of pain 297 (92.3) Change in pulse rate 6 (1.9) Change in blood pressure 2 (0. 6) Change in respiratory pattern 2 (0.6) Restlessness 10 (3.1) Sweating 0 (0) Grimacing 3 (0.9) Increased muscle tension 2 (0.6) Whining 0 (0) Whimpering 0 (0) Crying 200 (62.1) N = 322 (100%) Although more than half of the records described the problem of pain complaints, only seven records (2.2%) received the highest score in the documentation process, and 18 (5.7%) records contained evidence of planned, implemented interventions Fig. 1 Score for comprehensiveness in recording of pain management (N = 322). A score of 5 indicates optimal comprehensiveness. A score of 3 points is considered to be the minimum score for satisfactory documentation. and outcome notes for pain relief (Fig. 1). In most records there was no obvious plan of care, and no outcome notes that indicate the progress of the problem or the response to management. In conclusion, since a score of three was considered to be the minimum score for satisfactory documentation, more than 80% (273) of the records were ranked below the minimum score for a satisfactory documentation. 5. Discussion The study results revealed that the highest score in nurses documentation were found in the categories of pain location, pain duration and verbal statements of pain. These findings are consistent with previous studies that reported frequent documentation about these aspects in nursing records [8,22]. Most nursing notes in the study did not contain information about observation of nonverbal patient s behaviour of POP, limited information related to pharmacological and nonpharmacological intervention, and there was a real deficiency in recording the outcomes of intervention. Failure to record such pain aspects can form a real obstacle for nurses and other health care providers in care planning for patients in pain. Reviewed literature suggested that pain should be visible to all individuals involved in health care. Such an approach should include pain documentation [23 26]. The use of pain scales to assess the patients POP during the first day and subsequent days was not evident in the nurses notes. This might be explained by the lack of legislation and hospital policies that emphasize the importance of

8 80 M.S. Abdalrahim et al. using pain scales, also the absence of wellestablished guidelines for POP assessment and management. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has provided a set of guidelines to follow when caring for patients in acute pain. In those guidelines, the JCAHO recommended the use of the Numeric Rating Scale for adult patients population to measure the intensity of pain and to document it [23 25]. The study also found significant differences in the frequency of all the areas of documentation of POP management over the three postoperative days. A major difference was found between the first and the second postoperative day, and between the first and the third postoperative day. The data suggested that nurses may record the patients experience of pain initially, but subsequent pain assessment documentation was almost absent. This might be related to the shortage of nursing staff in surgical wards or lack of knowledge in the importance of on-going assessments. The infrequent documentation of subsequent assessments has also been found in some other studies [4,8,10]. The relatively low number of subsequent assessments recorded by nurses suggests that pain documentation should be emphasized during nursing education and training as well. It is also necessary for hospitals to require nurses notes on their charts for POP assessment and management. Documenting POP according to NANDA characteristics showed considerable deficiencies in the patients records. Pain assessment was mainly based on patients self-reporting of pain, and other characteristics of acute pain were barely mentioned in the records. The same was reported by Idvall and Ehrenberg [27] in their retrospective study of nursing documentation of POP management in the patients records. They found that pain assessment was mainly based on patients selfreport, but less than 10% of the records contained notes on assessment of pain with a definite instrument. Additionally, pain location dominated their documentation in the nurses notes. The process of POP management was not recorded in a comprehensive way. No full plan of care was found in the records, and the outcomes of care interventions were mostly omitted. Most of the records were ranked below the minimum score for a satisfactory documentation. The recording of POP interventions has major importance for the continuity of effective pain management, both for the patients and for quality of care improvement. Nursing records in the present study did not appear to be sufficiently comprehensive for any of these purposes. A plan individualizes the care, can provide continuity, helps in organizing the intervention, and in evaluating the care. The results of the study provided empirical evidence about POP nursing assessment and management in six surgical wards in Jordan. Since findings were based on the written notes of nurses, therefore, they were limited to what nurses wrote about the practice in assessing and documenting POP rather than what they actually were doing in practice. Our interpretation is that the findings of this study were based on the nurse s notes on patients records, not on their actual practice. Nurses did not document properly because they felt no one reads or utilizes the information they wrote, and that it is a waste of time. An alternative interpretation would be that nurses do not have enough knowledge and skills in documenting POP. These findings showed agreement with a study by Ehrenberg [11] revealed that nurses reported insufficient knowledge about how and what to record, and they considered this as a major constraining factor for adequate documentation [21]. Another interpretation is possible that the problem of incomplete documentation of POP could be due to the shortage of ward nurses. Such a staffing situation has previously been discussed as an organizational barrier for pain management [3]. Consequently, it is recommended to consider workload on the staff members when requesting care for patients in pain. Additionally, preprinted care plans could save nurses time and remind them about what to include in their assessment and interventions. The results of the study draw attention to the fact that surgical nurses lack knowledge of POP assessment and documentation, which indicates the importance of establishing pain management education programmes. One way of achieving this might be the introduction of pain control department into the hospital s system and staffed by a qualified pain advisor. A monitoring system of documentation also needs to be set up. To conclude, several tools supported by research were used to audit nursing documentation on patient s records. These tools assessed different aspects of nursing documentation of POP. A comprehensive look at the findings from these aspects indicated the need for improving POP assessment, management and documentation. This issue demands for adopting an acute pain service, which might be followed by regular records audit. Furthermore, nurses need to be accountable to improve their knowledge and skills in assessing POP to improve the quality of care. Our recommendation is to implement educational programmes through in-service training for improving pain management and documentation that can be evaluated

9 Documentation of postoperative pain by nurses in surgical wards 81 by proper mentor system. Continuous support from nursing administrators is required to upgrade nursing performance. Acknowledgement The authors would like to thank the University of Jordan for funding this research. The study was made possible by a grant from the scientific research deanship at the University of Jordan, to which the authors are deeply appreciative. References [1] Manias E, Bott M, Bucknall T. Observation of pain assessment and management: the complexities of clinical practice. J Clin Nurs 2002;11(7): [2] Smeltzer S, Bare B. Brunner and Suddarth s textbook of medical surgical nursing. 10th ed. Philadelphia: J.B. Lippincott; [3] Harkreaderm H, Hogan M. Fundamentals of nursing: caring and clinical judgment. 2nd ed. USA: Saunders Company; [4] Dalton J, Carlson J, Blau W, Lindley C, Greer S, Youngblood R. Documentation of pain assessment and treatment: how we are doing. Pain Manage Nurs 2001;2(2): [5] Stomberg M, Lorentzen P, Joelsson H, Lindquist H, Haljamäe H. Postoperative pain management on surgical wardsimpact of database documentation of anesthesia organized services. Pain Manage Nurs 2003;4(4): [6] Barak M, Poppa E, Tansky A, Drenger B. The activity of an acute pain service in a teaching hospital: five years experience. Acute pain 2005;8: [7] Hansson E, Fridlund B, Hallstrom I. Effects of quality improvement in acute care evaluated by patients, nurses, and physicians. Pain Manage Nurs 2006;17(3): [8] Chanvej L, Kovitwanawong N, Vorakul C. A chart audit of postoperative pain assessment and documentation: the first step to implement pain assessment as the fifth vital sign in a university hospital in Thailand. J Med Assoc Thai 2004;87(12): [9] Innis J, Bikaunieks N, Petryshen P, Zellermeyer V, Ciccarelli L. Patient s satisfaction and pain management: an educational approach. J Nurs Care Qual 2004;19(4): [10] De Rond M, de Wit R, Van Dam F, Muller M. A pain monitoring program for nurses: effects on communication, assessment and documentation of patients pain. J Pain Symptom Manage 2000;20(6): [11] Ehrenberg A. Nurses perception and practice concerning patient records. Nurs Sci Res Nord Countries 2001;59:9 14. [12] Murola L, Onkinen R, Makela B, Niemi T. Patient satisfaction with postoperative pain management effect of preoperative factors. Pain Manage Nurs 2007;8(3): [13] Stomberg M, Haljamäe H. Postoperative pain management: impact of quality assurance and audit documentation on clinical outcome. Curr Anesth Crit Care 2003;14: [14] Apfelbaum J, Chen C, Mehta S, Gan T. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be under managed. Anesth Analg 2003;97: [15] Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: evidence from published data. Br J Anaesth 2002;89: [16] Bines A, Paice J. Are your pain management skills up-todate? Nursing 2005;35(1):36 8. [17] Briggs M, Dean K. A qualitative analysis of the nursing documentation of post-operative pain management. J Clin Nurs 1998;7: [18] Manias E. Medication trends and documentation of pain management following surgery. Nurs Health Sci 2003;5: [19] Gillis A, Jackson W. Research for Nurses: methods and interpretation. 1st ed. Philadelphia: F.A. Davis Company; [20] North American Nursing Diagnosis Association, (NANDA) Nursing Diagnoses: Definitions and Classification NANDA, Philadelphia; [21] Ehnfors M, Smedby B. Nursing care as documented in patients records. Scand J Caring Sci 1993;7: [22] Schafheutle E, Cantrill J, Noyce P. Why is pain management suboptimal on surgical wards? J Adv Nurs 2001;33: [23] Curtiss P. JCAHO: meeting the standards for pain management. Orthop Nurs 2001;20(2): [24] Rosenquist RW, Rosenberg J. Postoperative pain guidelines. Reg Anesth Pain 2003;28(4): [25] Goldstein DH, Kerkhof EG, Blaine WC. Acute pain management services have progressed, albeit insufficiently in Canadian academic hospitals. Reg Anesth Pain 2004;51(3): [26] Berry P, Dabl J. The new JCAHO pain standards: Implications for pain management nurses. Pain Manage Nurs 2000;1:3 12. [27] Idvall E, Ehrenberg A. Nursing documentation of postoperative pain management. J Clin Nurs 2002;11: Available online at