Patient’s perception of acute post-operative pain and satisfaction with pain

management undergoing abdominal surgeries in an academic medical institute:

a cross-sectional study.
Satisfaction level, Post operative pain, Nurses response, Doctors response

Introduction:
The World Health Organization defines pain as “an unpleasant sensory or emotional
experience associated with actual or potential tissue damage, or described in terms of such
damage”. 1

Pain is a subjective experience, which cannot be easily measured. It requires

consciousness. 2 Pain is the result of a complex interplay between signaling systems,
modulation from higher centers and the unique perception of the individual. 3

Acute pain is almost always self-limited.4 When the condition that produces the pain
resolves, or when the nociceptive input is blocked by a local anaesthetic or altered by a
peripheral or central analgesic medication, the pain leaves.

Major abdominal surgical operations ideally require the Acute Pain Management Service
(APMS) for regular pain assessment and timely management of breakthrough pains 5 and
complications in the postoperative period. Evidence has suggested that APMS has improved
morbidity and reduced the duration of hospital stay. 6

The American Pain Society Quality of Care Committee designated pain as the fifth vital
sign, since then the health care professionals have become increasingly aware of proper pain
management policies and the need to assess pain management outcomes.7

Persistent pain after major abdominal surgery can lead to shallow breathing which
facilitates retention of secretion with eventual development of pneumonia contributing to
organ dysfunction and prolonged convalescence. Therefore, ineffective postoperative pain
management has physiological, psychological, ethical, and financial consequences. 8

The degree of patient satisfaction could simply be a reflection of the performance of the
health care providers and not an indication of the efficaciousness of pain management. 9 There
is a paucity of data regarding this aspect in Indian post -surgical patients. 10

The rationale of this study is to assess pain management practices and their
effectiveness after abdominal surgery in a tertiary care hospital having a 24 hr acute pain
service.
Aim:
1. To assess the occurrence of acute post-operative pain status in patients undergoing
abdominal surgeries.

2. To evaluate the relationship between acute pain control and patient satisfaction.

Objectives:
The primary objective of the study was to assess effectiveness of pain management
after major abdominal surgery.

Material and Method:

The methodology of the present study will be discussed under the following headings.

Study design:
The study was designed as a cross- sectional observational study.
Study group:
The study group includes the patients admitted in the IPD (In Patient Department) of the
Surgery Department in the Tertiary Health Care Teaching Institute in tribal region of central
India for major/minor abdominal surgeries.(n=200)

Study duration:
The study was conducted for the duration of two months from 1st May to 30th June
2019.

Study site:
The study was conducted in a department of Surgery in collaboration with department
of Pharmacology in a tertiary care teaching institute.

Inclusion criterion:
All the patients admitted to IPD of the institute during study duration were included in
the study.

Exclusion criteria:
Patients undergoing surgeries other than abdominal surgeries or patient undergone
more than one surgery were excluded from the study.

Ethics and consent:

Prior permission of Institutional Ethics Committee (Reg. no. ECR /1033 /Inst /MH /2018)
was taken for conducting the study. Written informed consent was obtained from each
participant after explaining them the study protocol. The study team did not interfere with any
of the treatment aspects of the patients.
Study tools:
1. Questionnaire :

A predesigned & pre-validated questionnaire was used in the study to assess the post-
operative pain status of the patients. The patients were made to understand the study survey in
the language they understood. They were given 11 questions survey, modified from the
American Pain Society’s Patient Outcome Questionnaire and the Patient Opinion of Pain
Management Tool.11

2. Visual Analogue Scale (VAS):

A Visual Analogue Scale was used to quantify the pain status of the patient and their pain
perception was assessed on the numeric 0-10, indicating the strength of pain perceived from no
pain to worst possible pain. This scale does not take into justification multi-dimentional
approaches to pain management, which should not only include the concept of adequate pin
control but also ‘patient satisfaction with pain control.’ 12

Scoring and assessment:

The assessment of pain outcomes has been conducted by measuring each patients
subjective level of pain control using pain intensity scales, most commonly the 0-10 numerical
scale (0 being no pain and 10 being the worst pain imaginable).

This survey also examined different aspects of pain intensity and satisfaction. Pain
intensity was measured by asking each patient to evaluate their current, most severe, and
average pain levels within the last 24 hours (questions 5–7), and patient satisfaction was also
measured (questions 7–11).

Statistical Analysis:

All completed questionnaires were cross checked to ensure data consistency and completeness.
All recorded data were coded and entered in the MS Excel 2019.

Analysis were performed using Statistical Package for the Social Sciences(SPSS) version for
Windows software full version 23. Descriptive statistics and bivariate analysis were used for the
analysis. And the relationship between the patient’s level of pain and satisfaction with pain
control has been calculated.

Observation and Results:

A total of 200 patients participated in this study, 160 (80%) of the respondents were males and
40 (20%) were females. The mean age of respondents was 37.43± 10.329 years but the highest
number of participant were found in the age group of 31-50 years (64%). [fig.1: a, b]

11-30 years [52=26%]

31-50 years
[128=64%]
51-70 years [20=10%]

Male [160=80%]
Female [40=20%]

All the patients enrolled in the study had experienced pain in past 24 hours. Hence the patients
were asked questions 4-6, which were qualitative questions designed to assess each patient’s
current, average, and worst levels of pain control over the previous 24 hours. The mean scores
of all the 3 questions are tabulated in Table 1. Responses of the patients on the Visual Analogue
Scale are shown in Table 2 and fig.3.

Table 1: Mean of current, average and worst levels of pain score

 Pain status Mean score ± S.D
Current 2.995 ± 0.61

Worst possible 8.9 ± 0.617

Average 6.195 ± 0.46

Questions Response on Visual Analogue Scale TOTAL

0 1 2 3 4 5 6 7 8 9 10

Q.4 0 0.5% 17.5% 64% 18% 0% 0% 0% 0% 0% 0% 100%

Q.5 0 0% 0% 0% 0% 0% 0% 0.5% 23% 62.5% 14% 100%

Q.6 0 0% 0% 0% 0% 3% 74.5% 22.5% 0% 0% 0% 100%

Table 2: Visual Analogue Scale (VAS) Results [n=200]:

 80%

70%

60%
% of respondents

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10

Responses on visual analogue scale

Current status of pain
Worst pain status in last 24
hours
Average pain status in past 24
hours

We had described pain according to their score as follows: no

pain (0), mild pain (1-3), severe pain (4-7) and very severe pain (≥8).

It was found that 164 (82%) patients had a mild pain as their current pain status, 199 (99.5%)
had very severe pain as worst pain status and all 200 (100%) had a severe average pain status.
[Table 3, 4, 5 and fig. 4, 5, 6]
Table 3: Current pain status in study population [n=200]

Score on VAS Pain n (%)

0 No 0 (0)
1-3 Mild 164 (82)
4-7 Severe 36 (18)
≥8 Very severe 0 (0)

Table 4: Worst pain status in past 24 hours in the study population [n=200]

Score on VAS Pain n (%)

0 No 0 (0)
1-3 Mild 0 (0)
4-7 Severe 1 (0.5)
≥8 Very severe 199 (99.5)

Table 5: Average pain status in past 24 hours in the study population [n=200]

Score on VAS Pain n (%)

0 No 0 (0)
1-3 Mild 0 (0)
4-7 Severe 200 (100)
≥8 Very severe 0 (0)
 Mild pain (score 1-3)

Severe pain (score 4-7)

Severe pain (score 4-7)

Very severe pain (score ≥8)

 Severe pain (score 4-7)

Questions 7-10 were quantitative questions designed to assess patient satisfaction with pain
control and evaluate the various factors that contribute to patient satisfaction. In total, 79%
and 83% of respondents reported that they were “satisfied” with how their nurses and
physicians, respectively, responded to their complaints regarding pain. The question regarding
waiting times for the administration of pain medication demonstrated varying results (question
9). Among respondents who requested pain medication, 26 (63%) received medication within
10 minutes of asking, 56 (28%) within 11–20 minutes and 18 (9%) within 21–30 minutes. [fig. 7,
8, 9]
 90%
80%
70%
60%
% of respondents

50%
40%
30%
20%
10%
0%
Very Slightly Dissatisfied Satisfied Slightly Very
dissatisfied satisfied [32 [10 =5%] [158 =79%] dissatisfied satisfied
[0] =16%] [0] [0]

9000%
8000%
7000%
6000%
% of respondents

5000%
4000%
3000%
2000%
1000%
0%
Very Slightly Dissatisfied Satisfied Slightly Very
dissatisfied satisfied [8 =4%] [166 =83%] dissatisfied satisfied
[0] [21 =10.5%] [0] [4 =2%]
satisfaction level of patients
 0-10 mins [126 = 63%]
11-20 mins [56 = 28%]
21-30 mins [18 = 9%]
Number of respodents

YES NO

Experience of any pain after medication

Spearman’s rank correlation coefficients were calculated to determine the relationship

between each patient’s level of pain and their satisfaction with pain control. Based on the 200
participants who answered questions, the correlation coefficient was determined to be r =
0.117 (95% confidence interval =0.096 to 0.139). A slight, but non-significant, upward trend line
was observed (i e, satisfaction increased as the level of pain increased). This positive correlation
was not significantly different from 0, as implied by the 95% confidence interval, indicating the
insignificance of the trend line.

8
7
6
5
Pain score

4
3
2
1
0
0.5 1 1.5 2 2.5 3 3.5 4 4.5

Mean score of level of satisfaction

Figure 11. Relationship between patient satisfaction and pain control (n = 200).
Note: Spearman correlation (95% CI): 0.117 (0.096 to 0.139)

Discussion:

Existing literature on patient’s perception of acute post-operative pain and satisfaction with
pain management in patients undergoing abdominal surgeries is not conclusive with some data
showing significant perception of pain and some shows no perception of pain. Similarly in some
studies patients are well satisfied and in some they are not so satisfied with the pain
management and post operative care.

In the present cross sectional ,observational study, total of 200 patients participated in which
predesigned & pre-validated questionnaire was used in the study to assess the post-operative
pain status of the patients and a Visual Analogue Scale(VAS) was used to quantify the pain
status of the patient and their pain perception was assessed on the numeric scale (0-10). The
singular use of this tool, however, carries clinical restrictions. This scale does not take into
justification multi-dimentional approaches to pain management, which should not only include
the concept of adequate pin control but also ‘patient satisfaction with pain control.’ 12
Some authors like Teresa A pellino et al. did the similar studies in which they developed the
instrument and their perception of pain rated using 7 point likerts scale and the overall score
out of 7 was calculated.13

Some author Muller –staub M et al. did a descriptive cross-sectional study, in which they
examined patient satisfaction using a revised version of the questionnaire "Patient satisfaction
with nursing care" in a convenience sample of 114 patients. The instrument measures patient
satisfaction by means of 37 items on a 5-point Likert-scale. 14
Marie N hanna et al. assessed the perception of pain and satisfaction of patient using odds
ratio.15

In the present study total 200 participants were participated in which majority of the
participants were male. Authors like Teresa A pellino et al. suggested no significant effect on
gender and perception of pain. 13

Authors Ingrid Svensson et al. reported Sex, age, pre‐operative expectation and actual
experience of pain relief, and the overall pain experience were found to be factors associated
with the probability of being satisfied/dissatisfied. 16

All the patients enrolled in the present study had experienced pain in past 24 hours. In some
studies of Teresa A pellino et al. and Ingrid Svensson et al. patient also reported pain in last 24
hours. 13,16

In the present study majority of the cases the current pain status was found to be mild pain and
worst possible pain was found to be very severe pain. Average pain was found to be severe
pain.

In the present study total, 79% and 83% of respondents reported that they were “satisfied”
with how their nurses and physicians, study conducted by Jorge malouf et al 17 shows that
patients were highly satisfied with pain management, even when they were in pain. Moreover,
it establishes that patient dissatisfaction with treatment was highly related to the satisfaction
with caregivers and pain intensity.

Stahmer et al18 reported that patient satisfaction with pain management is associated with the
amount of pain relief achieved. Considering the overall high level of satisfaction, it appears that
pain relief alone is not the only factor that affects patient satisfaction with pain management.

In the present study 63% participants suggested that time lag for receiving the pain relief
medication in the study population is 0 to 10 minutes and in 28% cases the time lag is 11 to 20
minutes. This finding of the present study correlates with the finding of the study by shay
Phillips et al.19
In the study done by shay Phillips et al. 19 the correlation coefficient was determined to be r =
−0.31 (95% confidence interval = −0.79 to 0.39). This negative correlation was not significantly
different from 0, as implied by the 95% confidence interval, indicating the insignificance of the
trend line. But in contradiction to there study, in the present study spearman’s rank correlation
coefficients was determined to be r = 0.117. It shows the positive co-relation between patient’s
level of pain and their satisfaction with pain control.

Limitations:

 The present study was designed as a cross-sectional observational study.

 We did not address care in the intensive care unit, outpatient care, or pediatric
patients.

Conclusions:

1. The study was conducted in sample size of 200 with majority of the respondents was
male.

2. Majority of the participants belongs to age group of 31 to 50 years.

3. Majority of the patients felt the post operative pain in 24 hours of the surgery.
4. In majority of the cases the current pain status was found to be mild pain and worst
possible pain was found to be very severe pain. Average pain was found to be severe
pain.
5. In the present study total, only 79% and 83% of respondents reported that they were
“satisfied” with how their nurses and physicians

6. 63% participants suggested that time lag for receiving the pain relief medication in the
study population is 0 to 10 minutes.

7. The overall standard of response of hospital staff is poor towards the patients pain.

Reccomendations:

The standard protocol should be made for improving response of the nurses and
doctors towards the pain of the patients.

Implications:

This study will contribute to understanding that institutions should use pain intensity scores
together with a measure of patient pain satisfaction when assessing regulatory and quality
control programs.

The present study will help to improve treatment facilities of the hospital.
Conflict of interest: NIL

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