Preoperative Pain Management Education: An Evidence-Based Practice Project Katherine F. O’Donnell, DNP, APRN, FNP-BC Purpose: The purpose of this evidence-based practice project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients’ pain management outcomes. Design: The project was conducted in an outpatient general surgery service at a teaching institution for patients undergoing same-day surgery. Intervention patients received one-on-one education on postoperative pain management including how to take medications, managing medication side effects, using nonpharmacologic methods, and reporting inadequate postoperative pain control. Comparison patients received general education from multiple health care providers, and this information may not have been consistent. Methods: Intervention patients received education at the first preoperative clinic visit. Patients in the intervention and comparison groups completed the Revised American Pain Society Patient Outcome Questionnaire during their first postoperative clinic visit. Results were analyzed by the Mann-Whitney U test/Wilcoxon rank sum test. Findings: A 12-month project (N 5 99) showed statistically significant results (P 5 .020 and P 5 .001, respectively) in questions about side effects and whether the patient was encouraged to use nonpharmacologic methods to reduce pain. The intervention group reported the effects of pain on mood (P 5 .067) and use of nonpharmacologic methods (P 5 .052); however, these results were not statistically significant. Conclusions: More intervention patients than comparison patients reported medication side effects and were encouraged to use nonpharmacologic methods for reducing postoperative pain. Intervention patients also reported the effects of pain on mood and the use of nonpharmacologic methods more frequently than comparison patients. Preoperative pain management education may increase patients’ knowledge in key areas of postoperative pain management to prevent negative outcomes. Keywords: preoperative pain management education, postoperative pain, pain management outcomes, evidence-based practice. Ó 2017 by American Society of PeriAnesthesia Nurses Katherine F. O’Donnell, DNP, APRN, FNP-BC, Department of General and Minimally Invasive Surgery, University of Texas Health Science Center, San Antonio, TX. Conflict of interest: None to report. Address correspondence to Katherine F. O’Donnell, Medical Arts and Research Center, 8300 Pain Management Education Discussion Post

Floyd Curl Drive Suite 4A, San Antonio, TX 78229; e-mail address: odonnellk@uthscsa.edu. Ó 2017 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 https://doi.org/10.1016/j.jopan.2017.11.001 956 THE MANAGEMENT OF PAIN is one of the greatest clinical challenges for nurses who care for patients during the postoperative period. It can be even more challenging for patients who must manage their own pain after discharge from the health care facility. Research shows that postoperative pain continues to be undermanaged despite decades of education and evidence-based guidelines.1 A 2015 study showed a reduction in the Journal of PeriAnesthesia Nursing, Vol 33, No 6 (December), 2018: pp 956-963 PREOPERATIVE PAIN MANAGEMENT EDUCATION 957 severity of postoperative pain in the last decade, but many patients still reported severe pain.2 Patients may find the management of their own pain after discharge equally challenging and daunting. It is important that postoperative pain is well controlled, as ineffective treatment of postoperative pain may lead to negative outcomes such as deep vein thrombosis, atelectasis, pulmonary embolism, chronic pain, increased length of hospital stay, and readmission for pain management.3,4 Pain can limit the ability to return to work quickly, placing financial and emotional stress on patients and families.5 Preoperative education is a way to prepare patients to manage their pain and have a successful postoperative recovery. Education should include information on the importance of pain control, goals of treatment, how much pain the patient may experience, and the importance of reporting poorly controlled pain that interferes with recovery activities.1 Pain management options that should be explained to patients include both pharmacologic and nonpharmacologic methods.3,7,8,10 Overview of the Literature The framework for this project was based on the Iowa Model of Evidence-Based Practice to Promote Quality Care, which is an evidence-based practice model of care.11 Using the model one must identify problem-focused triggers or knowledgefocused triggers, which may be related to current practice to synthesize available evidence and introduce practice changes to improve outcomes. The effects of these changes on patient outcomes are monitored over time.12,13 In 2010, 48.3 million surgical and nonsurgical procedures were performed in the United States. These numbers continue to increase, making postoperative pain the most common cause of pain.6 Postoperative pain is considered acute pain and results from tissue damage, inflammation, and the healing process.4 Most patients report pain after surgery, and pain levels vary depending on the type of surgery, comorbidities, previous experiences with pain, age, gender, and patient expectations.4 This combination of factors makes it difficult to predict how much pain a patient will experience and how well pain will be tolerated, emphasizing the wide variability among patients and their pain experience. Inadequate assessment and management of postoperative pain can result in patient anxiety, insomnia, stress, and limited mobility.4 Poor communication between patients and health care providers, unrealistic patient expectations, and insufficient patient education all contribute to suboptimal pain control.3,4 Other obstacles to adequate pain management include lack of a comprehensive assessment plan, improper use of pain assessment tools, inadequate documentation, and barriers related to clinicians’ knowledge and attitudes about pain.7,8 Numerous pain assessment tools exist for evaluating and documenting pain in most patients, including pediatric, nonverbal, critically ill, or cognitively impaired patients.3 Assessment of pain includes use of age and condition appropriate tools, ongoing documentation, treatment measures, reassessment of the patient, and their response to treatment, including any adjustments in the treatment plan.3,9 Project Design: The Iowa Model Postoperative pain management was identified as a problem for clinicians at the University of Texas Health Science Center San Antonio, TX, outpatient surgery clinic. Using the Iowa Model, postoperative pain management served as the project’s problem-focused trigger.Pain Management Education Discussion Post

11 Patients often reported poorly controlled pain after surgery, inadequate knowledge about pain and analgesics, and limited understanding about medication side effects. Other problems included frequent requests for medication refills, visits to the emergency room for pain control, and the inability to return to work and normal activities because of poorly controlled pain. Using postoperative pain as the problem-focused trigger to initiate change, the author, hereby referred to as the project director, developed an evidence-based practice tool to educate patients about postoperative pain management. The goal was to educate patients undergoing elective laparoscopic cholecystectomy about taking medications correctly, managing side effects, the use of nonpharmacologic methods, and reporting any medication side effects. Patients were also instructed to report inadequate pain control, uncontrolled nausea and vomiting, and severe constipation after surgery. KATHERINE F. O’DONNELL 958 Project Implementation Before implementation, meetings were held to educate other providers and support staff (medical assistants and schedulers) about the project goals, and to ask for their input and feedback. Everyone received a copy of the project abstract, the patient education materials, and the patient questionnaire. The University of Texas Health Science Center San Antonio, TX, Institutional Review Board approved the project as exempt. Data were collected from January 2013 through January 2014. Patient Education Information Tool and Postoperative Questionnaire All project participants were scheduled for elective laparoscopic cholecystectomy. During the first preoperative visit, patients in the intervention group received one-on-one education about postoperative pain management that included information on taking medications correctly, managing and reporting medication side effects, using nonpharmacologic methods for pain relief, and the importance of reporting inadequate pain control as soon as possible. The project director developed a written education tool in both English and Spanish that highlighted important pain management points (Box 1). Each intervention patient received a copy of the tool and was instructed to make an appointment with the project director 2 weeks after surgery. The project director was responsible for providing the educational material, collecting and storing questionnaires, and ensuring patients returned for the postoperative visit. All patients returned 2 weeks postoperatively. At the first postoperative visit, patients in the intervention group and patients in the comparison group that did not receive structured preoperative education were asked to complete the Revised American Pain Society Patient Outcome Questionnaire14,15 (Supplementary Appendix). The tool asks patients to answer 12 questions and measures six postoperative pain quality aspects: pain severity/relief; impact of pain on activity; sleep and mood; side effects of treatment; helpfulness of information; ability to participate in decision making about pain management; and use of nonpharmacologic methods. Severity of pain and/or symptoms is measured using a 0 to 10 rating scale. Pain Management Education Discussion Post

The questionnaire is available on the Internet and can be used without permission (americanpainsociety.org). Demographic data were collected for age and gender of each patient. Results Ninety-nine patients completed questionnaires at the first postoperative visit, 38 in the intervention group and 61 in the comparison group Box 1. Patient Education Information Tool What you need to know about postoperative pain Pain control after surgery is very important. When your pain is controlled you sleep better, eat better, and return to normal activities sooner. You may recover more quickly from your surgery and get back to work sooner. The following information will help you understand how to manage your pain after surgery. 1. Take pain medication as directed. The best time to take medication is when the pain first begins. If pain is worse with activity such as walking or going to the bathroom, take the medication on a regular schedule. 2. Manage side effects early. Some medications cause constipation or nausea. Take medications with food to avoid nausea and also take a stool softener daily to prevent constipation. 3. Report side effects such as severe nausea, vomiting, or constipation. 4. Comfort measures such as heat, ice, massage, relaxation, walking, or listening to music may help. 5. Communicate with your provider if your pain is not controlled. You may need different medication or a stronger dose to relieve your pain. 6. Be sure to make a postoperative visit and discuss any problems with your pain management. PREOPERATIVE PAIN MANAGEMENT EDUCATION (Figure 1). Results were analyzed by the MannWhitney U test/Wilcoxon rank sum test. A P value less than .050 was considered to be statistically significant. Statistically significant results were found in questions about reporting side effects (P 5 .020) (Figure 2), and encouragement by health care providers to use nonpharmacologic methods for pain management (P 5 .001) (Figure 3). Patients in the intervention group reported the effect of pain on mood (P 5 .067) (Figure 4) and use of nonpharmacologic methods (P 5 .052) (Figure 5); however, these results were not statistically significant. Reporting Side Effects Educating patients about potential medication side effects, as well as managing patient expectations, is important to avoid complications and adverse outcomes.4 Patients in the intervention group reported drowsiness after surgery, which can lead to limited mobility and pose a safety hazard. Both the patient and family should understand the multiple causes of pain and possible side effects of anesthesia and analgesia. Providing this information can reduce unnecessary patient suffering and anxiety as well as avoid prolonged negative side effects that delay recovery.4 Patients should 959 be encouraged to use multimodal analgesia and nonpharmacologic methods to relieve pain.16 Patients and families need to be involved in preoperative pain management education about using multimodal methods, how they work, and what to expect. It is important for patients and health care providers to collaborate to achieve optimal pain management.3 Encouraging Use of Nonpharmacologic Methods Intervention patients reported that health care providers encouraged the use of nonpharmacologic methods. Methods such as relaxation, guided imagery, and behavioral health interventions can be combined with a multimodal approach and act synergistically to relieve pain.Pain Management Education Discussion Post

17 Educating patients about pain management that includes using these methods should start at the preoperative visit and continue throughout the postoperative period.4,10 Effect of Pain on Mood and Emotions The intervention group reported that postoperative pain had an effect on mood and emotions such as depression. The relationship between pain and mood or emotions was not included in Figure 1. Demographics. This image is available in color online at www.jopan.org. KATHERINE F. O’DONNELL 960 Figure 2. Reporting side effects. This image is available in color online at www.jopan.org. the patient education tool; however, poorly controlled pain can lead to anxiety, prolonged hospitalization, and lack of self-efficacy or confidence in one’s ability to perform normal activities after surgery.13 Preoperative education can reduce anxiety and depressed mood to improve outcomes including pain control, analgesic use, and length of hospital stay.18 This information can be included if the tool is revised. Use of Nonpharmacologic Methods Intervention patients reported the use of nonpharmacologic methods to manage pain including guided imagery, massage, distraction, and relaxation. Relaxation was used as an effective method to reduce postoperative pain in patients having upper abdominal surgery.10 Other methods including ice packs and listening to music can Figure 3. Encouraging use of nonpharmacologic methods. This image is available in color online at www.jopan.org. PREOPERATIVE PAIN MANAGEMENT EDUCATION 961 Figure 4. Effect of pain on mood and emotions. This image is available in color online at www.jopan.org. be used along with analgesics in reducing postoperative pain. Discussion The purpose of this project was to provide preoperative education to improve postoperative pain management outcomes. Patients who received structured education identified and reported side effects more often and also were encouraged to use nonmedical (nonpharmacologic) methods by health care providers. Side effects can occur from a combination of the surgical procedure, anesthesia, and pain medications; therefore, it is important that patients understand these factors. Medication side effects should be reported if these interfere with a patient’s recovery. Using methods such as guided imagery, massage, ice packs, and music can enhance pain control after surgery. A relationship was found between intervention patients and reporting the Figure 5. Use of nonpharmacologic methods. This image is available in color online at www.jopan.org. KATHERINE F. O’DONNELL 962 effect of pain on mood, and the use of nonpharmacologic methods to relieve pain. Information about the effect of pain on mood and emotion was not included in the original patient education tool, but can be added in the future.

Identifying side effects of pain medications and medication ineffectiveness early on can prevent complications such as nausea, vomiting, allergic reaction, and prolonged, poorly controlled pain. It is possible that those who did not receive education did not report side effects as often, leading to negative outcomes. When patients understand how pain affects their mood, they understand the importance of taking pain medications correctly and reporting poorly controlled pain as soon as possible after surgery. Limitations The project was limited by a small sample size and restricted time for educating patients. A total of 123 patients received preoperative education from the project director, but some were lost to follow-up because they saw other providers at the postoperative visit, or they did not complete the questionnaire as instructed. Some patients in the comparison group reported receiving preoperative education, but it is unclear who provided the information or what content was covered. Most patients received general education on discharge from surgery, but some lost the information, did not understand it or did not follow the instructions. Finally, patients may see multiple health care providers before surgery, making it difficult to insure each patient receives consistent and appropriate preoperative education. Future Recommendations The patient education tool is now incorporated in the electronic medical record for all patients anticipating elective surgery. Future projects could use telephone surveys about postoperative pain management to increase the sample size, including patients having both elective and nonelective (emergent) surgery. Educating all those involved in postoperative pain management, including medical assistants, nurses, resident, and faculty physicians, is important to ensure patients receive consistent information during the perioperative period.3,4 Conclusions Managing postoperative pain is essential for recovery, but remains challenging for both patients and health care providers. Poorly controlled pain can delay recovery, leading to prolonged hospital stays, immobility, and negative outcomes such as deep vein thrombosis and chronic pain. These sequelae can impact the ability to return to work and normal activities. This project provided education to patients anticipating elective surgery to improve postoperative pain management outcomes. Pain management education included information on taking medications correctly, managing and reporting medication side effects, using nonpharmacologic methods for pain relief, and the importance of reporting inadequate pain control as soon as possible. Intervention patients reported side effects and were encouraged to use nonpharmacologic methods for pain management; these results were statistically significant. Intervention patients also reported the effect of pain on mood and also using nonpharmacologic methods to control pain; these results were not statistically significant. Results suggest that preoperative patient education may increase knowledge in key areas of postoperative pain management and prevent negative postoperative outcomes. Acknowledgments The author would like to acknowledge Jimmy Rose, PE, MS, Engineering Supervisor, Lower Colorado River Authority for assistance with graphics; and Martin G. Schwacha, PhD, Professor, Department of Surgery, University of Texas Health Science Center, San Antonio Director, Research Residents Program for assistance with statistical analysis. Supplementary Data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jopan.2017.11. 001. References 1. Chou R, Gordon DB, de Leon-Ca …