Literature_Review_on_Pain_Assesment

Introduction The importance of evidence based practice has been emphasised by many key health care organisations, giving the opportunity and responsibility for nurses to commit to evaluating current clinical practice and identify research to improve care (NICE,2010; NMC,2008). The importance of evaluating care standards is paramount in determining whether clinical standards and set guidelines are being achieved in practice. Nursing research has become a helpful asset to the health care systems when contending with the rising costs of health care and ever growing vast services available to the nation. Through the use of research, nursing practice has aided in the health service in remaining sustainable by becoming more strategic and cost effective (DOH, 2008). This literature review is based on postoperative pain assessment within a ward setting. It is the purpose of this literature review to collate, critically evaluate and synthesise the literature on the most current issues surrounding the pain assessment process. By examining primary sourced data the aim of this study is to gain an impartial, comprehensive view of the pain assessment process. Through the main body of this literature review, themes will be identified regarding both the patient and nurse perspective and barriers to the equality in pain management care. A conclusion and recommendations will then be offered based on the results. Over half a billion pounds is spent on pain medication annually by the National Health Service and this is expected to rise with the age of the population (Donaldson, 2008). With such advancement in analgesia, nursing staff must understand the influences in the pain assessment process which is resulting in inadequate pain relief being such prevalence in hospitals (Bedard et al., 2006; Devine et al.,1999; McCaffery et al.,2000; Watt-Watson et al., 2001). Several studies have shown the detrimental effects of high levels of postoperative pain (Lyn et al., 2005; Fortier et al, 1996), it is therefore important to understand these issues with the current systems in place, so an intention of change can be made in the future based on the best evidence shown through this review. Methodology and Results This review contains many different methods of research including both qualitative clinical trial studies and quantitative data, alongside the use of policies regarding assessment tools already validated in practice. The literature reviewed was related to one dimensional assessment tools (Breivik et al., 2008). These are the numerical, verbal and visual scales used for patients post-operatively within a surgical setting. The purpose of the use of all three validated pain assessment tools is to provide the greatest range of research; as the investigation in to just one or two scales provided little depth of latest results and statistics. The investigation was of a multi field search, databases used were: Cinahl Plus, The Cochrane Library, PubMed, Wiley Online Libary, Science Direct and EBSCOhost. The use of specific websites such as the National Institute for Health and Clinical Excellence, Department of Health and government websites were searched in pursuit of clinical guidelines, frameworks and policies relating to pain assessments or relating factors. The key words used for the search were ‘pain assessment’ with either ‘postoperative’ or ‘management’, ‘patient perspective pain assessment’, ‘nursing perspective of pain’ ‘ Patient satisfaction’, ‘pain attitudes post operatively’ and ‘pain scales’. The search conducted was exclusive to English language articles however it was not limited to just British published research in order to gain a greater deal of results to strengthen the review. The publication date was restricted from 1992-2011 as earlier work was important to note, however the majority of the studies used in this review have been published in the last ten years. Furthermore some articles were allowed below the restriction due to clinical importance. Most articles found were from a primary source, this was primarily driven by database searches, and although books were used, up to date information from them was limited. The use of primary data allows this review to reduce or identify the levels of bias relating to each article. Any bias or limitations of an article will be indicated in both the body of each theme or conclusion, and any smaller scale studies or weak correlations will be further supported by other research. Many from the 1,204 results found were excluded due to the irrelevance of the subject or missing data. The majority of studies were of qualitative studies such as observation or questionnaires with some reference to quantitative data. Pain Assessment Acute pain is often described as a subjective human experience, which affects both the physical and psychological aspects of a person for a limited period of time. There are many who try to define pain, some illustrating pain as a scientific consequence of a biological stimulus, signalling tissue damage. Others define pain with sensory emotional factors and regard it as existential (Torrance & Serginson, 1999). Individuals who experience pain often come in to contact with the health care service, and assessment tools are used to understand and measure the pain levels of a patient. This is with the aim to easily quantify and measure the results of the pain management strategy being used to improve quality of care (Gould et al., 1992; Dunwoody et al., 2008; Aubrum et al., 2003). Validated post operative pain assessments most commonly involves the determination of pain intensity by the patient post operatively through the use of a one-dimensional scale, such as the numeric rating scale (NRS), the visual analogue scale (VAS) or Verbal rating scale (VRS) (Breivik et al., 2000; Gagliese, et al., 2005). Although all three assessments have been validated by many organisations, research has shown that unified assessment tools are not enough when assessing a patients pain levels or the effectiveness of their pain management. In the case of numerical rating tools, Dijkers (2010) supports Onhahaus & Adler (1975) in the belief that patients cannot conceptualise their pain intensity numerically when the pain is a continuous sensation, with which only words can describe. This study however had a small sample of participants (185) and only 36 participants completing 10 direct comparisons between VRS and NRS. In comparison, a study by Breivik et al (2008) found the VAS and NRS superior for assessment of pain intensity, and is equally sensitive in assessing acute pain after surgery. The results also found they both are superior to a four-point verbal categorical rating scale (VRS). This is because interpretation of the descriptive words used for pain may vary between patients or have little relevance (Heikkinen et al., 2005; Mackintosh, 2005). Another important issue raised by researchers is that the numerical score by one patient, may have a completely different meaning to another, this also opens up the question of how much pain intensity is significant to both the patient and staff (Manias et al., 2002; Sloman et al., 2005). Some studies have attempted to try and identify a clinically significant improvement in pain intensity (Walraven et al., 1999; Sloman et al., 2005; Breivik et al., 2008) all with differing results because of different methodology, however each patient should be assessed as individuals as their pain is both personal and subjective as ‘pain is whatever the experiencing person says it is, existing whenever he says it does’ (McCaffery 1972, cited in Alexander et al., 1994, p 736). Having adequate pain assessment by using validated tools appropriate to the individual is an essential prerequisite of successful pain management, as without adequate pain assessment there will ultimately be failings in the pain management (Harmer & Davies, 1998). It is therefore important for each nurse to recognise that assessing pain with validated assessment tools have limitations even when used correctly, as areas for improvement could be identified from both a patient perspective and nursing perspective. Therefore to improve the quality of postoperative pain management it is important these barriers are explored. Nursing Perspective Nurses have a professional responsibility to assess pain, and this is a critical skill in order to prevent or reduce the experience of pain felt by the patient. This in itself is a significant goal needed to be achieved to prevent complications from surgery relating to inadequate pain management, such as immobility or deep vein thrombosis (Stubhaug & Breivik, 2008). Nurses play a key role in pain management as they are in a position to consistently systematically assess and evaluate the effectiveness of pain treatments, with the opportunity to report and change any interventions already in place. Adopting best clinical practice guidelines, nurses can offer the most holistic and optimal pain management strategy to aid in recovery (NMC, 2008). This review however has identified influencing factors that show nurses are not adequately or consistently using evidence based postoperative pain assessment practices (Devine et al., 1999; Starck, 2001). Nurse Communication A study has shown that patients expressing their pain by a validated scale or their own words had the same response strategy by the nurses (MacDonald et al., 2007). This offers insight to the reasoning behind the lack of communication, as it not the scales resulting in bad communication, other factors may exist that results on pain still being such an issue on the wards. Teaching must be given to staff to help them understand how to aid communication between not only themselves, but between themselves and the patient about unrelieved pain. This is in order to enhance comfort and improve satisfaction as inadequate communication exists between patients and nurses (Davis et al., 2000). Recent studies by MacDonald et al (2000) and Rodgers & Todd (2000) found communication for patients pain was indirect and left little opportunity for the patient to feel comfortable in expressing their pain. Another perspective is the way nursing and clinical staff asks questions to the patient, in many cases nursing staff only assess pain when they are taking the patients observations, and assess pain in a more social context rather than a clinical one. This is unaided by not asking specific questions or not delving into too much detail (McDonald et al., 2000; Rodgers & Todd, 2000). This results in the patient suppressing their concerns or pain in order to answer in a social accepted manner such as ‘ im fine’ rather than expressing their pain to their nurse. The form of communication is important for nursing staff to understand, having a friendly but professional balance for communicating with patient could be considered difficult but it is an important aspect when assessing a patient for their pain. Without having the trust or support of the patient, the true perspective of a patient in pain will not be understood by the nurse. This does not only complicate the healing process for the patient, but communication barriers or issues within this relationship may not be resolved. The lack of communication and other factors add to the complexity of pain management, these issues all intertwine with each other making changes for the best a challenging task on any ward. Assessment and Documentation Nurses often assess pain infrequently (Gelinas et al., 2004; Manias et al., 2004), and this is supported in many studies. Less than one third of nursing staff in MacDonald et al (2007) study planned to actively reassess a patient’s pain and only 4.1% of nurses felt it was necessary to keep treating a patients pain until an acceptable level of pain was achieved for the patient. This could be a result of nurses feeling a lack of responsibility or power as it is seen as the responsibility of a doctor to prescribe medication (Manias et al., 2002; MacDonald et al., 2007). This idea is supported by Carlsons (2010) study as nurses supported the statement that they are not only hesitant to contact physicians if pain control is inadequate, but agree patients do not receive adequate pain relief. Assessment must account for the special needs of vulnerable patients such as the elderly and ethnic minorities and is vital when assessing post operative pain. Older adults may use a range of words other than ‘pain’ to describe their pain experience. A patient who has a cognitive impairment may have difficulty using a variety of pain measurement tools. Nursing staff should be able to identify those patients in need and other tools such as the pain assessment checklist for seniors with limited cognitive ability should be used (Fuchs-Lacelle & Hadjistavropoulos, 2004).  Consistent documentation can offer the opportunity of a good pain management plan is essential for each patient (Starck et al., 2000). However audits have found 88% on average of medical notes have limited documentation relating to the pain assessment of the patient (Lellan, 1997; Manias et al., 2000). Postoperative care should focus on assessment and documentation at least every four hours with the reassessment of pain relief at peak intervals for each pain management intervention such as mobilising (Sherwood et al., 2003; Be̕dard et al., 2006), these studies however show practice is to the contrary. Nursing Knowledge Another Perspective is that pain post operatively is viewed by staff as a necessary side effect of surgery (Twycross, 2002) and pain management on wards is good (Marlies et al., 2000). The positive perception of nurses concerning their ideas on adequacy of pain management in their work environment is a potential deterrent to changing behaviour (Carlson, 2010). Underestimating a patient’s pain and the issue may be a result of inadequate education for staff on pain assessment and management. An example of this is a study conducted by Brown and McCormack (2006) that showed a lack of education left the nurse indifferent to the individual needs of each patient. Education programs addressing these issues have shown to increase the nursing knowledge of pain, (Weissman et al., 1995; Ferrell et al., 1993) however more recent studies have found little improvement in nursing knowledge of pain management with opioids, or actively sourcing pain education programs after basic education (McCaffery & Robinson, 2002; Simpson et al., 2002; Tanabe et al, 2000; Marlies et al., 2000). Nursing Experience Nursing staff have been shown to have practices that are not evidence based when assessing pain and influences from previous experience do not always benefit the patient. Studies conducted by Middleton (2004) and Sloman et al (2005) supports best evidence based practices by stating that a patients physical pain is individual, and does not correlate to physiological damage from a surgical procedure. It is therefore discouraging to find a nurse stating ‘ I don’t think he was supposed to experience pain like that’ judging from past experience (Klopper et al., 2006). Another example of devaluing a patients report of pain is a nurse expressing ‘Ive seen most of the patients....who had similar operation to his, so i think they experience the same pain’. Another nurse established this with ‘yeah, the type, you know, we rate pain, you know according to the type of surgery’ (Klopper et al., 2006). Undervaluing a patients report of pain is unethical but studies have shown this to be common practice (McCaffery et al., 2000; Horbury et el., 2005; Trentin et al., 2001; Idvall et al., 2002), the nurses in these cases believed to know better than the patient on their pain and this has added to the prevalence of pain postoperatively. Patients’ self-reporting of their pain is regarded as the gold standard of pain assessment measurement as it provides the most valid and accurate measurement of pain, as pain should be seen as an individual experience (Melzack and Katz, 1994) and should not be overridden by the nurses experience of pain. Patient Perspective Evidence shows that in spite of pain management guidelines, patients are still suffering high levels of pain postoperatively (Starke et al., 2000; Devine et al., 1999). A substantial amount of research has been identified targeting health care professionals and the institution in which they care for patients. It is now important to review research concerning not only the barriers formed by the institution and nurses, but explore the attitudes and experiences of patients in order to understand these barriers created. To provide high quality care for patients, important and influencing barriers must be recognised by the nurses and practitioners if the quality of care is to improve on the wards. Although many barriers created by the patient cannot necessarily be changed by nursing staff, by nursing staff being aware that barrier do exist, new care plan pathways and education may bring better understanding to both the patient and nurse when communicating and assessing pain. Patient Communication Having patient-centred communication has been recognised as an essential tool to high standards of care and positively affecting patients’ satisfaction and health (Stewart et al., 2000; Roter, 2004). Communicating pain to nursing staff is a complex issue that is remaining difficult for patients and this may be linked to the theory of Parson sick role theory, which traditionally both the nurse and patient play different roles. Patient conduct within this role is to co-operate with medical staff with the purpose of becoming well. Patients alerting staff to unresolved pain may be seen as not fulfilling the clinically appropriate role. By questioning the care being received the consequences for the patient could be seen as being socially deviant. In addition to also having pain may result in a delayed discharge so they cannot return to being an active citizen in society (Latimer, 2000; Faulkner & Aveyard, 2002). An example of this is a quote from a practitioner telling his patient ‘We can’t have you languishing in pain-you can’t do things’ (Evans, 2010). By participating in this role patients will be seen in a positive light, and ‘take their own bodies as objects, survey their pain and report it in neat, orderly numbers from one to ten. Watched on all sides’. (Evans, 2010, p29) Another perspective is raised by Dihle et al., (2006) through observation. This study found nursing staff were disconnected with their patients, and so patients themselves found little in the opportunity to ask for support with pain without sounding the bell. This would then highlight the patient to other patients, reducing the feeling of privacy. This situation is repeated by another observational studies, showing the patient felt they were bothering the busy nursing staff by ringing the bell when they were in pain (Evans, 2010; Idval et al, 2008; Carr, 2002). This in practice appears to be common as staff shortages increasing and patients having more intensive care needs. Patients who are self-reporting their pain to nursing staff may be influenced by numerous factors including their age, mood, sleep deprivation, side effects of medications. This may result in patients not reporting pain accurately to the nurse (Peter & Watt-Watson, 2002), and an example of this is of a patient being unable to communicate as they have become too drowsy as a result of a side effect of their medication. Patient Knowledge It is the right of the patient to receive clear information regarding their treatment; this is to give them the opportunity to participate in the decisions relating to their recovery (Taylor & Stanbury, 2009). Attention must be given to the patients’ perspective of thier knowledge of pain and assessment. As patients who understand the procedure and pain management techniques are more likely to be less anxious and post-operative pain has less impact on their general activity (Be̕dard et al., 2006; Sheard & Garrud, 2006; Daltroy et al., 1998). There are many patient related barriers to patients understanding the necessity of accurate pain assessment and the use of analgesics for recovery. These barriers include the patients’ previous ideas of pain, fear of addiction, side effects to analgesics, and the idea that ‘good’ patients do not talk about pain (Be̕dard et al., 2006) This can result in not actively volunteering information and patients becoming passive when the pain assessment is being completed, which can ultimately affect the pain management process. Patients who have more understanding of the healing process may be less anxious, and this can have a positive effect on the recovery process. Such as experiencing less pain and less postoperative depression that is linked to increased pain levels (Kane et al., 2000; Kalkman et al., 2003; Kudoh et al., 2003). A recent study conducted by Smith et al (2009) found that a 30 minute education and communication programme for patients found a significant difference in the barriers relating to pain management. The barriers discussed were relating to the misconceptions of analgesia, and how to communicate effectively with nursing staff. This is supported by other recent studies supporting that preoperative information results in improving analgesic therapy, and reducing the restrictive behaviour of analgesics (Wilder-Smith & Schuler, 1992; American Pain Society, 1995; Max, 1990; Calvin et al., 1999; Stacey et al., 1997; The British Centre cited in Sherwood et al, 2003; Be̕dard et al., 2006). An example of improvement through the use of clear information for patients is a study conducted by Carr (2002) that found post intervention 70% of patients were found refusing analgesia. After implementing the ‘Model for improvement’ (Langley et al., 1996) 62% of patients accepted analgesics and 68% of those who refused reported no pain. In this study patients were encouraged to become active participants in their pain management and not become passive about the care they received. This was observed in a study by Manias et al (2006) where 60% of patients were acting as passive recipients of care and were not proactively supporting their own pain management needs. This is concerning as a large survey showed that within 36 national health service hospitals, 42% of patients had to ask for medication and 87% of patients had pain levels from moderate to severe (McQuaya et al., 1997). Patient Satisfaction Patient satisfaction is an indicator, if not an elusive one, used to determine the effectiveness of pain management. The issue with relating patient satisfaction to pain management as it does not always identify the assessment and management of pain was to a high standard (Dawson et al., 2002; Gordan et al., 2002; Be̕dard et al., 2006), In some cases patient satisfaction may be related to the overall stay within the hospital, e.g. the room, meals, ect. Patient satisfaction can also differ greatly with each patient as each individual has a different expectation of surgery post operatively, and ideas on what is satisfactory or not (Sherwood et al., 2003). A clear example of this is a study by Bostrom et al (1997) that found 79% of patients were experiencing moderate to high levels of pain, but 83% were satisfied with their pain management. A different approach by Be̕dard et al (2006) found that even with an evidence based education program for patients that found decreased levels of pain, patients from both phases were equally satisfied with pain management. This may be linked to a study exploring interactions between patients and their nursing staff and the outcomes of high levels of satisfaction (Sherwood et al., 2000; Dawson et al., 2002; Idval et al., 2002; Idval et al., 2008; Be̕dard et al., 2006). As long as the nurses were represented as being the ‘good’ and ‘busy’, then regardless of issues relating to the pain assessment and management, the patient would be satisfied with the care (Evans, 2010). This even extends to patients excusing bad pain management and blaming their poorly managed pain to themselves. As long as the patient perceives the nursing and clinical staff show concern for the patient the patient is satisfied. This notion is concerning for both the development of staff and the welfare of the patient. Nursing staff have the understanding that care they offer is of a high standard, based on the supporting statements of the patient. If patients are suffering in silence, then the awareness and ultimately the need for change will not exist on the wards. Conclusion Accurate pain assessment is the first stage of pain management and without this being consistent and clear, pain management will ultimately fail regardless of the technological and pharmacological advances in medicine. As without the true assessment of pain, decisions regarding analgesia and care cannot be made, resulting in pain being poorly managed. Managing postoperative pain is an essential for increasing better outcomes for both the nursing staff, the patient and ultimately the National Health Service. The studies used within this literature review have differed greatly on the scale, so to offer the most concrete evidence for the findings; many studies have been used to show validity. Furthermore, the use of many articles based in all areas of surgical nursing was purposeful to gain an understanding of the prevalence of pain that is on all surgical wards. Qualitative research has many advantages exploring the interactions of the nurse and patient. Some studies however may have had different results if researcher were not so visible when these interactions were taking place. However, due to the amount of studies provided and consistency of the findings throughout, this review has highlighted issues both with the institution, nursing staff and patient. It is now important to recommend changes based on best evidence. Recommendations for practice To improve post operative pain assessment a series of sustained interventions targeting the institution and nursing practice has to be made, to improve the patient understanding and involvement in postoperative care. With these recommendations, further clarity on pain assessment and accountability for poorly managed pain could then result in a more collaborative approach to pain management and better patient outcomes. The recommendations are: * Further large scale qualitative studies examining both the nurse and patient barriers to postoperative pain assessment with impartial researchers reducing the levels of bias in results. * Due to the shortfalls of some existing studies a more accurate and clear methodology is required. * Develop a more rigorous pathway of pain assessment linked with the already validated uni-dimensional tools. * Introduce education programs for both patient and health care providers to learn skills and knowledge to manage pain effectively. References Alexander, M., Fawcett, J & Runciman, P. (1994) Nursing Practice; Hospital and Home. London: Churchill Livingstone LTD. American Pain Society (1995) Quality Improvement Committee. ‘Quality improvement guidelines for the treatment of acute and cancer pain’, (274) 23 pp. 1847-1880. Aubrun, F., Paqueron, X., Langeron, O., Coriat, P & Riou, B. (2003) ‘What pain scales do nurses use in the post anaesthesia care unit'’, European Journal of Anaesthesiology, 20 (9), pp. 745-749. Bedard, D., Purden, M., Sauve-Larose, N., Certosini, C., & Schein, C. (2006) ‘The Pain Experience of Post Surgical Patients Following the Implementation of an Evidence-Based Approach’, Pain management Nursing, 7 (3), pp. 80-92. Bostrom, B., Ramberg, T., Davis, B & Fridlund, B. (1997) ‘Survey of post-operative patients’ pain management’, Journal of Nursing Management, 5 (6) pp. 341-349. Brevik, H., Borchgrevink, P., Allen, M., Rosseland, L., Romundstad, L., Hals, E., Kvarstien, G & Stubhaug, A. (2008) ‘Assesment of pain’, British Journal of Anaesthesia, 101 (1), pp. 17-24. Breivik, E., Bjornsson, G & Skovlund, E. (2000). ‘A comparison of pain rating scales by sampling from clinical trial data’, Clinical Journal of Pain, 16 (1), pp. 22-28. Brown, B & McCormack, B. (2006) ‘Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study’, Journal of Clinical Nursing, 15 (10), pp. 1287-1298. Calvin, A., Becker, H., Biering, P & Grobe, S. (1999) ‘Measuring patient opinion of pain management’, Journal of Pain Symptom Management, 18 (1), pp. 17-26. Carr, E. (2002) ‘Refusing analgesics: using continuous improvement to improve pain management on a surgical ward’, Journal of Clinical Nursing, 11 (6), pp. 743-752. Carlson, C. (2010) ‘Prior conditions influencing Nurses decisions to adopt evidence-based post-operative pain assessment practices’, Pain Management Nursing, 11 (4), pp. 245-258. Daltroy, L., Morlino, C., Eaton, H., Poss, R., Liang, M. (1998) ‘Preoperative education for total hip and knee replacement patients’, Arthritis and Rheumatism, 11 (6), pp. 469-478. Dawson, R., Spross, J., Jablonski, E., Hoyer, D., Sellers, D., Soloman, M. (2002) ‘Probing the paradox of patients’ satisfaction with inadequate pain management’, Journal of Pain Symptom Mangement, 23 (3), pp. 211-220. Davis, G., Hiemenz, M., White, T. (2002) ‘Barriers to managing chronic pain of older adults with arthritis’, Nursing Scholarship, 34 (2), pp. 121-126. Department of Health (2008) Departmental Report 2008: The Health and Personal Social Services Programmes. London: The Stationary Office. Devine, E., Bevsek, S., Brubakken, K., Johnson, B., Ryan, P., Sliefert, M & Rodgers, B. (1999) ‘AHCPR Clinical practice guideline on surgical pain management: adoption and outcomes’, Research in Nursing and Health, 22 (2), pp. 119-130. Dihle, A., Bjölseth, G & Helesth, S. (2006) ‘The gap between saying and doing in post operative pain management’, Journal of Clinical Nursing, 15 (4), pp. 469-479. Dijkers, M. (2008) ‘Comparing quantification of pain severity by verbal rating and numeric rating scales’, The journal of spinal cord medicine, 33 (3), pp.232-242. Donaldson, L. (2008) ‘On the state of Public Health, Pain: Breaking through the barrier.’ Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_096250.txt (Accessed 20/04/2011) Dunwoody, C., Krenzischek, D., Pasero, C., Rathmell, J & Polomana, R (2008) ‘Assessment, physiological monitoring and consequences of inadequately treated acute pain’, Pain Management Nursing, 9 (1), pp. 11-21. Evans, A .(2010) ‘Governing Post-Operative Pain: The Construction of ‘Good and Active’ Patients, ‘Good and Busy’ Nurses and the Production of Docile Bodies’, The Nursing Journal, 2 (3), pp. 24-31. Faulkner, M & Aveyard, B. (2002) ‘Is the hospital sick role a barrier to patient participation'’ Available at: http://www.nursingtimes.net/nursing-practice-clinical-research/is-the-hospital-sick-role-a-barrier-to-patient-participation/206373.article Accessed 18/04/2011. Ferrell, B., Grant, M., Ritchey, K., Ropchan, R & Rivera, L. (1993) ‘The pain resource nurse training program: An unique approach to pain management’, Journal of Pain and Symptom Management, 8 (8), pp. 549-556. Fuchs-Lacelle, S & Hadjistavropoulos, T. (2004) ‘Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC)’ Pain Management Nursing, 5 (1), pp. 37-49.  Gagliese, L., Weizblit, N., Ellis, W & Chan, V. (2005) ‘The measurement of postoperative pain: A comparison of intensity scales in younger and older surgical patients’, Pain, 117 (3), pp. 412-420. Gelinas, C., Fortier, M., Viens, C., Fillion,L & Puntillo, K. (2004) ‘Pain assessment and management in critically ill intubated patients: A retrospective study’, American Journal of Critical Care, 13 (2), pp. 126–135. Gordan, D., Pellino, T., Miaskowski, C., Mc Neill, J., Paice, J., Laferriere, D & Bookbider, M. (2002) ‘A 10 year review of quality improvement in pain management; Recommendations for standardized outcome measures’, Pain Management Nursing, 3 (4), pp. 116-130. Gould, T., Crosby, D., Harmer, M., Lloyd, S., Lunn, J., Rees, G., Roberts, D & Webster, J. (1992) ‘Policy for controlling pain after surgery; effect of sequential changes in management’, British Medical Journal, 305 (1), pp. 1187-1193. Harmer, M & Davies, K. (1998) ‘The effect of education, assessment and a standardised prescription on postoperative pain management. The value of clinical audit in the establishment of acute pain services’, Anaesthesia, 53 (5), pp. 424-30. Heikkien, K., Salantera, S., Kettu, M., Taittonen, M. (2005) ‘Prostatectomy patients’ postoperative pain assessment in the recovery room’, Journal of Advanced Nursing, 52 (6), pp. 592-600. Horbury, A., Henderson, A., Bromley, B. (2005) ‘Influences of patient behaviour on clinical nurses' pain assessment: Implications for continuing education’, The Journal of Continuing Education in Nursing, 36 (1) (2005), pp. 18–24. Idvall, E., Hamrin, E., Sjöström, B & Unosson, M. (2002) ‘Patient and nurse assessment of quality of care in postoperative pain management’, Qual saf Health Care, 11 (4), pp. 327-334. Idvall, E., Bergqvisy, A., Silverhjelm, J & Mitra, U. (2008) ‘Perspectives of Swedish patients on postoperative pain management’, Nursing and Health Sciences, 10 (2), pp. 131-136. Kane, Z., Sevarino, F., Alexander, G., Pincus, S & Mayes, L. (2000) ‘Preoperative anxiety and post operative pain in women undergoing hysterectomy: a repeated- measures design’, Journal of Psychosomatic Research, 49 (6), pp. 417-422. Kalkman, C., Visser, K., Moen, J., Bonsel, G., Grobbee, D & Moons, K. (2003) ‘Preoperative predictors of severe postoperative pain’, Pain, 105 (3), pp. 415-422. Klopper, H., Andersson, H., Minkkinen, M., Ohlsson, C., Slöström, B. (2006) ‘Strategies in assessing postoperative pain-A South African study’, Intensive and Critical Nursing, 22 (1), pp. 12-21. Kudoh, A., Katagai, H & Takazawa, T. (2003) ‘Increased postoperative pain scores in chronic depression patients who take antidepressants’, Journal of Clinical Anaesthesia, 14 (6), pp. 421-425. Langley, G., Nolan, K., Nolan, T., Norman, C & Provost, L. (1996) ‘The improvement guide.’ Sanfancisco,CA: Jossey Bass inc. Latimer, J. (2002) ‘The Conduct of Care.’ Melbourne: Blackwell Science. Lellan, K. (1997) ‘A chart audit reviewing the prescription and administration trends of analgesia and the documentation of pain, after surgery’, Journal of Advanced Nursing, 26 (2), pp. 345-350. Lyn, L & Wang, R. (2005) ‘Abdominal surgery, pain and anxiety: preoperative nursing intervention’, Journal of Advanced Nursing, 51 (3), pp. 252-260. MacDonald, D., McNulty, J., Erickson, K., Weiskopf, C. (2000) ‘Communicating pain and pain management needs after surgery’, Applied Nursing Research, 13 (2), pp. 70-75. MacDonald, D., LaPorta, M., Medows-Oliver, M. (2007) ‘Nurses response to pain communication from patients: A post-test experimental study’, International Journal of Nursing Studies, 44 (1), pp. 29-35. Mackintosh, C. (2005) ‘Appraising pain.’ In Banks,C.,Mackrodt,K (eds) Chronic Pain Management. London: Whurr Publishers. pp. 92-112. Manias, E., Botti, M., Bucknall, T. (2006) ‘Patients’ Decision-Making Strategies for Managing Postoperative Pain’, The Journal of Pain, 7 (6), pp. 428-437. Manias, E., Botti, M., Bucknall, T. (2002) ‘Observation of pain assessment and management; the complexities of clinical practice’, Journal of Clinical Nursing, 11 (6), pp. 724-733. Manias, E., Bucknall, T & Botti, M. (2004) ‘Assessment of patient pain in the patient pain in the post operative context’, Western Journal of Nursing Research, 26 (7). Pp. 751-769. Max, M. (1990) ‘Improving outcomes of analgesic treatment; is education enough'’ Annals of Internal Medicine, 113 (11), pp. 885-889. Marlies, E., Wit, R., Dam, F., Campen, B., Hartog, Y., Klievink, R. (2000) ‘A pain monitoring program for nurses: Effects on Nurses’ Pain Knowledge and Attitude’, Journal of Pain and Symptom Management, 19 (6), pp. 457-467. McCaffery, M., Robinson, E. (2002) ‘Your patient is in pain; Here’s how you respond’, Nursing, 32 (10), pp. 36-54. McCaffery, M., Ferrell, B & Pasero, C. (2000) ‘Nurses’ personal opinions about patients pain and their effect on recorded assessments and titration of opioid doses’, Pain Management Nursing, 1 (3), pp. 79-87. McCaffery, M & Pasero, C. (1999) Pain: Clinical manual. (2nd ed). St Louis: Mosby. McQuaya, H., Moore, A & Justins, D. (1997) ‘Fortnightly Review: Treating acute pain in hospital’ British Medical Journal, Available at : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2126780/pdf/9183203.pdf (Accessed: 16/04/2011). Melzack, R & Katz, J. (1994) ‘Pain measurement in persons in pain.’ In: Wall, P.D., Melzack, R. Textbook of Pain. London: Churchill Livingstone. Middleton, C. (2004) ‘Barriers to the provision of effective pain management’, Nursing Times, 100 (3), pp. 42-45. National Institute for Health and Clinical Excellence (2010) Putting guidance in to practice. Available at: http://www.nice.org.uk/usingguidance/ (Accessed 23/05/2011). Nursing and Midwifery Council (2008) The code in full. Available at: http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/ ( Accessed 26/04/2011). Ohnhaus, E & Adler, R. (1975) ‘Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale’, Pain, 1 (4) pp. 379-384. Peter, E & Watt-Watson, J. (2002) ‘Unrelieved pain: an ethical and epistemological analysis of distrust in patients’, Canadian Journal of Research, 34 (2), pp. 65-80. Rodgers, M., Todd, C. (2000) ‘The right kind of pain: talking about symptoms in oncology consultations’, Palliative Medicine, 14 (4), pp. 299-307. Roter, D. (2004) ‘Patient centred communication: more than a string of words’, Journal of General Internal Medicine, 19 (11), pp. 279–280. Simpson, k., Kautzman, L., Dodd, S. (2002) ‘The effects of a pain management education program on the knowledge level and attitudes of clinical staff’ Pain Management Nursing, 3 (3), pp. 87-93. Sheard, C & Garrud, P. (2006) ‘Evaluation of generic patient information: Effects on health outcomes, knowledge and satisfaction’, Patient Education and Counselling, 61 (1), pp. 43-47. Sherwood, G., McNeill, J., Starck, P., Disnard, G. (2003) ‘Changing acute pain management outcomes in surgical patients’, AORN Journal, 77 (2), pp. 374-395. Sherwood, G., Adams-McNeill, J., Starck, P., Nieto, B & Thompson, C. (2000) ‘Qualitative assessment of hospitalized patients' satisfaction with pain management’, Reasearch in Nursing and Health, 23 (6), pp. 486-495. Sloman, R., Rosen, G., Rom, M., Shir, Y. (2005) ‘Nurses’ assessment of pain in surgical patients, Journal of Advanced Nursing, 52 (1), pp. 125-132. Smith, M., DuHamel, K., Edgert, J & Winkel, G. (2009) ‘Impact of a brief intervention on patient communication and barriers to pain management: Results from a randomised controlled trial, Patient Education and Counselling, 81 (1), pp. 79-86. Stacey, B., Rudy, T & Nellhaus, D. (1997) ‘Management of patient controlled analgesia: a comparison of primary surgeons and a dedicated pain service’, Anaesthesia and Analgesia, 85 (1), pp. 130-134. Starck, P., Sherwood, G., Adams-Mcneill, J. (2000) ‘Pain management outcomes: Issues for advanced Practice nurses’, The Internet Journal of Advanced Nursing Practice, Available from: http://www.ispub.com/journal/the_internet_journal_of_advanced_nursing_practice/volume_9_number_2_8/article/pain_management_outcomes_issues_for_advanced_practice_nurses .html (Accessed 05/05/2011) Starck, P., Sherwood, G., Adams-Mcneill, J & Thomas, E. (2001) ‘Identifying and addressing medical errors in pain management’, Journal of quality improvement, 27 (4), pp. 191-199. Stewart, M., Brown, J., Donner, A., McWhinney, I., Oates, J., Weston, W & Jordan, J. (2000) The impact of patient-centred care on outcomes, Journal of Family Practice, 49 (9), pp. 796–804. Stubhaug, A., Breivik, H. (2008) ‘Prevention and treatment of hyperalgesia and persistent pain after surgery’. In: Brevik, H., Shiple, M (eds) Pain best practice and research compendium. London: Elsevier. Tanabe, P & Buschman, M. (2000) ‘Emergency nurses’ knowledge of pain management principles’, Journal of Emergency Nursing, 26 (4), pp. 299-305. Taylor, A & Stanbury, L. (2009) ‘A review of postoperative pain management and the challenges’, Current Anaesthesia & Critical Care, 20 (4), pp. 188-194. Torrance, C & Serginson, E. (1999) Surgical Nursing. 12th edition Edinburgh: Harcourt Publishers Limited. Trentin, L., Visentin, M., Marco, R & Zanolin, E. (2001) ‘Prevalence of pain in public hospital: correlation between patients and caregivers’, Journal of Headache and Pain, 2(2), pp. 73-78. Twycross, A. (2002) ‘Educating nurses about pain management; the way forward’, Journal of Clinical Nursing, 11 (6), pp. 705-714. Walraven, V., Mahon, J., Moher, D., Bohm, C & Laupacis, A. (1999) ‘Surveying physicians to determine the minimal important difference: Implications for sample size calculation’, Journal of Clinical Epidemiology, 52 (8), pp. 717-723. Watt-Watson, J., Stevens, P., Garfinkel, P., Striner, D & Gallop, R. (2001) ‘Relationship between nurses’ pain knowledge and pain management outcomes for their post-operative cardiac patients’, Journal of Advanced Nursing, 36(4), pp. 355-545. Weissman, D., Dahl, J & Beasley, J. (1993) ‘The Cancer Pain Role Model Program of the Wisconsin Cancer Pain Initiative’, Journal of Pain Symptom Management, 8 (1), pp. 29-35. Wilder-Smith, C & Schuler, L. (1992) ‘Postoperative analgesia: pain by choice' The influence of patients’ attitudes and patient education’, Pain, 50 (3), pp. 257-262.