Högskolan i Skövde

Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers’ survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994–1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.

The aims of this study were to investigate what words elderly patients, who had undergone hip surgery, used to describe their experience of pain in spoken language and to compare these words with those used in the Short-Form McGill Pain Questionnaire (SF-MPQ) and Pain-O-Meter (POM). The study was carried out at two orthopaedic and two geriatric clinical departments at a large university hospital in Sweden. Altogether, 60 patients (mean age =77) who had undergone orthopaedic surgery took part in the study. A face-to-face interview was conducted with each patient on the second day after the operation. This was divided into two parts, one tape-recorded and semi-structured in character and one structured interview. The results show that a majority of the elderly patients who participated in this study verbally stated pain and spontaneously used a majority of the words found in the SF-MPQ and in the POM. The patients also used a number of additional words not found in the SF-MPQ or the POM. Among those patients who did not use any of the words in the SF-MPQ and the POM, the use of the three additional words 'stel' (stiff), 'hemsk' (awful) and 'räd(d)(sla)' (afraid/fear) were especially marked. The patients also combined the words with a negation to describe what pain was not. To achieve a more balanced and nuanced description of the patient's pain and to make it easier for the patients to talk about their pain, there is a need for access to a set of predefined words that describe pain from a more multidimensional perspective than just intensity. If the elderly patient is allowed, and finds it necessary, to use his/her own words to describe what pain is but also to describe what pain is not, by combining the words with a negation, then the risk of the patient being forced to choose words that do not fully correspond to their pain can be reduced. If so, pain scales such as the SF-MPQ and the POM can create a communicative bridge between the elderly patient and health care professionals in the pain evaluation process.

This paper is a report of a study to explore nursing students' own worst experiences of pain as well as their conceptions of the worst pain imaginable. Background.

Pain is a personal experience, often assessed using a visual analogue scale. The endpoints of this scale are labelled with the extremes for pain experience (e.g. no pain to worst pain imaginable). People may understand the meaning of `no pain', but it is unclear what meaning they assign to `worst pain imaginable'. This indicates that a rating along the Visual Analogue Scale-line is dependent on the individual's previous experiences. Methods. Data were collected during the autumn of 2002. In total, 549 nursing students completed a questionnaire focusing on two main questions: `What is the worst experience of hurt, ache or pain you have had?' and `What is the worst pain imaginable for you?' Content analysis was used for data analysis. Results. The students' worst experience of pain was mostly related to acute or traumatic painful conditions, pain associated with female physiology, inflicted pain, psychological suffering and chronic painful conditions. The worst pain imaginable was described as condition-related pain, overwhelming pain, experiences of losses, deliberately inflicted pain, psychological suffering and as vicarious pain. Conclusion. The findings imply that nursing students, when they are imagining pain, include dimensions such as hope of relief, grief, control over the situation, powerlessness and empathy for and suffer with other people's pain. Further research is needed to explore why professional experience as a nurse diminishes the ability to imagine patients' pain.

Aim. The aim of this study was to examine how older patients who had undergone hip surgery described their experience of pain.

Background. A verbal report of pain is considered to be the single most reliable indicator of a person's pain experience. When assessing pain, healthcare professionals must be able to interpret the content of pain reports in order to understand older patient's pain experiences.

Methods. The study was carried out in two orthopaedic and two elder care wards in a large university hospital in Sweden in 2000. Altogether, 38 patients with hip replacement (mean age = 75) and 22 patients with hip fracture (mean age = 81) took part. A face-to-face interview was conducted with each patient on the second day after operation. Data were transcribed and analysed using descriptive qualitative content analysis.

Findings. Participants expressed their pain in a nuanced and detailed way in everyday language. Four main themes with sub-themes emerged: (a) objectification (localizing; quantifying; characterizing; temporalizing); (b) compensating (substitution; picturing); (c) explaining (functionalizing pain and its relief; externalizing pain and its relief); (d) existentializing (present pain orientation; future pain orientation).

Conclusions. Exploring the ways older patients talk about pain is expected to result in a better understanding of the older patient's need of empathic individualized care and in the optimization of pain management.

The purpose of this study was to compare elderly patients' and nurses' ratings of pain and pain tolerance. Data were collected through structured interviews with the patients. The attending nurses completed a questionnaire after conducting a pain assessment. Independent of each other, patients and nurses were asked to rate on a VAS when pain should be treated (pain tolerance) and pain intensity. The VAS has been used both by patients and nurses. The initial selection consisted of 43 patients; however, 9% (n = 4) were unable to complete the VAS. These patients were not significantly older than those who completed the study (n = 39). The results shows that nurses tend to overestimate mild pain and underestimate severe pain. Nurses rated pain tolerance significantly lower than patients. The results also suggest that nurses with training beyond basic nursing education tend to assess patients' pain more accurately than those without additional training. For patients who reported that they had pain prior to hospitalization, the nurses' pain ratings showed a higher agreement than for those who reported that they did not have pain before being hospitalized. At the time of the interviews, 21% (n = 8) of patients felt that their pain was so great they needed treatment. Those patients also were recognized by the attending nurses as being in pain. To improve elderly patients' pain management, practicing nurses must collaborate with researchers to develop specific empirical research nursing knowledge within geriatric pain management. This research-based knowledge should be incorporated into nurses' clinical practice regarding pain management. Specific guidelines must be developed for the assessment, treatment, and documentation of elderly patients' pain.

The aim of this study was to determine the quantitative meaning nursing students ascribe to the pain terms hurt (ont), ache (värk) and pain (smärta). In total, 549 nursing students filled in a questionnaire including questions about age, gender, and health care work experience. The students were also requested to rate response using a Visual Analogue Scale (VAS) rating for different statements about hurt, ache and pain. The results show that there were significant differences (p < 0.001) between rated intensity of the statements of hurt, ache and pain. There were, however, large variations in the students’ ratings of the pain terms; hurt ranged from 3 to 97 mm, ache from 7 to 97 mm and pain from 27 to 100 mm. There were no significant differences between male and female students regarding their ratings of hurt and ache when they were used to describe the worst self-experienced pain. Female students rated their experience of pain significantly higher (p < 0.001) on the VAS compared with male students. There was no significant correlation between previous experience of health care work and rated intensity of hurt, ache and pain. In conclusion, this study shows that there exist significant differences between the pain terms hurt, ache and pain according to a rating on a VAS. However, the results also demonstrate that there are large individual variations in how the students quantify the fictitious patient statements of hurt, ache and pain.

This study examined the applicability of three different pain rating scales, the Visual Analogue Scale (VAS), the Graphic Rating Scale (GRS) and the Numeric Rating Scale (NRS), in geriatric patients. Data collection was performed in a geriatric clinic at a university hospital. A structured interview was conducted with 167 patients (mean age = 80.5 years). Patients rated their current experience of pain twice with a 5-minute pause in-between on the VAS, GRS and NRS, and were then asked if they experienced pain, ache or hurt (PAH) or other symptoms. The correlations were high and significant both between the ratings of the VAS, GRS and NRS (r = 0.78-0.92; p < 0.001) (alternative-forms reliability), and between the test and retesting (r = 0.75-r = 0.83; p < 0.001) (test-retest reliability). A logistic regression analysis showed that the probability to accomplish a rating on the pain scales decreased with advancing age of the patient, and this was especially marked for the VAS. The probability of agreement between the patients' ratings of pain and the verbal report of PAH tended to decrease with advancing age; this was especially so for the VAS. Patients who verbally denied PAH but reported pain on the scales rated it significant lower (p < 0.001) than those who verbally reported PAH and rated the pain as well. Eighteen percent of patients who denied pain but rated a pain experience verbally expressed suffering or distress. The study suggests that pain rating scales such as the VAS, GRS and NRS can be used to evaluate pain experience in geriatric patients. However, agreement between verbally expressed experience of PAH, and the rated experience of pain tended to decrease with advancing age. This indicates that the pain-evaluating process will be substantially improved by an additional penetration supported by a wide variety of expression of hurt, ache, pain, discomfort and distress.

Although pain is a frequent problem among elderly patients, they are often omitted in clinical trials and few studies have focused on assessing pain relief in this population. The aim of this study was to compare geriatric patients' verbally reported effect of analgesics with changes in pain experience rated with four different rating scales: the Visual Analogue Scale (VAS), the Graphic Rating Scale (GRS), the Numeric Rating Scale (NRS), and the Pain Relief Scale (PRS). Altogether 53 geriatric patients (mean=82 yrs) with non-pathological fractures in 4 geriatric units at a large university hospital were selected. In connection with the administration of analgesics, the patients were asked to "Mark the point that corresponds to your experience of pain just now at rest" on the VAS, GRS and NRS. This was repeated after 1.5-2 hours, and a direct question was asked about whether the analgesic medication given in connection with the initial assessment had had any pain-alleviation effect. Two comparisons were conducted with each patient. The results show that the probability of accomplishing a rating on the VAS, GRS, NRS, and PRS was lower with advancing age in these elderly fracture patients. The correlations between the ratings of the VAS, GRS and NRS were strong and significant (r=0.80-0.95; p<0.001) both at the initial assessments and at the re-assessments. However, the verbally reported effects of the analgesics were often directly opposite to the changes in rated pain. Therefore, application of the VAS, NRS, GRS and PRS for the purpose of assessing pain relief must be combined with supplementary questions that allow the patient to verbally describe possible experience of pain relief.

Smärta är inte en del av det normala åldrandet, men många äldre drabbas av sjukdomar som leder till smärta. Smärta är en subjektiv sensorisk och emotionell obehagsupplevelse med faktisk eller potentiell vävnadsskada. Varje person upplever smärta på sitt sätt och denna uppfattning får avgörande betydelse för hur hälso- och sjukvårdspersonal kan förhålla sig till människor med smärta.

Utgångspunkten för denna avhandling var att studera smärtförekomst bland äldre och att evaluera användandet av smärtskalor. Våra resultat visar att skattningsskalor kan vara till hjälp.

Artikeln baserad på Ingrid Berghs avhandling: Pain in the elderly - Rating scales, prevalence and verbal expression of pain relief

The aim of this study was to investigate the prevalence of pain and its characteristics, and to examine the association of pain with cognitive function and depressive symptoms, in a representative sample of 70-year-old men and women. Data were collected within the gerontological and geriatric population studies in Göteborg, Sweden (H-70). A sample of 124 men and 117 women living in the community took part in the study. A questionnaire was applied which included four different aspects of pain experience: prevalence, frequency of episodes of pain, duration and number of locations. In close connection to this, depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale. The prevalence of pain during the last 14 days was higher in women (79%; n = 91) than in men (53%; n = 65) (P<0.001). Women (68%; n = 78) also reported pain that had lasted for >6 months to a greater extent than men (38%; n = 46) (P<0.001). The frequency of episodes of pain was also higher among women, 64% (n = 74) reporting daily pain or pain several days during the last 14 days while 37% of the men (n = 45) did so (P<0.001). Women (33%, n = 38) also reported pain experience from ≥3 locations more often than men (11%; n = 13) (P<0.001). On the other hand, the association between depressive symptoms and pain experience was more evident in men than in women. Women were taking significantly more antidepressants compared to men (P<0.03). The results show that pain is common in 70-year-old people and especially in women. However, associations between depressive symptoms and the four aspects of pain experience were more pronounced among men. 

Assessing pain in children is one of nurses’ most difficult tasks and provides the foundation for efficient pain management. Young children lack the verbal skills to describe their experience of pain and they also have problems in differentiating pain from other unpleasant experiences. The aim of this study was to review current research regarding pain assessment in children. A literature search was carried out in the CINAHL and Medline databases, using the search words «pain assessment», «pain measurement», «pain rating scales», «children» and «nursing» and was limited to the years 1997–2002. Twelve articles satisfied the inclusion criteria and were analysed. The results are highlighted in five areas: Assessment of pain in children; Assessment of pain in infants; Tools and scales for assessing pain; Factors influencing the nurse’s assessment of pain; pain assessment as a basis of efficient pain therapy. The results of the study point to problems in pain assessment and the importance of children’s pain being adequately assessed. Accordingly, it is of utmost importance when possible to be able to take into account the individual child’s experience of pain.

Aim and objective. The aim of this study was to explore strategies in caring for women with postpartum psychosis used by nurses.

Background. The most serious type of psychiatric illness in connection with childbirth is postpartum psychosis. Nearly two in 1000 newly delivered women are stricken by postpartum psychosis. Most of these patients need psychiatric care to recover. While earlier studies point to the need for psychiatric care, knowledge of specific nursing strategies in caring for postpartum psychosis patients remains limited.

Methods. Interviews with 10 experienced psychiatric nurses were carried out, transcribed verbatim and an inductive content analysis was made.

Result. The main strategies for care found in this study were: (i) To create a patient–nurse relationship and (ii) To apply nursing therapeutic interventions. Presence, continuity and nurse-patient partnership contributed to create a relationship and incorporate the rest of the care team. To satisfy the patients’ basic needs and feeling of security was the foundation of the nursing therapeutic interventions. Confirmation and giving hope were also used as nursing therapeutics as well as information to the patient and her relatives about her illness.

Conclusion. The conclusion of the study is that strategies used by nurses are a combination of general and psychiatric nursing approaches but the specificity in caring knowledge for caring patients with postpartum psychosis requires further development.

Relevance to clinical practice. The result of the study indicates that it is important to organize patient care for postpartum psychosis with continuity and consistency and to support the nurse to create a relationship and therapeutic intervention with the patient. The present study shows the importance of further developing specific nursing theories that can be applied when caring for patients with postpartum psychosis. It also shows the need for further pedagogical education for mental health

Living kidney donor programs, based on willingness among family members and close relatives to donate, have made it possible to perform a satisfactory number of kidney transplantations. Early graft loss in the recipient may occur and it is not known if such an event will result mainly in acute, rather transient, emotional reactions or if long-lasting reactions may be evoked in the living kidney donor. The aim of the present study was to assess and describe the remaining experiences of donors (n = 10) more than 3 yr after early recipient graft loss or death of the recipient. A phenomenographic, interview-based research approach was used. Five different fields or domains were identified: (i) the decision to donate; (ii) the information provided; (iii) care received at the time of donation; (iv) responses at graft failure; and (v) concerns remaining at the time of the interview. All donors expressed that they had volunteered to donate and that no stress had been put on them. The information given prior to and in connection with the donation procedure was deemed insufficient but all donors were satisfied with the medical care provided in connection with the nephrectomy and in the immediate post-operative period. Graft failure was immediately accepted on the intellectual level by nine of 10 donors but still evoked emotional reactions and responses included a wish that continuing contact with the transplant staff had been provided. The present interview-based study shows that it is of importance that the donor is thoroughly informed about all donor as well as recipient-related factors including the potential risk of recipient graft failure. In case of graft failure, or the death of the recipient, the transplant unit staff members should offer contact for discussions of medical matters as well as for psychosocial support. In individual cases it may be necessary to maintain such a supportive contact channel for a prolonged period of time.

The military emergency care education of nurses is primarily concerned with the treatment of soldiers with combat-related injuries. Even though great progress has been made in military medicine, there is still the pedagogical question of what emergency care education for military nurses should contain and how it should be taught. The aim of this study was to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education. A descriptive study was performed to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education in nursing. There were statistical differences between nurses with general nursing education and nurses with a general nursing education and supplementary education. A reasonable implication of the differences is that the curriculum must be designed differently depending on the educational background of the students. Hence, there is an interaction between background characteristics, e.g., the level of previous education and differences pertaining to clinical experience of the participants, and the impact of the exercise itself.

The purpose of this study was to identify the criteria nurses actually used to assess postoperative pain and the kind of knowledge they drew on from past experience. A series of semistructured interviews were performed with 10 nurses while they conducted pain assessments with 30 postsurgical patients. Data were analyzed on the basis of Dahlgren and Fallsberg’s (1991) analytic approach called phenomenography. Findings were compared with Sjöström’s 1995 study of nurses in Sweden. Nurses in this study, much like the group in Sweden, used three categories of criteria (i.e., how the patient looked, what the patient said, and experience with similar circumstances) and drew on their past experiences in four different ways (i.e., in terms of a typology of patients, a focus on listening to patients, what to look for, and what to do for patients) when assessing postoperative pain. In the most frequently reported strategy, nurses relied on criteria related to the patient’s appearance and drew on their past experience in terms of what physical signs to look for (e.g., facial expressions, bodily movement, and heart rate). The variety of strategies used by nurses in this study opens an avenue for further investigating the linkage between underlying conceptions of pain (as essentially subjective vs. objective phenomenon) and the quality and effectiveness of nurses’ assessments of pain and its management in postoperative and other contexts across nursing.

Pain assessment is examined in the perspective of action science with the aim to discover espoused theories and theories-in-use for pain assessment. In action science there are 2 sets of theories of action: espouse theories and theories-in-use, which often exist in practice inconsistently with each other resulting in haphazard actions. Espoused theories of pain and pain assessment and a set of theories-in-use were revealed. Alignments between the espoused theories and the theories-in-use, and disparities between these theories were found in the pain assessment situations. The findings point to possible explanations regarding problems in pain assessment, and provide insights into our understanding of nursing practice especially in relation to pain assessment.

The purpose of this validation study was to describe strategies used in postoperative pain assessment among a group of nurses in South Africa. A mixed qualitative and quantitative study was conducted in a 950-bed academic hospital complex. Surgical nurses (n = 12) carried out pain assessments of postoperative patients (n = 36) in pain. Data were collected using detailed interviews and pain intensity was estimated on a visual analogue scale (VAS, 0–10 cm). Nurses used four categories of criteria (a) how the patient looks, (b) what the patient says, (c) the patient's way of talking, and (d) experience of similar circumstances and drew on their past experiences in five different ways: (a) some patients report lower pain intensity than expected, (b) a typology of patients, (c) a focus on listening to patients, (d) what to look for, and (e) what to do for patients were identified.

The system of categories described by Sjöström [Sjöström B. Assessing acute postoperative pain. Assessment strategies and quality of clinical experience and professional role. Göteborg: Acta Universitatis Gothoburgensis; 1995] was valid for this sample with an additional category. The different categories seem to be complementary and necessary for assessing pain in others. The findings have implications for professionals who provide care for patients in pain.

The study's rationale: Patients’ active participation in their own care is expected to contribute to increased motivation to improve their own condition, better treatment results and greater satisfaction with received care. Knowledge of patients’ understanding of participation is of great importance for nurses in their efforts to meet patient expectations and for quality of nursing care.

Aim: The aim was to explore the meaning of patient participation in nursing care from a patient point of view.

Methodological design and justification: Six tape-recorded focus group interviews with 26 Swedish informants described opinions on and experiences of patient participation. The informants consisted of patients in somatic inpatient care as well as discharged patients from such a setting. The Grounded Theory method was used and the data were analysed using constant comparative analysis.

Ethical issues and approval: The ethics of scientific work was followed. Each study participant gave informed consent after verbal and written information. The Ethics Committee of Göteborg University approved the study.

Findings: The patients emphasised the importance of collaboration to improve participation. The core category, Insight through consideration, was generated from four inter-related categories: (i) Obliging atmosphere; (ii) Emotional response; (iii) Concordance; and (iv) Rights and their 15 subcategories.

Conclusions: The meaning structures of patient participation in nursing care revealed from a patient point of view, seemed to mainly consist of not only external factors presented by the institutions – by the professionals – but also internal patient factors. The patients’ view of participation should be considered to a greater degree in nursing practice and education, as should also further development of nursing care policy programmes, evaluation and quality assurance criteria. For further development, studies are needed in similar and other settings.

Recent implementation of modern armoured fighting vehicles in Swedish army forces has been substantial. In consequence, changes in the knowledge area of battlefield emergency care have been so large that a new professional competence is demanded. The aim of this study was to explore and describe how nurses perceive battlefield emergency care. A qualitative design was used comprising in-depth research interviews with 11 male registered nurses who all had been trained as company nurses in the Armed Forces. Three major themes were described; Unpredictable and invisible, a contextual leadership and assimilation acts. From the first major theme, the characteristic of battlefield emergency care is that it is unpredictable and invisible with the subthemes: menacing, unknown, challenging and complicated. From the next major theme, that a contextual leadership is important to have, with the subthemes: field manners, responsibility capacity and capacity to determine. The third major theme assimilation acts with the subthemes: experience from combat casualty care, education, working experience and by utilizing research findings.

If we are to be able to offer patients individualised and qualitatively good professional care, emergency care must be conducted on the basis of scientific and well-tried experience.

Aim. The aim of this study was to investigate the meanings of the concept of patient participation in nursing care from a nurse perspective.

Background. Participation is essential and increases patients’ motivation and satisfaction with received care. Studies of patient participation in nursing care are not congruent regarding definition, elements and processes. This lack of clarity is amplified by several terms used; patient/client/consumer involvement or collaboration, partnership and influence. Despite the fact that several nursing theories have emphasized the importance of patient participation, an empirically grounded theory has yet to be published.

Methods. Seven focus group interviews were held with nurses providing inpatient physical care at five hospitals in West Sweden. The focus groups consisted of Registered Swedish nurses (n = 31) who described the meaning and implementation of patient participation in nursing care. A Grounded Theory approach has been applied to tape-recorded data. Constant comparative analysis was used and saturation was achieved.

Results. Mutuality in negotiation emerged as the core category for explaining nurses’ perspectives on patient participation in nursing care. It is characterized by four interrelated sub-core categories: interpersonal procedure, therapeutic approach, focus on resources and opportunities for influence. Mutuality in negotiation constitutes the dynamic nurse–patient interaction process.

Conclusions. The study clarifies that patient participation can be explained as an interactional process identified as mutuality in negotiation based on four components.

Relevance to clinical practice. The results are important and can be used in nursing practice and education. Application in a clinical context means nursing care organized to include all the components presented. The results can also be used in quality assurance to improve and evaluate patient participation.

The study's rationale: Patient participation is an essential factor in nursing care and medical treatment and a legal right in many countries. Despite this, patients have experienced insufficient participation, inattention and neglect regarding their problems and may respond with dependence, passivity or taciturnity. Accordingly, nurses strategies for optimising patient participation in nursing care is an important question for the nursing profession. Aim and objective: The aim was to explore Registered Nurses' strategies to stimulate and optimise patient participation in nursing care. The objective was to identify ward nurses' supporting practices. Methodological design and justification: A qualitative research approach was applied. Three focus groups with experienced Registered Nurses providing inpatient somatic care (n = 16) were carried out. These nurses were recruited from three hospitals in West Sweden. The data were analysed using content analysis technique. Ethical issues and approval: The ethics of scientific work was adhered to. According to national Swedish legislation, no formal permit from an ethics committee was required. The participants gave informed consent after verbal and written information. Results: Nurse strategies for optimising patient participation in nursing care were identified as three categories: 'Building close co-operation', 'Getting to know the person' and 'Reinforcing self-care capacity' and their 10 subcategories. Conclusions: The strategies point to a process of emancipation of the patient's potential by finding his/her own inherent knowledge, values, motivation and goals and linking these to actions. Nurses need to strive for guiding the patient towards attaining meaningful experiences, discoveries, learning and development. The strategies are important and useful to balance the asymmetry in the nurse-patient relationship in daily nursing practice and also in quality assurance to evaluate and improve patient participation and in education. However, further verification of the findings is recommended by means of replication or other studies in different clinical settings.

The concept of patient participation has an array of interpretations and lacks clarity. The purpose of this article is to explore the concept of patient participation within the context of nursing practice. The method described by Walker and Avant (1995) is used. The critical attributes of the concept are identified. Formation of model, borderline, and contrary cases exemplifies key characteristics. Antecedents, consequences, and empirical referents presented allow for further refinement of the key attributes defining the concept. Patient participation in nursing practice can be defined as an established relationship between nurse and patient, a surrendering of some power or control by the nurse, shared information and knowledge, and active engagement together in intellectual and/or physical activities.

Major technical and pharmacological achievements in recent years have greatly influenced the practice of anesthesia. Clinical signs related to the main aspects of anesthesia, i.e., hypnosis, analgesia, and muscular relaxation, are increasingly obtainable from variables supplied by the monitoring equipment. It is not known, however, to what extent more indirect, patient-associated clinical signs of pain/depth of anesthesia are still considered of importance and relied on in the intraoperative management of surgical patients. The aims of the present study were to assess what clinical signs, indirect as well as monitor-derived, are considered indicative of intraoperative pain or depth of anesthesia by nurse anesthetists during general anesthesia. In connection with anesthetic management of surgical patients, Swedish nurse anesthetists (N = 40) were interviewed about clinical signs that they routinely assessed and were asked if the observed signs were considered indicative mainly of intraoperative pain or depth of anesthesia. It was found that skin-associated responses (temperature, color, moisture/stickiness) were commonly considered to indicate intraoperative pain rather than depth of anesthesia. Respiratory movements, eye reactions, and circulatory responses were considered to be indicative of either pain or insufficient depth of anesthesia. The present data indicate that indirect physiological signs are still considered of major importance by anesthesia nurses during the anesthetic management of surgical patients.

Adequate pain relief after surgery is essential for avoiding pain-associated stress and patient comfort in the postoperative period. The Swedish nurse anesthetist has an important role in the intraoperative management of the surgical patient by assessing and moderating individual physiological response evoked by surgical stimuli during general anesthesia. The extent to which knowledge of specific individual response patterns are used to plan postoperative pain management is unknown. The aim of the present study was to assess the role of the nurse anesthetist in planning early postoperative pain management for surgical patients. Nurse anesthetists (N = 101) at 4 academic hospitals in Sweden responded to a questionnaire focusing, in addition to demographic data, on intraoperative routines for postoperative pain management, perceived clinical relevance of used routines, personal involvement (in addition to existing routines) in postoperative pain management, factors influencing pain alleviation requirements, and the potential role of the nurse anesthetist for improved postoperative pain management. We found that type of anesthesia and type of surgical procedure were both factors considered important for postoperative pain management. A majority of the participants believed that pain management approaches were not appropriately individualized to the patient.

Aim. To compare pain levels reported by patients with those documented by ward nurses and to find out to what extent the amount of opioids given correlated with the pain level. Secondly, to study if pain management and nurses' approaches to this task had improved during a two-year period, including an educational pain treatment program for ward staff. Background. The management of postoperative pain continues to remain problematic and unsatisfactory and ward nurses play an important role for this task. Design. The study was a cross-sectional, descriptive, two-part study based on survey data from both patients and nurses on two urology surgical wards. Methods. Part I of the study included 77 patients and 19 nurses. Part II took place approximately two years later and included 141 patients and 22 nurses. Data were collected the day after surgery by asking patients about 'worst pain' experienced. The pain scores given by the patients were compared with those documented in the patients' records and with the doses of opioids administered. Nurses' approaches to pain management were sought after, by using a categorical questionnaire. Results. The nurses' ability to assess pain in accordance with the patients' reports had increased slightly after two years even if and the number of documented pain scores had decreased. Forty per cent of the nurses reported that they did not use visual analogue scale and that they did not assess pain at both rest and activity, neither did one fourth evaluate the effect of given analgesics. Conclusion. The study showed a discrepancy in pain scoring between nurses and patients, where active treatment was related to nurses' documentation rather than to patients' scoring. Relevance to clinical practice. The study shows a need for more accurate pain assessment, since the patient experiences and suffers pain and the nurse determines upon treatment.

Background: There is a belief that the amount of pain perceived is merely directly proportional to the extent of injury. The intensity of postoperative pain is however influenced by multiple factors aside from the extent of trauma.The purpose of the study was to evaluate the relationship between preoperative factors that have been shown to predict postoperative pain and the self- reports of pain intensity in a population of 155 men undergoing radical prostatectomy (RP), and also to investigate if previous pain score could predict the subsequent pain score.Methods: The correlation between potential pain predictors and the postoperative pain experiences during three postoperative days was tested (Pitmans´ test). By use of a logistic regression analysis the probability that a Visual Analogue Scale (VAS) score at one occasion would exceed 30mm or 70mm was studied, depending on previous VAS score, age, depression and pain treatment method.Results: Age was found to be a predictor of VAS >30mm, with younger patients at higher risk for pain, and preoperative depression predicted VAS >70mm. The probability that VAS would exceed 30mm and 70mm was predicted only by previous VAS value. Day two however, patients with epidural analgesia were at higher risk for experiencing pain than patients with intrathecal or systemic opioid analgesia.Conclusion: The results show that it would be meaningful to identify RP patients at high risk for severe postoperative pain; i.e. younger and/or depressive patients who might benefit from a more aggressive therapy instituted in the very early postoperative period.

Background

Inadequate management of postoperative pain is common, and postoperative pain is a risk factor for prolonged pain. In addition to medical and technical factors, psychological factors may also influence the experience of postoperative pain.

Methods

Pain was measured postoperatively at 24, 48, and 72 hr in hospital and after 3 months at home in 140 patients undergoing radical prostatectomy (RP). Patients answered questionnaires about anxiety and depression (HAD scale) and health-related quality of life (SF-36) at baseline and 3 months after surgery.

Results

In the first 3 postoperative days, mild pain was reported by 45 patients (32%), moderate pain by 64 (45%), and severe pain by 31 (22%) on one or more days. High postoperative pain scores were correlated with length of hospital stay and with high pain scores at home. Forty patients (29%) reported moderate (n = 35) or severe (n = 5) pain after discharge from hospital. Patients who experienced anxiety and depression preoperatively had higher postoperative pain scores and remained anxious and depressed 3 months after surgery. The scores for the physical domains in the SF-36 were decreased, while the mental health scores were increased at 3 months. Anxiety and depression were negatively correlated with all domains of the SF-36.

Conclusion

There is a need for nurses to be aware of the psychological status of RP patients and its impact upon patients' experience of postoperative pain and recovery. The ability to identify patients with psychological distress and to target interventions is an important goal for future research.