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Contents lists available at ScienceDirect

Pain Management Nursing

journal homepage: www.painmanagementnursing.org

Review Article

Understanding Nurse Characteristics that Influence Assessment and

Intention to Treat Pain in Postoperative Patients: An Integrative
Literature Review
Susan Slatyer, Ph.D., B.Nurs. (Hons.), R.N. ∗,1, Helen Myers, M.Nurs., B.Sc., R.N. †,
Michelle A. Kelly, Ph.D., M.N., B.Sc., R.N. †
∗
College of Science, Health, Engineering & Education, Murdoch University, Perth, Western Australia
†
Curtin School of Nursing, Curtin University, Perth, Western Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: An understanding of nurse characteristics that influence pain management, which are po-
Received 4 March 2021 tentially amenable to change, can help to refine and improve nurse education and practice, resulting in
Received in revised form 9 February 2022
better patient outcomes. The purpose of this review was to identify nurse characteristics that influence
Accepted 7 March 2022
their assessment of and intention to treat postoperative pain.
Available online xxx
Design: Integrative literature review.
Data sources: A systematic search of electronic databases (CINAHL, Scopus, PsycINFO, Medline, and Em-
base), using these constructs “pain assessment”, “pain management”, “postoperative pain”, “nurses”, “cul-
tural beliefs” and “nurses’ perceptions” was conducted for the period 20 0 0 to October 2020.
Review/Analysis methods: Following a systematic screening process, the included articles were analyzed
and synthesized to identify themes and subthemes.
Results: A total of 40 articles were included with three main themes identified: nurse knowledge; nurse
sociocultural factors, personal beliefs and attitudes, and other characteristics; and believing or doubting
the patient. There was evidence that targeted education interventions can improve nurse knowledge and
nurses’ clinical practice in relation to pain management. What was less clear was which nurse attitudes
and biases influenced their pain management practice or how these could be changed.
Conclusions: More studies are needed to investigate the influence of cultural characteristics on pain as-
sessment and management. There is a need for further quantitative studies that explore the relationship
between nurse characteristics and their pain management practice. Intervention studies using innovative
educational approaches that change attitudes and biases, and improve practice are needed.
© 2022 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Surgical procedures in hospitals are common, involving high dures were documented and grouped according to the anatomical
numbers of patients. Globally, over 300 million surgeries take place site and method of surgical access to facilitate comparison of pain
each year (Carr & Morlion, 2017). Pain is a common experience af- intensities between various types of surgery. Data were collected
ter surgery (Gan, 2017). Despite the considerable focus in the lit- where available on the amount of opioid medication (as morphine
erature on pain management, it is evident that the prevalence of equivalents) administered after discharge from the postanesthetic
postoperative pain remains a global issue. A large prospective co- care unit. The median worst pain intensity reported by patients
hort study conducted across 105 hospitals in Germany investigated was 5.0 (IQR 4.0-7.0) on a 0-10 numerical rating scale. Compari-
the pain intensity self-reported by surgical patients (n = 70,518) on son of pain scores between 179 surgical groups in a sub-sample
the first postoperative day related to types of surgical procedures of 50,199 patients revealed that patients who had undergone rel-
and pain treatment (Gerbershagen et al., 2013). Surgical proce- atively small procedures often reported considerable pain, poten-
tially because these patients were given less analgesia than re-
quired (Gerbershagen et al., 2013).
1
Address correspondence to Susan Slatyer, Associate Professor, Discipline of In the US, a study conducted in an academic private nonprofit
Nursing, College of Science, Health, Engineering & Education, Murdoch University, medical center included 441 surgical patients who self-rated their
90 South Street, Murdoch, Western Australia 6150
pain on the day of discharge using both a 5-point verbal categor-
E-mail address: [email protected] (S. Slatyer).

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1524-9042/© 2022 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
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2 S. Slatyer, H. Myers and M.A. Kelly / Pain Management Nursing xxx (xxxx) xxx

ical scale (ranging from “no pain” to “extreme pain”) and a 0-10 in hospital settings nurses are the primary health professionals re-
numerical rating scale (Buvanendran et al., 2015). Most patients sponsible for assessing and responding to patients’ experiences of
had undergone orthopaedic surgery (43%), with other types of postoperative pain (Schiavenato & Craig, 2010).
surgery being general (43%), neurosurgical (13%), and gynecologic Considering the persisting prevalence of postoperative pain, this
(10%). Overall, 54% of patients reported “moderate to extreme study examined the current literature to explore nurse characteris-
pain” and 12% reported “severe to extreme” pain using the verbal tics which may influence their assessment and intention to treat
categorical scale on the day of discharge. The mean numerical pain postoperative pain. An understanding of those factors potentially
scale reported by patients on the day of discharge was 4.18 (SE ± amenable to change can help to refine and improve nurse edu-
0.11). There was no difference in pain intensity between surgical cation and clinical pain management practice, ultimately resulting
types (Buvanendran et al., 2015). The authors of a small cohort in better patient outcomes. Therefore, this study aimed to identify
study of 41 patients who underwent major surgery for head and nurse characteristics that influence the assessment and manage-
neck cancer at a tertiary academic oncology program in Canada ment of pain in postoperative patients. The specific research ob-
concluded that pain management could be improved in that center jectives were to explore how nurses’ personal or professional char-
(Hinther et al., 2018). This study conducted a retrospective analysis acteristics influence their assessment and management of pain in
of pain assessment and patient’s self-reported pain scores using a postoperative patients; and which characteristics of nurses influ-
0-10 numerical rating scale over post-operative days 1-14. Findings ence the assessment and management of pain postoperative pa-
indicated that pain assessment was most frequent on days 1-4, tients.
and median pain scores ranged from 0-4.5, with daily maximum
pain scores ranging from 8-10 (Hinther et al., 2018). Method
More recently, a study of patients hospitalized for at least three
days in general wards was conducted in a 1,500-bed hospital in Study Design
Taiwan (Wu et al., 2020). Data were collected using an investigator-
developed survey that captured patients’ self-reported presence The purpose of an integrative review is to enable greater un-
and intensity of pain; experience of pain management; overall sat- derstanding of phenomena by combining results from diverse data
isfaction; and demographics. Of the 1,079 patients who completed sources, including both qualitative and quantitative methodolo-
the survey, 69% (n = 719) had experienced pain while in hospital. gies, and experimental and non-experimental designs. This type
Comparative data analysis indicated surgical patients were more of review is particularly useful for understanding nursing practice
likely to experience pain (odds ratio [OR]: 3.401, p < .001) and which occurs in conjunction with multiple agents within complex
strong pain (OR: 1.5 < 0.001) than medical patients. Of the 544 work environments, not easily investigated by experimental design
surveyed patients who had undergone surgery, 443 (82%) reported (Whittemore & Knafl, 2005).
pain, with 209 patients (38%) rating this pain at ≥7 on a 0-10 nu- The search strategy was refined from an initial scoping review
merical rating scale (Wu et al., 2020). of the literature. A Population/Intervention/Comparison/Outcome
Similarly, patients (n = 736) admitted to hospital in Argentina (PICO) framework was used to develop inclusion and exclusion
were asked to self-rate their pain intensity using a 0-10 numerical criteria and key search terms (Schardt et al., 2007). The relevant
scale (Stonski et al., 2019). Data were analyzed separately for medi- databases were identified, and search strategies were developed for
cal, surgical, and obstetric patients. Pain prevalence at 48 hours af- each database.
ter admission was higher in surgical patients (70%) compared with
medical patients (37%), although pain prevalence in obstetric pa-
tients (77%) was higher. However, median pain intensity was the Data Sources
same for all groups (medical: median 7, IQR 6-8; surgical: median
7, IQR 5-8; obstetric: median 7, IQR 5-8) (Stonski et al., 2019). A systematic search of five databases—CINAHL, Scopus,
Pain control has been conceptualized as both a health issue and PsycINFO, Medline, and Embase—was conducted. Inclusion cri-
a basic human right (Brennan et al., 2016;International Association teria were English language report published in a refereed journal,
for the Study of Pain IASP., 2022). The goal of postoperative pain or produced by relevant organizations, from 20 0 0 to October 2020
management is to reduce or eliminate pain to restore patient func- inclusive; primary research articles conducted in any country,
tion, promote recovery, and enhance mental and physical comfort results reported for postoperative patients or settings. Exclusion
(Shoqirat et al., 2018). Although seemingly a straightforward pro- criteria were results related to community settings or cancer
cess, effective postoperative pain management is a complex under- patients only; results for nurses not reported separately; nurse
taking. characteristics not linked with pain management practice. There
The assessment and treatment of pain is currently understood were six constructs used in the search strategy: (1) Pain Assess-
through the lens of a biopsychosocial framework (Society, 2017; ment; (2) Pain Management; (3) Postoperative Pain; (4) Nurses;
Schug et al., 2020). The framework conceptualizes an individual’s (5) Cultural Beliefs And (6) Nurses’ Perceptions. Reference lists of
experience of pain as an interaction between physical causes, in- relevant articles were used to identify other potentially relevant
cluding tissue damage (biological), with the way people think articles.
about and respond emotionally to pain (psychological), influenced
by life experiences and the world in which they live (social) Screening
(Chou et al., 2016; Schug et al., 2020). This understanding un-
derpins practice guidelines for postoperative pain assessment that The search of the five databases produced 1,394 articles. After
privilege the patient’s self-report over the clinician’s observation of removal of duplicates there were 886 remaining. The titles and ab-
‘objective’ data such as patient behavior (Chou et al., 2016). Con- stracts were screened independently by two authors against the
sistent with the biopsychosocial framework, effective pain manage- inclusion/exclusion criteria with 731 articles excluded from further
ment incorporates a multimodal approach, combining various anal- review. The full text of the remaining articles were screened in-
gesic medications supplemented with non-pharmacologic comfort dependently by two authors with a further 115 articles excluded.
measures (Chou et al., 2016; Schug et al., 2020). While successful Reasons for exclusion included: nurse characteristics not linked to
pain management requires input from the interprofessional team, practice (n = 41); did not examine nurse characteristics (n = 27);

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
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Fig. 1. Flow diagram of search results and study selection

research not conducted in a postoperative population (n = 25); re- selection and identification (Fig. 1). The studies came from a wide
sults for surgical nurses not reported separately (n = 9); not re- variety of countries including United States of America (n = 11),
search (n = 8); full-text article not available in English (n = 4); Jordan (n = 5), Australia (n = 4), Thailand (n = 4), United King-
and article only available as a conference abstract (n = 1). Any dis- dom (n = 3), Canada (n = 2), France (n = 2), China (n = 1), Eritrea
agreements were discussed by at least two of the three authors (n = 1), Israel (n = 1), Northern Ireland (n = 1), Poland (n = 1),
and the research assistant who supported elements of the database Saudi Arabia (n = 1), South Korea (n = 1), South Africa (n = 1),
search until consensus was reached. The remaining articles were and Sweden (n = 1), indicating the universality of this topic. Set-
screened for quality using the Joanna Briggs Institute (JBI) criti- tings included primarily surgical settings in acute care or commu-
cal appraisal tools (Joanna Briggs Institute JBI, 2020). Guided by nity hospitals (37/40). Three studies took a broader perspective—
Whittemore and Knafl (2005), low methodological quality was not all hospitals in the country (Cano Romero et al., 2017; Hirsh et al.,
a criterion for exclusion considering the diverse sampling frame 2009), and all nurses who attended pain management conferences
used that yielded empirical sources representing a variety of meth- (McCaffery et al., 20 0 0). If other health professionals were in-
ods. Therefore, no articles were removed due to quality issues. cluded, only the results for surgical nurses were considered in this
review.
Data Analysis Study designs included one randomized controlled trial, nine
quasi-experimental pre-post studies, 17 descriptive studies, and
The final articles were summarized in table format for data syn- 15 qualitative studies including two ethnographies and four using
thesis, and analysis. Information included author, title, year, coun- phenomenography/phenomenology. Eleven studies involved an in-
try, location, population, setting, design, intervention (where appli- tervention, usually an education intervention (8/11), sometimes in
cable), data collection methods, nurse variables, pain management conjunction with the implementation of pain management guide-
variables, characteristics, and results (Supplementary Table 1). The lines (3/8), with two interventions based on performance feedback,
extracted data pertaining to the study objectives: nurse variables and one a peer intervention model. A range of data collection pro-
and pain management variables, were grouped and summarized cedures were used, including questionnaires, validated scales, med-
(Whittemore & Knafl, 2005). Results of quantitative and interven- ical record review, pain diaries, interviews, observations, field work
tion studies were examined to identify significant associations be- notes, responses to vignettes, and focus groups.
tween nurse variables and pain management practice or outcomes. Analysis of included articles generated three main themes de-
Findings of qualitative studies were reviewed to determine factors scribing nurse characteristics that impact pain management prac-
perceived to influence nurses’ pain management responses and be- tice: (1) Nurse knowledge; (2) Nurse sociocultural factors, personal
haviors. Conclusions of each sub-group analysis were then synthe- beliefs and attitudes, and other characteristics; and (3) Believing or
sized to describe common themes and subthemes of nurse char- doubting the patient. A summary of the main constructs from each
acteristics that impacted on pain assessment and management for theme is given below.
postoperative patients (Whittemore & Knafl, 2005).
Theme 1: Nurse Knowledge
Results
Nurses’ knowledge was the primary topic of 11 studies in which
A total of 40 articles were included in the final review. The an intervention, targeted at improving nurses’ knowledge of pain
PRISMA process (Moher et al., 2009) was used to summarize study assessment and management was implemented and evaluated. Re-

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
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sults of these studies showed that targeted interventions improved Subtheme 2: Nurse Attitudes toward Pain
nurses’ knowledge and changed their pain assessment and man- Nurse attitudes toward pain have the potential to impact their
agement practice. Of interest, in the five studies that examined at- assessment and management practices. If nurses view pain as nor-
titudes/biases in addition to knowledge (Abdalrahim et al., 2011; mal, or lack empathy toward patients with pain, this may affect
Bonkowski et al., 2018; Edwards et al., 2001; Maunsaiyat et al., their practice. This topic was explored in five studies.
2009; Schreiber et al., 2014), only one reported a significant change Manias et al. (2002) observed that nurses expected patients to
in attitudes (Abdalrahim et al., 2011) following the intervention. A tolerate a certain amount of pain rather than trying to alleviate it,
summary of the intervention studies is provided in Supplementary particularly when they were mobilizing. Nurses often overlooked
Table 2. patient pain unless it was viewed as out of the ordinary in some
Relationships between nurses’ knowledge and other character- way. A later study by Mackintosh-Franklin (2014) similarly found
istics were explored in several studies. Some studies found no dif- that nurses considered pain to be a normal part of the postoper-
ference in knowledge levels based on the nurse’s: ative process, indicating they may be limited in their motivation
to address pain. Additionally, most participants did not appear to
• education level (Abdalrahim et al., 2011; Kaki et al., 2009; Puls- be emotionally engaged with patients’ pain, mostly focusing on the
McColl et al, 2001; Watt-Watson et al., 2001) technical aspects of pain management (Mackintosh-Franklin, 2014).
• experience (Abdalrahim et al., 2011; Kaki et al., 2009; Puls- While lack of empathy was seen by nurses as a barrier to pain
McColl et al., 2001; Watt-Watson et al., 2001) management (Tomaszek & Debsk, ˛ 2018), an earlier study by Watt-
• gender (Kaki et al., 2009) Watson et al. (20 0 0) found no relationship between nurses with
• age (Watt-Watson et al., 2001). greater empathy and patients experiencing less pain or receiving
Other studies found significant differences in knowledge levels more analgesia. Youngcharoen et al. (2016) found that nurse atti-
based on the nurse’s: tudes and perceived norms were related to their pain management
intentions.
• age (Shoqirat et al., 2019a)
• country of birth (Watt-Watson et al., 2001) Subtheme 3: Nurse Attitudes toward Patients’ Age, Gender and
• participation in continuing education (Tomaszek, & Debsk,
˛ Culture
2018; Watt-Watson et al., 2001) The influence of nurse attitudes towards patient age, gender,
• education level (Shoqirat et al., 2019a; Tomaszek, & Debsk,
˛ and culture emerged in nine studies in the review. In three studies
2018) this topic was directly explored using vignettes, presenting nurses
• nurse experience (Shoqirat et al., 2019a). with case studies which varied according to certain patient char-
acteristics (age and smiling/grimacing facial expressions) and then
However, Watt-Watson et al. (2001) found no relationship be-
measuring their response. Two studies found variations in nurses’
tween nurses’ knowledge and patients’ pain intensity, or amount
decision making around pain assessment and management were
of analgesia received by the patient.
influenced by:

Theme 2: Nurse Sociocultural Factors, Personal Beliefs and Attitudes, • patients’ age (Hirsh et al., 2009; Horbury et al., 2005)
and Other Characteristics • sex, race, and pain expression cues accounted for (Hirsh et al.,
2009).
Many of the included studies explored nurses’ sociocultural
In their observation of nursing practice, Brown and McCor-
characteristics, and beliefs and attitudes. Four subthemes were
mack (2006) reported that older patients were less likely to be
identified within this theme: nurse experience, education and
asked about their pain. Shoqirat et al. (2019c) found nurse percep-
other demographics; nurse attitudes toward pain; nurse attitudes
tions such as gender and age stereotypes influenced pain manage-
towards patient age, gender, or culture; and nurse attitudes toward
ment. Patients who frequently used their call bell to seek nurses’
addiction and fear of side effects.
attention, or whose family members demanded pain relief on their
relative’s behalf were more likely to get pain management, al-
Subtheme 1: Nurse Experience, Education, and Other Demographics though nurses harbored negative attitudes toward these patients
Five studies explored the influence of nurse experience, edu- and families (Shoqirat, 2015). Harper et al. (2007) in a study of
cation, and other demographics on pain assessment and manage- pain management among military nurses revealed how nurses be-
ment. Nurse experience was a factor in three studies with experi- lieved that young men, particularly those in the military, under-
enced nurses observed to: reported or would not report their pain because of gender norms
• be better at pain assessment and management for men in British society. The nurses also believed that, in general,
(Chatchumni et al., 2016a; Manias, 2003) military personnel are stoic and will not express pain.
• have a more positive approach towards older people (Brown & Only one study explored the influence of cultural character-
McCormack, 2006). istics on pain assessment and management. Chatchumni et al.,
(2016b) found that due to the cultural characteristics of Thai peo-
Treatment options can be influenced by nurse characteristics, ple, patients were unlikely to express pain directly and therefore
such as the length and type of professional experience, along with nurses needed to use other strategies to assess pain. They also
life experiences all of which build knowledge and shape their per- noted that ‘offering help’ had a higher cultural value than ‘request-
spectives. Kidanemariam et al. (2020) investigated nurses’ use of ing help’ and therefore nurses would wait to be asked to provide
non-pharmacologic pain relief and found that those with greater pain relief while patients would wait to be offered pain relief.
age, higher education, and hospitalization of a close relative had
higher usage of non-pharmacologic methods. Carlson (2010) re- Subtheme 4: Nurse Attitudes toward Addiction and Fear of Side
ported that nurses who were more likely to adopt evidence-based Effects
practice guidelines had read more professional journals or had Six studies explored nurse attitudes toward opioid addic-
previously used evidence-based guidelines, a desire for career ad- tion and fears about side effects from opioid administration.
vancement, or higher level of education. Kaki et al. (2009) reported that nurse knowledge/attitudes toward

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
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opioids was poor, with only a minority correctly understanding Kaki et al., 2009; McCaffery et al., 20 0 0). The implication was that
the likelihood of patients developing addiction, tolerance, or physi- the nurse’s failure to believe the patient directly impacted upon
cal dependence to opioids. How these affected treatment decisions whether the patient would receive appropriate medication to re-
was not reported, however Horbury et al. (2005) found that nurses’ lieve their pain. In comparing nurses’ and patients’ ratings of pain,
treatment decisions were influenced by fears of respiratory depres- both Klopper et al. (2006) and Sloman et al. (2005) found that
sion and addiction. Most recently, Shoqirat et al. (2019b) found nurses consistently underrated pain when compared with patients.
that nurses’ lack of confidence and fear contributed to reluctance Chatchumni et al., (2016b) observed that pain ratings were col-
to administer opioids. lected from the patient but did not form the basis for decision
Attitudes toward opioids can be changed however, with making about pain management. Richards and Hubbert (2007) ob-
Abdalrahim et al. (2011) reporting that nurses’ attitudes to- served that nurses sometimes found it hard to put aside their own
ward pain and addiction, and concern over side effects, im- personal biases about believing the patient (feeling the patient was
proved following an educational intervention, in which nursing drug-seeking, or the pain they were reporting was not what was
documentation of patient pain also improved, suggesting that expected with that surgery) when providing pain management for
nurse attitudes toward pain and addiction, as well as nurse the patient.
knowledge, were affecting pain assessment and management.
Schafheutle et al. (2001) found that often nurses did not ask
about pain during medication rounds, sometimes because the pa- Discussion
tient was suspected of drug misuse or addiction. In the one study
that investigated nurse demographics in relation to nurse attitudes, This review included 40 articles examining nurse characteristics
Shoqirat et al. (2019b) found that negative attitudes toward pain that influence the assessment and management of pain in postop-
management and opioid use were associated with greater age and erative patients. Although many more studies were retrieved for
years of experience. full text review, most of these failed to link nurse characteristics
to their pain assessment and management practice and were thus
Theme 3: Impact on Pain Assessment of Nurses Believing or Doubting excluded. The remaining articles provided some useful insights into
the Patient nurses’ practice, although there were gaps in the literature which
require further investigation.
Believing or doubting patients’ reports of pain was another The included studies spanned 20 years (Duncan & Pozehl, 20 0 0;
theme identified in the review. Although it is recommended that Jang et al., 2020; Kidanemariam et al., 2020; Watt-Watson et al.,
patients’ self-report of pain is paramount, this was not evidenced 20 0 0) and five continents (e.g., Bonkowski et al., 2018; Cui et al.,
in the way nurses assessed pain in practice. 2018; Klopper et al., 2006; Tomaszek & Debska,
˛ 2018). Pain man-
Nurses had expectations about how much pain a patient should agement guidelines have evolved over that time, although it is ac-
be experiencing and often did not believe the patient if their knowledged that many countries have less well-developed practice
self-report did not match these expectations (Harper et al., 2007; guidelines than others. In the US, the Joint Commission on Accredi-
Jang et al., 2020; Mackintosh-Franklin, 2014; Manias, 2003). These tation of Healthcare Organizations (JCAHO) pain management stan-
expectations (and therefore their pain assessments) were based on: dards introduced in 20 0 0 sought to integrate a rights-based ap-
proach to pain management, putting responsibility for systematic
• the type of surgery the patient had (Harper et al., 2007;
comprehensive pain assessment on healthcare organizations across
Kim et al., 2005; Mackintosh-Franklin, 2014; Manias, 2003)
the board (Baker, 2017). In 2011, JCAHO responded to concerns
• the nurse’s previous experience caring for surgical patients
that these pain management standards encouraged opioid use
(Harper et al., 2007; Kim et al., 2005; Klopper et al., 2006)
by adding a note specifying the value of non-pharmacologic ap-
• how much anesthesia the patient had received and time since
proaches in pain management (Baker, 2017). In 2016, the American
administration (Klopper et al., 2006)
Society for Pain Management Nursing (ASPMN) Position Statement
• patients’ sociocultural characteristics (Jang et al., 2020;
counseled nurses that prescription of opioid medication should not
Klopper et al., 2006).
be based only on a unidimensional measure of pain intensity be-
It was evident that nurses who did not believe patients’ self- cause this discounts the other important elements of a compre-
report tended to try and verify the ‘subjective’ self-report with hensive assessment (Pasero et al., 2016). That same year, guidelines
‘objective’ measures of the patients’ pain level (Chatchumni et al., for the management of post-operative pain were published by the
2016a; Kim et al., 2005). In addition to the patient’s self-report, American Pain Society and American Society of Anesthesiologists
nurses’ assessment of pain integrated: (Chou et al., 2016). Recommendations included: pre-operative as-
sessment and education to facilitate post-operative pain manage-
• patients’ non-verbal cues (Chatchumni et al., 2016a;
ment; use of validated assessment tools; regular reassessment to
Harper et al., 2007; Horbury et al., 2005; Jang et al., 2020;
monitor and adjust post-operative pain treatments; and the use of
Kaki et al., 2009; Kim et al., 2005; Klopper et al., 2006;
multimodal analgesia comprising medication and techniques tar-
McCaffery et al., 20 0 0; Richards & Hubbert, 2007)
geting different mechanisms in the nervous system (Chou et al.,
• vital signs measurements (Harper et al., 2007; Klopper et al.,
2016).
2006; Richards & Hubbert, 2007)
The 2018 Consensus Statement published by the ASPMN and
• patients’ requests for pain relief (Jang et al., 2020)
the American Pain Society recognised JCAHO’s advocacy for in-
• patients’ medical history (Jang et al., 2020)
dividualized pain management and recommended analgesic pre-
• time since surgery (Jang et al., 2020).
scriptions providing a dosage range that considers characteristics
Non-verbal cues were often believed over patients’ self-report of both patient and medication (Drew et al., 2018). Nurses then
(Horbury et al., 2005; Kaki et al., 2009; Kim et al., 2005; base decisions about medication dosage within this range on in-
McCaffery, Ferrell & Pasero, 20 0 0). depth knowledge of the medication and the individual patient, in-
The results of some studies showed that nurses administered cluding a pain assessment a valid and reliable tool (Drew et al.,
pain relief based on their rating of the patient’s pain rather than 2018). This is followed up with nursing evaluation and documen-
the patient’s self-report (Ene et al., 2008; Horbury et al., 2005; tation of the patient’s response to the medication dose and tim-

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
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ing, along with communication to the patient and members of the patients’ sociocultural characteristics, so that intervention studies
health care team (Drew et al., 2018). can be planned.
The current review identified that nurse knowledge was the In the education intervention studies that also examined
most frequently examined characteristic, generally in the form of nurse attitudes (Abdalrahim et al., 2011; Bonkowski et al., 2018;
an intervention study (Abdalrahim et al., 2011; Bonkowski et al., Edwards et al., 2001; Maunsaiyat et al., 2009; Schreiber et al.,
2018; Cui et al., 2018; Duncan & Pozehl, 20 0 0; Duncan 2014), only one reported a change in nurse attitudes
& Pozehl, 2001; Edwards et al., 2001; Ene et al., 2008; (Abdalrahim et al., 2011). This finding suggests that different
Maunsaiyat et al., 2009; Ravaud et al., 2004; Schreiber et al., 2014; types of interventions beyond knowledge acquisition are required
Tapp & Kropp 2005). What was evident from these studies was to tackle nurse attitudes and biases. There were no studies that
that nurses’ pain knowledge prior to the implementation of an in- specifically focused on how to change nurse attitudes or biases.
tervention was generally poor. Undergraduate nursing education is As patient and nurse populations within a country become in-
the foundation for nurses’ knowledge levels and subsequent prac- creasingly diverse (Leininger, 2002), an understanding of cultural
tice. The amount and type of pain management content in nurs- beliefs about what pain means, the influence of culture on pain
ing education curricula has generally been regarded as inadequate, expression, and expectations of pain relief are of paramount im-
with students’ knowledge not showing improvement in the past 20 portance to ensure effective pain relief for postoperative patients
years (Cousins et al., 2022). Moreover, there are significant differ- (Green et al., 20 03; Lasch, 20 0 0). A recent paper provided expert
ences in the proportion of nursing curricula devoted to pain man- opinion that culture can have an effect on pain expression and
agement education between, and even within, countries. For ex- management (Bautista et al., 2021). It is important not to gener-
ample, total hours of pain education included in nursing programs alize how individuals from a particular culture view pain, since
have been variously reported at a median of 10.2 hours (range 2- pain is a subjective experience, and every individual is unique.
36 hours) in the UK (Briggs et al., 2011) and a mean of 87 hours However, this paper offered insights from neuroscience nurses
(range 21-240 hours) in Spain (Miró et al., 2019). The authors of a working in 10 countries into the influence of cultural traditions
study in Jordan assessing student nurses’ knowledge and attitudes on how pain is reported and addressed in their region of the
to pain management presented anecdotal evidence of no formal world. For example, Asian cultures often view pain expression as
pain education in the nursing curriculum in that country in 2013 a sign of weakness, particularly in males. In India, Hinduism sees
(Khalaileh and Qadire, 2013). These comments were supported by pain as a consequence of past behavior with suffering the path
Omran and colleagues (2014), who suggested that their findings of to redemption and in Buddhist traditions one can offer their pain
Jordanian nurses’ (n = 263) poor knowledge scores were due in experience as a sacrifice that brings benefit to all (Bautista et al.,
part to the “few contact hours allocated to pain education in the 2021). Many people in the Philippines believe that reporting pain
curriculum and the fragmented pain content covered in various puts burden on others. Other cultures, such as Australian Indige-
nursing courses” (p. 78). In Thailand, the nursing curriculum in- nous peoples and the Nguni and Soho groups in South Africa,
cludes a “foundation course” on pain education, although it’s tim- often look to traditional pain remedies and spiritual practices
ing, duration, and content are unclear (Chatchumni, 2016). Differ- (Bautista et al., 2021). In contrast, the biomedical model prevail-
ences in nursing curricular relate to requirements of national ac- ing in Western societies engenders a healthcare culture focused
crediting boards for portions of content e.g., pain assessment, and on physical aspects of disease and treatment (Ibeneme et al.,
national health priorities. 2017). In the United States (US), chronic pain patients’ per-
Targeted education in the practice setting had a clear positive ceptions about the superiority of analgesic medication were
impact on nurses’ pain knowledge and their subsequent practice. identified as a barrier to the use of non-pharmacologic approaches
This suggests that implementing pain management interventions (Becker et al., 2017). Similarly, in the US, health professionals
in postoperative settings is warranted. Of interest were the two tend to expect that patients will experience pain after surgery
studies which used performance feedback to change nurse practice and look to prescription of opioid medication to manage pain
(Duncan & Pozehl, 20 0 0; Duncan & Pozehl, 2001). When nurses while non-pharmacologic measures are under-used (Bautista et al.,
were presented with information by the researchers about the ef- 2021). Despite evidence that cultural beliefs inform how both
fectiveness of their practice their practice changed, even without patients and nurses understand and respond to pain, the effects
receiving pain management education. This provides a potential of cultural mismatch between nurses’ and patients’ beliefs and
method to explore to change nurse behaviors in relation to pain expectations around pain were not explored in any of the included
management. studies.
Several nurse factors, attitudes, and biases that influence post- Believing or doubting the patients’ report of pain was an im-
operative pain management were examined in the included stud- portant theme that emerged in this review. McCaffery (1968) sem-
ies, with most of these studies using a qualitative research inal definition, “Pain is whatever the experiencing person says it
design (Abdalrahim et al., 2011; Brown & McCormack, 2006; is, existing whenever the experiencing person says it does” has
Cano Romero et al., 2017; Chatchumni et al., 2016b; Harper et al., been the prevailing definition of pain for the last few decades
2007; Hirsh et al., 2009; Horbury et al., 2005; Kaki et al., 2009; (p. 95). Current evidence-based pain management guidelines em-
Mackintosh-Franklin, 2014; Manias et al., 2002; Schafheutle et al., phasize that pain is principally a subjective experience arising
2001; Shoqirat, 2015; Shoqirat et al., 2019b; Shoqirat et al., 2019c; from the interaction between biologic processes and the individ-
Watt-Watson et al., 20 0 0; Youngcharoen et al., 2016). It was ap- ual’s psychological responses and social influences (Chou et al.,
parent that nurse experience, education, professional commitment, 2016; Schug et al., 2020). Accordingly, there has been a world-
attitude to pain and opioids, and biases in relation to patients’ age, wide push to recognize pain as the fifth vital sign; with patient
gender, race, and culture influenced their pain management prac- self-report of pain, often captured as a rating using a pain assess-
tice. ment tool, as the ‘gold standard’ for determining whether a pa-
What was lacking in the literature, however, were strong quan- tient is experiencing pain (Scher et al., 2018). It was evident in this
titative studies that measured the relationships between these fac- review that nurses used a variety of methods to assess patients’
tors and nurses’ practice. Of particular importance are studies that pain, particularly if they did not believe the patient’s self-report
quantify the influence of those nurse characteristics amenable to (Chatchumni et al., 2016a; Harper et al., 2007; Horbury et al.,
change such as attitudes to pain and opioids, and biases based on 2005; Jang et al., 2020; Kaki et al., 2009; Kim et al., 2005;

Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
2022.03.003
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S. Slatyer, H. Myers and M.A. Kelly / Pain Management Nursing xxx (xxxx) xxx 7

Klopper et al., 2006; Mackintosh-Franklin, 2014; Manias, 2003; There is also a need for further quantitative studies that explore
McCaffery, Ferrell & Pasero 20 0 0; Richards & Hubbert, 2007). the relationship between nurse characteristics that are linked to
If nurses supplement the patient’s self-report with other meth- nurse practice. Intervention studies using innovative educational
ods of pain assessment to garner a more nuanced understanding of approaches that change attitudes and biases and improve practice
the pain experience, then this is useful. Asking probing questions are needed.
if the patient reports no pain when some level of pain would rea-
sonably be expected based on the surgery type may encourage the Implications for Practice
patient to feel comfortable in discussing their pain level. Patients
may not report pain, or may modulate their expression of pain, The findings of this review have implications for surgical
for reasons such as fear of being viewed negatively by nurses, sto- nurses, nurse educators, and nurse researchers. Persisting evi-
icism, or cultural beliefs about pain (Bach et al., 2018; Schiavenato dence that nurses’ responses to patients’ pain reports are influ-
& Craig, 2010). enced by their perceptions of patients’ characteristics and behav-
The problem arises if nurses’ biases, attitudes, or other charac- iors highlights the need to address nurses’ attitudes and biases.
teristics are interfere with pain assessment, leading the nurse to Self-reflection may assist surgical nurses to surface and examine
assign a lower level of pain to the patient than that reported or their own expectations of patients’ pain experiences, unconscious
experienced when this is not warranted. As discussed, results from bias, and gaps in knowledge. Further evaluation of interventions
some of the included studies, showed that nurses administer pain that assist nurses to uncover and address opportunities for prac-
relief based on their own assessment of pain, rather than the pa- tice improvement, such as the use of performance feedback, is
tients’ rating (Ene et al., 2008; Horbury et al., 2005; Kaki et al., warranted. Low levels of nursing knowledge about pain manage-
20 09; McCaffery et al., 20 0 0). Therefore, if nurses consistently un- ment suggest the need to address content in undergraduate nurs-
derrate patient pain it will result in patients being undertreated for ing curricula, and the benefit of educational interventions, which
their pain (Klopper et al., 2006; Sloman et al., 2005; Wooldridge & have been shown to be effective, delivered in the practice setting.
Branney, 2020). Considering the influence of culture on nurses’ practice, more re-
What was not evident in the literature was how nurse biases or search is needed to explore how culture shapes nurses’ and pa-
attitudes shaped their acceptance of patients’ self-report of pain. tients’ responses to pain; the impact of cultural mismatches; and
This makes it difficult to plan appropriate interventions to improve interventions to address these. Additionally, there is an imperative
the way in which nurses use their clinical judgment in conjunction for more empiric studies that not only measure nurse characteris-
with the patients’ self-report of pain to produce accurate pain as- tics in relation to pain management but also rigorously link these
sessments. More studies exploring the way in which nurses’ biases to outcomes in terms of nurse practice and patient outcomes. High
and attitudes lead them to underestimate patient pain are war- quality evidence of which nurse characteristics are most influential,
ranted given the importance of untreated or undertreated pain in and the mechanisms underlying their impact is needed to provide
patients’ recovery from surgery. clear direction for education and targeted interventions likely to
effective.
Limitations
Key Practice Points
This integrative review has several limitations. Firstly, 31 of 40
included articles are more than five years old. Considering how • Targeted education interventions can improve nurse knowledge
practice guidelines have evolved, older studies in this review may and their clinical practice in relation to pain management.
not reflect the levels of knowledge and attitudes that currently in- • More studies are needed to investigate the influence of cultural
fluence nurses’ pain assessment and management. Nevertheless, characteristics (of both the nurse and the patient) on pain as-
this study presents a picture of nursing pain management over sessment and management.
time, suggesting that little has changed such as nurses’ appar- • There is a need for further quantitative studies that explore
ent tendency to believe or doubt patients’ self-reports of pain the relationship between nurse characteristics that are linked
on the basis of perceived patient characteristics and behaviors. to nurse practice so that intervention studies can be designed.
Secondly, while we included studies in any geographic location, • Intervention studies that use innovative educational approaches
studies published in languages other than English were excluded. that change attitudes and biases and improve practice are
Thirdly, despite some studies being of lower quality, the guidance needed.
of Whittemore & Knafl (2005) was followed and all studies meet-
ing the inclusion criteria were considered in this integrative re- Acknowledgments
view.
This work was supported with funding from the Western Aus-
Conclusions tralian Nurses Memorial Charitable Trust. The authors thank Yukiko
Kuno for assisting with the database search and article screening
This integrative review provided useful information to aid in for this review.
understanding nurse characteristics which may impact on their
pain assessment and management practice for postoperative pa-
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tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
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Please cite this article as: S. Slatyer, H. Myers and M.A. Kelly, Understanding Nurse Characteristics that Influence Assessment and Inten-
tion to Treat Pain in Postoperative Patients: An Integrative Literature Review, Pain Management Nursing, https://doi.org/10.1016/j.pmn.
2022.03.003