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Postoperative pain assessment and management in adolescents
Pain 79 (1999) 207–215
Postoperative pain assessment and management in adolescents Marjorie L. Gillies a ,*, Lorraine N. Smith b, William Ll. Parry-Jones a,1 a
University of Glasgow, Department of Child and Adolescent Psychiatry, Caledonia House, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK b University of Glasgow, Nursing and Midwifery School, 68 Oakfield Avenue, Glasgow G12 8LS, UK Received 18 February 1998; received in revised form 7 August 1998; accepted 21 August 1998
Abstract A 3-year study investigated the experience and management of postoperative pain following elective surgery in an adolescent sample, using a variety of valid, reliable instruments and semi-structured interviews. In addition to the adolescent subjects, the views of one parent of each adolescent were sought and a sample of health professionals comprising surgeons, anaesthetists and nurses were interviewed about acute pain in adolescent patients. This paper presents some of the main findings pertaining to pain assessment and management. Pain, experienced by most adolescents on the 1st and 3rd postoperative days, was influenced by the presence of anxiety and depression, in addition to the maturational stage; differences between in-patients and day cases are highlighted. Recommendations for practice include the need for more effective pain management and raising awareness of the importance of both psychological state and adjustment to adolescence in this age-group. 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Postoperative pain; Adolescents; Emotion; Maturation
1. Introduction Adolescent medicine is emerging as a speciality in its own right in the UK. Although adolescents have different needs from children and adults, they are often nursed with adults or children (Gillies and Parry-Jones, 1992). It is argued that adolescents’ care should be provided by individuals with a specialist interest in their particular needs. Young people mature in various ways, and over different periods and thus their communication skills, their need for independence and self-control and their ability to adapt to pubertal changes differ (Coleman, 1980). These have implications for the management of pain in adolescents (Favaloro, 1988; Gillies, 1998). There has been an increased focus on adolescent pain, e.g. recurrent pain and the importance of stress management (Smith et al., 1989); non-acute pain and psychological factors (Magni et al., 1990); chronic pain (Cohall and CombeOrlowski, 1989; Silverberg, 1991); acute pain in venepuncture (Fradet et al., 1990); pre-menstrual symptoms and men* Corresponding author. Tel.: +44-141-201-0732; fax: +44-141-2019261; e-mail: [email protected] 1 Posthumously.
strual pain (Shye and Jaffe, 1991); adolescent migraine (McGrath et al., 1992); and phantom limb pain (McGrath and Hillier, 1992). However, little is known about the extent to which the adolescent in acute pain differs from others in acute pain. Furthermore, while the relationship between emotion and pain is well recognised in adults (McCaffery and Beebe, 1989) and children (Cohen, 1993; McGrath, 1993), little is known about the psychological aspects of acute postoperative pain in adolescence. Extrapolation would lead one to believe that anxiety influences pain intensity in adolescents as it does in other age-groups but the added phenomenon of maturational stage may complicate this relationship further. An essential element of pain management is the measurement of intensity (Tesler et al., 1991; Savedra et al., 1992). The development and use of pain measures in adults and children has been reported widely (Gillies, 1993; Marvin, 1995) but adolescents are rarely sampled and when they are, they are often grouped under ‘children’ rather than being identified separately (Vanden Berg et al., 1995). The education of health professionals needs to focus more on pain (Association of Anaesthetists of Great Britain and Ireland, Royal College of Anaesthetists and The Pain Society, 1993), particularly as the attitudes of health profes-
0304-3959/99/$ - see front matter 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S03 04-3959(98)001 78-X
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sionals are a barrier to effective pain relief (Kachoyeanos and Zollo, 1995). There is no evidence that dependency on strong analgesics given in hospital is the problem that some health professionals believe it to be (Wall, 1997). In fact Berde et al. (1991) suggested that wider use of patient controlled analgesia (PCA) is safe for adolescents and might facilitate the healing process. This 3-year study examined the postoperative pain experience of adolescents and included psychological and maturational measures. Although it set out to answer a range of research questions, only the principal results concerning questions 1–3 and 5–6 are reported.
2. Research questions 1. What is the intensity of postoperative pain in hospitalised adolescents? 2. What is the impact of postoperative pain on different levels of maturational adjustment using the Offer SelfImage Questionnaire and on anxiety using the Hospital Anxiety and Depression Scale? 3. To what extent do the experiences of in- and day patients differ? 4. What are the responses of parents to pain in their adolescent children? 5. To what extent do nursing and medical health professionals recognise adolescent responses to pain? 6. What is the actual therapeutic response of nursing and medical health professionals to postoperative pain in adolescents?
3. Method 3.1. Sample selection and size The adolescent sample was based on 1991 in-patient surgery discharge figures for a large urban health board where 55% of all in-patient discharges aged 12–20 years had undergone a surgical procedure. The surgical specialities with the highest proportion for this age-group were identified as gynaecology, general surgery, orthopaedics, ear nose and throat (ENT), oral and plastic surgery. The sample size was set at 80 admissions for each of general surgery, ENT and gynaecology and 50 admissions in each of plastics, orthopaedics and oral surgery. The inclusion criteria were agreed as in-patients or day patients undergoing elective surgery; from one of the six specified National Health Service (NHS) hospitals; and from one of the six specified surgical specialities. Patients were to be aged 12–20 years inclusive but, as a condition of funding, the upper age limit was reduced from 20 to 18 years. Patients excluded were those undergoing local rather than general anaesthesia; termination of pregnancy; endoscopies other than laparoscopy or arthroscopy which involved sur-
gical incision; patients with known learning disabilities and re-admissions or pilot study participants. Consecutive admissions were recruited initially up to the agreed number per surgical speciality. The adolescent sample size was determined by the need for statistical power, sample diversity and the number of hospitals involved. Although it was set at 400 or 11% of the population, the final number was less. In a study such as this, a sample of 300 will allow the percentage of the population experiencing moderate-severe pain to be estimated with a standard error of ±3%; the final number was 351. The proposed sizes of the other two samples were set at one relative of each adolescent (n = 400) and randomly selected health professionals (n = 157) from all hospitals and surgical specialties. 3.2. Data collection tools Data were collected using the Adolescent Paediatric Pain Tool (APPT), a coloured visual analogue scale, the Hospital Anxiety and Depression Scale (HADS), the Offer SelfImage Questionnaire-Revised (OSIQ-R) and semi-structured interviews. The APPT is a valid and reliable American tool which measures acute postoperative pain in adolescents aged 8–17 years. It comprises a 10 cm word-graphic rating scale for pain intensity, location of pain by marking a body outline and a choice of pain descriptors. It was selected as the most appropriate pain measure given the age of the sample and the type of pain to be measured (Tesler et al., 1991; Savedra et al., 1992). The coloured analogue scale is a 10 cm measure on which a red triangle increases in size as pain intensity increases; the range is ‘no pain’ to the ‘worst pain ever’. The scale was developed by the authors for use with school-age children (Gillies, 1995a; Gillies, 1995b) and was used when piloting this study (Gillies et al., 1997). Validation of the coloured analogue scale against the APPT was incorporated into the research design. The HADS is a well-published British measure of anxiety and depression, which is recommended for the detection and management of emotional problems in medical and surgical departments (Zigmond and Snaith, 1983). It has been used world-wide in a variety of situations and is available in several languages (Button et al., 1997; Lisspers et al., 1997). The scale has been validated for use with adolescents (Button et al., 1997; White et al., 1997). Its 14 items are categorised as anxiety or depression and are rated as asymptomatic, borderline or clinical (Zigmond and Snaith, 1983). This measure was selected because it has established validity, has been used in surgical departments before and is brief and quick to score. The OSIQ-R is a validated American measure of psychological adjustment to adolescence (or maturational state) which results in five ratings of self-esteem, from very high to very low (Offer et al., 1992). It has been tested in
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nine countries including Britain and is widely published (Agrawal, 1978; Brennan and Loideain, 1980; Rosenthal et al., 1980; Siefen et al., 1996; Wrate et al., in preparation). A British study provided some validation of the OSIQ-R in head-injured subjects although the sub-sample was small (n = 31) (Bogan et al., 1997); further papers are in preparation. The OSIQ-R was considered to be the most appropriate measure of maturational stage available. The adolescent semi-structured interview focused on pre and postoperative experiences. A self-report questionnaire with similar wording was completed by parents. Health professionals were asked in a semi-structured interview about their attitudes to adolescent patients and their pain assessment and management practices with adolescents in general (as opposed to the subjects). 3.3. Procedure Preoperatively, following consent, adolescents completed the HADS and the OSIQ-R. On the first postoperative day (day 1), they rated their pain using the APPT and the coloured analogue scale, the HADS was repeated and a semi-structured interview was conducted; nursing documentation was reviewed for notes on the presence of pain, the effect of analgesics, pain relieving drugs prescribed and frequency of administration. On the 3rd postoperative day (day 3), continuing pain (measured on a 10 cm analogue scale) and its management was assessed in a telephone interview. In the absence of a telephone, a brief questionnaire was completed and returned in a stamped addressed envelope (SAE). Parents completed the self-report questionnaire after the surgery. Interviews with the health professionals took place, by appointment, at any point during data collection. 3.4. Response rate Of 466 adolescents recruited preoperatively to the study, 351 participated on day 1 (75%); 86% of their parents took part (n = 301) as did 153 health professionals (97%). On day 3, 76% of the 351 adolescents (n = 268) responded; this included follow-up on two occasions for non-respondents. Parents who failed to return their questionnaire were sent a further questionnaire and SAE, on up to two occasions. Methodological difficulties included cancelled operations, refusal to consent and problems with recruitment caused by the reduction in the age-limit. In addition, recruited subjects were lost to the study due to e.g. their medical condition preventing further participation (n = 43) or withdrawal of consent (n = 29). Statistical analysis was conducted using Minitab 10.2. Since the large number of different surgical interventions resulted in small numbers of subjects for each operation, data were compressed (e.g. orthopaedic) to allow statistical analysis. Where possible, data were analysed according to surgical intervention. The APPT pain ratings were grouped
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into no pain (0), mild (1–3), moderate (4–6) and severe (7– 10) to allow analysis where numbers were small. Similarly, total self-image (TSI) scores on the OSIQ-R were compressed from five to three ratings (low, average, high). Descriptive statistics were used in conjunction with chisquared and single sample t-tests and ANOVA. 3.5. Ethics approval Ethics approval was obtained from each of the participating hospitals. Access to patients, surgeons and anaesthetists was granted by all Clinical Directors; however, the consultants in one surgical directorate refused to participate and therefore their patients were excluded from the study. Directors of Nursing allowed access to nurses. Written consent was obtained from all adolescents and also from one parent if the adolescent was under 16 years. Verbal consent was given by all participating parents and health professionals. 3.6. Pilot Study The pilot study indicated that many adolescents were in pain on their 1st postoperative day, that their needs were seldom recognised and the management of their pain was inconsistent. It also suggested that the training of health professionals concerning pain assessment and management was generally inadequate (Gillies et al., 1997).
4. Results 4.1. Patient demographics The adolescent sample consisted of 287 in-patients and 64 day cases. The mean age was 15.3 years (range 12 to 18); 63% were female for both in-patients and day cases. The sample distribution by surgical speciality, age and sex is described in Table 1. As can be seen, the planned stratification by speciality was not achieved owing to a variety of recruitment difficulties (paper in preparation). There were more females than males in every speciality other than orthopaedics. A large number of surgical interventions (n = 108) were carried out. The most common operations per speciality are detailed in Table 2. Day patients were discharged home on the day of their operation and most in-patients went home on the day after surgery. 4.2. Health professional demographics The 157 health professionals comprised 76 trained nurses from the participating wards and 77 doctors (43 surgeons and 33 anaesthetists) of all designations. Most anaesthetists (74%) and surgeons (90%) were male while most nurses (99%) were female.
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Table 1 Distribution of surgical specialties by sex and age Surgical speciality
ENT (n = 159) Oral (n = 80) Plastic (n = 52) Orthopaedic (n = 34) General (n = 20) Gynaecology (n = 6) Total (n = 351)
Sex
Male Female Male Female Male Female Male Female Male Female Female Male Female
Age (years)
Total
12
13
14
15
16
17
18
9 8 3 3 3 1 0 1 1 0 1 16 14
8 17 3 10 3 2 0 1 0 2 0 14 32
6 25 2 8 5 7 3 5 0 3 0 16 48
8 15 4 11 2 3 1 1 0 1 0 15 31
6 13 3 9 3 6 2 2 3 1 2 17 33
10 9 0 10 1 3 6 4 1 1 1 18 28
10 15 6 8 5 8 7 1 4 3 2 32 37
4.3. Intensity of pain As the APPT had not been tested in the UK before (Savedra, 1996 pers. commun.), there were no normative data. The day 1 pain intensity ratings with the APPT were not related statistically to the ratings with the coloured analogue scale used concurrently (r = −0.036; t = −1.71, P = 0.088). Pain intensity on day 1 (APPT) and on day 3 (1–10 scale), however, were related statistically (r = 0.447; t = 7.54, P = ,0.001*). In addition, simple regression indicated that the day 1 APPT ratings explained 20% of the variability in the day 3 ratings (t-ratio = 8.14, P = ,0.001*, r2 = 0.200). The coloured analogue scale, on the other hand, was not predictive of pain ratings on day 3 (tratio = 0.33, P = 0.74, r2 = 0.000). Visual analogue scales are a widely-accepted reliable means of measuring pain. Therefore, it is suggested that Table 2 Most common operations per surgical speciality Surgical speciality (n)
Most commonly performed operations (n)
ENT (159)
(Adeno)tonsillectomy (99) Rhinoplasty ± septoplasty (14) Nasal diathermy (14) Extraction of teeth (34) Exposure of teeth (18) Extraction of wisdom teeth (12) Bilateral breast reduction (5) Copper laser treatment to port wine stain (5) Bilateral bat ear repair (4) Unilateral arthroscopy (12) Partial lateral menisectomy (3) Unilateral excision exostosis femur (3) Circumcision (4) Excision thyroglossal cyst (2) Excision branchial cyst (2) Ligation varicose veins (2) Excision pilonidal sinus (2) Laparsocopy (3)
Oral (80)
Plastic (52)
Orthopaedic (34)
General (20)
Gynaecology (6)
57 102 21 59 22 30 19 15 9 11 6 128 223
the correlation of the ratings from the coloured analogue scale and word graphic rating scale (APPT) provides some evidence of validation in British subjects. However, as more subjects reported moderate-severe pain with APPT (50%) than with the coloured analogue scale (30%), the APPT was deemed to be the more sensitive measure. The difference between the measures may be related to the superior sensitivity of the word graphic rating scale when compared with visual analogue scales (Tesler et al., 1991). The findings, therefore, are reported only in relation to the APPT. On day 1, 91% of adolescents were in pain according to APPT ratings: mild (41%), moderate (40%), severe (10%). Pain intensity was not related to chronological age (F = 1.11, P = 0.358). Pain ratings were related to operation groups (F = 4.64, P = ,0.001*), the most painful being (adeno)tonsillectomy (mean rating 5.55); the least painful was dental extractions (mean rating 2.08), excluding extraction of wisdom teeth (mean rating 5.40). In comparison with day patients, in-patients were significantly more likely to experience moderate or severe pain (t = 20.92, P = ,0.001*). Females experienced more severe pain than males, the proportion of females rising as pain intensity rose (x2 = 30.26, d.f. = 3, P = , 0.001*). Approximately three quarters of the responding adolescents on day 3 reported pain (mean rating 2.77). Of these (n = 196), 35% rated their pain as moderate (n = 51) or severe (n = 18). Following either in-patient or day-patient discharge, approximately 71% of each group took analgesics, usually paracetamol or coproxamol. 4.4. Psychological adjustment to adolescence The OSIQ-R was completed satisfactorily by 89% adolescents. The mean total self-image score (TSI) score was 50 (range 21 to 74), consistent with the findings of Bogan et al. (1997) (mean TSI score 51; range 31 to 68) and with the normative American population (Fig. 1). According to the
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OSIQ-R, the proportion of patients within this study with a tendency to mental health problems (16%) fell within the normal range of 10 to 21% (Steinberg, 1994). Psychological adjustment to adolescence was related weakly to surgical intervention (x2 = 27.15, d.f. = 12, P = 0.008*); for example, a higher proportion of those having rhinoplasty (36%) had low TSI scores and were deemed to be poorly adjusted psychologically, when compared with normative American data (16%). In contrast, both general and orthopaedic surgical patients were considered to be well adjusted on OSIQ-R ratings. Pain intensity was related to total self-image; that is those with lower TSI scores experienced more severe pain (x2 = 9.50, d.f. = 3, P = 0.02*). Inpatients were less well adjusted than day patients (x2 = 9.16, d.f. = 2, P = 0.01*).
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Fig. 1. Distribution of the Total Self-Image scores (OSIQ-R)
omy (pre-operative x2 = 0.01, d.f. = 1, P = 0.932; postoperative x2 = 6.55, d.f. = 2, P = 0.038).
4.5. Anxiety 4.7. Recognition of adolescent pain by health professionals More than half the adolescents displayed symptoms of clinical anxiety pre and post-operatively (HADS). Anxiety levels were higher preoperatively than post-operatively, the mean difference being 0.62 (95% CI, 0.23–1.01; P = 0.002*). Post-operatively, there was a significant difference (x2 = 6.83, d.f. = 2, P = 0.009*) between in-patients and day patients, in that 46% of the former experienced anxiety symptoms while only 28% of day patients did. Those with the lowest TSI scores were most likely to be anxious (x2 = 21.17, d.f. = 2, P = ,0.001*). A total of 69% of patients with postoperative symptoms of borderline or clinical anxiety, were in moderate-severe pain (x2 = 46.76, d.f. = 6, P = ,0.001*). Postoperative anxiety on day 1 was related weakly (x2 = 19.07, d.f. = 6, P = 0.04*) to pain intensity on day 3. Anxiety was not related to age (pre-operative x2 = 12.10, d.f. = 12, P = 0.438; postoperative x2 = 8.81, d.f. = 12, P = 0.719) or the most common operation, tonsillectomy (pre-operative x2 = 0.22, d.f. = 2, P = 0.898; postoperative x2 = 1.77, d.f. = 2, P = 0.413). There were too many individual operations (n = 108) to do more detailed analysis. 4.6. Depression Depression, according to the HADS, was very uncommon preoperatively (,4%) but rose markedly post-operatively (29%), the greatest impact being on in-patients. The preoperative minus postoperative mean difference was 3.30 (95% CI, 2.88–3.71; t = 15.53, P = ,0.001*). Patients with symptoms of depression post-operatively were significantly more likely to experience moderate to severe pain (x2 = 44.40, d.f. = 2, P = ,0.001*); in other words, the proportion of adolescents with symptoms of depression rose as pain intensity rose. Postoperative borderline or clinical depression on day 1 was related to pain on day 3 (x2 = 25.05, d.f. = 6, P = ,0.001*). Depression was not related to age (pre-operative x2 = 4.84, d.f. = 6, P = 0.565; postoperative x2 = 9.27, d.f. = 12, P = 0.680) or tonsillect-
The views of health professionals about the care of adolescent patients were mixed as was their understanding of the term ‘adolescence’. Although few (n = 15) had received training about the health care of adolescents, the majority (n = 148) had experience of working with this group. Approximately half of all health professionals had attended at least one lecture in pain assessment and management however there were differences between the groups. More anaesthetists (79%) than nurses (42%) or surgeons (35%) had attended a lecture about pain assessment and, similarly, more anaesthetists (88%) than surgeons (60%) or nurses (42%) had undertaken pain management training. Most of each group (88% surgeons, 95% nurses, 100% anaesthetists) had experience every day or week of assessing and managing postoperative pain. Within the 2 weeks prior to interview, 76% anaesthetists had read a pain publication compared with 16% nurses and 9% surgeons: 36% nurses and 32% surgeons rarely or never read about pain whereas all anaesthetists did so (x2 = 64.627, d.f. = 8, P = , 0.001*). The majority of health professionals (98%) believed that their pain assessments were always (1%), usually (70%) or sometimes (27%) accurate. However, almost half the adolescents felt that nurses did not know when they were in pain. Generally, health professionals assessed pain intensity by using verbal and non-verbal communication and by measuring clinical signs, e.g. blood pressure. Over 75% of health professionals were aware of pain assessment tools such as analogue and faces scales, PCA charts and objective measures. Many of the health professionals (87%) who had (ever) used pain measurement tools with adolescents (n = 54) reported that they were useful. Pain was thought by health professionals to alter adolescents’ mood (95%), behaviour (86%) and self-esteem (62%). Fear, anxiety and lack of sleep were also considered to increase pain perception. While over 25% of health professionals felt that male and female adolescents reacted to
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pain similarly, more than half believed that the two reacted differently; that is, males were perceived as more stoical than females who were allowed to complain more. Nevertheless, 25% of health professionals reported that they had never told an adolescent that it was ‘okay’ to admit to pain. In fact, although most adolescents admitted their pain, usually to nurses, 46% of health professionals believed that adolescents denied being in pain. Furthermore, onein-three health professionals did not always believe adolescents’ complaints of pain. Despite the apparent inconsistencies between adolescent and health professional responses, 40% of health professionals estimated that half of the adolescents would be in moderate-severe pain following surgery: this was the case. 4.8. Therapeutic response of health professionals Given their experience, 93% of health professionals felt able to respond to adolescent pain. Many (70%) stated that, in general, pain after surgery could always or usually be prevented. For one-in-five adolescents, pain relief started before surgery when premedication included an opiate or milder analgesic. Opiates were often given intraoperatively (85%) while local anaesthesia, as a pain-relieving method, was less common (29%), despite its not infrequent use in children. Almost all (99%) adolescents were prescribed postoperative analgesics which were categorised as non-steroidal anti-inflammatory drugs (NSAID) (19%); opiates (58%); or ‘others’, e.g. paracetamol or coproxamol (92%). Often they were prescribed in combination. Nurses aimed to relieve pain completely (61%) or largely (39%) with analgesics and most (89%) stated that they gave analgesics regularly, that is, at least 4–6 hourly. This is in marked contrast to the findings from drug kardexes where, although 75% adolescents received at least one dose, only small proportions of subjects received analgesics regularly within 24 h of surgery (Table 3). Opiates were given to 55 of the 187 in-patients and five of the eight day cases for whom these drugs were prescribed. Of the 52 day cases who were not prescribed opiates, 19 were given alternative pain relieving drugs. However, differences in administration occurred between in-patients and day cases, with milder analgesics being given more to in-
patients than day cases: NSAIDS (in-patients 65%; day patients 27%) and ‘other analgesics’ (in-patients 82%; day patients 41%). The differences in analgesic administration to the two patient groups were statistically significant (NSAID x2 = 6.97, d.f. = 1, P = 0.008*; ‘other analgesics’ x2 = 37.49, d.f. = 1, P = ,0.001*). More females (43%) than males (39%) requested pain relief in the first 24 h. When asked for, analgesics were given immediately (75%), some time later (19%) or not at all (3%). Almost one-in-three adolescents (29%) refused analgesics. A quarter of doctors expressed concerns about prescribing analgesics for adolescents, including drug dependency, over/under-dosage and side-effects. Interestingly, 11% of both health professionals and adolescents believed that adolescents worried about becoming dependent on drugs given in hospital. While 20% of health professionals believed that parents worried about drug dependency, in fact, only 5% of parents reported worrying about this. Almost 25% of nurses were concerned about administering analgesics to adolescents because of a risk of overdosage. Fewer males (64%) than females (83%) received ‘other’ analgesics (x2 = 13.40, d.f. = 1, P = ,0.001*) but there was little or no difference in opiate (females 30%; males 28%) or NSAID (58% each) administration. Although some pain relieving drugs were administered regularly, many adolescents were not given prescribed (prn.) analgesics and seven (2%) received none at all. The low frequency of drug administration may account for the fact that 10% of adolescents worried about not being given analgesics, 12% were concerned that analgesics were not given quickly enough and 7% worried about both. Continuity of care requires accurate documentation. Reference in the nursing notes to pain and the effect of analgesics occurred infrequently. Only 22% of nursing notes made specific comment about the presence or absence of pain. Indirect reference, e.g. ‘analgesia given’ was more frequent (43%); otherwise, pain was not mentioned (35%). The effectiveness of analgesics was noted in 12% of nursing notes. Despite these findings, evaluation of pain relief was perceived by health professionals as very important (72%) or important (25%).
5. Discussion Table 3 Frequency of analgesic administration (day 1) by drug type Frequency At prescribed times Regularly: 4–6 hourly prn. Not regularly: ,4–6 hourly but more than once Once Never a
PCA.
NSAID % (n = 66)
Opiate % (n = 196) a
5.1. Pain intensity and pain relief Other % (n = 320)
6 5 12
1 2 4
1 12 36
35 42
22 71
26 25
This was the first large British assessment of adolescent postoperative pain. It demonstrates that pain is undertreated in adolescents as evidenced by the number in moderatesevere pain on day 1 and day 3. The results provide evidence of undertreatment of postoperative pain similar to that reported in children and adults (Royal College of Surgeons of England, The College of Anaesthetists, 1990). With few exceptions, the lack of formal training in ado-
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lescent healthcare was reflected in poor understanding of the needs of adolescents; for example, they were said to ask for pain relief as a means of attention-seeking. Pain management may have been compromised further by nurses underestimating analgesic requirements and by mistaken beliefs or negative attitudes such as: ‘Adolescents clock-watch for drugs’. ‘Postoperative pain is not all that sore. [It’s] not in the same league as labour or renal colic’. Formal pain assessment was not carried out systematically despite the fact that over a third of the health professionals estimated that adolescents would be in moderate to severe pain post-operatively. Pain assessment tools were acknowledged but many doctors and nurses depended upon unreliable methods of assessment. Prescription of postoperative analgesics was widespread although more powerful drugs such as opiates were prescribed less frequently. The fear of creating drug dependency in adolescents probably affected both prescribing practice as fewer opiates were prescribed, and drug administration in that although patients generally received one analgesic dose, pain relieving drugs were not administered regularly. Male and female reactions to pain were perceived as different by many health professionals and this may have been reflected in the fact that many more females than males received milder analgesics. However, strong analgesics were administered less frequently than milder drugs to both sexes. In this study, there can be no doubt that females experienced more severe pain than males. 5.2. The influences of emotional state and maturational stage The link between emotion and pain has been debated repeatedly and this study offers further support to the circular relationship between pain and anxiety. It was not surprising that many patients displayed symptoms of anxiety preoperatively and that for some, this continued post-operatively. The relationship between higher levels of pain and symptoms of clinical anxiety supports the findings of Savedra et al. (1988) that adolescents associate pain with mental distress. Symptoms of depression, post-operatively, were also linked with moderate-severe acute pain. This unusual measurement in a postoperative situation, revealed interesting findings, i.e. the marked increase in symptoms between the pre- and postoperative assessments. It is likely that symptoms of depression go unrecognised and that if more attention was paid to the psychological consequences of acute pain, its management might be more effective. The sample was normally distributed in terms of selfesteem. The finding that those with low total self-image (TSI) scores (i.e. poorly-adjusted) experienced more pain than those with high scores (i.e. well-adjusted) suggests that perceived pain intensity is associated with psychological adjustment to adolescence. In addition, one explanation of the difference in TSI scores between in-patients and day
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patients could be that, because day patients were the better adjusted group, selection by health professionals of young patients for day surgery may include informal judgement of individual coping skills. Further details about emotional state and maturational stage are given in a paper in preparation. 5.3. Differences between in-patients and day cases A higher proportion of in-patients than day cases experienced moderate-severe pain on the 1st and 3rd postoperative days. The management of their pain clearly differed with opiates being prescribed and administered more frequently to in-patients. In the light of increasing day surgery, it is concerning that a relatively high proportion of day patients were not prescribed or given opiates, even after a surgical incision. This is particularly important when in reality opiate dependency is not the problem it is believed to be (Wall, 1997), even in children (McCaffery and Wong, 1993). The importance of effective analgesia has grown as earlier discharge following surgery has increased and has resulted in assistance in pain relief being requested of community-based health professionals. This is particularly important since, as reported in this paper, no differences existed between in-patients and day patients in their selfadministration of analgesics once home. The differences between the experiences of in-patients and day cases may be explained by several factors: day patients were at home for both postoperative assessments rather than being in an unfamiliar hospital environment; generally, in-patient surgery is more serious in nature than day surgery; and this results in more severe pain which, if undertreated, increases anxiety and possibly depression. However, in the context of this study, most operations were minor (the in-patients were discharged home on the day after surgery). Consequently, other reasons for in and day patient differences, such as psychological adjustment to adolescence or personality, should be considered. 5.4. Predictors of pain While age is a predictor of pain in children (Fradet et al., 1990; Palermo and Drotar, 1996) this was not the case for the adolescents in this study. However, the statistically significant links between day 1 anxiety or depression and day 3 pain intensity may facilitate the early identification of those most at risk of experiencing moderate-severe pain several days post-surgery. More research is required in this area.
6. Conclusions This study demonstrates that pain-relieving practice is not evidence-based, e.g. the use of assessment tools and analgesics. Validated, developmentally appropriate pain measures such as the APPT are recommended to enhance pain assess-
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ment; in addition, a review of prescribing practice and analgesic administration would facilitate effective pain relief. Although this was the first occasion that the APPT has been used in the UK, the sample was sufficiently large to provide initial normative data for British subjects. Therefore, the APPT is recommended as a simple, brief, validated measure. The financial cost of introducing a variety of context and age-specific pain assessment tools may account for their under-use. However, systematic pain assessment should improve the quality of care delivered and might reduce possible long-term sequelae. Auditing pain assessment and management would provide baseline data for setting standards. Further research is required to determine whether the link between psychological adjustment to adolescence (or maturational stage) and pain can be replicated and to identify factors which may predict those more at risk of experiencing pain post-operatively. Attention needs to be paid routinely to the psychological well-being of adolescents who are to undergo elective surgery. A simple screening measure such as the HADS would identify those with symptoms of anxiety or depression. In addition, after further research, such screening may allow early identification of those at risk of experiencing more pain, especially for inpatients. Practically, anxiety-reducing time should be incorporated into patient care, particularly in relation to those patients identified as being at risk Enhanced education for health professionals on adolescence and on pain might lead to changed attitudes. Patients, including adolescents, have a right to receive high quality care including systematic assessment and relief of pain symptoms. The current failure to implement research findings highlights the need for improved research dissemination strategies if clinical effectiveness is to be demonstrated.
7. Key messages The need to improve pain management for adolescents is essential. To achieve this there needs to be a change in attitudes to both adolescents and the relief of their pain. Promoting the seriousness of adolescent health care, the need to adequately recognise pain and then administer analgesics are first steps. Thereafter, attention to maturational stage and psychological well-being is required to improve the elective surgery and recovery experience of young people.
Acknowledgements Professor W.Ll. Parry-Jones was very involved throughout this project and in the initial report writing but died before publication was possible. His encouragement and enthusiasm for the project was second to none. This
research was funded by the Acute Health Committee of the Scottish Office Home and Health Department. The content of the paper represents the view of the authors alone. Many thanks are due to Mr Harper Gilmour, Department of Public Health, University of Glasgow, for statistical advice.
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Savedra, M., Tesler, M., Holzemer, W. and Ward, J., Adolescent Pediatric Pain Tool (APPT) User’s Manual, University of California, San Francisco, CA, 1992. Shye, D. and Jaffe, B., Prevalence and correlates of pre-menstrual symptoms: a study of Israeli teenage girls, J. Adolescent Health, 12 (1991) 217–224. Siefen, G., Kirkcaldy, B., Athanasou, J. and Peponis, M., The self-image of Greek, Greek-migrant and German adolescents, Soc. Psychiatry Psychiatr. Epidemiol., 31 (1996) 241–247. Silverberg, M., Chronic abdominal pain in adolescents, Pediatr. Ann., 20 (1991) 179–185. Smith, M., Tyler, D., Womack, W. and Chen, A., Assessment and management of recurrent pain in adolescence, Pediatrician, 16 (1989) 85–93. Steinberg, D., Adolescent services in child and adolescent psychiatry. In: M. Rutter, E. Taylor, and L. Hersov (Eds.), Modern Approaches, 3rd edition, Blackwell Scientific, Oxford, 1994, pp. 1006–1022. Tesler, M., Savedra, M., Holzemer, W., Wilkie, D., Ward, J. and Paul, S., The word-graphic rating scale as a measure of children’s and adolescents’ pain intensity, Res. Nursing Health, 14 (1991) 361–371. Vanden Berg, A., Savva, D., Honjol, N. and Rama Prabhu, N., Comparison of total intravenous, balanced inhalational and combined intravenous inhalational anaesthesia for tympanoplasty, septorhinoplasty and adenotonsillectomy, Anaesth. Intensive Care, 23 (5) (1995) 574–582. Wall, P., The generation of yet another myth on the use of narcotics (Editorial), Pain, 73 (1997) 121–122. White, D., Sims, R., Leach, C., Cottrell, D. and Atkinson, M., The Validation of the Hospital Anxiety and Depression Scale for use in Adolescents. Paper presented at the Royal College of Psychiatrists Conference, Edinburgh, 1997. Zigmond, A. and Snaith, R., The Hospital Anxiety and Depression Scale, Acta Psychiatica Scandinavica, 67 (1983) 361–370.
Postoperative pain assessment and management in adolescents Marjorie L. Gillies a ,*, Lorraine N. Smith b, William Ll. Parry-Jones a,1 a
University of Glasgow, Department of Child and Adolescent Psychiatry, Caledonia House, Royal Hospital for Sick Children, Glasgow G3 8SJ, UK b University of Glasgow, Nursing and Midwifery School, 68 Oakfield Avenue, Glasgow G12 8LS, UK Received 18 February 1998; received in revised form 7 August 1998; accepted 21 August 1998
Abstract A 3-year study investigated the experience and management of postoperative pain following elective surgery in an adolescent sample, using a variety of valid, reliable instruments and semi-structured interviews. In addition to the adolescent subjects, the views of one parent of each adolescent were sought and a sample of health professionals comprising surgeons, anaesthetists and nurses were interviewed about acute pain in adolescent patients. This paper presents some of the main findings pertaining to pain assessment and management. Pain, experienced by most adolescents on the 1st and 3rd postoperative days, was influenced by the presence of anxiety and depression, in addition to the maturational stage; differences between in-patients and day cases are highlighted. Recommendations for practice include the need for more effective pain management and raising awareness of the importance of both psychological state and adjustment to adolescence in this age-group. 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Postoperative pain; Adolescents; Emotion; Maturation
1. Introduction Adolescent medicine is emerging as a speciality in its own right in the UK. Although adolescents have different needs from children and adults, they are often nursed with adults or children (Gillies and Parry-Jones, 1992). It is argued that adolescents’ care should be provided by individuals with a specialist interest in their particular needs. Young people mature in various ways, and over different periods and thus their communication skills, their need for independence and self-control and their ability to adapt to pubertal changes differ (Coleman, 1980). These have implications for the management of pain in adolescents (Favaloro, 1988; Gillies, 1998). There has been an increased focus on adolescent pain, e.g. recurrent pain and the importance of stress management (Smith et al., 1989); non-acute pain and psychological factors (Magni et al., 1990); chronic pain (Cohall and CombeOrlowski, 1989; Silverberg, 1991); acute pain in venepuncture (Fradet et al., 1990); pre-menstrual symptoms and men* Corresponding author. Tel.: +44-141-201-0732; fax: +44-141-2019261; e-mail: [email protected] 1 Posthumously.
strual pain (Shye and Jaffe, 1991); adolescent migraine (McGrath et al., 1992); and phantom limb pain (McGrath and Hillier, 1992). However, little is known about the extent to which the adolescent in acute pain differs from others in acute pain. Furthermore, while the relationship between emotion and pain is well recognised in adults (McCaffery and Beebe, 1989) and children (Cohen, 1993; McGrath, 1993), little is known about the psychological aspects of acute postoperative pain in adolescence. Extrapolation would lead one to believe that anxiety influences pain intensity in adolescents as it does in other age-groups but the added phenomenon of maturational stage may complicate this relationship further. An essential element of pain management is the measurement of intensity (Tesler et al., 1991; Savedra et al., 1992). The development and use of pain measures in adults and children has been reported widely (Gillies, 1993; Marvin, 1995) but adolescents are rarely sampled and when they are, they are often grouped under ‘children’ rather than being identified separately (Vanden Berg et al., 1995). The education of health professionals needs to focus more on pain (Association of Anaesthetists of Great Britain and Ireland, Royal College of Anaesthetists and The Pain Society, 1993), particularly as the attitudes of health profes-
0304-3959/99/$ - see front matter 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S03 04-3959(98)001 78-X
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sionals are a barrier to effective pain relief (Kachoyeanos and Zollo, 1995). There is no evidence that dependency on strong analgesics given in hospital is the problem that some health professionals believe it to be (Wall, 1997). In fact Berde et al. (1991) suggested that wider use of patient controlled analgesia (PCA) is safe for adolescents and might facilitate the healing process. This 3-year study examined the postoperative pain experience of adolescents and included psychological and maturational measures. Although it set out to answer a range of research questions, only the principal results concerning questions 1–3 and 5–6 are reported.
2. Research questions 1. What is the intensity of postoperative pain in hospitalised adolescents? 2. What is the impact of postoperative pain on different levels of maturational adjustment using the Offer SelfImage Questionnaire and on anxiety using the Hospital Anxiety and Depression Scale? 3. To what extent do the experiences of in- and day patients differ? 4. What are the responses of parents to pain in their adolescent children? 5. To what extent do nursing and medical health professionals recognise adolescent responses to pain? 6. What is the actual therapeutic response of nursing and medical health professionals to postoperative pain in adolescents?
3. Method 3.1. Sample selection and size The adolescent sample was based on 1991 in-patient surgery discharge figures for a large urban health board where 55% of all in-patient discharges aged 12–20 years had undergone a surgical procedure. The surgical specialities with the highest proportion for this age-group were identified as gynaecology, general surgery, orthopaedics, ear nose and throat (ENT), oral and plastic surgery. The sample size was set at 80 admissions for each of general surgery, ENT and gynaecology and 50 admissions in each of plastics, orthopaedics and oral surgery. The inclusion criteria were agreed as in-patients or day patients undergoing elective surgery; from one of the six specified National Health Service (NHS) hospitals; and from one of the six specified surgical specialities. Patients were to be aged 12–20 years inclusive but, as a condition of funding, the upper age limit was reduced from 20 to 18 years. Patients excluded were those undergoing local rather than general anaesthesia; termination of pregnancy; endoscopies other than laparoscopy or arthroscopy which involved sur-
gical incision; patients with known learning disabilities and re-admissions or pilot study participants. Consecutive admissions were recruited initially up to the agreed number per surgical speciality. The adolescent sample size was determined by the need for statistical power, sample diversity and the number of hospitals involved. Although it was set at 400 or 11% of the population, the final number was less. In a study such as this, a sample of 300 will allow the percentage of the population experiencing moderate-severe pain to be estimated with a standard error of ±3%; the final number was 351. The proposed sizes of the other two samples were set at one relative of each adolescent (n = 400) and randomly selected health professionals (n = 157) from all hospitals and surgical specialties. 3.2. Data collection tools Data were collected using the Adolescent Paediatric Pain Tool (APPT), a coloured visual analogue scale, the Hospital Anxiety and Depression Scale (HADS), the Offer SelfImage Questionnaire-Revised (OSIQ-R) and semi-structured interviews. The APPT is a valid and reliable American tool which measures acute postoperative pain in adolescents aged 8–17 years. It comprises a 10 cm word-graphic rating scale for pain intensity, location of pain by marking a body outline and a choice of pain descriptors. It was selected as the most appropriate pain measure given the age of the sample and the type of pain to be measured (Tesler et al., 1991; Savedra et al., 1992). The coloured analogue scale is a 10 cm measure on which a red triangle increases in size as pain intensity increases; the range is ‘no pain’ to the ‘worst pain ever’. The scale was developed by the authors for use with school-age children (Gillies, 1995a; Gillies, 1995b) and was used when piloting this study (Gillies et al., 1997). Validation of the coloured analogue scale against the APPT was incorporated into the research design. The HADS is a well-published British measure of anxiety and depression, which is recommended for the detection and management of emotional problems in medical and surgical departments (Zigmond and Snaith, 1983). It has been used world-wide in a variety of situations and is available in several languages (Button et al., 1997; Lisspers et al., 1997). The scale has been validated for use with adolescents (Button et al., 1997; White et al., 1997). Its 14 items are categorised as anxiety or depression and are rated as asymptomatic, borderline or clinical (Zigmond and Snaith, 1983). This measure was selected because it has established validity, has been used in surgical departments before and is brief and quick to score. The OSIQ-R is a validated American measure of psychological adjustment to adolescence (or maturational state) which results in five ratings of self-esteem, from very high to very low (Offer et al., 1992). It has been tested in
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nine countries including Britain and is widely published (Agrawal, 1978; Brennan and Loideain, 1980; Rosenthal et al., 1980; Siefen et al., 1996; Wrate et al., in preparation). A British study provided some validation of the OSIQ-R in head-injured subjects although the sub-sample was small (n = 31) (Bogan et al., 1997); further papers are in preparation. The OSIQ-R was considered to be the most appropriate measure of maturational stage available. The adolescent semi-structured interview focused on pre and postoperative experiences. A self-report questionnaire with similar wording was completed by parents. Health professionals were asked in a semi-structured interview about their attitudes to adolescent patients and their pain assessment and management practices with adolescents in general (as opposed to the subjects). 3.3. Procedure Preoperatively, following consent, adolescents completed the HADS and the OSIQ-R. On the first postoperative day (day 1), they rated their pain using the APPT and the coloured analogue scale, the HADS was repeated and a semi-structured interview was conducted; nursing documentation was reviewed for notes on the presence of pain, the effect of analgesics, pain relieving drugs prescribed and frequency of administration. On the 3rd postoperative day (day 3), continuing pain (measured on a 10 cm analogue scale) and its management was assessed in a telephone interview. In the absence of a telephone, a brief questionnaire was completed and returned in a stamped addressed envelope (SAE). Parents completed the self-report questionnaire after the surgery. Interviews with the health professionals took place, by appointment, at any point during data collection. 3.4. Response rate Of 466 adolescents recruited preoperatively to the study, 351 participated on day 1 (75%); 86% of their parents took part (n = 301) as did 153 health professionals (97%). On day 3, 76% of the 351 adolescents (n = 268) responded; this included follow-up on two occasions for non-respondents. Parents who failed to return their questionnaire were sent a further questionnaire and SAE, on up to two occasions. Methodological difficulties included cancelled operations, refusal to consent and problems with recruitment caused by the reduction in the age-limit. In addition, recruited subjects were lost to the study due to e.g. their medical condition preventing further participation (n = 43) or withdrawal of consent (n = 29). Statistical analysis was conducted using Minitab 10.2. Since the large number of different surgical interventions resulted in small numbers of subjects for each operation, data were compressed (e.g. orthopaedic) to allow statistical analysis. Where possible, data were analysed according to surgical intervention. The APPT pain ratings were grouped
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into no pain (0), mild (1–3), moderate (4–6) and severe (7– 10) to allow analysis where numbers were small. Similarly, total self-image (TSI) scores on the OSIQ-R were compressed from five to three ratings (low, average, high). Descriptive statistics were used in conjunction with chisquared and single sample t-tests and ANOVA. 3.5. Ethics approval Ethics approval was obtained from each of the participating hospitals. Access to patients, surgeons and anaesthetists was granted by all Clinical Directors; however, the consultants in one surgical directorate refused to participate and therefore their patients were excluded from the study. Directors of Nursing allowed access to nurses. Written consent was obtained from all adolescents and also from one parent if the adolescent was under 16 years. Verbal consent was given by all participating parents and health professionals. 3.6. Pilot Study The pilot study indicated that many adolescents were in pain on their 1st postoperative day, that their needs were seldom recognised and the management of their pain was inconsistent. It also suggested that the training of health professionals concerning pain assessment and management was generally inadequate (Gillies et al., 1997).
4. Results 4.1. Patient demographics The adolescent sample consisted of 287 in-patients and 64 day cases. The mean age was 15.3 years (range 12 to 18); 63% were female for both in-patients and day cases. The sample distribution by surgical speciality, age and sex is described in Table 1. As can be seen, the planned stratification by speciality was not achieved owing to a variety of recruitment difficulties (paper in preparation). There were more females than males in every speciality other than orthopaedics. A large number of surgical interventions (n = 108) were carried out. The most common operations per speciality are detailed in Table 2. Day patients were discharged home on the day of their operation and most in-patients went home on the day after surgery. 4.2. Health professional demographics The 157 health professionals comprised 76 trained nurses from the participating wards and 77 doctors (43 surgeons and 33 anaesthetists) of all designations. Most anaesthetists (74%) and surgeons (90%) were male while most nurses (99%) were female.
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Table 1 Distribution of surgical specialties by sex and age Surgical speciality
ENT (n = 159) Oral (n = 80) Plastic (n = 52) Orthopaedic (n = 34) General (n = 20) Gynaecology (n = 6) Total (n = 351)
Sex
Male Female Male Female Male Female Male Female Male Female Female Male Female
Age (years)
Total
12
13
14
15
16
17
18
9 8 3 3 3 1 0 1 1 0 1 16 14
8 17 3 10 3 2 0 1 0 2 0 14 32
6 25 2 8 5 7 3 5 0 3 0 16 48
8 15 4 11 2 3 1 1 0 1 0 15 31
6 13 3 9 3 6 2 2 3 1 2 17 33
10 9 0 10 1 3 6 4 1 1 1 18 28
10 15 6 8 5 8 7 1 4 3 2 32 37
4.3. Intensity of pain As the APPT had not been tested in the UK before (Savedra, 1996 pers. commun.), there were no normative data. The day 1 pain intensity ratings with the APPT were not related statistically to the ratings with the coloured analogue scale used concurrently (r = −0.036; t = −1.71, P = 0.088). Pain intensity on day 1 (APPT) and on day 3 (1–10 scale), however, were related statistically (r = 0.447; t = 7.54, P = ,0.001*). In addition, simple regression indicated that the day 1 APPT ratings explained 20% of the variability in the day 3 ratings (t-ratio = 8.14, P = ,0.001*, r2 = 0.200). The coloured analogue scale, on the other hand, was not predictive of pain ratings on day 3 (tratio = 0.33, P = 0.74, r2 = 0.000). Visual analogue scales are a widely-accepted reliable means of measuring pain. Therefore, it is suggested that Table 2 Most common operations per surgical speciality Surgical speciality (n)
Most commonly performed operations (n)
ENT (159)
(Adeno)tonsillectomy (99) Rhinoplasty ± septoplasty (14) Nasal diathermy (14) Extraction of teeth (34) Exposure of teeth (18) Extraction of wisdom teeth (12) Bilateral breast reduction (5) Copper laser treatment to port wine stain (5) Bilateral bat ear repair (4) Unilateral arthroscopy (12) Partial lateral menisectomy (3) Unilateral excision exostosis femur (3) Circumcision (4) Excision thyroglossal cyst (2) Excision branchial cyst (2) Ligation varicose veins (2) Excision pilonidal sinus (2) Laparsocopy (3)
Oral (80)
Plastic (52)
Orthopaedic (34)
General (20)
Gynaecology (6)
57 102 21 59 22 30 19 15 9 11 6 128 223
the correlation of the ratings from the coloured analogue scale and word graphic rating scale (APPT) provides some evidence of validation in British subjects. However, as more subjects reported moderate-severe pain with APPT (50%) than with the coloured analogue scale (30%), the APPT was deemed to be the more sensitive measure. The difference between the measures may be related to the superior sensitivity of the word graphic rating scale when compared with visual analogue scales (Tesler et al., 1991). The findings, therefore, are reported only in relation to the APPT. On day 1, 91% of adolescents were in pain according to APPT ratings: mild (41%), moderate (40%), severe (10%). Pain intensity was not related to chronological age (F = 1.11, P = 0.358). Pain ratings were related to operation groups (F = 4.64, P = ,0.001*), the most painful being (adeno)tonsillectomy (mean rating 5.55); the least painful was dental extractions (mean rating 2.08), excluding extraction of wisdom teeth (mean rating 5.40). In comparison with day patients, in-patients were significantly more likely to experience moderate or severe pain (t = 20.92, P = ,0.001*). Females experienced more severe pain than males, the proportion of females rising as pain intensity rose (x2 = 30.26, d.f. = 3, P = , 0.001*). Approximately three quarters of the responding adolescents on day 3 reported pain (mean rating 2.77). Of these (n = 196), 35% rated their pain as moderate (n = 51) or severe (n = 18). Following either in-patient or day-patient discharge, approximately 71% of each group took analgesics, usually paracetamol or coproxamol. 4.4. Psychological adjustment to adolescence The OSIQ-R was completed satisfactorily by 89% adolescents. The mean total self-image score (TSI) score was 50 (range 21 to 74), consistent with the findings of Bogan et al. (1997) (mean TSI score 51; range 31 to 68) and with the normative American population (Fig. 1). According to the
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OSIQ-R, the proportion of patients within this study with a tendency to mental health problems (16%) fell within the normal range of 10 to 21% (Steinberg, 1994). Psychological adjustment to adolescence was related weakly to surgical intervention (x2 = 27.15, d.f. = 12, P = 0.008*); for example, a higher proportion of those having rhinoplasty (36%) had low TSI scores and were deemed to be poorly adjusted psychologically, when compared with normative American data (16%). In contrast, both general and orthopaedic surgical patients were considered to be well adjusted on OSIQ-R ratings. Pain intensity was related to total self-image; that is those with lower TSI scores experienced more severe pain (x2 = 9.50, d.f. = 3, P = 0.02*). Inpatients were less well adjusted than day patients (x2 = 9.16, d.f. = 2, P = 0.01*).
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Fig. 1. Distribution of the Total Self-Image scores (OSIQ-R)
omy (pre-operative x2 = 0.01, d.f. = 1, P = 0.932; postoperative x2 = 6.55, d.f. = 2, P = 0.038).
4.5. Anxiety 4.7. Recognition of adolescent pain by health professionals More than half the adolescents displayed symptoms of clinical anxiety pre and post-operatively (HADS). Anxiety levels were higher preoperatively than post-operatively, the mean difference being 0.62 (95% CI, 0.23–1.01; P = 0.002*). Post-operatively, there was a significant difference (x2 = 6.83, d.f. = 2, P = 0.009*) between in-patients and day patients, in that 46% of the former experienced anxiety symptoms while only 28% of day patients did. Those with the lowest TSI scores were most likely to be anxious (x2 = 21.17, d.f. = 2, P = ,0.001*). A total of 69% of patients with postoperative symptoms of borderline or clinical anxiety, were in moderate-severe pain (x2 = 46.76, d.f. = 6, P = ,0.001*). Postoperative anxiety on day 1 was related weakly (x2 = 19.07, d.f. = 6, P = 0.04*) to pain intensity on day 3. Anxiety was not related to age (pre-operative x2 = 12.10, d.f. = 12, P = 0.438; postoperative x2 = 8.81, d.f. = 12, P = 0.719) or the most common operation, tonsillectomy (pre-operative x2 = 0.22, d.f. = 2, P = 0.898; postoperative x2 = 1.77, d.f. = 2, P = 0.413). There were too many individual operations (n = 108) to do more detailed analysis. 4.6. Depression Depression, according to the HADS, was very uncommon preoperatively (,4%) but rose markedly post-operatively (29%), the greatest impact being on in-patients. The preoperative minus postoperative mean difference was 3.30 (95% CI, 2.88–3.71; t = 15.53, P = ,0.001*). Patients with symptoms of depression post-operatively were significantly more likely to experience moderate to severe pain (x2 = 44.40, d.f. = 2, P = ,0.001*); in other words, the proportion of adolescents with symptoms of depression rose as pain intensity rose. Postoperative borderline or clinical depression on day 1 was related to pain on day 3 (x2 = 25.05, d.f. = 6, P = ,0.001*). Depression was not related to age (pre-operative x2 = 4.84, d.f. = 6, P = 0.565; postoperative x2 = 9.27, d.f. = 12, P = 0.680) or tonsillect-
The views of health professionals about the care of adolescent patients were mixed as was their understanding of the term ‘adolescence’. Although few (n = 15) had received training about the health care of adolescents, the majority (n = 148) had experience of working with this group. Approximately half of all health professionals had attended at least one lecture in pain assessment and management however there were differences between the groups. More anaesthetists (79%) than nurses (42%) or surgeons (35%) had attended a lecture about pain assessment and, similarly, more anaesthetists (88%) than surgeons (60%) or nurses (42%) had undertaken pain management training. Most of each group (88% surgeons, 95% nurses, 100% anaesthetists) had experience every day or week of assessing and managing postoperative pain. Within the 2 weeks prior to interview, 76% anaesthetists had read a pain publication compared with 16% nurses and 9% surgeons: 36% nurses and 32% surgeons rarely or never read about pain whereas all anaesthetists did so (x2 = 64.627, d.f. = 8, P = , 0.001*). The majority of health professionals (98%) believed that their pain assessments were always (1%), usually (70%) or sometimes (27%) accurate. However, almost half the adolescents felt that nurses did not know when they were in pain. Generally, health professionals assessed pain intensity by using verbal and non-verbal communication and by measuring clinical signs, e.g. blood pressure. Over 75% of health professionals were aware of pain assessment tools such as analogue and faces scales, PCA charts and objective measures. Many of the health professionals (87%) who had (ever) used pain measurement tools with adolescents (n = 54) reported that they were useful. Pain was thought by health professionals to alter adolescents’ mood (95%), behaviour (86%) and self-esteem (62%). Fear, anxiety and lack of sleep were also considered to increase pain perception. While over 25% of health professionals felt that male and female adolescents reacted to
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pain similarly, more than half believed that the two reacted differently; that is, males were perceived as more stoical than females who were allowed to complain more. Nevertheless, 25% of health professionals reported that they had never told an adolescent that it was ‘okay’ to admit to pain. In fact, although most adolescents admitted their pain, usually to nurses, 46% of health professionals believed that adolescents denied being in pain. Furthermore, onein-three health professionals did not always believe adolescents’ complaints of pain. Despite the apparent inconsistencies between adolescent and health professional responses, 40% of health professionals estimated that half of the adolescents would be in moderate-severe pain following surgery: this was the case. 4.8. Therapeutic response of health professionals Given their experience, 93% of health professionals felt able to respond to adolescent pain. Many (70%) stated that, in general, pain after surgery could always or usually be prevented. For one-in-five adolescents, pain relief started before surgery when premedication included an opiate or milder analgesic. Opiates were often given intraoperatively (85%) while local anaesthesia, as a pain-relieving method, was less common (29%), despite its not infrequent use in children. Almost all (99%) adolescents were prescribed postoperative analgesics which were categorised as non-steroidal anti-inflammatory drugs (NSAID) (19%); opiates (58%); or ‘others’, e.g. paracetamol or coproxamol (92%). Often they were prescribed in combination. Nurses aimed to relieve pain completely (61%) or largely (39%) with analgesics and most (89%) stated that they gave analgesics regularly, that is, at least 4–6 hourly. This is in marked contrast to the findings from drug kardexes where, although 75% adolescents received at least one dose, only small proportions of subjects received analgesics regularly within 24 h of surgery (Table 3). Opiates were given to 55 of the 187 in-patients and five of the eight day cases for whom these drugs were prescribed. Of the 52 day cases who were not prescribed opiates, 19 were given alternative pain relieving drugs. However, differences in administration occurred between in-patients and day cases, with milder analgesics being given more to in-
patients than day cases: NSAIDS (in-patients 65%; day patients 27%) and ‘other analgesics’ (in-patients 82%; day patients 41%). The differences in analgesic administration to the two patient groups were statistically significant (NSAID x2 = 6.97, d.f. = 1, P = 0.008*; ‘other analgesics’ x2 = 37.49, d.f. = 1, P = ,0.001*). More females (43%) than males (39%) requested pain relief in the first 24 h. When asked for, analgesics were given immediately (75%), some time later (19%) or not at all (3%). Almost one-in-three adolescents (29%) refused analgesics. A quarter of doctors expressed concerns about prescribing analgesics for adolescents, including drug dependency, over/under-dosage and side-effects. Interestingly, 11% of both health professionals and adolescents believed that adolescents worried about becoming dependent on drugs given in hospital. While 20% of health professionals believed that parents worried about drug dependency, in fact, only 5% of parents reported worrying about this. Almost 25% of nurses were concerned about administering analgesics to adolescents because of a risk of overdosage. Fewer males (64%) than females (83%) received ‘other’ analgesics (x2 = 13.40, d.f. = 1, P = ,0.001*) but there was little or no difference in opiate (females 30%; males 28%) or NSAID (58% each) administration. Although some pain relieving drugs were administered regularly, many adolescents were not given prescribed (prn.) analgesics and seven (2%) received none at all. The low frequency of drug administration may account for the fact that 10% of adolescents worried about not being given analgesics, 12% were concerned that analgesics were not given quickly enough and 7% worried about both. Continuity of care requires accurate documentation. Reference in the nursing notes to pain and the effect of analgesics occurred infrequently. Only 22% of nursing notes made specific comment about the presence or absence of pain. Indirect reference, e.g. ‘analgesia given’ was more frequent (43%); otherwise, pain was not mentioned (35%). The effectiveness of analgesics was noted in 12% of nursing notes. Despite these findings, evaluation of pain relief was perceived by health professionals as very important (72%) or important (25%).
5. Discussion Table 3 Frequency of analgesic administration (day 1) by drug type Frequency At prescribed times Regularly: 4–6 hourly prn. Not regularly: ,4–6 hourly but more than once Once Never a
PCA.
NSAID % (n = 66)
Opiate % (n = 196) a
5.1. Pain intensity and pain relief Other % (n = 320)
6 5 12
1 2 4
1 12 36
35 42
22 71
26 25
This was the first large British assessment of adolescent postoperative pain. It demonstrates that pain is undertreated in adolescents as evidenced by the number in moderatesevere pain on day 1 and day 3. The results provide evidence of undertreatment of postoperative pain similar to that reported in children and adults (Royal College of Surgeons of England, The College of Anaesthetists, 1990). With few exceptions, the lack of formal training in ado-
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lescent healthcare was reflected in poor understanding of the needs of adolescents; for example, they were said to ask for pain relief as a means of attention-seeking. Pain management may have been compromised further by nurses underestimating analgesic requirements and by mistaken beliefs or negative attitudes such as: ‘Adolescents clock-watch for drugs’. ‘Postoperative pain is not all that sore. [It’s] not in the same league as labour or renal colic’. Formal pain assessment was not carried out systematically despite the fact that over a third of the health professionals estimated that adolescents would be in moderate to severe pain post-operatively. Pain assessment tools were acknowledged but many doctors and nurses depended upon unreliable methods of assessment. Prescription of postoperative analgesics was widespread although more powerful drugs such as opiates were prescribed less frequently. The fear of creating drug dependency in adolescents probably affected both prescribing practice as fewer opiates were prescribed, and drug administration in that although patients generally received one analgesic dose, pain relieving drugs were not administered regularly. Male and female reactions to pain were perceived as different by many health professionals and this may have been reflected in the fact that many more females than males received milder analgesics. However, strong analgesics were administered less frequently than milder drugs to both sexes. In this study, there can be no doubt that females experienced more severe pain than males. 5.2. The influences of emotional state and maturational stage The link between emotion and pain has been debated repeatedly and this study offers further support to the circular relationship between pain and anxiety. It was not surprising that many patients displayed symptoms of anxiety preoperatively and that for some, this continued post-operatively. The relationship between higher levels of pain and symptoms of clinical anxiety supports the findings of Savedra et al. (1988) that adolescents associate pain with mental distress. Symptoms of depression, post-operatively, were also linked with moderate-severe acute pain. This unusual measurement in a postoperative situation, revealed interesting findings, i.e. the marked increase in symptoms between the pre- and postoperative assessments. It is likely that symptoms of depression go unrecognised and that if more attention was paid to the psychological consequences of acute pain, its management might be more effective. The sample was normally distributed in terms of selfesteem. The finding that those with low total self-image (TSI) scores (i.e. poorly-adjusted) experienced more pain than those with high scores (i.e. well-adjusted) suggests that perceived pain intensity is associated with psychological adjustment to adolescence. In addition, one explanation of the difference in TSI scores between in-patients and day
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patients could be that, because day patients were the better adjusted group, selection by health professionals of young patients for day surgery may include informal judgement of individual coping skills. Further details about emotional state and maturational stage are given in a paper in preparation. 5.3. Differences between in-patients and day cases A higher proportion of in-patients than day cases experienced moderate-severe pain on the 1st and 3rd postoperative days. The management of their pain clearly differed with opiates being prescribed and administered more frequently to in-patients. In the light of increasing day surgery, it is concerning that a relatively high proportion of day patients were not prescribed or given opiates, even after a surgical incision. This is particularly important when in reality opiate dependency is not the problem it is believed to be (Wall, 1997), even in children (McCaffery and Wong, 1993). The importance of effective analgesia has grown as earlier discharge following surgery has increased and has resulted in assistance in pain relief being requested of community-based health professionals. This is particularly important since, as reported in this paper, no differences existed between in-patients and day patients in their selfadministration of analgesics once home. The differences between the experiences of in-patients and day cases may be explained by several factors: day patients were at home for both postoperative assessments rather than being in an unfamiliar hospital environment; generally, in-patient surgery is more serious in nature than day surgery; and this results in more severe pain which, if undertreated, increases anxiety and possibly depression. However, in the context of this study, most operations were minor (the in-patients were discharged home on the day after surgery). Consequently, other reasons for in and day patient differences, such as psychological adjustment to adolescence or personality, should be considered. 5.4. Predictors of pain While age is a predictor of pain in children (Fradet et al., 1990; Palermo and Drotar, 1996) this was not the case for the adolescents in this study. However, the statistically significant links between day 1 anxiety or depression and day 3 pain intensity may facilitate the early identification of those most at risk of experiencing moderate-severe pain several days post-surgery. More research is required in this area.
6. Conclusions This study demonstrates that pain-relieving practice is not evidence-based, e.g. the use of assessment tools and analgesics. Validated, developmentally appropriate pain measures such as the APPT are recommended to enhance pain assess-
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ment; in addition, a review of prescribing practice and analgesic administration would facilitate effective pain relief. Although this was the first occasion that the APPT has been used in the UK, the sample was sufficiently large to provide initial normative data for British subjects. Therefore, the APPT is recommended as a simple, brief, validated measure. The financial cost of introducing a variety of context and age-specific pain assessment tools may account for their under-use. However, systematic pain assessment should improve the quality of care delivered and might reduce possible long-term sequelae. Auditing pain assessment and management would provide baseline data for setting standards. Further research is required to determine whether the link between psychological adjustment to adolescence (or maturational stage) and pain can be replicated and to identify factors which may predict those more at risk of experiencing pain post-operatively. Attention needs to be paid routinely to the psychological well-being of adolescents who are to undergo elective surgery. A simple screening measure such as the HADS would identify those with symptoms of anxiety or depression. In addition, after further research, such screening may allow early identification of those at risk of experiencing more pain, especially for inpatients. Practically, anxiety-reducing time should be incorporated into patient care, particularly in relation to those patients identified as being at risk Enhanced education for health professionals on adolescence and on pain might lead to changed attitudes. Patients, including adolescents, have a right to receive high quality care including systematic assessment and relief of pain symptoms. The current failure to implement research findings highlights the need for improved research dissemination strategies if clinical effectiveness is to be demonstrated.
7. Key messages The need to improve pain management for adolescents is essential. To achieve this there needs to be a change in attitudes to both adolescents and the relief of their pain. Promoting the seriousness of adolescent health care, the need to adequately recognise pain and then administer analgesics are first steps. Thereafter, attention to maturational stage and psychological well-being is required to improve the elective surgery and recovery experience of young people.
Acknowledgements Professor W.Ll. Parry-Jones was very involved throughout this project and in the initial report writing but died before publication was possible. His encouragement and enthusiasm for the project was second to none. This
research was funded by the Acute Health Committee of the Scottish Office Home and Health Department. The content of the paper represents the view of the authors alone. Many thanks are due to Mr Harper Gilmour, Department of Public Health, University of Glasgow, for statistical advice.
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