Critical Care Nurses' Experiences: “A Good Relationship with the Patient is a Prerequisite for Successful Pain Relief Management”

Original Article Critical Care Nurses’ Experiences: ‘‘A Good Relationship with the Patient is a Prerequisite for Successful Pain Relief Management’’ Jan-Olov Lindberg, RN, CCN, MSc, ˚ ¨ m, RN, CCN, MSc, PhD and Asa Engstro ---

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From the Division of Nursing, ˚ Department of Health Science, Lulea ˚, University of Technology, Lulea Sweden. ˚ sa Address correspondence to A Engstro¨m, RN, CCN, MSc, PhD, ˚ Department of Health Science, Lulea University of Technology, SE-971 87 ˚ , Sweden. E-mail: asa. Lulea [email protected] Received February 3, 2010; Revised March 10, 2010; Accepted March 24, 2010. 1524-9042/$36.00 Ó 2011 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2010.03.009

ABSTRACT:

There is a lack of studies describing how critical care nurses experience assessing and treating pain in patients receiving postoperative care in an intensive care unit (ICU). The aim of this study was to describe those experiences. Qualitative personal interviews with six critical care nurses in an ICU in northern Sweden were conducted during 2009. The interview texts were subjected to qualitative content analysis, which resulted in the formulation of one theme and four categories. It was important to be able to recognize signs of pain in patients unable to communicate verbally. In older patients, anxiety could be interpreted as an indication of pain. Pain was primarily assessed by means of a visual analog scale. Being unable to treat pain successfully was experienced as failing in one’s work. Pharmacologic treatment was always the first choice for relief. The environment was experienced as a hindrance to optimal nursing care, because all postoperative patients shared a room with only curtains between them. The work of assessing and treating pain in patients receiving postoperative care is an important and frequent task for critical care nurses, and knowledge in the field is essential if the patients are to receive optimal nursing care and treatment. Patients cared for in an ICU might benefit from nonpharmacologic treatment. Being without pain after surgery implies increased well-being and shorter hospitalization for the patient. Ó 2011 by the American Society for Pain Management Nursing After surgery, most patients are moved to a postoperative care unit where they receive care from, among others, critical care nurses (CCNs). Many patients experience pain after their surgeries, and one important task for the CCNs is to assess and treat postoperative pain (Svensson, Sjo¨stro¨m, & Haljama¨e, 2001). Acute pain is a form of warning signal aimed at limiting tissue injury (Jones, 2001). The Pain Management Nursing, Vol 12, No 3 (September), 2011: pp 163-172

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International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. The IASP suggests that if patients consider what they experience to be pain and describe the experience as pain then it should be accepted as pain (Loeser & Treede, 2008). One factor, besides the surgery, that influences the experience of postoperative pain is how the patient feels in other ways. The experience of pain is influenced by many factors, including cultural, social, and cognitive factors (Eccleston, 2001). The patient’s previous experiences of pain, such as its duration, intensity, extent, what it led to, why the pain arose, and if the patient could control it, are all factors that can influence how the patient experiences and copes with future pain (Van Damme, Crombez, & Ecclestone, 2008). There are several methods available to nurses for assessing the character and intensity of a patient’s pain. One method is to observe signs of pain in the behavior of the patient, e.g., through their body language or whether they are anxious. Raised blood pressure, pulse, and respiratory frequency in the postoperative patient can be signs of pain (Klopper, Andersson, Minkkinen, Ohlsson, & Sjo¨stro¨m, 2006; Sjo¨stro¨m, Jakobsson, & Haljama¨e, 2000). Nurses use their knowledge of how other patients who have had similar surgeries experience pain and of how to treat it (Kim, Schwartz-Barcott, Tracy, Fortin, & Sjo¨stro¨m, 2005; Klopper et al., 2006). Nurses also use their knowledge about pharmacologic principles to assess the patient’s need for pain relief soon after surgery (Kim et al., 2005). Asking the patients to explain the pain verbally is considered to be a most trustworthy method, but there are studies that show that nurses trust their own judgement and experience about how pain is usually manifested after a particular surgery and do not always trust what the patients say about their experience of pain (Schafheutle, Cantrill, & Noyce, 2000). A visual analog scale (VAS) is one of the most commonly used instruments for assessing pain. The VAS represents a patient’s subjective experience of pain. It is a 100-mm solid line on which the patient places a mark representing level of pain. The left end is anchored by descriptors indicating ‘‘zero—no pain’’ and the right end is labelled ‘‘ten—worst pain imaginable’’ (Winkelman, Norman, Maloni, & Kless, 2008). According to Jones, Vojir, Hutt, and Fink (2007) a VAS is not always suitable for use in older patients, because such a scale can be experienced as hard to understand and the different numbers for varying severity of pain can be difficult to distinguish between. The scale that

older people and young children prefer uses faces indicating the presence and intensity of pain with a smile or a grimace. This scale with faces is called the Wong-Baker faces pain rating scale. A smiling face means ‘‘no hurt,’’ a crying face means ‘‘hurts worst,’’ and between them four faces illustrate ‘‘hurts a little bit,’’ ‘‘hurts a little more,’’ ‘‘hurts even more,’’ and ‘‘hurts a whole lot’’ (Garra et al., 2010). Suffering postoperative pain is an unpleasant experience, and it is ethically indefensible for a nurse to not relieve the pain. Patients with untreated or insufficiently treated pain have said that they experience a loss of autonomy, loss of control, and a feeling of not being taken seriously (Cousins, Brennan, & Carr, 2004). The experience of acute pain causes physiologic changes in the patient, making it harder for him or her to sleep, causing tiredness and exhaustion (Helms & Barone, 2008). Inadequate management of postoperative pain can lead to several other physiologic changes, such as increased cardiac activity and reduced ability to cough and breathe adequately, is associated with gastrointestinal problems, such as nausea and vomiting, and may inhibit movement, leading to increased risk of thrombosis in the lower limbs (Huang, Cunningham, Laurito, & Chen, 2001). Insufficient treatment when experiencing acute pain can lead to the pain continuing to exist after the injury or wound could be expected to have healed and may lead to the patients suffering chronic pain (Manias, 2003). Living with chronic pain for many patients means a reduced quality of life and such patients need a different kind of treatment (Widar, Ahlstro ¨ m, & Ek, 2004). Thus postoperative pain should be treated actively and the treatment must be adapted to the unique individual needs. Methods for treating pain can be divided into pharmacologic and nonpharmacologic. The former aim to obstruct nociception to influence the patient’s experience of pain, and the latter may be cognitive, aimed at influencing the patient’s behavior when experiencing pain or at persuading the patient to change his or her focus regarding the pain (Van Damme et al., 2008). Despite an increased interest in postoperative pain and its treatment, it has been shown that postoperative pain is not always treated optimally (Apfelbaum, Chen, Mehta, & Tong, 2003; Dolin, Cashman, & Bland, 2002). In the early postoperative phase, the nurse has the main responsibility for continual assessment of the patient’s need for pain relief. Assessment continues with intervention and evaluation, until the patient feels that the pain has been relieved. The fact that patients in the study by Wikstro¨m-Ene, Nordberg, Bergh, Johansson-Gaston, and Sjo¨stro¨m (2008) said that they did not receive

Critical Care Nurses’ Experiences

sufficient pain relief in the postoperative phase, combined with the fact that nurses play a central role in the treatment of patients’ pain, led us to study the experiences of CCNs in assessing and treating pain in patients in postoperative care. Pain causes the patients suffering and difficulties in returning to mobility, which can lengthen their stay in hospital. It is, therefore, necessary for CCNs to have the competence to assess and treat pain individually. This study may lead to CCNs reflecting and individually adapting pain relief interventions with the aim of increasing the well-being of the postoperative patient.

METHODS Research Aim The aim of this study was to describe the experiences of CCNs in assessing and treating pain in patients receiving postoperative care in an intensive care unit (ICU). Ethical Considerations The University Ethics Committee approved the study, and the heads of the ICU gave their permission for it to be performed. Information about the study was repeated orally to the participants prior starting the interviews. Assurances were given that all data would remain confidential, that participation was voluntary, and that participants had the right to withdraw at any time without prejudice. Participants were also given opportunities to talk about feelings evoked by the interview situation. Participants and Procedure The heads of an ICU in the northern part of Sweden were informed about the study and gave their permission for it to be carried out by signing a consent form. The head nurse of the ICU contacted seven CCNs who were experienced in assessing and treating pain in patients receiving postoperative care in the ICU. The seven CCNs were sent an information letter about the study and a request for their participation; six were interested in participating and answered the letter by signing a consent form. The first author then contacted them by telephone and made appointments for the interviews according to the participants’ wishes. All six CCNs had experiences they wanted to talk about that accorded with the aim of the study. Polit and Beck (2008, p. 355) refer to this as choosing a purposive sample. The CCNs who participated were aged 31-48 years (median 43 years) and they had 3-22 years’ (median 12 years) experience of working as CCNs.

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Data Collection The data were collected during 2009 by means of semistructured interviews using an interview guide (Table 1). Further clarifying questions were asked, e.g., can you please develop what you said? How did you feel then? Can you please give an example? How do you mean? The interviews lasted for 20-70 minutes and took place in a quiet room in the ICU. The interviews were transcribed verbatim, and the authors reviewed the transcripts to ensure accuracy (Kvale & Brinkmann, 2009). Data Analysis The authors applied qualitative content analysis to the interview text, as described by Downe-Wamboldt (1992). Each interview was read through several times to gain a sense of the content as a whole. The entire text was then read to identify meaning units, guided by the aim of the study. The meaning units were condensed and sorted into categories related by content, constituting an expression of the manifest content of the text. All categories were then compared, and a theme, i.e., a thread of meaning that appeared in the categories, was identified (Baxter, 1991).

FINDINGS The analysis resulted in one theme and four categories (Table 2). The findings are presented in the text below and are illustrated with quotations from the interview text. The overall theme was: ‘‘A good relationship with the patient is a prerequisite for successful pain relief management.’’ Understanding the Individual Patient’s Experience of Pain The CCNs said it was important for them to apprehend how the patients they nursed expressed their pain. Several of the patients they cared for in the ICU after surgery had difficulties talking about their pain, and the CCNs described how they used other ways to find out whether the patient was in pain. The CCNs described the various signs they observed when a patient might be experiencing pain, e.g., that the patient did not look relaxed. Other signs of pain might be that the patient cried, hyperventilated, was anxious, and/ or was in a cold sweat and indicated by their body language that they were not comfortable and could not relax. Apart from observing the patients, the CCNs said they used measured parameters of vital signs of the patients they nursed to complement their observations of the patients’ pain.

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TABLE 1. Interview Guide Used in the Study Aimed at Describing the Experiences of Critical Care Nurses in Assessing and Treating Pain in Patients Receiving Postoperative Care in an Intensive Care Unit Questions Describe what you interpret as signs of pain in patients receiving postoperative care. Describe what influences your decision about how to treat pain in patients receiving postoperative care. Describe your experiences of the weaknesses and strengths of different methods for treating postoperative pain. Describe what you experience as difficult with assessing and treating pain in a postoperative patient. Describe your experiences of alternative treatments to pharmacologic treatments when treating pain in patients in postoperative care. Tell me about patients who cannot verbally communicate their pain; describe your experience of assessing and treating their postoperative pain. Describe your experiences of patients who do not become pain free after your treatment of the pain. Is it important for you to treat pain in patients receiving postoperative care? Why?

‘‘Worried faces with tears and restless movements and changes in physical parameters like a higher pulse, blood pressure, and faster breathing are seen as expressions of pain.’’

The CCNs said that when they nursed older people they judged whether the older patient became anxious, confused or angry, because these could be an indication that they were in pain. The CCNs emphasized the importance of understanding the specific patient and their experience of pain. ‘‘Intensified anxiety. I interpret that as pain and then I actually usually give pain treatment.’’ ‘‘It is very individual from one person to another. some of them have almost no pain at all while the next patient has serious pain after the same surgery.’’

To get an idea about how severe the patient’s pain was, the CCNs used a VAS. Most of the CCNs did not use the scale itself, but instead explained to the patients verbally how it worked, i.e., zero means no pain at all and ten means the worst possible pain. According to the CCNs it was easier for patients to use the VAS when they were given information about it before the surgery. The CCNs said that not all patients who were nursed in the ICU understood a VAS, so they had to change their strategy to evaluate the pain by using other descriptions.

TABLE 2. Overview of Theme (n ¼ 1) and Categories (n ¼ 4) Constructed from the Analysis of the Interviews Theme A good relationship with the patient is a prerequisite for successful pain relief management

Category Understanding the unique patient’s experience of pain Succeeding or failing to relieve pain Trusting the patient and getting help from the physician Treating the pain when pharmacologic treatment is not sufficient

‘‘I used to say one to ten; I think that is the easiest way for them to understand.’’ ‘‘Some don’t understand this, so I ask about light, medium or severe pain.’’

Succeeding or Failing in Relieving Pain The CCNs stated that most patients who had undergone surgery needed early pain relief to reduce the pain. The CCNs stated that relieving pain was part of their mindset and something they wanted to do. They wanted to do what they could to make the patient feel as well as possible during postoperative care. ‘‘Yes, I want the patient to be satisfied. I mean, I want them to be comfortable’’

Failing to relieve pain and suffering in the patients in postoperative care was seen by the CCNs as a failure in nursing. One of the CCNs described it as a personal failure and felt she was a bad CCN when the patients experienced pain and discomfort despite assiduous attempts to relieve the pain. ‘‘If the pain relief doesn’t work, I get frustrated. It is the worst mark you can get. You are not allowed to fail in that. Then I feel really bad.’’

Sometimes it happened that the patients participated in and influenced the choice of pain relief before the surgery. This could worry the CCNs, because they knew from experience that some surgeries could cause severe pain if the patient did not have spinal or epidural anaesthesia. The CCNs then thought that the pain and suffering were unnecessary and that it might not be a good idea to allow the patient to choose the method of pain relief for all kind of surgeries. ‘‘It leads to frustration when the patients haven’t had epidural anesthesia, as you know then they will experience pain.’’

Critical Care Nurses’ Experiences

Nursing patients in pain and discomfort was felt to be frustrating by the CCNs, and they experienced an inner satisfaction and happiness when they managed to relieve pain. The CCNs could relax when they felt that the patients’ pain had subsided and the patients seemed to feel well. The CCNs also stated there are so many different ways to relieve the pain that no one should need to experience severe pain after surgery. ‘‘Then it becomes so much better. then I am also pleased.’’ ‘‘There are so many ways to relieve pain, so no one will have to lie here in pain.’’

Trusting the Patient and Obtaining Help from a Physician The CCNs had learned that pain is an individual experience and that every patient experiences pain in her/ his own way. If the patients said they were in pain, that was their personal experience and the CCNs trusted their word. The CCNs tried to ignore their own subjective evaluation and trust what the patients said. On the other hand, situations could arise when the CCNs thought that some patients could not be in such severe pain as they claimed, and in those situations the CCNs thought that they could not completely trust the patient. ‘‘We have learned that as long as they say they are in pain, they are in pain.’’ ‘‘Then I could sometimes feel among those who have had terrible pain and been given big doses of morphine and finally fallen asleep and then I thought they fall asleep when their pain is less . then when they wake up the first thing they say is that they are in pain and I thought how have you had time to feel pain?’’

The CCNs stated that treating pain in patients in the postoperative care almost always involved the pharmacological relief of pain and anxiety. They said that the tradition was to be liberal with analgesics and side effects were not viewed as seriously as before. The question often concerned arriving at the correct quantity of analgesics to allow the patients to be free of pain. The CCNs thought this was an efficient way to relieve pain as it was often fast and effective. ‘‘I use medicine as my first choice. I think it is good if pain is the problem . as I said before, sometimes you have to guess what the problem is.’’ ‘‘Today I’m generous and not so afraid of the side effects. Frequently the way to get rid of the pain is a matter of what dose to give’’

Opiates, principally morphine, given intravenously were described by the CCNs as a well tested

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analgesic and were the first choice of pain relief for most of the postoperative patients. The CCNs thought it was safe to use morphine, because they used it so frequently in postoperative patients; it also had a good effect on anxiety that the patients might feel. The CCNs administered morphine to those patients who were unable to express their pain but seemed restless and anxious. According to the CCNs, however, morphine did not always work; the patients could suffer side effects without any reduction in their pain. In such cases, the CCNs explained that they had to try other pharmacologic remedies to relieve the patient’s pain. ‘‘We use morphine a lot; it is a well tested method for relieving pain. It feels safe to use it, but I don’t know if it’s a false safety.’’

The CCNs felt that they were rather independent regarding what to do when the patients were in pain. They could administer heavy doses of various kinds of analgesics within the general prescription without contacting a physician. If they were unable to alleviate the patient’s pain by changing analgesics, they contacted the physician, who then had to give new directives for how to make the patient pain free. ‘‘We are rather independent about relieving pain. But we do have a limit, I’m not sure if it’s 20 mg morphine within half an hour or something; in those situations we are supposed to contact them [the physicians].’’

Treating Pain when Pharmacologic Treatment Is Not Sufficient Treating pain, according to the CCNs, was about using pharmacologic methods, but they did state that changing the position of the patient was an alternative. The CCNs would, for example, try changing the position of the patient’s leg if the leg had been operated on, or lay the patient on their side after they had been lying on their back. One CCN said that the staff were interested in learning alternative pain relief methods, although these were sometimes regarded to be rather unconventional and not very effective. ‘‘Sometimes it seems changing the position relieves the pain; you can, for instance, raise the leg of the patient into a better position, a higher position.’’ ‘‘I feel that there isn’t any interest here, alternatives are still a bit way-out.’’

Some CCNs mentioned that massage might be an alternative or supplement to pharmacologic treatment when the patient is in pain, but massage was not currently used, because the CCNs felt there was no time to give patients massage when they were in pain. CCNs said that taking time to be there for the patient, being present and talking to them, was a complementary

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way of reducing pain. The environment in the ICU was seen as an obstacle to the provision of good nursing care and the relief of pain. The patients who had undergone surgery lay in big rooms with only curtains between the beds, and the CCNs found it difficult to have intimate conversations with the patients for reasons of confidentiality. ‘‘We have no time, even if that would work.’’ ‘‘Not everyone takes time to be with the patients; we work differently.’’ ‘‘Then there’s the confidentiality: for that reason it is not a good environment for deeper conversations.’’

DISCUSSION The aim of this study was to describe the experiences of CCNs in assessing and treating pain in patients receiving postoperative care in an ICU. The overall theme—‘‘a good relationship with the patient is a prerequisite for successful pain relief management’’— meant that the relationship with the patient influenced whether or not the CCNs would understand the patient’s need for pain relief. A patient’s experience of nursing care can be seen as conveying a message about a problem, a need and a wish addressed to the nurse. Nursing care needs are about whether the patient can feel trust in the nurse, that he or she is competent, can communicate, and knows how to improve the well-being of the patient. Patients describe the nursing care they receive in their descriptions of how their relationship with the nurse works. The patient’s need for nursing care should be understood in terms of the patient’ s apprehension of suffering, but also as related to the well-being experience. The nurse’s awareness and knowledge regarding patient needs and wishes and the importance of their encounters helps in understanding the message the patient conveys concerning the need for nursing care (Fagerstro¨m, Eriksson, & BergbomEngberg, 1998). Ferell (2005) states that the care of people in pain includes forming a relationship and having compassion and respect. The findings show that CCNs felt it was important to recognize and identify how the patients expressed their pain. Because many of the patients who received postoperative care could not verbally articulate their pain, the CCNs used alternative ways to assess its presence. The CCNs said that they gauged the presence of pain by observing the patient’s expression: Does the patient look troubled? Does the patient have tears in their eyes or are they restless? This is in line with Ge´linas, Fillion, and Puntillo (2008), who describe an instrument they developed to identify the pain of patients unable to verbally express their pain. The

instrument is called the critical-care pain observation tool (CPOT) and uses the indicators facial expression, body movements, muscle tension, compliance with the ventilator (intubated patients), or vocalization and then scores the actually descriptions of the patient (Ge´linas, Fillion, Puntillo, Viens, & Fortier, 2006). The CCNs in this study said they used the physiologic parameters of the patient, such as measuring their pulse, blood pressure and breathing frequency as a complement to observing the patient’s behavior to assess the experience of pain. That was done even though none of the CCNs could say for sure whether any changes in the physiologic parameters were due to the patient’s experiencing pain. Assessing pain according to physiologic parameters is in line with the way anesthesia nurses work. They use physiologic parameters to assess pain in patients who breathe spontaneously or are mechanically ventilated, looking for changes such as how deeply and frequently the patient breathes, raised blood pressure, pulse rate, and whether the patient is in tears or a cold sweat. These parameters, following a nonverbal pain scale (Kabes, Graves, & Norris, 2009), can be interpreted as a reliable sign of pain, according to Warre´n Stromberg, Sjo¨stro¨m, and Haljama¨e (2001). Fever also can result in a high pulse, stress can raise blood pressure, and fear can produce faster breathing, all of which are well known within health care, yet Klopper et al. (2006) and Sjo¨stro¨m et al. (2000) state that these parameters are used to assess pain and are reliable, given that the CCN must also judge that the patient is suffering from pain and not from fear, fever, or anxiety. The present findings show that when the CCNs cared for older postoperative patients who became anxious, angry and confused, the CCNs interpreted this as a sign that the older patient was in pain. It is particularly important for a CCN to be able to assess pain in older patients, because they represent a large group within postoperative care. Herr, Bjoro, and Decker (2006) evaluated tools used for pain assessment for nonverbal older adults with dementia. Their results indicated that there was no standardized tool based on nonverbal behavior pain. They suggested observing the older person for behaviors to establish a baseline of behavior, and then pain-related behaviors should be observed during activity, such as aggression, agitation, or increased pacing. If the presence of pain is uncertain, a pain treatment intervention can be warranted to evaluate presence of pain; if the intervention appears to provide pain relief, pain may be assumed to be the likely cause and the intervention continued (Herr, Bjoro, & Decker, 2006). The CCNs stated that they used a VAS as a starting point when assessing the severity of the patient’s pain

Critical Care Nurses’ Experiences

in postoperative care. The CCNs used a VAS verbally, asking the patients to rate their subjective experience of pain from ‘‘zero—no pain’’ to ‘‘ten—the worst conceivable pain.’’ It is common for nurses to assess pain in this way. Bergh, Jakobsson, Sjo¨stro¨m, and Steen (2005) examined how older patients experienced pain after a hip surgery by using a VAS. According to Jones et al., (2007), this causes difficulties, because older people may find it hard to understand a VAS and become confused by trying to keep the numbers in order. It is problematic for the staff to understand the subjective experience when the patient says that the level of pain is, for instance, four, because four is a subjective value and yet treatment may be given according to that value. The patients who came to the ICU after their surgery needed treatment for their postoperative pain, and the CCNs had a strong desire to relieve their pain. Blondal and Halldorsdottir (2009) show similar findings where the nurses are highly motivated to treat the pain of the patients to increase their well-being. Huang, Cunningham, Laurito, and Chen (2001) showed that there are patients who do not dare to say how much pain they are in, because they are afraid of side effects and becoming dependent on medication. That means that patients must be told about pain and its treatment both before and after the surgery and that CCNs also need knowledge about alternatives to pharmacologic treatments and how to use them in postoperative care. In the present study, none of the CCNs said anything about asking about the nature of the pain, i.e., scorching, piercing, or shooting, etc. Because different kinds of pain are experienced, the CCNs should find out more than simply whether the patient is in need of pain relief (Jones, 2001). The findings show that the patients’ own opinions about how to relieve pain might be a hindrance to optimal treatment. This occurred primarily after serious surgeries for which the patient chose to not have epidural or spinal pain treatment. The CCNs then felt frustrated by those decisions, because they knew from their experience that the patients would suffer serious pain that would be difficult to manage in a way that was satisfactory for both patient and CCN. Manias, Bucknall, and Botti (2005) show that the demand for more access to health information and influence over decisions concerning one’s own treatment increases. It is, therefore, urgent that the patients who are to undergo surgery know what the surgery entails and about postoperative pain. It may help such a patient if the staff recommend the best current type of pain treatment for the specific surgery to be performed on the patient. Kastanias, Denny, Robinson, Sabo, and Snaith (2009) showed that information about pain and pain

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management is very important to patients and that they want to know what the analgesic plan is, what will be done if it does not work, about the side effects of analgesics, and what kind of pain they can expect. Staff need to focus on improving their pain management education and counseling in these areas. The findings show that the CCNs felt satisfied when pain treatment was administered with good results, i.e., the patient became pain free and could relax and perhaps sleep for a while. Blondal and Halldorsdottir (2009) describe the responsibility that nurses take in nursing the patients. This involves various motivational factors, such as duty, morality, knowledge with experience, self-confidence, and conviction. Respect for the patient is shown to be a fundamental reason for acting. Some nurses state that the nursing of a patient is something that comes from within, whereas for others it is a task to be performed. If the patient experiences pain, nurses try actively to relieve it (Blondal & Halldorsdottir, 2009). If a patient said they were in pain, the CCNs in the present study trusted them and tried to put their own personal judgements aside. That was not always easy, and sometimes the CCNs found it difficult to really believe that the patient was in such pain as they said. Judging that the patient was not in pain when he or she could sleep a while is not correct; McCaffery and Pasero (1999) state that the patient must be not only asked but also believed regarding the amount of pain they are in. Wikstro¨m-Ene, Nordberg, Bergh, Johansson-Gaston, and Sjo¨stro¨m (2008) showed that nurses often underrate patients’ pain. Those authors compared the VAS value the nurses had documented with the value the patients gave. It was shown that the patients’ pain experience was often underrated. The nurses were then given pain education for 2 years, and when the same test was repeated the patients’ and the nurses’ approximations of experienced pain were closer. Bearing this in mind, it is the utmost importance that CCNs learn to trust patients’ subjective evaluation of their pain. Treating postoperative pain was principally about giving pharmacologic remedies, and the CCNs in this study said they had become more liberal with analgesics than earlier. Morphine administered intravenously was their first choice of treatment, and they found it effective because it also reduced the patients’ anxiety and the side effects were manageable. When morphine did not relieve the pain, the CCNs tried some other analgesic, and if that too failed to work they contacted a physician for new instructions. Manias, Bucknall, and Botti (2005) stated that pharmacologic treatment is the most common way of dealing with postoperative pain. Treating postoperative pain other than

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pharmacologically is unusual, but there are studies (Crowe, Chang, Fraser, Gaskill, Nash, & Wallace, 2008, Engwall & So¨rensen Duppils, 2009, Good, Cranston Anderson, Ahn, Cong, & Stanton-Hicks, 2005) that show benefits from nonpharmacologic treatments. Roykulcharoen and Good (2004), show that patients who were offered the chance to listen to relaxation music and relaxation exercises experienced reduced pain and increased control over their situation. When CCNs reflected about what is included in treating postoperative pain, it became obvious that it is exclusively about pharmacologic treatments. Changing the position of the patient, by raising a leg or helping them to lie on their side, was something the CCNs made to make them more comfortable or because the patient asked for it, but seldom to reduce the patients’ pain. The CCNs mentioned that massage could be used to relieve the patient’s pain, but this was not done, because the CCNs felt they did not have the time. This finding is in contrast to that of Richards and Hubbert (2007), who found that nurses chose morphine as a last resort and at a dose lower than that prescribed by the physician. This was because the nurses were afraid of the side effects of morphine, such as breathing depression. Instead they changed the patient’s position, tried to make the patient think of something else, gave the patient time, massage, cold and heat treatment, and then, possibly, analgesia. It was not shown, however, what the consequences were for the patients. Respiratory depression is still a side effect of morphine and is characterized by profound changes in breathing pattern, respiratory rate, and the contribution of the rib cage to tidal volume (Leino, Mildh, Lertola, Seppa¨la¨, & Kirvela¨, 1999). The findings in the present study show that for the CCNs, taking time for the patients and really being present is one way of relieving pain, but it was also obvious that not all of the staff took time to be with the patients. It is difficult to have serious conversations with patients in a postoperative part of an ICU where they are separated only by curtains. The confidentiality requirements that the CCNs had to take into consideration hindered them from talking to the patients. Manias, Botti, and Bucknall (2002) studied how nurses observe and treat pain in patients and showed that patients who had asked for pain treatment often had to wait because the nurse was interrupted by some other aspect of their work. Thus it was difficult for the nurse to satisfy the patient’s need for analgesics at once. Such a finding could explain CCNs’ feeling that they did not have time to give massage or have serious conversations with the patients who receive postoperative care. If CCNs felt that they had time to be with the

patients and to sit down and really talk, they would possibly also find more pain and suffering. The environment in the postoperative rooms in ICUs is seldom optimal for such conversations. To reduce the patients’ suffering and discomfort, it is of the utmost importance that their experience of pain is minimized throughout their stay in hospital. Svensson, Sjo¨stro¨m, and Haljama¨e (2001) showed that patients who experience severe pain before and during surgery experience severe pain after surgery; therefore almost everyone who nurses patients must be able to assess and treat their pain. Limitations This study has limitations; for example only six CCNs were interviewed, which is a rather small group. The number of interviews required was the number needed to answer the research question (Kvale & Brinkmann, 2009). The interviews were rich in content and described similar experiences, which revealed a pattern which the authors found to adequately serve as a basis for the findings and which reached what Polit and Beck (2008, p. 357) name as data saturation. The small number of participants can, therefore, be seen as a strength; it provides the opportunity to gain a close and thorough knowledge of those participating in the study. The participants, context, data collection, and analysis were described as thoroughly as possible to enable the readers to evaluate possible transferability to other contexts.

CONCLUSION The aim of the study was to describe the experiences of CCNs in assessing and treating pain in patients receiving postoperative care in an ICU. Most patients who receive postoperative care in an ICU experience pain to a varying extent, and CCNs in this study treated the patients’ pain by giving analgesics. The motivation for not giving nonpharmacologic treatment was that there was not enough time, the environment was an obstacle, or the CCNs had no interest in learning about how to do it. The fact that some patients are afraid of pharmacologic treatment and may not tell anyone about their pain for fear of side effects must be considered. Because the findings show that the CCNs were really motivated to relieve the postoperative pain the patients experienced, there should be more interest in learning nonpharmacologic methods to complement pharmacologic treatments aimed at relieving pain and increasing the well-being of patients who have been operated on. The work of assessing and treating the pain of patients in postoperative care is an important and common task for CCNs, and

Critical Care Nurses’ Experiences

knowledge in the field is essential if patients are to receive optimal nursing care and treatment. Being pain free after surgery means increased well-being and a shorter stay in hospital for the patient.

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Acknowledgments The authors thank the CCNs who participated in this study and Pat Shrimpton for revising the English language.

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