Applied Nursing Research 27 (2014) 53–58

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

Healthcare Professionals' Perceptions of the Use of Pain Scales in Postoperative

Pain Assessments
Lotta Wikström, RN, PhD student a, b,⁎, Kerstin Eriksson, RN, PhD student a, b, 1,
Kristofer Årestedt, RN, PhD c, d, e, 2, Bengt Fridlund, RNT, Professor a, 3, Anders Broström, RN, Professor a, f, 4
a
School of Health Sciences, Jönköping University, Jönköping, Sweden
b
Department of Anaesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
c
School of Health and Caring Sciences, Linnaeus University, Kalmar, Sweden
d
Department of Medical and Health Sciences, Division of Nursing Science, Linköping University, Linköping, Sweden
e
Palliative Research Centre, Ersta Sköndal University College and Ersta Hospital, Stockholm, Sweden
f
Department of Clinical Neurophysiology, University Hospital, Linköping, Sweden

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

Article history: Aim: To describe how healthcare professionals perceive the use of pain scales in postoperative care.
Received 13 June 2013 Background: Pain scales are important but not an obvious choice to use in postoperative care. No study has
Revised 24 October 2013 explored how healthcare professionals experience the use of pain scales.
Accepted 2 November 2013 Methods: An explorative design with a phenomenographic approach was used. The sample consisted of 25
healthcare professionals. Semistructured interviews were performed.
Keywords:
Results: Four descriptive categories emerged - the use of pain scales facilitated the understanding of postoperative
Postoperative pain
Pain scales
pain, facilitated treatment, demanded a multidimensional approach and was affected by work situations.
Pain assessments Conclusions: Healthcare professionals described that pain scales contribute to the understanding of patient's
postoperative pain. It is important to ensure patient understanding and be aware about variations in pain ratings.
Dialogue and observations are necessary to be certain what the ratings mean to the patient. The use of pain scales
depends on patient's needs and organization.
© 2014 Elsevier Inc. All rights reserved.

1. Introduction
An investigation of postoperative pain normally begins with a
screening followed by a more thorough assessment if patients are in
pain (e.g., including questions on location and duration of the pain).
Pain is however a subjective experience that can be hard to
communicate, both between patient and staff, as well as between
staff with different professions. It is therefore recommended in
guidelines that patient's self-report of pain should be screened by
using a valid pain scale (Gordon et al., 2005). The extent to which pain
scales are used (Abdalrahim, Majali, & Bergbom, 2008, Ene, Nordberg,
Bergh, Gaston-Johansson, & Sjöström, 2008) and how assessments of
postoperative pain are performed are explored only in a few studies
(Klopper, Andersson, Minkkinen, Ohlsson, & Sjöström, 2006, Manias,
Bucknall, & Botti, 2004). The results indicate that the use of pain scales
Conflict of Interest. None.
⁎ Corresponding author. Tel.: +46 36321000; fax: +46 36325055.
E-mail addresses: charlotta.wikstrom@lj.se (L. Wikström), kerstin.eriksson@lj.se
(K. Eriksson), kristofer.arestedt@lnu.se (K. Årestedt), Bengt.Frinlund@hhj.hj.se
(B. Fridlund), anders.brostrom@hhj.hj.se (A. Broström).
1
Tel.: +46 363 21000; fax: +46 363 25055.
2
Tel.: +46 480 446974; +46 709 206462 (mobile).
3
Tel.: +46 361 01233; +46 767 611233 (mobile).
4
Tel.: +46 10103 25 34.
such as numeric rating scale (NRS), visual analogue scale (VAS) or
verbal scale (VS) is not an obvious choice.
The implementation of validated pain scales has been difficult in
clinical settings despite educational programs (Ene et al., 2008).
Screening for the presence of pain, without using pain scales still
occurs and is instead based on the patient's appearance and behavior,
what they express and how much pain “it usually is” after a certain
type of surgery. Age, sex or ethnicity is taken into consideration
(Klopper et al., 2006), and changes in vital signs such as pulse rate,
blood pressure and respiratory rate are also used (Richards & Hubbert,
2007; Clabo, 2007).
Quality of care is related to a well -functioning communication
between healthcare professionals (Havens, Vasey, Gittell, & Lin, 2010),
and pain scales are described as improving the screening of patient's
pain and communication between healthcare professionals and
patients (Gordon et al., 2005). The nurse's performance in screening
for postoperative pain is mainly focused in research because they are
described as playing an important role in postoperative pain
management (Dihle, Bjölseth, & Helseth, 2006, Schafheutle, Cantrill,
& Noyce, 2004). No studies describing the enrolled nurse's or
physician's use of pain scales have been found. However, in Sweden
enrolled nurses perform much of patient's daily care including
screening for pain, but they are not trained to distributing drugs to
patients. Further, according to Hartog, Rothaug, Goettermann,

0897-1897/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.apnr.2013.11.001
54 L. Wikström et al. / Applied Nursing Research 27 (2014) 53–58
Zimmer, and Meissner (2010) the physician's competence in this area
is necessary to obtain a well-functioning pain management. To
contribute to a better understanding on how pain scales can provide
an improved communication around pain, the aim of this study was to
describe how healthcare professionals perceive the use of pain scales
in postoperative care.
2. Methods
2.1. Design, method description and setting
With permission from the Regional Ethics Committee for Human
Research in Linköping, Sweden, an explorative design with a
phenomenographic approach was chosen. The goal with phenomen-
ography is to explore variations in people's perceptions of the
surrounding world (e.g., how they perceive, understand and remem-
ber various aspects of a phenomenon). It is substance-oriented
(searching for the underlying structure of variance) and differentiates
between two types of description: the first order perspective (i.e., the
real facts that can be observed), and the second order perspective (i.e.,
how the person perceives something). Phenomenography uses the
second order perspective (Marton & Both, 1997). Phenomenology on
the other hand aims to find the essence of a phenomenon (Holloway &
Wheeler, 2006).
The study was performed in one university and three county
hospitals in the south of Sweden. Healthcare professionals of different
professions working with postoperative care in orthopedic and
general surgery wards were asked to participate. In Sweden
physicians, nurses and enrolled nurses have knowledge about pain
screening, but it is mainly performed by nurses. National guidelines
recommend pain screening using NRS, VAS or a verbal scale;
frequency of assessments is, however, not specified. Three of the
included hospitals had routines according to the national guidelines
(i.e., performing screenings at least every fourth hour using pain
scales). The fourth hospital used assessments based on expressions,
appearances and behaviors of the actual patient. All hospitals used
electronic patient records.
2.2. Participants
A purposeful sample of healthcare professionals with clinical
experience of pain scales in postoperative care was selected. The
physicians were all performing both surgery and ward rounds, while
the selected nurses end enrolled nurses' performed daily care duties.
The selection was based on variation in age, sex, profession and
employment on a surgical or orthopedic ward. One physician and one
enrolled nurse declined participation, without giving reasons.
Characteristics of the participants (n = 25) are shown in Table 1
(downgrading of Table 1).
2.3. Data collection
According to the phenomenographic tradition semi-structured
interviews (Marton & Both, 1997) were conducted. An interview
guide (Table 2) was designed by the research team which had long
experience of postoperative pain and phenomenography. The guide
was based on recommendations from the American Pain Society
(Gordon et al., 2005). Before the interviews the importance of
Table 1
Socio-demographic characteristics of healthcare professionals (n = 25).
Sex; male, female
Age; years, range
Profession, enrolled nurses, nurses, physicians
Years of experience in postoperative care; 1–5, 6–10, N10
Employment: orthopedic, general surgery
Table 2
Interview guide used in the data collection with healthcare professionals (n = 25).
What does the patient's pain mean to you as a health professional?
How do you perceive the importance of assessment with a pain scale the first
postoperative days?
How do you perceive your responsibility/role in pain assessment?
How do you perceive the patients responsibility/role in pain assessment?
How do you perceive pain assessment in relation to action/pain treatment?
How do you perceive assessing pain several times a day?
telling self-perceived experiences and concrete examples to avoid
superficial descriptions from what is heard from other healthcare
professionals was stressed. Probing questions such as “could you
explain more” were used. Two pilot interviews were performed.
Since the guide worked well the pilot interviews were included in
the data analysis. The interviews took place in a quiet room on the
ward where the participant was employed and lasted up to
40 minutes; they were audiotaped and transcribed verbatim. The
number of interviews from the three professions reflects the
proportion of users of pain scales at the included units. The main
researcher who has long experience of postoperative pain manage-
ment performed all interviews between June and November 2012
(downgrading Of Table 2).
2.4. Data analysis
Data analysis was conducted according to the phenomenographic
tradition described by Sjöström and Dahlgren (2002) (Table 3). The
main researcher carried out the data analysis with continuous
reflections on each step from the other members in the research
team until consensus was established (downgrading of Table 3).
3. Findings
An overview of the findings and quotations in relation to all
perceptions is presented in Table 4.
3.1. The use of pain scales facilitated the understanding of
postoperative pain
3.1.1. Pain scales facilitated the discovery of pain
Pain scales were perceived being useful in detecting pain in
patients who for various reasons, i.e., tiredness after anesthesia and
fear of unnecessary interruptions, did not tell healthcare professionals
about their pain. Frequent screenings for pain were described as
necessary to detecting pain early. An interval of 3 to 4 hours was
expressed too long the first day after surgery, especially for those
patients who did not report pain.
Table 3
Phenomenographic data analysis according to Sjöström and Dahlgren (2002) as used in
the present study.
1. Familiarization. The 25 interviews containing 242 pages (A4) were read several
times to become familiar with the data and obtain a sense of the whole.
2. Compilation. Answers from all responders on a certain topic were compiled into
statements. A total of (420) significant statements corresponding to the aim of
this study were identified.
3. Condensation. The individual statements were reduced.
4. Grouping. Groupings were made on similar statements. Totally there were 17
pre-perceptions found that distinctly differed from one another.
5. Comparison. Including statements in the perceptions were thoughtfully read to
ensure similarities within the perception and differences between the
perceptions.
6/19 6. Naming. Perceptions and the emerged descriptive categories were discussed and
23–63 named with an adequate level of abstraction to emphasize their essence.
6/15/4 7. Contrastive comparison. The obtained descriptive categories were compared in
8/6/11 terms of similarities and differences. Finally 4 descriptive categories and 13
17/8 perceptions were found, Table 4.
 L. Wikström et al. / Applied Nursing Research 27 (2014) 53–58 55

Table 4
Quotations/Perceptions from the performed interviews with health care professionals.

Statements Perceptions Descriptive categories

“The scale is a good complement to the conversation about the pain, it may well be that you miss Pain scales facilitated discovery of The use of pain scales facilitated the
any patient with pain … someone who does not dare....and can say a number, instead.” (N, a: pain understanding of postoperative pain
57, 11 y.o.e)
“I see this as important (pain screening several times a day).. I get to know when the patient is in Pain scales visualized pain progress
pain.. in order to ease the pain when it hurts the most.” (N, a: 23, ½ y.o.e)
“When you have a number.. instead of “don't have much pain” “have much pain”…it's easier Pain scales facilitated handover
when you take over to understand.” (N, a: 51, 7 y.o.e.) between healthcare professionals
“If you often ask the patient using a scale, maybe they do not come up in pain peaks.. but remain Pain scales facilitated prevention of The use of pain scales facilitated
on an even level. That's how I see the scale.” (E.N. A: 61, 43 y.o.e.) pain treatment of pain
“And it's also different.. Some can say a high number but say no, not so much pain that I need an Pain scales facilitated choice of pain
injection. But my first thought would be: the higher number the more pain killer. Then you treatment
probably go with injections instead of tablets.” (N, a: 47, 22 y.o.e.)
“..NRS is a good tool, above all to communicate pain and to convey how good the analgesic effect Pain scales facilitated evaluation of
was.” (Ph, a: 31, 3 y.o.e) pain treatment
“… it's not always that patients understand even if they received information, but it is an Pain scales demanded additional The use of pain scales demanded a
important role you have to inform the patients because assessments of pain intensity begins assurance of patients' understanding multi-dimensional approach
with information.” (N, a: 23, ½ y.o.e.)
“..and then I ask if they think it is acceptable to have that level of pain and if they answer no I Pain scale interpretation demanded
begin to discuss whether they want pain relief and what level they want to come down to.” (N, additional dialogue
a: 24, ½ y.o.e.)
“All figures and measurements you use could make you blind, one has to see what the patients Pain scale interpretation demanded
looks like and say.” (N, a: 39, 12 y.o.e.) additional observations
“..I think it is about giving the right information.. to receive an adequate rating..” (N, a: 30, 10 Pain scales usage was affected by The use of pain scales was affected by
y.o.e.) health care professional's knowledge work situations
“..It is all about your own routines and how long you've been working too, often it's the young Pain scales usage was affected by
ones who perform pain assessments.” (N, a: 24 ½ y.o.e.) habits of healthcare professionals
“You can't write (in electronic records) that when the patient moves it is 7 and when the patient Pain scales usage was affected by
is resting it is 1-2..this may lead to improper training, rehabilitation.. because they don't dare management
move because of pain.” (E.N. a 43, 6 y.o.e.)
“Directly postoperatively.. you need doing it often.. if you have a short acting treatment it has to Pain scales usage was affected by
be done several times an hour.” (Ph, a: 37, 12 y.o.e.) prioritization of tasks

N: nurse, E.N.: enrolled nurse, Ph: physician, a:age, y.o.e: years of experience.

3.1.2. Pain scales visualized the pain progress
Performing pain screening with a scale several times per day was
perceived to increase the understanding of the patient's experience of
pain. Fluctuations in pain intensity over 1 day or several days were
described as more easy to follow. Healthcare professionals described
being able to detect when and in which situations the patients
experienced pain. This was expressed helpful in giving a picture of the
effects of pain relieving actions and supported decisions of adjust-
ments to medication.
3.1.3. Pain scales facilitated handover between healthcare professionals
Together with information on what medication was given, the
documentation from pain scales was perceived supportive in
handovers and during ward rounds. The ratings were described as
explaining choice of treatment, which gave the healthcare pro-
fessionals a sense of security. The ratings were also expressed to
enable prioritizing patients; when patients gave a high rating the
healthcare professionals acted faster. Further, pain scales were
perceived to avoid the risk for misunderstandings and enable
descriptions of pain with a common language if used by all
healthcare professionals.
lasting pain conditions, ensure comfort and help the patient to go back
to normal life as soon as possible.
3.2.2. Pain scales facilitated choice of pain treatment
Pain scales were described as useful in the choice of drugs or pain
relieving care actions such as cold packs at breakthrough pain. It was
perceived useful in the choice of giving the patient long lasting or
short acting drugs and in the decision on what doses would be given
to the patient. Other care actions described were to give comfort by
changing patient positions, and time to talk.
3.2.3. Pain scales facilitated evaluation of pain treatment
The healthcare professionals described that pain scales were useful
tools in the evaluation of pain relieving actions when the patients
expressed their pain intensity before and after treatment. It was
perceived to be an approach that gave a clear answer about if pain
relieving care actions were needed and if chosen actions had to be
supplemented or not by comparing the ratings before and after given
treatment or other pain relieving care actions.
3.3. The use of pain scales demanded a multidimensional approach

3.2. The use of pain scales facilitated treatment of pain
3.2.1. Pain scales facilitated prevention of pain
The length of stay after surgery was in general described as short
which gave healthcare professionals little time to evaluate pain
treatment. Frequent screenings for pain after surgery were expressed
to enable being “one step ahead” in controlling pain. This approach
was perceived to result in prevention of break through pain and
enhanced the opportunities of individualized treatment with respect
to pain intensity, side effects, ability to mobilize and carry out
necessary exercises. Low ratings were expressed to prevent long
3.3.1. Pain scales demanded additional assurance of
patients' understanding
Assuring a patient's understanding of pain was described impor-
tant as there were patients who experienced difficulties in explaining
pain intensity with a rating. Pain scales were perceived not to be
appropriate for all patients. Before using a scale it was described
essential to assess the patient's cognitive abilities. It was expressed
necessary to explain the scales several times because it could be hard
to discover cognitive impairments as patient's condition could
fluctuate during the postoperative phase. The patients' willingness
to express their pain with a scale was perceived unrelated to the
56 L. Wikström et al. / Applied Nursing Research 27 (2014) 53–58
understanding of the scale. It was perceived to be wrong to persuade
patients who preferred using their own language describing their
postoperative pain.
3.3.2. Pain scale interpretation demanded additional dialogue
Healthcare professionals perceived difficulties in interpretation of
the patient's ratings. Difficulties in converting experienced pain into a
rating were perceived as a reason. There were patients who reported
low ratings but asked for treatment and vice versa. Additional
dialogue was described important to find out what the ratings mean
to the patient. To question the patients about the need for pain
treatment, side effects, pain at rest, movement in bed or out of bed and
in different positions was perceived to be one approach to find out
the need for pain relieving actions regardless the answer from the
pain scales.
3.3.3. Pain scale interpretation demanded additional observations
As healthcare professionals perceived difficulties in interpretation
of the answers from the patients they also expressed the need for
additional observations. A fear of depending on readings from the
scale and forgetting “the clinical eye” was described. When observa-
tions conflicted with what the patient expressed, a desire to believe
the patient and fears of missing a patient in pain were described. A
holistic perspective i.e., to observe the patient's facial expressions,
eyes and movements or breathing, heart rate and blood pressure was
perceived essential.
3.4. The use of pain scales was affected by work situations
3.4.1. Pain scales usage was affected by healthcare
professional's knowledge
Insecurity about how to use a scale was expressed by healthcare
professionals. One risk described was that they added their own
values to the patient's ratings, while another was that patients
compared their ratings with other patients. The healthcare pro-
fessionals expressed it being essential to convey the nature of
subjectivity of the pain experience to the patients. Knowledge about
the pain scales was described explaining that healthcare professionals
would spend time on explaining and motivating the patients to use
pain scales. The lack of education was perceived as one reason why
healthcare professionals choose not to use pain scales.
3.4.2. Pain scales usage was affected by habits of healthcare professionals
Personal habits were perceived as related to length of experience
and age, older healthcare professionals with long experience were
described more likely to use other approaches than pain scales when
screening for pain. Pain screenings were described by healthcare
professionals as “this is how I usually do it”. For example, two different
scales were described as being mixed on the same occasion to
facilitate the understanding of the patient's pain and descriptions of
worst possible pain varied.
3.4.3. Pain scales usage was affected by management
It was perceived that management and local guidelines affected
performance of pain screenings. Directions and encouragement from
the management were expressed as stimulating factors. The impor-
tance of creating simple routines for screening was emphasized as
implementation of new routines was expressed as resource demand-
ing. Monitoring records on paper was perceived to enhance the
adherence to routines while insufficient documentation possibilities
in electronic records were described as a potential risk factor when
prescribing pain treatment.
3.4.4. Pain scales usage was affected by prioritizing of tasks
To obtain time, a need for combining screening for pain with other
care routines was expressed. Frequent screenings were described as
needed the first day/days after surgery and should be stopped when
the patient “found pain manageable”. Pain screenings with defined
intervals were perceived inadequate because the patients' different
needs of attention are related to patient's personality, experienced
pain, duration of drugs given and possible side effects (downgrading
of Table 4).
4. Discussion of methodological issues
In qualitative research credibility, dependability, confirmability
and transferability build trustworthiness. Credibility refers to the
truth of interpretation of data (Holloway & Wheeler, 2006). This was
strengthened by the knowledge in the research team which consisted
of researchers with experience from postoperative pain and phenom-
enography. Dependability refers to the stability i.e., a high inter
subjective agreement in repeated research (Holloway & Wheeler,
2006, Sjöström & Dahlgren, 2002). The interview guide and all steps in
the study are described in Tables 3 and 4 to enable replicating the
study. Confirmability refers to the objectivity of data (Holloway &
Wheeler, 2006). The interviews were conducted by the main
researcher who had limited experience interviewing which can affect
the first interviews. Further, pre-understanding can affect the
interviewing and analyzing process, but the research team contrib-
uted with an objective methodological approach rather than a clinical
approach during the analysis. It is also possible to value the relevance
of the perceptions by reading quotes in Table 4. Transferability refers
to the results that can be applicable in other settings (Holloway &
Wheeler, 2006). The participants in this study represented three
professions from both surgical and orthopedic settings from four
different hospitals and had varied experience of using pain scales. A
purposeful sample was carried out when including participants,
although a strategically choice is the preferred method for data
collection (Marton & Both, 1997). This was caused by the fact that only
some units included enrolled nurses in routines on pain screenings
and few physicians had experience of using pain scales. Results from
phenomenographic research are possible to transfer to similar
settings bearing in mind that further perceptions are possible to
find. Humans vary in their way of experiencing phenomena, and the
phenomenographic approach can illuminate differences important to
refer to in meetings with healthcare professionals and patients in both
education and clinical practice.
5. Discussion
The main findings of this study were that healthcare professionals
perceived that pain scales facilitated the understanding of postoper-
ative pain and the choice of treatment and pain relieving care actions.
The use of pain scales was described as demanding a multidimen-
sional approach i.e., additional assurance of patient understanding,
additional dialogue and observations, but was also expressed to be
affected by knowledge, support from ward management, guidelines
and tools for documentation.
Pain scales in this study were perceived to facilitate the
understanding of postoperative pain in several aspects i.e., to detect
pain, follow pain over time and represent a common language. The
need for screening pain was expressed as being more important when
patients' did not tell pain, which coincide with recommendations of
the performing of reassessments according to the patient's needs
(Gordon et al., 2005). Dihle et al. (2006) found that nurses who took
an active role in detecting pain seemed to achieve better pain relieved
patients. This has been explained by Idvall, Bergqvist, Silverhjelm, and
Unosson (2008) who found that patients who expressed great trust in
healthcare professionals expected to be asked about pain. Further,
pain scales were described in this study to avoid the risk for
misunderstandings by enabling descriptions of pain in a common
language. This result is in line with Young, Horton, and Davidhizar
 L. Wikström et al. / Applied Nursing Research 27 (2014) 53–58
(2006) who stated that pain scales contributed to better understand-
ing of patient's pain.
Few, if any, studies have described how pain scales could
contribute to choice of treatment and pain relieving care actions in
clinical practice. Pain scales were in this study to describe how to
facilitate pain treatment by supporting and explaining the choice of
treatment. High ratings were helping healthcare professionals to take
quicker actions by choosing short acting drugs or changing patient's
position. To achieve low ratings were expressed as necessary to
prevent pain which often requires treatment with opioids. However,
pain management algorithms focusing on adequate titrating of
opioids in relation to patient's ratings have resulted in increased
patient satisfaction. They have also increased incidences of serious
adverse drug reactions (Vila et al., 2005). Screening for pain with pain
scales are therefore recommended in guidelines to be complemented
by assessments of side effects from drugs, effects on physical function
and patient satisfaction (Gordon et al., 2005). This was also expressed
as being essential by the healthcare professionals in this study.
However, several ratings over time were expressed as visualizing pain
progress that they were not always used to in clinical decisions. This
can be explained by the difficulties in interpreting pain ratings.
Screening for pain with pain scales were described as being
complex and demanding a multidimensional approach. Ensuring
patients' understanding of pain scales was described as essential, but
achieving appropriate ratings was sometimes perceived as a challenge
when patients lacked preoperative information and when patient's
cognitive condition postoperatively could fluctuate. Coker, Papaioan-
nou, Kaasalainen, and Dolovich (2012) also described patients'
difficulties in converting experienced pain into a number. These
findings correspond with Young et al. (2006) who described nurses'
difficulties in interpreting patient's ratings when they did not
correspond with what nurses could observe clinically. A desire to
believe that patients pain ratings and fears of missing a patient in pain
was expressed. To overcome described difficulties our findings
suggest that patient's knowledge about how to use pain scales is
essential and that additional dialogue and observations supplement
patient's pain ratings.
Our findings clearly reflected the fact that pain is a subjective and
individual experience. Healthcare professionals described that pa-
tients varied in how they converted pain into a rating. This might
cause problems to differentiate a cut-off point between mild and
moderate pain as mentioned in other studies (Dijk et al., 2012).
Gerbshagen, Rothaug, Kalkman, and Meissner (2011) found NRS 4 as
the threshold for tolerable postoperative pain, and most patients from
another recent study considered NRS 5–6 as bearable postoperative
pain (Dijk et al., 2012). The nature of pain can explain why our and
other studies (Klopper et al., 2006, Schafheutle et al., 2004) have
found that the performance of pain screening include interpretation of
what the patient says and looks like. These findings strengthen that
additional dialogue and observations are important in clinical
situations to reassure what the ratings mean to the patients. Fears
for under- and overtreatment seems relevant if relying on pain scales
only (Dijk et al., 2012, Hanks, 2008).
Work situations such as healthcare professionals' habits in this
study were found to affect the use of pain scales. How changes of
behavior (i.e., using pain scales) in clinical practice occur is not well
studied but is raised as being one barrier in implementation of
evidence based care (Nilsen, Roback, Broström, & Ellström, 2012). We
found that healthcare professionals with good knowledge of pain
scales used them more and expressed the need for spending more
time achieving patient understanding of the pain scales. This is in line
with research where information is found to increase patient's
satisfaction of pain management (Warren Stomberg, Wickström,
Joelsson, Sjöström, & Haljamäe, 2003). On the contrary, lack of
knowledge could lead to personal habits that could cause mis-
understandings. One example in this study was the described benefits
57
of mixing pain scales (NRS, VS) on the same occasion. This approach
demands awareness of the limited possibilities in achieving an
appropriate rating when the ratings from the two scales were
compared. However, healthcare professionals should bear in mind
that the NRS have recently been shown to have weak correlation
(0.38) with the VS. This indicates that words on the VS can be valued
differently by patients (Dijkers, 2010).
Our findings indicate that the use of pain scales also is depending
on organizational factors such as encouraging leadership and
possibilities to perform reliable documentation. Care managers play
an important role to enhance quality in care (Warren Stomberg et al.,
2003). The healthcare professionals in this study described simple
routines on documentation to be one factor for success in using pain
scales. Monitoring records on paper were reported to enhance the
adherence to routines which coincide with findings from Gordon et al.
(2008) who implemented a monitoring record including important
parameters reflecting patient's pain. Despite that electronic records
have been used for several years in clinical practice there are
remaining difficulties to achieve resembling documentation. Elec-
tronic records were, in this study, described as reducing adherence to
routines on screening for pain and were perceived as a potential risk
for under treatment. Our findings describe a need for further
development on easily accessible documentation of postoperative
pain for all healthcare professionals. This is also identified by Samuels
(2012) who has demonstrated the need for standardized documen-
tation in electronic medical records.
The expressed difficulties in interpretation of pain ratings could be
explained by the need for a deeper knowledge about what conclusions
from patient's ratings it is possible to make when having to take into
consideration the variations of experiencing and expressing pain.
However, Rognstad et al. (2012) found that healthcare professionals
described themselves as competent in postoperative pain manage-
ment. Despite this, many patients still suffer from postoperative pain
(Fletcher, Fermian, Mardaye, & Aegerter, 2008). Interdisciplinary,
collaborative care planning is highlighted by Carr, Reines, Schaffer,
Polomano, and Lande (2005) and Gordon et al. (2008) to avoid this.
Good relations and communications between nurses and physicians
are showed to enhance the quality of patient care (Havens et al.,
2010). Further, documentation of patient's pain, side effects, function
and satisfaction were keys to better understanding (Gordon et al.,
2008) and could contribute to continuous measurements of quality of
care with rapid feedback, available to all healthcare professionals
(Meissner et al., 2008, Samuels, 2012).
5.1. Implications for practice and future research
In clinical situations the pain scales are in several aspects useful in
screening patient's pain. Frequent pain screening the first day/days
after surgery may enhance the possibilities of avoiding break through
pain and can be especially helpful in communication with patients
who are reluctant in telling pain. Pain scales are good tools in
following patients' pain over time which is helpful in decisions on
when pain relieving actions are most needed. Further, the ratings can
guide decisions on choices of doses of drugs and other pain relieving
strategies and is a good tool in reassessments.
Difficulties in the interpretation of pain ratings could be overcome
by a deeper knowledge about how to use pain scales. However,
achieving appropriate ratings from pain scales demand awareness of
the subjectivity of pain experiences, as well as to allow for variations
of experiencing and expressing pain. Further, efforts to ensure a
patient understanding include assessing patient's cognitive condition
and to give uniform information about the end points of the scales.
Pain ratings should be supplemented with a dialogue and observa-
tions including effects, side effects and function and patient
satisfaction to reassure what the ratings mean to the patient.
Furthermore, it is essential to ask questions about the pain intensity
58 L. Wikström et al. / Applied Nursing Research 27 (2014) 53–58
at rest and at activity to achieve a true rating that can support relevant
choices of pain relieving actions. However, healthcare professionals
should respect patients' choice to express their pain with their own
words referring to difficulties in interpreting pain into a rating. These
findings need to be emphasized in local guidelines as patient's safety
is in danger when healthcare professionals solely rely on a rating
when treating pain.
Pain scales can contribute to a common language between
healthcare professionals in handovers, ward rounds, consultations
and documentation. Developing electronic monitoring sheets for
postoperative pain, made accessible for all healthcare professionals,
would encourage interdisciplinary discussions on improvements for
postoperative pain both in the daily work and in the work on
improvements of routines. Whether efforts on enhancing quality of
pain screening and documentation would lead to enhancing a
patient's quality of life, the first postoperative day's remains to be
examined in future research.
6. Conclusion
Healthcare professionals describe that frequent screening for pain
with pain scales contribute to the understanding of patient's
postoperative pain and facilitate the choice of treatment and other
pain relieving care actions if ratings are considered by all healthcare
professionals. It is important to ensure patient understanding and
be aware about patient's variations in interpretation of pain
ratings. Additional dialogue and observations are necessary to
reassure what the ratings mean to the patient. The use of pain
scales depends on patient's needs and how the management of ward
work is organized.
Acknowledgments
The authors express special thanks to the Academy for Health Care,
County Council of Jönköping, Sweden and (FORSS) The Research
Council of Southeast Sweden.
The authors express special thanks to Sweden and the Department
of Anaesthesia and Intensive Care at Ryhov County Hospital who have
given financial support.
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