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Investigación y Educación en Enfermería

Print version ISSN 0120-5307
On-line version ISSN 2216-0280

Invest. educ. enferm vol.37 no.2 Medellín May/Aug. 2019

http://dx.doi.org/10.17533/udea.iee.v37n2e10 

Review Article

Effectiveness of nursing educational interventions in managing post-surgical pain. Systematic review

Efetividade das intervenções educativas de enfermagem no manejo da dor pós-cirúrgico. Revisão sistemática

Antonio Reaza-Alarcón1  , Beatriz Rodríguez-Martín2 

1 Nurse. Universidad de Castilla-La Mancha, Facultad de Ciencias de la Salud, Talavera de la Reina (Toledo), Spain. Email: areazal96@gmail.com

2 Nurse, Masters, Ph.D. Associate Professor, Universidad de Castilla-La Mancha, Facultad de Ciencias de la Salud, Talavera de la Reina (Toledo), España. Visiting Researcher; University College Dublin, Ireland. Email: Beatriz.RMartin@uclm.es

Abstract

Objective.

Analyze and integrate studies that inquire on the benefits of nursing educational interventions to manage post-surgical pain.

Methods.

A systematic search was conducted in the databases of Scopus, Medline (Pubmed), Web of Science, The Cochrane Library, and CINAHL of systematic reviews, randomized clinical trials, and quasi-experimental studies published in English and Spanish until 2018 that analyzed the effectiveness of educational interventions in managing post-surgical pain in adult patients.

Results.

Twelve studies complied inclusion criteria, of which nine reported less pain in the group receiving the educational intervention. These interventions also helped to diminish the level of anxiety and improved functionality to perform activities of daily life. The level of quality of the studies was medium.

Conclusion.

Although the review showed that nursing educational interventions could influence on the relief of post-surgical pain, more rigorous studies are necessary, with bigger sample sizes and higher methodological quality, which help to establish the real effectiveness in managing post-surgical patients with pain.

Key words: effectiveness; nursing research; pain, postoperative; pain management; patient education as topic; review.

Resumo

Objetivo.

Analisar e integrar os estudos que indagarão nos benefícios das intervenções educativas de enfermagem para o manejo da dor pós-cirúrgico.

Métodos.

Se realizou uma busca sistemática nas bases de dados Scopus, Medline (Pubmed), Web of Science, The Cochrane Library e CINAHL de revisões sistemáticas, ensaios clínicos aleatorizados e estudos quase-experimentais publicados em inglês e castelhano até 2018 que analisassem a efetividade das intervenções educativas no manejo da dor pós-cirúrgico em pacientes adultos.

Resultados.

Doze estudos cumpriram critérios de inclusão, dos quais nove reportaram menos dor no grupo que recebeu a intervenção educativa. Estas intervenções também ajudaram a diminuir o nível de ansiedade e melhoraram a funcionalidade para realizar as atividades da vida diária. O nível de qualidade dos estudos foi médio.

Conclusão.

Embora a revisão mostrou que as intervenções educativas de enfermagem poderiam influir no alivio da dor pós-cirúrgico, são necessários estudos mais rigorosos, com maiores tamanhos de amostras e de maior qualidade metodológica, que ajudem a estabelecer a real efetividade no manejo do paciente pós-cirúrgico com dor.

Palavras-Chave: efetividade; pesquisa em enfermagem; dor pós-operatória; manejo da dor; educação de pacientes como assunto; revisão.

Introduction

Pain is a serious public health problem of global relevance. The International Association for the Study of Pain defines pain as an unpleasant emotional and sensory experience associated to current or potential tissue damage. By being a subjective experience, its measurement varies according to the person’s perception.1 Besides, according to its nature, pain can be acute, produced by tissue damage, of sudden onset and which ceases with the passage of time; or chronic, when it occurs during a long period of time, causing a limiting problem in daily life and which is aggravated by factors, like age, gender, and environmental and psychological factors, among others.1 In the recent decades, knowledge has increased on the physiopathology of pain. However, evidence shows that its treatment continues being poor and insufficient. In this sense, postoperative pain is still a challenge in the management of post-surgical patients, having important physiological, psychological, economic and social consequences.2) Prior studies show that over 80% of patients subjected to a surgical process experience pain. Of this percentage, 75% of patients experience moderate, severe, or extreme pain.3,4 Other studies indicate that nearly half the patients have severe pain due to inadequate healing.5,6

It is known that in the perception of pain, multiple factors influence, such as the type of intervention, age, gender, or the patient’s own expectations, which hinders foreseeing the level of pain patients can experience after surgery.7) Prior research show that efficient post-surgical control contributes to facilitating the patient’s physical and psychological recovery, diminishes the hospital stay, and improves quality of life and levels of stress. Also, reducing social and health costs.8 Furthermore, nursing professionals are trained to educate patients in the control and management of pain. We know that one of the obstacles to manage effectively post-surgical pain is the patient’s lack of knowledge or misunderstandings. Thereby, educational interventions can impact upon patients by modifying their behavioral pattern, knowledge, attitudes, and skills to achieve improved health. Hence, good preoperative information, provided by nursing professionals, can help to prepare patients for the postoperative phase, equipping them with autonomy to become active components of their care and treatment, which will contribute to better managing pain.1 Most prior studies have focused on relief of post-surgical pain and management of anxiety.

To our knowledge, no prior systematic reviews exist that additionally analyze other variables, like the development of daily activities or the vital constants. The objective of this review is to analyze and integrate studies that inquire on the effects of nursing educational interventions on the relief of post-surgical pain.

Methods

This study conducted a systematic review of randomized clinical trials (RCT), quasi-experimental studies, systematic reviews and meta-analyses that analyzed the effectiveness of educational interventions, conducted during the preoperative and postoperative phases, on the relief and prevention of post-surgical pain. The search included articles published in English and Spanish in the databases of Scopus, Medline (Pubmed), Web of Science, The Cochrane Library, and CINAHL. It included articles to February 2018 to analyze studies reflecting the association between the educational intervention and relief and decrease of post-surgical pain in patients subjected to any type of surgery. Table 1 gathers the search strategy used. In addition, a secondary search was conducted through the references cited by the studies found in our initial search and which were related with the principal objective of the study.

Table 1 Search strategy used in the databases analyzed 

Two reviewers performed independently the search and selection of the articles; thereafter, agreeing on the results. This process used the following criteria. Inclusion criteria: 1) Systematic reviews, RCT, quasi-experimental studies, and meta-analyses inquiring on the effectiveness of educational interventions in managing post-surgical pain; 2) Studies published to February 2018 in English or Spanish; and 3) Studies including in their sample a population over 18 years of age. Exclusion criteria: 1) Studies showing very low quality after the evaluation with instruments for their analysis (score < 40% of the instrument’s maximum score); 2) Educational interventions aimed at the relatives; and 3) Studies including in their sample patients with mental pathology. The study followed the principles of the PRISMA Declaration.9

To analyze the quality of articles potentially eligible, the following instruments were used: Checklist for Systematic Reviews and Research Syntheses from the Joanna Briggs Institute and AMSTAR to evaluate the systematic reviews, the JADAD scale to evaluate the RCT, Joanna Briggs Institute Checklist for Quasi-experimental Studies to evaluate quasi-experimental studies and the Newcastle-Ottawa Scale (NOS) to evaluate the quality of the meta-analyses. The AMSTAR scale has 16 items with four possible responses.10 The Checklist for Systematic Reviews and Research Syntheses is an instrument to evaluate the quality of systematic reviews and has 11 items with 11 being the maximum score.11 The NOS has eight items, with a star granted in each item referring to the categories of selection and exposition, and a maximum of two in the comparison.11 The JADAD scale has five items, with a score from 0 to 5, considering those aspects related with the study bias, like randomization or masking.12 The quasi-experimental studies were evaluated with the Joanna Briggs Institute Checklist for Quasi-experimental Studies, which has nine items, with 9 being the maximum score.13

Results

The initial search in the databases selected found 3 068 articles after eliminating articles duplicated in various databases. After a first review of the titles and abstracts 3055 articles were eliminated because of dealing with themes different from the object of study. Thereafter, 13 articles were reviewed in full text, from which one article was excluded because it had an insufficient score after its quality analysis (Figure 1). Finally, 12 articles were included in this review. Table 2 summarizes the principal characteristics of the studies analyzed.

Figure 1 Flow diagram of the search and selection process 

In relation with the type of study, six of the articles analyzed were controlled randomized trials (CRT),14-19 a systematic review and meta-analysis20 and five quasi-experimental studies.21-25 Regarding the geographical area, the studies were conducted in seven countries: South Korea,14 China,15,17,21,25 Canada,16 Finland,18 Norway,19 Spain,22 the United States (23, and Holland.24 The studies included analyzed the effectiveness of different educational interventions aimed at the management and relief of post-surgical pain. In this sense, some of the studies analyzed the effectiveness of educational interventions online,1,3 others on educational interventions aimed at managing pain and anxiety;2,4,5,7 certain studies inquired on the relationship between knowledge on the consumption of opioids and the pain management,6,8,10,11 while others analyzed the effectiveness of an educational intervention in ambulatory surgery (22 or the relationship between pain and post-surgical rehabilitation.12

Furthermore, certain heterogeneity was found regarding the types of interventions used in the studies, finding the following interventions: educational interventions based on the delivery of graphic material,15,17,19,22,25 use of audiovisual material and new technologies (14,16,24,25 as support to the educational intervention and interventions based on informative talks.18,21,23 In all cases, the educational intervention was directed by the patients, except in one of the studies14 in which the intervention was aimed at both patients and nursing professionals.

The principal result measurements analyzed in the studies were pain, anxiety, or level of knowledge about the patient’s pain. As secondary results, consumption of analgesics, functional rehabilitation, quality of life, vital constants, or functional disability associated with pain were analyzed.15,16,22,24,25 In relation with the scales and instruments used by the studies to measure the results, the studies included used the Numerical Graduation Scale,14,16,19,23-25 the Visual Analog Scale (VAS),15,18,21,22 the Brief Pain Inventory-Short Form (BPI-SF) scale 17)1 and the State-Trait Anxiety Inventory (STAI).15,18,20,21

Table 2 Principal characteristics of the articles analyzed 

Regarding the principal results reported in these studies after these interventions, while certain studies found a significant reduction of post-surgical pain after the educational intervention,14,15,25 other did not report statistically significant reduction of pain after the intervention.16,17,20,22-24 In these last studies, although no significant differences were reached, the levels of pain in the experimental group were lower. Additionally, all those studies that analyzed anxiety found statistically significant differences in the levels of anxiety between the groups after the educational intervention.15,17,20,21

Studies inquiring on the interference of pain in the activities of daily life found that, after the educational intervention, pain interfered less in the experimental group, which is why these patients had less problems to mobilize, walk, or perform actions, like coughing.16,18,21-23,25 Other results reported in the studies were that the educational intervention increased the participants’ knowledge about analgesics, as well as their consumption, improving adherence treatment after the intervention.22 Besides, greater therapeutic adherence permitted better control of pain and with it less problems in mobility.22 In another study, the educational intervention helped in the functional improvement and rehabilitation of the member affected,25) while a study reflected that the educational intervention had no effect on the patient’s vital constants (cardiac frequency, blood pressure, and respiratory frequency).15

In relation to the methodological quality of the studies analyzed, it was found that the six RCT, evaluated with the JADAD scale,12 obtained scores of 2 points,14,16 3 points15,17,19, and 4 points from a maximum of 5 points.18 The study evaluated with the Joanna Briggs Institute Checklist for Systematic Reviews11) reached a score of 8 points from a maximum of 11 points;20 and the five quasi-experimental studies evaluated with the Joanna Briggs Institute Checklist for Quasi-experimental Studies,13 obtained scores of 6 points,24 7 points21,23) and 8 points 22,25 over a maximum score of 9 points.

Discussion

The results of the studies included in this systematic review do not permit generalizing that the educational interventions aimed at patients for the knowledge of pain and its management to be effective in controlling or reducing post-surgical pain, due to the controversy found in the results. However, the results found show greater pain relief in patients receiving these interventions, as well as lower incidence of pain in performing daily activities after the intervention, like mobilization, walking, or resting. Additionally, educational interventions improve the expectations of patients on post-surgical pain, modify negative preconceptions of opioid analgesics, and improve the use of analgesics during the post-operative period. Regarding prior studies that have only analyzed the association between the educational interventions and relief of post-surgical pain, this review contributes with the analysis of the benefits of the educational interventions to perform daily activities after surgery 16,18,21-23,25 or the relationship between the educational interventions and the vital constants (cardiac frequency, respiratory frequency, and blood pressure) of post-operative patients.15

Following the line of prior studies, most of the articles analyzed coincide in that the information provided during the educational intervention is an important tool to raise awareness and sensitize patients on the concept of pain and the need for its treatment, producing a behavioral change in patients toward this pain.15-18,20,25 As shown in other studies, the results suggest a change, after the educational intervention, in the expectations of patients on post-surgical pain and modification of prior negative conceptions about opioid drugs used in pain management.22-24 In this sense, the results from this review show that patients’ increased knowledge improves its inclusion in the treatment, providing patients an active role, reducing their fear, anxiety, barriers, prejudice, and beliefs when using analgesics.15,16,22-24

However, although prior studies show the benefits of the educational interventions, certain studies in this review do not confirm this fact, not finding that the educational intervention presents any repercussion on relieving post-surgical pain or on the interaction of pain in daily activities.16,17,20,22-24 Although most of the studies suggest that the educational intervention can be useful in managing post-surgical pain, said association cannot be confirmed because not all the studies found in this review are conclusive, and some articles lack sound scientific evidence to ensure the results.

The results from this review show that educational interventions carried out by nursing can improve relief of post-surgical pain.22 In addition, nursing educational interventions reduce mobility problems, improve adherence to treatment after surgery22, and increase patient satisfaction.23 Nursing interventions aimed at increasing patients’ knowledge about analgesia before the intervention help the person identify and control pain, thus, reducing possible barriers during treatment.23,25 During the clinical practice, educational interventions help patients to assume an active role, allowing them to express their pain more precisely and learn that therapeutic alternatives exist.23,25 Hence, educational interventions are a tool that help nursing professionals to improve the process of making shared decisions, adherence to treatment, and management of post-surgical pain.22

The principal strength of this review is that it has followed the recommendations of the PRISMA Declaration and has evaluated the quality of the studies included with different instruments, according to the type of study. The study had mainly two limitations: the first is that of having found few studies with not very high level of rigor and very diverse applied methodology, and the second, is that considering only articles published in Spanish or English in the databases analyzed constitutes a limitation, when excluding possible relevant articles published in other languages.

The conclusion of this review is that educational interventions could influence on the relief of post-surgical pain, as well as aid in the development of daily activities, like moving about or breathing. Furthermore, educational interventions improve management of post-surgical anxiety and reduce barriers during the treatment follow up. In spite of the aforementioned, more rigorous studies are necessary, with larger sample sizes and higher methodological quality, which help to learn with certainty the effect of educational interventions in managing post-surgical patients with pain and extract relevant information that permits developing new pre-operative protocols that help to reduce pain and its post-operative complications.

References

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Received: January 15, 2019; Accepted: June 04, 2019

Conflicts of interest:

none.

How to cite this article:

Reaza-Alarcón A, Rodríguez-Martín B. Effectiveness of nursing educational interventions in managing post-surgical pain. Systematic review. Invest. Educ. Enferm. 2019; 37(2):e10.

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