A tentative model for developing strategic and clinical nursing quality indicators: Postoperative pain management

International Journal of Nursing Practice 1999; 5: 216–226

INTRODUCTIONThe selection of indicators is important in quality devel-opment; systematic analysis is needed to define these indi-

✠ R E S E A R C H P A P E R ✠

A tentative model for developing strategic and

clinical nursing quality indicators:

Postoperative pain management

Ewa Idvall RNT, LicMScPostgraduate student, Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linköping, Sweden

Elisabeth Hamrin RN, BM, DMScProfessor Emeritus, Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linköping, Sweden

Liselotte Rooke RNT, PhDAssociate Professor, Department of Management, County Council of Skåne, Sweden

Björn Sjöström RNT, PhDLecturer, Department of Advanced Nursing Education, Göteborg University, Sweden

Accepted for publication December 1998

Idvall E, Hamrin E, Rooke L, Sjöström B. International Journal of Nursing Practice 1999, 5: 216–226A tentative model for developing strategic and clinical nursing quality indicators: Postoperative pain

management

The purpose of the study was to evaluate the usefulness of a tentative model, based on important aspects of surgicalnursing care, for designing strategic and clinical quality indicators. Objective postoperative pain management was chosenfor the model because it is a priority area in surgical nursing care. Items within a questionnaire were designed by usingthe tentative model as a base and by means of a literature review.The questionnaire, directed to clinical nurses (n = 233),was compiled to establish the validity and the usefulness of the indicators. Fourteen items were assessed as essential forachieving high quality outcomes in postoperative pain management (11 as realistic to carry out, and 13 as possible fornurses to influence) with mean scores ≥ 4 (on a 5-point scale).The conclusion reached was that the tentative model com-bined with a literature search was found to be effective for designing items that might be useful as strategic and clinicalindicators of quality in postoperative pain management.

Key words: clinical nursing research; nursing care; pain, postoperative; quality assurance, health care;quality indicators.

Correspondence: Ewa Idvall, Sjögrensgatan 8, S-593 34 Västervik,

Sweden.Fax: + 46 490 3 1111;E-mail: <[email protected]>

cators. In a study by Lindeman as early as 1975 the item‘determine valid and reliable indicators of quality nursingcare’ had the highest positive response on the question‘impact upon patients’ welfare’.1 Another highly rankeditem on the same question was ‘establish the relationshipbetween clinical nursing research and quality of care’.1

Developing nursing quality indicators 217

These statements are still relevant to clinical practice andKitson et al. presented a paper in 1996 on the theme ofintegrating research and practice.2 There is a need forsimple quality indicators that are convenient to use inroutine, clinical work and that could be useful for com-parison of units and in collaboration with other profes-sionals. It is, however, also desirable that such indicatorsshould broaden perspectives and direct care towardshigher quality which would justify the concept and use ofstrategic and clinical quality indicators of nursing care. Aclinical indicator is identified as ‘a quantitative measurethat can be used as a guide to monitor and evaluate thequality of important patient care and support serviceactivities’.3 In the present study, strategic indicators implyspecific, clear and well-selected aspects of nursing carebased on research findings that should direct care to higherquality outcomes.

THEORETICAL BACKGROUNDIn a previous study by Idvall and Rooke,4 importantaspects of nursing care were developed that might have animpact on the quality and effects of care in surgical wards.These aspects were generated from a qualitative approach,using focus-group interviews with clinical nurses workingin surgical wards. The tape-recorded interviews weretranscribed verbatim and the data were examined line byline to identify units of information.This unitizing servedas the basis for defining categories and, finally, dimensions.The dimensions and categories are presented as a tenta-tive model, based on important aspects of surgical nursingcare (Fig. 1), which is useful as a starting point for outlin-ing clinical quality indicators.

A model is a symbolic representation of an empiricalexperience and an attempt to objectify the concept it rep-resents, replicating a reality with various degrees of pre-cision, according to Chinn and Kramer.5 In the presentstudy, the tentative model describes elements of perfor-mance and prerequisites for achieving the goal ‘highquality of care’, and predicts that if the prescriptions sug-gested are fulfilled, the goal will be reached.The substanceof the model is meant to be strategic and clinical in thesense that it represents different, important aspects ofdaily surgical nursing care.

Therefore, to evaluate the usefulness of the tentativemodel for designing quality indicators in surgical nursingcare, one priority area, namely postoperative pain man-agement, was chosen. Unfortunately, inadequate painrelief is a common experience for hospitalized patients.6–8

In a previous study, postoperative pain management wasemphasized by clinical nurses as important for high qualityin surgical nursing care, and they considered themselvesto have a great impact in this area.4The importance of painand postoperative pain management is well documentedin the literature9 and could be described as high-volume,high-risk, problem-prone and high-cost surgical wardactivity.

Thus, the aim of the present study was to evaluate theusefulness of the tentative model, based on importantaspects of surgical nursing care, for designing strategic andclinical quality indicators (Fig. 1).

METHODSConstruction of strategic and clinical

quality indicatorsItems were designed to be useful as nursing quality indi-cators in postoperative pain management by using the ten-tative model as a base, and by means of a literature review.

The authors formulated one item suitable for each ofthe model’s 15 categories. The purpose was to pinpointstrategic parts of postoperative pain management thatwould be useful for assessing the quality of care, ratherthan to cover the whole area. Literature was reviewed forresearch-based knowledge that would be useful fordesigning the items in the different categories. Searchstrategies included locating articles that concerned post-operative pain management, nursing and the different cat-egories in the model.

DIMENSIONS

Elements of performance

Detecting and acting on

signs and symptoms

Performing prescriptions

Performing pre- and

postoperative care

Performing general care

Informing and educating

Promoting relationships

Acting on behalf of patients

Protecting the privacy of patients

Prerequisites

Staffing

Environment/equipment

Competence/knowledge

Routines

Responsibility

Attitudes

Team work

C

A

T

E

G

O

R

I

E

S

Figure 1. A tentative model based on important aspects of surgi-cal nursing care with two dimensions and 15 categories.

218 E. Idvall et al.

A considerable source of information was the Clinical

Practice Guideline for Acute Pain Management: Operative or

Medical Procedures and Trauma from the United StatesDepartment of Health and Human Services’ Agency forHealth Care Policy and Research (AHCPR).10 To developthe guideline AHCPR convened an interdisciplinary panelcomposed of authorities in pain management. The Clini-cal Practice Guideline development process included anexhaustive literature search to define the knowledge baseand critical evaluation of the assumptions and commonwisdom of the field. Fourteen of the 15 items constructedin the present study were supported by AHCPR’s ClinicalPractice Guideline. The 15 items, supportive literatureand rationale are shown in Tables 1 and 2.

ProceduresA questionnaire directed to clinical nurses who wereexperienced in postoperative pain management was com-piled to elicit feedback on the relevance, face validity andusefulness of the items designed for achieving high qualityin postoperative pain management.

QuestionnaireThe questionnaire was constructed in four parts. The first covered background variables: (i) sex; (ii) age;(iii) number of years as registered nurse (RN);(iv) number of years working in surgical nursing care;(v) work location in the country; (vi) type of hospital;(vii) type of ward; and (viii) own experiences of painintensity on a numerical rating scale (0–10).

To establish face validity and usefulness, the second partof the questionnaire consisted of the 15 items (Tables 1and 2) each of which was to be assessed from three pointsof view:1. Whether the item was essential for achieving high-quality postoperative pain management for adult patientsin a surgical ward.2. Whether the item was realistic to carry out.3. Whether the item was open for nurses to influencemanagement.

A Likert-type response scale was used, scaled from oneto five: 1 = strongly disagree; 2 = disagree; 3 = uncertain;4 = agree; 5 = strongly agree. All items were positivelydirected.

The third part of the questionnaire contained 15 iden-tical items and the nurses were asked to choose threeitems in each of the dimensions, elements of performance

and prerequisites, respectively, which they conceived tobe the most crucial for achieving high quality in postop-erative pain management. The nurses were also asked todescribe a postoperative pain situation that was hard tomanage but where their activities had influenced theoutcome.

SampleThe questionnaires were mailed with a stamped and self-addressed return envelope to all nurses who were regis-tered for participation in a total of six training courses inacute pain management between the years 1995 and 1997(n = 233). The Swedish Nurses Association for Pain Man-agement and the medical company Abbott Scandinavia Incarranged the 2-day intensive courses. This population ofnurses was selected because of their obvious special inter-est in and clinical experience of pain management.

Two reminders were sent to non-respondents. Theresponse rate to the questionnaire was 90%. Drop-outanalysis showed no difference between respondents (n = 210) and non-respondents (n = 23) according towhere in Sweden they worked, the type of hospital or typeof ward. Two non-respondents had moved to unknownaddresses, and an additional three sent the questionnaireback unanswered. Twenty-seven respondents had notanswered all 47 partial questions, having missed from oneto seven partial questions. In the data analysis this wascompensated for by mean substitution.

The development of strategic and clinical quality indi-cators is illustrated by a flowchart (Fig. 2).

StatisticsData were analysed using StatSoft Statistica, version 4.5(Stat Soft,Tulsa, OK, USA). Descriptive statistics are pre-sented as arithmetic means and standard deviation for thesake of clarity, though the questionnaire is referred to asan ordinal scale. Friedman two-way analysis of variance(ANOVA) followed by the Wilcoxon matched two pairstest were used to test the differences between the assess-ments of each item according to whether it was regardedas essential, realistic to carry out, and open to influenceby nurses. Differences of opinion were tested by theMann–Whitney U-test between groups of respondentsregarding their years as a registered nurse, years in thesurgical unit, working units, type of hospitals and age.


Table 1 Items formulated in each category in the dimensions ‘elements of performance’, rationale and supportive literature

Category Item Rationale Supportive literature

Detecting and acting 1. The patient’s perception of Pain is subjective and there is a risk that the staff will AHCPR 199210

on signs and symptoms pain must be assessed regularly underestimate the patient’s experience of pain.The Paice 199511

with the help of a pain patient’s self-report on pain intensity, using a pain Sjöström 199512

assessment instrument (e.g. assessment tool, is important for pain treatment.The

the VAS scale). staff must respect the pain score.

Performing 2. Pharmacological pain Prevention is better than treatment, as established pain AHCPR 199210

prescriptions treatment must be is more difficult to suppress. Pain prevention can yield Rawal 199413

administered preventively. both short- and long-term benefits. Standard orders for Juhl 199614

the use of analgesics will minimize the number of

patients in severe pain.

Performing pre- and 3. The patient’s pain must be To avoid postoperative complications early Seers 198715

postoperative care assessed in connection with mobilisations of the patient is essential.Thus it is AHCPR 199210

mobilization (e.g. on breathing important that deep breaths, coughing and moving legs Meehan 199516

deeply or moving legs). do not increase pain.

Performing general 4. The patient must be given Comfort strategies can be complementary to AHCPR 199210

care help/support to find a pharmacological pain management, for example resting Closs 199217

comfortable position in bed or sleeping in a comfortable position in a comfortable Carr 199718

bed.

Informing and 5. The patient must receive Accurate pre-operative information and supportive Wallace198519

educating information pre-operatively contact can reduce anxiety by establishing reasonable VanDalfsen 199020

about pain treatment. expectations about the event. Anxiety is correlated to AHCPR 199210

pain experience. Informed patients report less pain.

Promoting 6. An individual goal for pain There is no direct correlation between the extent of Seers 198821

relationships treatment must be set up in organic injury and pain intensity. Other factors VanDalfsen 199020

collaboration with the patient. influence the patient’s report of pain.There are large AHCPR 199210

individual variations between patients, which are not

predictable.

Acting on behalf of 7. The nurse must act until a The nurses act for the patient to ensure satisfactory AHCPR 199210

patients level has been reached that is pain relief with the most appropriate balance of drug

acceptable to the patient. and non-drug strategies.

Protecting the privacy 8. The patient must be given For psychosocial wellbeing, sleep has an important AHCPR 199210

of patients the opportunity for peace and role.There is a close relationship between pain and Closs 199217

quiet so as to be able to sleep/ sleep.When planning for night-time nursing care, one

rest at night. has to consider both. Pain is a common cause of sleep

disturbance.


RESULTSBackground variables

The majority of the nurses were female, between 30 and50 years old, registered for more than 10 years, andworking in surgical wards in 22 of 23 counties in thecountry (Table 3).

ItemsAll eight items in the dimension ‘elements of perfor-mance’ (Table 1) were assessed as essential (agree orstrongly agree) by more than 90% of the respondents, and

mean scores varied between 4.5 and 4.9 (5-point scale).Six items (numbers 1–5 and 7) were assessed as realisticto carry out (agree and strongly agree) by more than 80%of the respondents, and mean scores varied between 3.8and 4.6. Seven items (numbers 1–7) were assessed asbeing possible for nurses to influence (agree and stronglyagree) by more than 80% of the respondents, and meanscores varied between 4.0 and 4.7.The scores for ‘essen-tial’ were significantly higher than the scores for ‘realistic’for each of the items. The scores for ‘nurses influence’were also significantly higher than the scores for ‘realistic’

Table 2 The items formulated in each category in the dimension ‘prerequisites’, rationale and supportive literature

Category Item Rationale Supportive literature

Staffing 9. Over half the caring High competence in the ward with registered nurses Heater 198822

staff on the ward must be in the majority makes it possible for the nurses to Prescott 199323

registered nurses. perform and follow up advanced individual care. Segesten 199724

Environment/equipment 10. There must be rooms Controlling the immediate environment and having AHCPR 199210

that produce a pleasant some privacy are factors that reduce stress and anxiety Kitson 199425

environment. known to be associated with experiences of pain.

Competence/knowledge 11. Nurses must possess Pain education for nurses has a positive impact on the AHCPR 199210

special knowledge of pain patient’s pain experience, for example nurses fear of Francke 199626

assessment and pain addiction can be reduced and non-pharmacological Jhul 199614

treatment. approaches can be made known.

Routines 12. There must be special Regular recordings in fixed protocols of pain intensity AHCPR 199210

rules for the documentation and treatment are necessary both to access the pain Rawal 199413

of pain assessment and pain treatment of the individual patient and to evaluate pain

treatment. management in the ward, department or hospital.

Responsibility 13. There must be a There must be clear lines of responsibility and clarity AHCPR 199210

particular nurse who is among professionals who coordinate pain

responsible for the management.

individual patient’s pain

treatment (e.g. a primary

nurse).

Attitudes 14. Nurses must believe Pain is whatever the experiencing person says it is, McCaffery 198327

what the patients tell them existing whenever he/she says it does. AHCPR 199210

concerning their pain. Sjöström 199512

Team-work 15. There must be Pain relief is a complex phenomena that results from AHCPR 199210

multiprofessional integrated knowledge and work of individuals of Pike 199328

cooperation with respect different professional training. Nurse–physician Rawal 199413

to pain. collaboration is essential.


(one exception). Four items, numbers 1, 2, 5 and 7, werechosen by more than 50% of the respondents as one ofthe three most crucial factors for achieving high quality.

In the dimension ‘prerequisites’ (Table 2) six of sevenitems (numbers 10–15) were assessed as essential (agree orstrongly agree) by more than 80% of the respondents, andmean scores varied between 3.8 and 4.9. Four items(numbers 11, 12, 14 and 15) were assessed as realistic tocarry out (agree and strongly agree) by more than 80% ofrespondents, and mean scores varied between 3.1 and 4.5.Three items (numbers 11,12 and 14) were assessed asbeing possible for nurses to influence (agree and stronglyagree) by more than 80% of the respondents, and meanscores varied between 3.0 and 4.6.The scores for ‘essen-tial’ were significantly higher than the scores for ‘realistic’and also for ‘nurse’s influence’ on each of the items.Threeitems were chosen by more than 50% of the respondents(numbers 11, 12 and 14), as one of the three most crucialfactors for achieving high quality.

The assessments of the 15 items are presented as mean± SD with respect to whether the item is essential, realis-tic to carry out and open to influence by nurses (Tables 4and 5) and the difference between these assessments hasbeen determined.

The differences in opinions on all items were testedbetween respondents from two different groups of hospi-tals (university hospitals vs central county, district countyand others) and showed no significant difference betweenthe items assessed as essential. Item number 6 showed a difference (P < 0.05) according to whether the item

was realistic to carry out and nurse’s influence, withhigher mean scores for the respondents from a universityhospital.

The two working unit groups (surgical wards vs inten-sive care units, anaesthesia department and others)showed differences (P < 0.05) on two items assessed asessential: (i) ‘The patient must be given the opportunityfor peace and quiet so as to be able to sleep/rest at night’;and (ii) ‘Nurses must believe what the patients tell themconcerning their pain’. The nurses working in surgicalwards gave higher mean scores.

In the two ‘years as RN’ groups (< 10 years and > 10years) three items differed significantly as being essential:(i) ‘The patient’s perception of pain must be assessed regu-larly with the help of a pain assessment instrument’(P < 0.05); (ii) ‘The patient must be given the opportunityfor peace and quiet so as to be able to sleep/rest at night’(P < 0.05); and (iii) ‘Over half the caring staff on the ward must be RNs’ (P < 0.01), and it was the group

The tentative model based on important aspects of surgical nursing

care with 15 categories

Priority area: postoperative pain management

Literature search

Construction of indicators for each category in the model

Testing for validity by a questionnaire

Figure 2. The development of strategic and clinical quality indicators.

Table 3 Background variables for the 210 questionnaire

respondents

Characteristics % Characteristics %

Sex Working unit

female 96 surgical ward 59

male 4 intensive care 23

anaesthesia 9

other 9

Age, years Hospital

< 30 9 university 43

30–50 81 central county 25

> 50 10 district county 23

other 9

Years as RN Experience of pain

intensity (0–10)

1–5 12 < 5 4

5–10 21 ≥ 5 67

>10 67 no answer 29

Years in surgical unit

< 1 3

1–5 19

5–10 28

> 10 50


Table 4 Mean scores and ± SD for items assessed in ‘elements of performance’

Item Essential (E) Realistic (R) Nurses ANOVA

mean ± SD mean ± SD influence (I) P-values††

mean ± SD

1. The patient’s perception of pain must be assessed regularly with the help of 4.5 0.7* 4.2 0.8† 4.6 0.7 < 0.001

a pain assessment instrument (e.g. the VAS scale).

2. Pharmacological pain treatment must be administered preventively. 4.7 0.6‡ 4.6 0.6 4.6 0.6 < 0.05

3. The patient’s pain must be assessed in connection with mobilization (e.g. 4.6 0.7* 4.3 0.8† 4.5 0.7 < 0.001

on breathing deeply or moving legs).

4. The patient must be given help/support to find a comfortable position in bed. 4.8 0.5* 4.5 0.7† 4.7 0.6 < 0.001

5. The patient must receive information pre-operatively about pain treatment. 4.9 0.4* 4.6 0.6§ 4.7 0.6** < 0.001

6. An individual goal for pain treatment must be set up in collaboration with 4.5 0.7* 4.0 0.9† 4.3 0.9** < 0.001

the patient.

7. The nurse must act until a level has been reached that is acceptable to the 4.9 0.4* 4.4 0.7† 4.6 0.6** < 0.001

patient.

8. The patient must be given the opportunity for peace and quiet so as to be 4.8 0.5* 3.8 0.9† 4.0 1.0** < 0.001

able to sleep/rest at night.

*Differences between E and R, P < 0.001; † differences between R and I, P < 0.001; ‡ differences between E and R, P < 0.05; § differences

between R and I, P < 0.01; **differences between E and I, P < 0.001††Friedman two-way analysis of variance (ANOVA);Wilcoxon matched pairs test, n = 210.

Table 5 Mean scores and ± SD for items assessed in ‘prerequisites’

Item Essential (E) Realistic (R) Nurses ANOVA

mean ± SD mean ± SD influence (I) P-values††

mean ± SD

9. Over half of the caring staff on the ward must be registered nurses. 3.8 1.3* 3.6 1.2† 3.2 1.3‡ < 0.001

10. There must be rooms that produce a pleasant environment. 4.3 0.8§ 3.1 1.1 3.0 1.2‡ < 0.001

11. Nurses must possess special knowledge of pain assessment and pain

treatment. 4.9 0.3§ 4.5 0.7 4.4 0.8‡ < 0.001

12. There must be special rules for the documentation of pain assessment and

pain treatment. 4.8 0.5§ 4.5 0.6** 4.6 0.6‡ < 0.001

13. There must be a particular nurse who is responsible for the individual

patient’s pain treatment (e.g. a primary nurse). 4.2 0.9§ 3.9 1.0** 4.0 1.0‡ < 0.001

14. Nurses must believe what the patients tell them concerning their pain. 4.9 0.4§ 4.5 0.7 4.6 0.7‡ < 0.001

15. There must be multiprofessional cooperation with respect to pain. 4.8 0.6§ 4.2 0.9 4.1 0.9‡ < 0.001

*Differences between E and R, P < 0.01; † differences between R and I, P < 0.001; ‡ differences between E and I, P < 0.001; § differences

between E and R, P < 0.001; ** differences between R and I, P < 0.05††Friedman two-way analysis of variance (A N OVA ) and Wilcoxon matched pairs test, n = 210.


RN > 10 years who found this more essential for qualityof care. Item number 1 and nurse’s influence also differedin the same direction (P < 0.05).

In two of the age groups (< 30 years and > 50 years)item number 14 ‘realistic to carry out’ (P < 0.01) and itemnumber 4 ‘nurse’s influence’ (P < 0.05) differed, withhigher mean scores for the group > 50 years. In the twogroups of ‘years of experience in a surgical ward’(< 10 and > 10) respondents, one item differed (P < 0.05),that is number 8 (realistic to carry out), with a highermean score for the group with less than 10 years’experience.

DISCUSSIONMethodological considerations

The tentative model based on important aspects of surgicalnursing care (Fig. 1), developed from focus group inter-views,4 was adopted for designing items that could beuseful as strategic and clinical indicators of quality in post-operative pain management.The development and deter-mination of quality indicators based on theories, modelsand frameworks have not frequently been described.29

However, Orem’s concept of self-care has been used tojudge outcome criteria developed by nurse experts30 andcomplementary to identifying key domains and qualityindicators in nursing homes.31 The tentative model in thepresent study certainly embraces several important aspectsof surgical nursing care but it may be argued that someaspects are missing. By means of the literature review onpostoperative pain management (Tables 1 and 2) one itemwas designed in each of the 15 categories. In several cat-egories it would have been possible to design more than oneitem, but a sufficient number of aspects of clinical impor-tance were thought to be covered by the tentative model.An explanation may be that the categories are general intheir character. Before the items can be tested for reliabil-ity as quality indicators in surgical wards, there is a need todefine them in a way that makes them measurable.

The tentative model, however, must also be tested inother priority areas (e.g. nutrition) before drawing theconclusion that it is a general model that is useful fordeveloping strategic and clinical quality indicators in sur-gical nursing care.

The purpose of the questionnaire directed to clinicalnurses was to establish the relevance, face validity and use-fulness of the items. When formulating items that areuseful as nursing quality indicators, it is important todecide whether the items are essential, realistic to carry

out and open to influence by nurses. These aspects havebeen described by Kitson et al. who emphasized profes-sional experience and research-based evidence as sourcesof information, stating that the criteria formulated shouldbe both relevant and achievable.32 In a study by Farrell andScherer, the basic assumption was made that the opinionsof practising nurses are a most valid source of informationabout what constitutes quality in nursing care.33 As in thepresent study, Farrell and Scherer used a 5-point Likertresponse scale in an attempt to minimize the influence ofthe midpoint (centring bias) and yet encourage diverseexpression of opinions.

It was important that the group of nurses who assessedthe items had experience in the field if the items were tobe generally accepted and eventually successfully imple-mented as relevant indicators. The assessing nurses hadlong experience as registered nurses and had worked fora long time in the relevant field and almost 70% had per-sonal experience of a pain intensity ≥ 5 (numerical ratingscale, 0–10), which demonstrates they had an awarenessof the phenomenon of pain. The high response rate mayindicate that the nurses thought it was an important andinteresting questionnaire.

Reflections on the resultsGenerally, all the items had high mean scores. Fourteenitems were assessed as essential, 11 as realistic to carry outand 13 as possible for nurses to influence with mean scores≥ 4. This confirmed that the items chosen have high facevalidity for the quality of care in postoperative pain man-agement and that the majority of the items were deemed asuseful in clinical nursing, realistic to carry out and possiblefor nurses to influence. Some items, however, could bedeemed less important in these aspects.This can be deter-mined by a mean score lower than 4. In a study by Farrelland Scherer, using the Delphi technique for reaching con-sensus on different items, items with mean scores of morethan 4 (on a 5-point scale) were accepted as having demon-strated consensus.33 It could also be argued that the itemshave content validity because they were chosen from a ten-tative model based on important aspects of surgical nursingcare and a literature review and assessed as essential. Con-sequently, they could be accepted as being strategic parts ofpostoperative pain management.

Elements of performanceMean scores were ≥ 4.5, according to whether the items(1–8) in ‘elements of performance’ were essential to


achieving high quality in postoperative pain management.The item ‘The patient must get the opportunity to restand sleep at night’ is the only item with a mean-scorelower than 4 with respect to being realistic to carry out.This can reflect environmental difficulties such as severalpatients in the same room, and noise from other patients,staff and bell-calls.The other items describe activities thatcould be influenced more easily by the nurses themselves.

There was a significant trend between assessments ofthe items in ‘elements of performance’, that is, the scoresfor ‘essential’ were higher than the scores for ‘realistic’which were lower than the scores for ‘nurses influence’(one exception). A similar trend was seen in a small studywhere clinical nurses in two surgical wards were asked toestablish threshold values of predetermined indicators forgood quality of care and what results they expected intheir own ward.34Thresholds for good quality of care werehigher than the values the nurses expected and the resultsevaluated in the wards had the lowest value. In the presentstudy, this trend (essential > realistic < nurses influence)may reflect the nurses’ high ambitions and knowledgeabout postoperative pain management and their opinionof nurses’ capacity to influence this area, but high work-load, inexperienced staff with a lack of knowledge andnegative attitudes may obstruct the implementation.However, all the mean scores were high.

The item ‘Pharmacological pain treatment must beadministered preventively’ had high mean scores on allthree aspects. This is notable, because nurses are notallowed to prescribe pharmacological pain treatment butobviously consider that they have great impact on theseprescriptions. One reason for this may be that it is rec-ommended practice to have standard orders for individ-ual patients for both basic analgesics for preventive careand other medications that the nurses themselves decidewhen to administer.13 Another reason may be that thenurses know they can argue in favour of a particular medi-cation and influence the prescribing physicians.

Two of the highest ranked items for the most crucialfactors for the quality of care were:1. ‘The patient’s perception of pain must be assessedregularly with the help of a pain assessment instrument,for example the VAS scale.’2. ‘The nurse must act until a level has been reached thatis acceptable to the patient’.

This can be compared to the statements in ACHPRClinical Practice Guideline such as, ‘Patient self-report isthe single most reliable indicator of the existence and

intensity of acute pain and any concomitant affective dis-comfort or distress. Neither behaviour nor vital signs cansubstitute for a self-report’.10

PrerequisitesThe item ‘Over half of the caring staff on the wards mustbe registered nurses’ was the only item (of 15) with amean score lower than 4 with respect to being essentialto achieving high quality of care. The scores for ‘realisticto carry out’ and ‘possible for nurses to influence’ are alsolower than 4. This is remarkable, because in Sweden thesuggested percentage of registered nurses in the totalcaring staff in acute care settings is 70–80%.24 When differences in opinions were tested between differentgroups of respondents there was a significant difference (P < 0.01) on this particular item in the group ‘years as RN’. The group with > 10 years’ experience as RNthought the item ‘Over half of the caring staff on the wardsmust be registered nurses’ was more essential. Are theyounger nurses more influenced by or dependent on theirassistants, or is the explanation that longer experiencemight induce the insight that high quality bedside nursingrequires a higher level of education? This subject is alsodiscussed in a report from the American Nurses Associa-tion, where one of the 10 important nursing quality indi-cators presented was the mixture of registered nurses andunlicensed staff.35 In a study from Chicago where nurseswere asked to rank a predetermined list of quality indica-tors, the nurses selected the ratio of registered nurses tothe number of beds as the top indicator of hospitalquality.36

The significant trend between the assessment of theitems in ‘prerequisites’ was that the scores for ‘essential’were higher than the scores for ‘realistic’ and for ‘nursesinfluence’.This pattern was different from the trend in thedimension ‘elements of performance’ where ‘nursesinfluence’ was not always lower than ‘essential’ and where‘nurses influence’ was higher than ‘realistic’. Obviously,the nurses meant that they have more influence on thecaring activities than on the prerequisites.

One of the highest ranked items as the most crucial forthe quality of care was ‘Nurses must believe what patientstell them concerning their pain’.That pain is a strictly per-sonal experience is advocated in McCaffery and Beeb’sbook Pain, which states:

The person with pain is the only authority about the existence and

nature of pain, since the sensation of pain can be felt only by the


person who has it. Personal values and intuition do not constitute a

professional approach.9

This is an important cornerstone in pain manage-ment. It is notable that there was a significant difference (P < 0.05) between the assessments of ‘Nurses mustbelieve what the patients tell them concerning their pain’with respect to being ‘essential’ in the groups working insurgical wards and others (mainly intensive care units andanaesthesia department), with a higher mean score fromthe nurses working in surgical wards. It is, however,important to keep in mind that the mean scores of bothgroups were high. It is likely that the group ‘others’ ismore used to looking for signs of pain (i.e. a high pulserate and respiratory rate) and caring for patients withwhom they can not communicate.

Clinical considerationsThe face validity, content validity and the usefulness wereestablished for the items related to achieving high qualityin postoperative pain management. The results should beuseful in clinical practice when discussing quality devel-opment in postoperative pain management. A valuablestarting point might be to consider the items ranked asmost crucial factors for high quality management.

CONCLUSIONThe tentative model, based on important aspects of sur-gical nursing care combined with a literature search, wasfound to be effective for designing items useful as stra-tegic and clinical indicators of quality in postoperativepain management.

ACKNOWLEDGEMENTSPart of this research was supported by the HealthResearch Council in the South-east of Sweden, theSwedish Foundation for Health Care Sciences and AllergyResearch and the medical company Abbott ScandinaviaInc. We are also grateful to Patrik Idvall for skilled com-puter assistance.

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A tentative model for developing strategic and clinical nursing quality indicators: Postoperative pain management