ORIGINAL ARTICLE

Preoperative Pain Management Education:

An Evidence-Based Practice Project
Katherine F. O’Donnell, DNP, APRN, FNP-BC

Purpose: The purpose of this evidence-based practice project was to eval-

uate the effectiveness of a preoperative pain management patient educa-
tion intervention on improving patients’ pain management outcomes.
Design: The project was conducted in an outpatient general surgery ser-
vice at a teaching institution for patients undergoing same-day surgery.
Intervention patients received one-on-one education on postoperative
pain management including how to take medications, managing medi-
cation side effects, using nonpharmacologic methods, and reporting
inadequate postoperative pain control. Comparison patients received
general education from multiple health care providers, and this informa-
tion may not have been consistent.
Methods: Intervention patients received education at the first preopera-
tive clinic visit. Patients in the intervention and comparison groups
completed the Revised American Pain Society Patient Outcome Question-
naire during their first postoperative clinic visit. Results were analyzed by
the Mann-Whitney U test/Wilcoxon rank sum test.
Findings: A 12-month project (N 5 99) showed statistically significant re-
sults (P 5 .020 and P 5 .001, respectively) in questions about side effects
and whether the patient was encouraged to use nonpharmacologic
methods to reduce pain. The intervention group reported the effects of
pain on mood (P 5 .067) and use of nonpharmacologic methods
(P 5 .052); however, these results were not statistically significant.
Conclusions: More intervention patients than comparison patients re-
ported medication side effects and whether they were encouraged to
use nonpharmacologic methods for reducing postoperative pain. Inter-
vention patients also reported the effects of pain on mood and the use
of nonpharmacologic methods more frequently than comparison pa-
tients. Preoperative pain management education may increase patients’
knowledge in key areas of postoperative pain management to prevent
negative outcomes.
Keywords: preoperative pain management education, postoperative
pain, pain management outcomes, evidence-based practice.
Ó 2017 by American Society of PeriAnesthesia Nurses

THE MANAGEMENT OF PAIN is one of the great-

Katherine F. O’Donnell, DNP, APRN, FNP-BC, Department of
General and Minimally Invasive Surgery, University of Texas
Health Science Center, San Antonio, TX.
Conflict of interest: None to report.
Address correspondence to Katherine F. O’Donnell, Medical
Arts and Research Center, 8300 Floyd Curl Drive Suite 4A, San
Antonio, TX 78229; e-mail address: odonnellk@uthscsa.edu.
Ó 2017 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
https://doi.org/10.1016/j.jopan.2017.11.001
est clinical challenges for nurses who care for
patients during the postoperative period. It can
be even more challenging for patients who must
manage their own pain after discharge from the
health care facility. Research shows that postoper-
ative pain continues to be undermanaged despite
decades of education and evidence-based guide-
lines.1 A 2015 study showed a reduction in the

Journal of PeriAnesthesia Nursing, Vol -, No - (-), 2017: pp 1-8 1

2 KATHERINE F. O’DONNELL
severity of postoperative pain in the last decade,
but many patients still reported severe pain.2 Pa-
tients may find the management of their own
pain after discharge equally challenging and daunt-
ing. It is important that postoperative pain is well
controlled, as ineffective treatment of postopera-
tive pain may lead to negative outcomes such as
deep vein thrombosis, atelectasis, pulmonary em-
bolism, chronic pain, increased length of hospital
stay, and readmission for pain management.3,4
Pain can limit the ability to return to work
quickly, placing financial and emotional stress on
patients and families.5
Overview of the Literature
In 2010, 48.3 million surgical and nonsurgical pro-
cedures were performed in the United States. These
numbers continue to increase, making postopera-
tive pain the most common cause of pain.6 Postop-
erative pain is considered acute pain and results
from tissue damage, inflammation, and the healing
process.4 Most patients report pain after surgery,
and pain levels vary depending on the type of sur-
gery, comorbidities, previous experiences with
pain, age, gender, and patient expectations.4 This
combination of factors makes it difficult to predict
how much pain a patient will experience and
how well pain will be tolerated, emphasizing the
wide variability among patients and their pain expe-
rience. Inadequate assessment and management of
postoperative pain can result in patient anxiety,
insomnia, stress, and limited mobility.4 Poor
communication between patients and health care
providers, unrealistic patient expectations, and
insufficient patient education all contribute to sub-
optimal pain control.3,4
Other obstacles to adequate pain management
include lack of a comprehensive assessment
plan, improper use of pain assessment tools, inad-
equate documentation, and barriers related to cli-
nicians’ knowledge and attitudes about pain.7,8
Numerous pain assessment tools exist for
evaluating and documenting pain in most
patients, including pediatric, nonverbal, critically
ill, or cognitively impaired patients.3 Assessment
of pain includes use of age and condition appro-
priate tools, ongoing documentation, treatment
measures, reassessment of the patient, and their
response to treatment, including any adjustments
in the treatment plan.3,9
Preoperative education is a way to prepare
patients to manage their pain and have a success-
ful postoperative recovery. Education should
include information on the importance of pain
control, goals of treatment, how much pain the
patient may experience, and the importance of
reporting poorly controlled pain that interferes
with recovery activities.1 Pain management op-
tions that should be explained to patients include
both pharmacologic and nonpharmacologic
methods.3,7,8,10
Project Design: The Iowa Model
The framework for this project was based on the
Iowa Model of Evidence-Based Practice to Promote
Quality Care, which is an evidence-based practice
model of care.11 Using the model one must
identify problem-focused triggers or knowledge-
focused triggers, which may be related to current
practice to synthesize available evidence and intro-
duce practice changes to improve outcomes. The
effects of these changes on patient outcomes are
monitored over time.12,13
Postoperative pain management was identified as a
problem for clinicians at the University of Texas
Health Science Center San Antonio, TX, outpatient
surgery clinic. Using the Iowa Model, postopera-
tive pain management served as the project’s
problem-focused trigger.11 Patients often reported
poorly controlled pain after surgery, inadequate
knowledge about pain and analgesics, and limited
understanding about medication side effects.
Other problems included frequent requests for
medication refills, visits to the emergency room
for pain control, and the inability to return to
work and normal activities because of poorly
controlled pain.
Using postoperative pain as the problem-focused
trigger to initiate change, the author, hereby
referred to as the project director, developed an
evidence-based practice tool to educate patients
about postoperative pain management. The goal
was to educate patients undergoing elective laparo-
scopic cholecystectomy about taking medications
correctly, managing side effects, the use of nonphar-
macologic methods, and reporting any medication
side effects. Patients were also instructed to report
inadequate pain control, uncontrolled nausea and
vomiting, and severe constipation after surgery.
PREOPERATIVE PAIN MANAGEMENT EDUCATION 3

Project Implementation appointment with the project director 2 weeks af-

Before implementation, meetings were held to
educate other providers and support staff (medi-
cal assistants and schedulers) about the project
goals, and to ask for their input and feedback.
Everyone received a copy of the project abstract,
the patient education materials, and the patient
questionnaire. The University of Texas Health Sci-
ence Center San Antonio, TX, Institutional Re-
view Board approved the project as exempt.
Data were collected from January 2013 through
January 2014.
Patient Education Information Tool and
Postoperative Questionnaire
All project participants were scheduled for elective
laparoscopic cholecystectomy. During the first pre-
operative visit, patients in the intervention group
received one-on-one education about postopera-
tive pain management that included information
on taking medications correctly, managing and re-
porting medication side effects, using nonpharma-
cologic methods for pain relief, and the importance
of reporting inadequate pain control as soon as
possible. The project director developed a written
education tool in both English and Spanish that
highlighted important pain management points
(Box 1). Each intervention patient received a
copy of the tool and was instructed to make an
ter surgery. The project director was responsible
for providing the educational material, collecting
and storing questionnaires, and ensuring patients
returned for the postoperative visit.
All patients returned 2 weeks postoperatively. At
the first postoperative visit, patients in the interven-
tion group and patients in the comparison group
that did not receive structured preoperative educa-
tion were asked to complete the Revised American
Pain Society Patient Outcome Questionnaire14,15
(Supplementary Appendix). The tool asks patients
to answer 12 questions and measures six postoper-
ative pain quality aspects: pain severity/relief;
impact of pain on activity; sleep and mood; side ef-
fects of treatment; helpfulness of information; abil-
ity to participate in decision making about pain
management; and use of nonpharmacologic
methods. Severity of pain and/or symptoms is
measured using a 0 to 10 rating scale. The question-
naire is available on the Internet and can be used
without permission (americanpainsociety.org). De-
mographic data were collected for age and gender
of each patient.
Results
Ninety-nine patients completed questionnaires at
the first postoperative visit, 38 in the interven-
tion group and 61 in the comparison group

Box 1. Patient Education Information Tool

What you need to know about postoperative pain

Pain control after surgery is very important. When your pain is controlled you sleep better, eat better,
and return to normal activities sooner. You may recover more quickly from your surgery and get back to
work sooner. The following information will help you understand how to manage your pain after
surgery.
1. Take pain medication as directed. The best time to take medication is when the pain first begins. If
pain is worse with activity such as walking or going to the bathroom, take the medication on a reg-
ular schedule.
2. Manage side effects early. Some medications cause constipation or nausea. Take medications with
food to avoid nausea and also take a stool softener daily to prevent constipation.
3. Report side effects such as severe nausea, vomiting, or constipation.
4. Comfort measures such as heat, ice, massage, relaxation, walking, or listening to music may help.
5. Communicate with your provider if your pain is not controlled. You may need different medication
or a stronger dose to relieve your pain.
6. Be sure to make a postoperative visit and discuss any problems with your pain management.
4 KATHERINE F. O’DONNELL
(Figure 1). Results were analyzed by the Mann-
Whitney U test/Wilcoxon rank sum test. A P
value less than .050 was considered to be statisti-
cally significant. Statistically significant results
were found in questions about reporting side ef-
fects (P 5 .020) (Figure 2), and encouragement
by health care providers to use nonpharmaco-
logic methods for pain management (P 5 .001)
(Figure 3). Patients in the intervention group re-
ported the effect of pain on mood (P 5 .067)
(Figure 4) and use of nonpharmacologic methods
(P 5 .052) (Figure 5); however, these results
were not statistically significant.
Reporting Side Effects
Educating patients about potential medication side
effects, as well as managing patient expectations,
is important to avoid complications and adverse
outcomes.4 Patients in the intervention group re-
ported drowsiness after surgery, which can lead
to limited mobility and pose a safety hazard. Both
the patient and family should understand the mul-
tiple causes of pain and possible side effects of
anesthesia and analgesia. Providing this informa-
tion can reduce unnecessary patient suffering
and anxiety as well as avoid prolonged negative
side effects that delay recovery.4 Patients should
Figure 1. Demographics. This image is available in color online at www.jopan.org.
be encouraged to use multimodal analgesia and
nonpharmacologic methods to relieve pain.16 Pa-
tients and families need to be involved in preoper-
ative pain management education about using
multimodal methods, how they work, and what
to expect. It is important for patients and health
care providers to collaborate to achieve optimal
pain management.3
Encouraging Use of Nonpharmacologic
Methods
Intervention patients reported that health care pro-
viders encouraged the use of nonpharmacologic
methods. Methods such as relaxation, guided imag-
ery, and behavioral health interventions can be com-
bined with a multimodal approach and act
synergistically to relieve pain.17 Educating patients
about pain management that includes using these
methods should start at the preoperative visit and
continue throughout the postoperative period.4,10
Effect of Pain on Mood and Emotions
The intervention group reported that postopera-
tive pain had an effect on mood and emotions
such as depression. The relationship between
pain and mood or emotions was not included in
PREOPERATIVE PAIN MANAGEMENT EDUCATION 5

Figure 2. Reporting side effects. This image is available in color online at www.jopan.org.

the patient education tool; however, poorly Use of Nonpharmacologic Methods

controlled pain can lead to anxiety, prolonged hos-
pitalization, and lack of self-efficacy or confidence
in one’s ability to perform normal activities after
surgery.13 Preoperative education can reduce anx-
iety and depressed mood to improve outcomes
including pain control, analgesic use, and length
of hospital stay.18 This information can be included
if the tool is revised.
Intervention patients reported the use of non-
pharmacologic methods to manage pain including
guided imagery, massage, distraction, and relaxa-
tion. Relaxation was used as an effective method
to reduce postoperative pain in patients having
upper abdominal surgery.10 Other methods
including ice packs and listening to music can

Figure 3. Encouraging use of nonpharmacologic methods. This image is available in color online at www.jopan.org.
6 KATHERINE F. O’DONNELL

Figure 4. Effect of pain on mood and emotions. This image is available in color online at www.jopan.org.

be used along with analgesics in reducing postop- nonmedical (nonpharmacologic) methods by

erative pain.
Discussion
The purpose of this project was to provide preoper-
ative education to improve postoperative pain
management outcomes. Patients who received
structured education identified and reported side ef-
fects more often and also were encouraged to use
health care providers. Side effects can occur from
a combination of the surgical procedure, anesthesia,
and pain medications; therefore, it is important that
patients understand these factors. Medication side
effects should be reported if these interfere with a
patient’s recovery. Using methods such as guided
imagery, massage, ice packs, and music can enhance
pain control after surgery. A relationship was found
between intervention patients and reporting the

Figure 5. Use of nonpharmacologic methods. This image is available in color online at www.jopan.org.
PREOPERATIVE PAIN MANAGEMENT EDUCATION
effect of pain on mood, and the use of nonpharma-
cologic methods to relieve pain. Information about
the effect of pain on mood and emotion was not
included in the original patient education tool, but
can be added in the future. Identifying side effects
of pain medications and medication ineffectiveness
early on can prevent complications such as nausea,
vomiting, allergic reaction, and prolonged, poorly
controlled pain. It is possible that those who did
not receive education did not report side effects
as often, leading to negative outcomes. When pa-
tients understand how pain affects their mood,
they understand the importance of taking pain med-
ications correctly and reporting poorly controlled
pain as soon as possible after surgery.
Limitations
The project was limited by a small sample size and
restricted time for educating patients. A total of
123 patients received preoperative education
from the project director, but some were lost to
follow-up because they saw other providers at the
postoperative visit, or they did not complete the
questionnaire as instructed. Some patients in
the comparison group reported receiving preoper-
ative education, but it is unclear who provided
the information or what content was covered.
Most patients received general education on
discharge from surgery, but some lost the informa-
tion, did not understand it or did not follow the
instructions. Finally, patients may see multiple
health care providers before surgery, making it diffi-
cult to insure each patient receives consistent and
appropriate preoperative education.
Future Recommendations
The patient education tool is now incorporated in
the electronic medical record for all patients antici-
pating elective surgery. Future projects could use
telephone surveys about postoperative pain man-
agement to increase the sample size, including pa-
tients having both elective and nonelective
(emergent) surgery. Educating all those involved in
postoperative pain management, including medical
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Conclusions
Managing postoperative pain is essential for recov-
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health care providers. Poorly controlled pain can
delay recovery, leading to prolonged hospital stays,
immobility, and negative outcomes such as deep
vein thrombosis and chronic pain. These sequelae
can impact the ability to return to work and normal
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logic methods for pain relief, and the importance
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and were encouraged to use nonpharmacologic
methods for pain management; these results were
statistically significant. Intervention patients also re-
ported the effect of pain on mood and also using
nonpharmacologic methods to control pain; these
results were not statistically significant. Results sug-
gest that preoperative patient education may in-
crease knowledge in key areas of postoperative
pain management and prevent negative postopera-
tive outcomes.
Acknowledgments
The author would like to acknowledge Jimmy Rose, PE, MS,
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Supplementary Data
Supplementary data related to this article can be
found at https://doi.org/10.1016/j.jopan.2017.11.
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