Part 1
Identify the type of sampling design used in the following examples

1. Thirty nursing faculty randomly sampled from a random selection of ten nursing schools.
2. A sample of 250 members randomly selected from a roster of ANA members.
3. Every 20th patient admitted to the ER in the month of June.
4. The first 20 males and the first 20 female patients admitted to the hospital with hypothermia.

Part 2

Related to the Heikkinen article, consider the following questions and give supporting rationales.

1. What was the target population?
2. What were the inclusion criteria?
3. What were the exclusion criteria?
4. Describe the sample characteristics.
5. Can you generalize the results of this study to the target population? Why or why not?

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Prostatectomy patients’ postoperative pain assessment in the recovery

room

Katja Heikkinen MNSc RN

Lecturer, Turku Polytechnic and Department of Nursing, University of Turku, Turku, Finland

Sanna Salanterä PhD RN

Adjunct Professor, Department of Nursing, University of Turku, Turku, Finland

Marjaana Kettu RN

Head of Department, Ophtalmology Clinic, Turku University Central Hospital, Turku, Finland

Markku Taittonen MD PhD

Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care, Turku University Central Hospital,

Turku,

Finalnd

Accepted for publication 16 February 2005

Correspondence:

Katja Heikkinen,

Department of Nursing,

University of Turku,

FIN – 20014,

Turku,

Finland.

E-mail: katheik@utu.fi

H E I K K I N E N K . , S A L A N T E R A S . , K E T T U M . & T A I T T O N E N M . ( 2 0 0 5 )H E I K K I N E N K . , S A L A N T E R Ä S . , K E T T U M . & T A I T T O N E N M . ( 2 0 0 5 ) Journal

of Advanced Nursing 52(6), 592–600

Prostatectomy patients’ postoperative pain assessment in the recovery room

Aim. This paper reports a study to assess the usability and use of different pain

assessment tools and to compare patients’ and nurses’ pain assessments in the

recovery room after prostatectomy.

Background. Pain assessment is the first step towards providing adequate pain relief

but poses problems because of the subjective nature of the pain experience and the

lack of quantifiable measurements. Pain tools have been tested in several clinical

settings, but not in the

recovery room.

Methods. Data were collected in the recovery room from 45 consecutive patients

who had undergone prostatectomy by asking them to evaluate their pain intensity

using visual analogue scale, numeric rating scale and verbal expressions. One of two

research nurses measured patients’ pain at regular intervals and at the same time as

the patients. Physiological parameters were also evaluated. Data were analysed as

frequencies and percentages. Sum variables were formed and results were analysed

using Spearman’s rank correlation, Pearson’s correlation and with multiple regres-

sion analysis.

Results. Patients varied in their ability to assess the intensity of their pain using

different tools, but assessments were correlated with each other and with nurses’

estimations. Nurses and patients obtained similar assessments, but nurses both

underestimated and overestimated patients’ pain. Patients’ verbal assessments varied

widely. Patients’ and nurses’ pain assessments showed no association with patients’

pulse or mean arterial blood pressure.

Conclusions. According to our results, it is not totally clear whether pain tools are

usable in the recovery room. This issue calls for further research.

Keywords: nursing, pain, pain measurement, prostatectomy, recovery room

592 � 2005 Blackwell Publishing Ltd

Introduction

Assessing pain in the recovery room is challenging, because

patients are still under sedation. Several tools for pain

assessment have been developed, but their suitability in the

recovery room is largely untested. In this study, we aimed to

evaluate the usability and use of pain assessment tools in the

recovery room.

Background

Relevant articles for the study were retrieved from the

following databases: Cochrane, Medline/PubMed, CINAHL.

The main keywords and their combinations were pain,

postoperative, pain measurement, instrument, prostatectomy,

and recovery room.

Postoperative pain

In this study, pain was defined according to the definition of

the International Association for the Study of Pain: ‘Pain is an

unpleasant sensory and emotional experience associated with

actual or potential tissue damage’ (Merskey & Bogduk 1994,

pp. 209–214). Pain is also regarded as a personal and

subjective experience that should be evaluated by patients

themselves whenever possible (McCaffery & Pacero 2001).

Postoperative pain is an expected outcome for patients

after surgical procedures and it impairs organ functions,

delays mobilization and overall recovery as well as increasing

the risk of postoperative complications (Kehlet 1997, Breivik

1998, Carr & Goudas 1999, Coll et al. 2004a). Nonetheless

there is long-standing evidence of inadequate pain relief, in

spite of increasing treatment options (Boström et al. 1997,

Watt-Watson et al. 2000). Mild pain seems to be common

following radical retropubic prostatectomy (Sall et al. 1997,

Dalpra & Zampieron 1998, Haythornthwaite et al. 1998).

It seems that people are prepared to accept postoperative

pain (Wulf et al. 1998, Dawson et al. 2001, Leinonen et al.

2001). Also, after prostatectomy, patients are very satisfied or

satisfied with their postoperative pain care, and such a

curative operation affects feelings and pain tolerance (Klein

et al. 1996, Worwag & Chodak 1998). Affective distress,

particularly anxiety before surgery, and the use of pain

medication afterwards, may be predictors of chronic pain

following prostatectomy (Haythornthwaite et al. 1998).

Pain assessment

Pain assessment is the first step towards adequate pain

relief. It has two major problems: first, the subjective

nature of the pain experience; and second, the lack of

quantifiable measurements (McGuire 1992, Watt-Watson

et al. 2000). Most prostatectomy patients are old, and as

such may need more time to assess their pain (Simons &

Malabar 1995, Melzack & Wall 1996). Older patients may

receive more attention and pain interventions than younger

patients, and evidence suggests that men might be given

more medication than women (Simons & Malabar 1995,

Yorke et al. 2004).

Information and other support may help patients evalu-

ate their experiences of pain, but the main difficulty is that

different people respond to pain in different ways. Hence,

direct comparisons are therefore impossible, even where the

underlying cause of pain is the same. Verbal assessments

may also be misinterpreted (McGuire 1992, Ferguson et al.

1997).

Pain measurement tools

The use of a simple, valid and reliable pain assessment tool in

the clinical practice would standardize assessment and

contribute to more effective management and evaluation of

pain (Taylor 1997). The most common tools are the visual

analogue scale (VAS) and 0–10 numeric rating scale (NRS)

(Jensen et al. 1986, Carpenter & Brockopp 1995, Coll et al.

2004b), as well as the verbal rating scale (VRS) or verbal

descriptor scale (VDS) (Bondestam et al. 1987). The quan-

titative analysis of the results from these scales is problematic,

because it yields a classification where pain is slotted into

given categories that are defined in advance. However, the

boundary lines between the different categories have not been

verified, which complicates the task of interpreting the results

(Chapman et al. 1985, Bondestam et al.

1987).

Although VAS provides only a unidimensional measure of

pain, its construct validity is good and it can adequately

distinguish between minimal, regular and maximal pain

(Price et al. 1983). Carpenter and Brockopp (1995) conclu-

ded that patients have a tendency to use the middle parts or

the ends of the scales. The VAS is easy to complete: it has

limited use if the patient is too ill to point at the line, if he or

she is unable to conceptualize pain in an abstract fashion

along a line, or if the patient is visually, cognitively or

physically impaired (Kremer et al. 1981, Chapman et al.

1985, Paice & Cohen 1997). The VAS may also be designed

as a red wedge that increases in size towards the right. This

has been found to simplify and clarify the use of the tool

(Zalon 1993).

Problems have also been reported in the use of NRS, but it

is still a useful tool for the purposes of assessing the intensity

of acute pain (Bondestam et al. 1987, Scott 1994, Heid &

Issues and innovations in nursing practice Pain assessment in the recovery room

� 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(6), 592–600 593

Jage 2002). The NRS offers more alternatives than VDS, but

less than VAS (Paice & Cohen 1997). The problem with

NRS

is that some people have difficulty describing the intensity of

pain by reference to numbers (Scott 1994, Ferguson et al.

1997, De Rond

et al. 1999).

Several studies on cancer patients have proven VAS, NRS

and VRS as valid tools (De Conno et al. 1994, Paice & Cohen

1997), but it was also found that patients did not rate their

pain in a mathematically equivalent way – VAS ratings were

lower than NRS ratings. On the other hand, many studies in

cancer patients have reported positive correlations between

estimations based on VAS and NRS (Carpenter & Brockopp

1995, Paice & Cohen 1997).

The reliability of VAS and NRS has not been widely tested

in surgical patients, and there are no earlier studies set in a

recovery room context. The NRS has been used in an

Australian intensive care unit to measure pain intensity and

pain distress (Ferguson et al. 1997), as well as in the clinical

area of an emergency department (Puntillo et al. 1999).

Sjöström et al. (2000) investigated the pain assessments of

critical care nurses (n ¼ 30), physicians (n ¼ 30) and post-
surgical patients (n ¼ 180) using VAS. Patients’ expressions
seem to be associated with the fact that nurses have

underestimated their pain.

In the recovery room, where patients are often tired and

unwell, it is important that pain assessment is a quick and

easy process with simple and sensitive measures (Jenkinson

et al. 1995), especially with the elderly (Closs 1996).

Analgesics and anaesthetics may influence patients’ aware-

ness and their ability to assess pain after operation (Bowman

1994). With VAS and NRS pain assessment can easily be

repeated, allowing for accurate estimates of the effectiveness

of pain management (Scott 1994).

Nurses’ assessments

Nurses are especially inclined to underestimate severe pain

(Ketovuori 1987, Zalon 1993, Dalpra & Zampieron 1998,

Puntillo et al. 1999) or to overestimate mild pain (Zalon

1993). Nurses have difficulty estimating patients’ pain

adequately; mistakes can also occur if patients are a

sleep

(Schaufheuthle et al. 2001). Nurses draw their conclusions

on the basis of observations and measurements of physio-

logical features such as blood pressure or pulse (McGuire

1992, Salanterä et al. 1999), which, however, are unreliable

indicators of pain because they are influenced by a large

number of other factors (Closs 1996). Nurses’ overestima-

tions tend to increase if a patient has a rising blood

pressure and pulse (Teske et al. 1983, Bondestam et al.

1987).

The study

Aims

The aim of the study was to explore the congruency of

patients’ and nurses’ pain assessments and the possibility of

measuring pain using a pain tool in the recovery room.

Design

A descriptive comparative cross-sectional study design was

used.

A convenience sample of 45 consecutive prostatectomy

patients was chosen and then pain was evaluated six times

consecutively.

Premedication and anaesthesia were standardized, and the

surgical procedure was performed under general and epidural

anaesthesia, which effectively reduce dynamic pain (Heid &

Jage 2002). These were based on the following criteria:

• Intervertebral epidural anaesthesia Th 12 L1.
• Start dose was bupivacaine 12Æ5 mg epidurally.
• After 1 h from the start of the procedure epidural infusion

was started: fentanyl 0Æ5 mg, bupivacaine 50 mg and

physiological saline 20 mL.

• The same pain medication continuing at 3–5 mL/h during
and after procedure.

• Combined anaesthesia was induced using: fentanyl 2 mg/
kg, propofol 2 mg/kg, rocuronium 1 mg/kg, nitrous oxide

and desflurane.

• Minimum alveolar concentration (MAC) was kept over
one and patients received no further relaxants (during the

procedure). As the epidural analgesia was effective patients

were given only 0Æ6 mg fentanyl, on average, during the

operation.

Participants

A convenience sample of 45 consecutive prostatectomy

patients during the year 2001 was enrolled. Power analysis

was not carried out because there are no previous studies

conducted in the recovery room. The mean age of patients was

62 years, range 47–73 years. The criteria of the American

Society of Anaesthesiologists (ASA) were used in classifying

patients into groups according to their physical condition. In

this classification, a healthy patient is ASA I, one with mild

systemic disease is ASA II and one with severe systemic disease

is ASA III. ASA IV refers to a patient with life-threatening

severe systemic disease and ASA V to a moribund patient. The

majority of patients in this study were in ASA class 2 (f ¼ 40);
a few were in class 3 (f ¼ 4) or 4 (f ¼ 1). The operation lasted
from 2 to 4 h.

K. Heikkinen et al.

594 � 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(6), 592–600

Data collection

Postoperative pain was studied with three pain intensity

scales being used by patients: a red-wedge version of VAS;

NRS scale (0–10); and the patients’ verbal expressions, VRS.

On the VAS scale, the two anchor points represented ‘no

pain’ and ‘worst imaginable pain’. Patients’ verbal descrip-

tions were classified into four categories: no pain, moderate

pain, intense pain and intolerable pain. Nurses rated patients’

pain using the NRS scale. Patients were informed about

the pain assessment tool and on how to use it by two research

nurses prior to the operation. The two nurses also estimated

the intensity of pain and collected the data. The pain

assessments were made every 15 minutes so that the nurse

assessed the pain before the patient’s own assessment. Every

other patient assessed their pain using VAS first, every other

using NRS first, whereas the verbal description was the last

assessment method. Pulse and blood pressure measurements

were collected from patient documents. The first measure-

ment was carried out when the patient was transferred into

the recovery room and subsequently every 15 min. The first

measurements were excluded from the analysis, because most

of the patients were asleep; thus only the measurements from

the second to the sixth were included.

Validity and reliability

The validity and reliability of both VAS and NRS have been

widely tested in different clinical areas (Paice & Cohen

1997). In this study, VAS and NRS tools and patients’ verbal

assessments varied. Patients’ verbal assessment(s) varied most

when compared with VAS; however, there was a positive

correlation between nurses’ and patients’ pain assessments.

Patient’s assessment did not influence nurse’s assessment,

because nurses always assessed the patients’ pain first.

Patients were shown how to use pain tools and they

understood the purpose of them. Patients were given the

same analgesia, because the use of different analgesia in

different patients would have affected the pain assessments.

Inter-relater reliability was used in the first five patients

(>10% of sample). Differences between the ratings were no

more than ±1 points on the NRS scale, which was

considered acceptable.

Ethical considerations

Ethical approval to conduct the study was obtained from the

nursing research committee of the organization concerned.

The study complied with the Helsinki declaration of the

World Medical Association Declaration of Helsinki (1964),

with the ethical rules of the International Council of Nurses

(ICN) (2002) and with Finnish national legislation on

patients’ rights (The Law on Patient’s Right 1992).

All participating patients received written information

about the purpose of the study and gave written consent.

They were told that participation was voluntary, that all the

information collected would be handled confidentially and

that they had the right to discontinue the research at any

stage. They were also told that refusal or a decision to

discontinue would have no influence on their care. The

identity of the patients was not disclosed at any stage of data

analysis or reporting.

Data analysis

The analyses were carried out with the Statistical Software

Package R (2003). Patients’ verbal descriptions were classi-

fied into four mutually exclusive categories of pain: 1, none;

2, moderate; 3, intense; and 4, intolerable.

The data were represented with frequencies and percent-

ages. Sum variables were formed by taking the average of the

last five measurements. The results were analysed with

Spearman’s rank correlation (rS), Pearson’s correlation (rP)

and multiple regression analysis. For the most part, the data

were normally distributed, but, because of the small amount

of data, non-parametric methods were also used in the

statistical analysis. The level of statistical significance was set

at P < 0Æ05.

Results

Patients’ and nurses’ pain assessments during the recovery

room

period

All of the patients recruited to the study participated

(n ¼ 45). Pain was assessed six times, starting 15 min after
the patient had been transferred to the recovery room. The

nurses’ and patients’ numerical pain assessments ranged from

0 to 9. Patients had higher NRS assessments than nurses

(Table 1).

Table 1 Nurses’ and patients’ numerical pain

estimations

Measurement Minimum Maximum Mean Median Variance SD

Patient with

VAS

0 9 1Æ96 2Æ2 3Æ63 1Æ91

Patient with
NRS

0 8 2Æ42 2Æ2 4Æ87 2Æ21

Nurse with

NRS

0 8 2Æ23 1Æ9 3Æ82 1Æ96

VAS, visual analogue scale; NRS, numeric rating scale.

Issues and innovations in nursing practice Pain assessment in the recovery room

� 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(6), 592–600 595

The nurses’ and patients’ assessments were divided into five

classification groups:

• 0, no pain;
• 1–3, mild pain;
• 4–6, moderate pain;
• 7–9, intense pain;
• 10, intolerable pain.

There were differences between nurses’ and patients’

assessments. Nurses both underestimated (19%) and overes-

timated (18%) patients’ pain. Overestimation was more

common in the first measurements. Most of the assessments

were at the same level (63%) (Table 2).

Nurses and patients agreed most frequently in their

assessments when they rated pain at 0 (using VAS and

NRS). Nurses’ assessments ranged from þ6 to �5 when
compared with the patients’ assessments. The biggest differ-

ences occurred when patients assessed their pain using the

NRS. Nurses would most typically overestimate the pain

experienced by patients in situations where patients said they

had ‘no pain’ (0) and underestimated pain when patients said

their pain was ‘mild’ (1–3) or ‘intense’ (7–9).

Nurses’ pain assessments were significantly related to those

of patients when patients used VAS (rS ¼ 0Æ821, P < 0Æ0001) or NRS (rS ¼ 0Æ880, P < 0Æ0001). The correlation between nurses’ and patients’ assessments with VAS ranged from

0Æ661 to 0Æ869; with NRS it ranged from 0Æ715 to 0Æ883. A

correlation was also seen between patients’ assessments based

on VAS and NRS (rP ¼ 0Æ95, P < 0Æ0001). Patients’ verbal descriptions were written down and

grouped into four classes: 1, no pain; 2, mild pain; 3, intense

pain; 4, intolerable pain. Only four categories were used

because patients did not use the term ‘moderate pain’ in their

verbal accounts. There was marked variation between the

numerical and the verbal responses; for example, the numer-

ical ratings from 4 to 6 could mean no pain, mild, intense or

intolerable pain. The verbal assessments of ‘no pain’ and

‘mild pain’ varied in numbers from 0 to 7 and ‘intense pain’

from 3 to 9. However, only one patient used the term

‘intolerable pain’; with VAS the value was 3, with NRS 8.

The most common assessment was no pain (46%), but only

one patient used the term ‘intolerable pain’; none described

their pain as intolerable in numbers. Most of the patients in

pain had mild (29%) or moderate pain (16%) (Table 3).

Patients’ verbal pain assessments showed a significant

correlation (rS) with the assessments based on VAS or NRS.

The correlation between the patients’ verbal assessments and

VAS assessments ranged from 0Æ448 to 0Æ627 (P ¼ 0Æ049 to
P ¼ 0Æ001), between verbal assessments and NRS assess-
ments from 0Æ504 to 0Æ708 (P ¼ 0Æ0168 to P ¼ 0Æ0001).

Nurses recorded patients’ blood pressure and pulse at each

assessment and the correlation between patients’ pain, pulse

and mean arterial blood pressure (MAP) was tested. There

was only a slight correlation between patients’ pulse and

MAP at the fifth and sixth measurement (rP ¼ 0Æ213–0Æ402,
P ¼ 0Æ008–0Æ161). Patients’ pain assessments with VAS were
not related to pulse (P ¼ 0Æ731) neither on NRS (P ¼ 0Æ655)
nor nurses’ assessments (P ¼ 0Æ913), but were related to the
pulse only at the first measurement (rS ¼ 0Æ503, P ¼ 0Æ018).

Patients’ pain assessments with VAS and NRS and nurses’

assessments were related to MAP only at the second

measurement (P ¼ 0Æ010–0Æ034). Patients’ verbal pain assess-
ments were not related to MAP (P ¼ 0Æ054). Their pain
assessments did not increase with rising MAP or pulse, but

there were also low pain assessments when MAP or pulse was

high, and vice versa.

The ability of patients to assess their pain depends upon

their level of consciousness and sedation. The level of

sedation was always measured in connection with pain

measurement. Sedation levels were divided into six categor-

ies: 0, awake; 1, tired, drowsy; 2, sleepy, dozes but wakes

easily; 3, under strong sedation, sleeps soundly but can be

woken; 4, in sound sleep, cannot be woken; 5, in normal

sleep.

At first measurement, patients’ sedation levels varied from

‘awake’ to ‘in sound sleep’. At second measurement, most

patients were sleepy (56%) or under strong sedation (24%).

Table 2 Nurses’ and patients’ pain assessments using the numeric

rating scale at five measurement points (%)

Measurement

point

Equivalent

estimations

Nurses’

overestimations

Nurses’

underestimations Total

2nd 61 21 18 100

3rd 58 23 19 100

4th 58 22 20 100

5th 70 11 19 100

6th 67 13 20 100

In total 63 18 19 100

Minimum 1 Minimum 1

Maximum 5 Maximum 6

Table 3 Patients’ and nurses’ pain assessments divided into five

groups (%)

Person/tool No pain Mild Moderate Intense Intolerable

Patient/VAS 44 30 20 6 0

Patient/NRS 43 26 21 10 0

Patient/verbally 71 19 0 9 1

Nurse/NRS 37 37 18 8 0

Total (%) 46 29 16 8 0

VAS, visual analogue scale; NRS, numeric rating scale.
K. Heikkinen et al.

596 � 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(6), 592–600

At fifth and sixth measurements, none of the patients was

under strong sedation (Table 4).

Patients’ pain assessments with VAS and NRS and nurses’

numerical assessments were examined with separate multiple

regression analysis models. Explanatory variables were the

other two pain assessments, MAP, pulse and average

sedation

level (during the past five measurements). The VAS and NRS

scales were significantly associated with each other

(P < 0Æ0001). Also the NRS scale and nurses’ numerical

assessments were associated (P ¼ 0Æ0289). MAP, pulse and
average sedation level were insignificant. The adjusted indices

of determination (R2) for the three models were 0Æ9051

(VAS), 0Æ9160 (NRS) and 0Æ7203 (nurses’ numerical assess-

ments).

Applicability of VAS and NRS during the recovery room

period

Only one patient expressed his pain spontaneously, whereas

all of the others waited for the nurse to ask how much pain

they were in. They differed in their ability to use VAS and

NRS for assessing their pain. In the second measurement,

11% of patients were unable to assess their pain with VAS,

whereas one was unable to use the NRS. The failure rate at

the other measurements ranged from 5% to 7%. The degree

of problems patients had assessing their pain depended on

sedation levels.

In respect of their views on the pain tools the patients were

divided into two categories: 22 (49%) preferred VAS,

whereas 19 persons (42%) preferred NRS. Four patients

(9%) did not say which tool was better. Half of patients

(51%) did not justify their choice in any way. The most

common reasons for their preferences were that NRS is easier

to use (11%); that numbers are easier (11%); and on the

other hand that VAS is simpler. The other reasons mentioned

were that NRS reminds people of school grades; that

numbers are hard to understand, and that VAS is better

because numbers are hard to remember. Two patients said

they liked both of the tools.

Discussion

There are several limitations that could influence this study.

Data were collected by just two researchers, which may have

caused some observer bias: results might vary more if there

were more observers. Patients formed one specific group; all

with the same diagnosis, operation and analgesia. This adds

reliability. The sample size was fairly small and power

calculation was not made. The findings, however, show a

clear trend. Also the convenience sample was used rather

than a random sample, thereby limiting the value of this

study. Further studies using a larger sample size and a

broader clinical field are also recommended.

This study reveals differences in nurses’ numerical pain

assessments and patients’ assessments based on VAS and

NRS. Most assessments were equivalent (63%) and correla-

ted with each other. Earlier studies in other pain assessment

situations have reported similar results (Paice & Cohen 1997,

Dalpra & Zampieron 1998). Both patients and nurses

frequently used the numerical value 0, but never the value

10. Carpenter and Brockopp (1995) found that patients

preferred to use the middle area or ends of the scales. In this

study, nurses overestimated patients’ pain in those situations

where patients rated their pain as zero, and underestimated

pain when patients regarded their pain as mild or intense.

Zalon (1993) has reported earlier similar results. It is possible

that patients do not express their pain clearly or that they do

not want to complain but to cope with it. There were

significant differences between nurses’ and patients’ assess-

ments: nurses’ assessments could be þ6 or �5 compared with
those of patients. This is a substantial enough difference to

have an impact on quality of patient care.

Difficulties in using VAS and NRS may have to do with the

researchers themselves (Chapman et al. 1985). In this study,

the results of the pain assessment tools were used as interval

scale variables; even though it was not possible to prove that

the distance between all the numbers was the same. It is

possible that not all patients were able to estimate their pain

in such terms, or that it was hard for them to understand

changes in their pain intensity in terms of a distance between

numbers (Scott 1994, Ferguson et al. 1997, De Rond et al.

1999). The NRS scale from 0 to 10 may be ambiguous, and

the numbers may be confused with school grades so that 10 is

thought to mean ‘no pain’ or ‘excellent’ (De Rond et al.

1999). Patients’ assessments based on NRS were higher (mean

2Æ42) than those based on VAS (mean 1Æ96); Carpenter and

Brockopp (1995) have reported similar results. Nonetheless,

assessments by patients and nurses did correlate with each

other, as has been reported in other studies (Carpenter &

Brockopp 1995, Paice & Cohen 1997). Nurses’ estimations

Table 4 Sedation levels (%)

Measurement Awake Tired Sleepy

Strong

sedation

In sound

sleep

Normal

sleep

First – 16 42 38 4 –

Second – 20 56 24 – –

Third – 42 49 9 – –

Fourth 2 51 40 7 – –

Fifth 9 55 36 – – –

Sixth 9 55 36 – – –

In total 4 45 43 8

Issues and innovations in nursing practice Pain assessment in the recovery room

� 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 52(6), 592–600 597

were lower (mean 2Æ23) than those of patients’ with NRS, and

this underestimation has also been shown in many other

studies (Ketovuori 1987, Dalpra & Zampieron 1998, Puntillo

et al. 1999).

It was found that patients’ numerical and verbal assess-

ments varied widely and showed no consistency. Problems

might occur if we rely simply on VAS or NRS and try to

comply with the rule that numerically expressed pain over

three has to be medicated.

Verbal assessments allow for much narrower a scale than

numerical ones, and changes in pain intensity do not show up

as readily as on a numerical scale. Furthermore, verbal pain

tools do not necessarily yield sufficiently sensitive and

accurate measurements of the development of patient’s pain

(Paice & Cohen 1997). The NRS scale, 0–10, may be too

wide; 0–5 might yield more useful results. Some patients

think that the expression ‘worst pain ever’ in the VAS scale is

ambiguous, because, it is hard to imagine what such pain

could be like, or whether it could be even more intense. On

the other hand, patients did not use such expressions as

‘intolerable pain’ or ‘moderate pain’ in their verbal accounts;

instead, their vocabulary was simpler. Interestingly, VAS and

NRS tools only indicate the intensity of pain, not its location

or quality, but the same was true of patients’ verbal

assessments (Bourbonnais 1981, De Conno et al. 1994).

Bondestam et al. (1987) and Teske et al. (1983) observed

that nurses might overestimate patients’ pain, and that this

tendency usually increases with increasing blood pressure and

pulse. In this study, neither pulse nor MAP was related to

patients’ or nurses’ pain assessments.

Patients, in this study, did not express their pain sponta-

neously. Their sedation level varied, which may be one reason

why not all of them were able to use VAS or NRS to assess

their pain. Especially in the first set of measurements, some of

the patients were unable to assess their pain with VAS and

NRS, or with either. In this study, the method of anaesthesia

was standardized (Ferguson et al. 1997) so that all patients

were in an equal position to assess their pain. The study by

Bowman (1994) also pointed at surgical patients’ difficulties

in assessing their pain, possibly because of their medication.

Half of the patients preferred to use VAS, half NRS. In this

study, we used a red pain scale because it has been found to

be easier to use (Zalon 1993). In the recovery room setting, it

is indeed better to use a bigger scale than normally. In this

study, the pain scale was identical to the pain scale used on

the ward, so it is possible that patients did not see it clearly

because the tool was small in size. In this study, patients said

they preferred the NRS because of its numbers, but Scott

(1994) reported that the use of NRS might be problematic

because some patients are unable to classify pain numerically.

Conclusions

The most important issue here is not necessarily the pain

assessment tool itself, but the fact that pain is assessed

systematically and that both nurse and patient understand the

meaning of the assessment. In the recovery room pain should

be estimated systematically, but which tool would be best for

this purpose calls for further research.

Author contributions

KH, SS, MK and MT were responsible for the study

conception and design. KH and MK performed the data

collection. KH and SS undertook the data analysis, made

critical revisions to the paper and provided statistical

expertise. KH was responsible for drafting the manuscript;

SS provided supervision.

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