For this assignment activity,  I want you to answer the questions below. Refer to module and text book readings.  Give rationales for all of your answers.

  1. Identify and define the most commonly used data collection methods for qualitative research?
  2. What are the most commonly used data collection methods used for each of the following qualitative research traditions:
    1. Ethnography
    2. Phenomenology
    3. Grounded Theory

Relative to the Heikkinen et al. article, answer the following questions and include supporting rationales.

  1. What data collection methods were used (be sure to include nurse measures, patient measures, and physiologic measures)?
  2. What are the strengths and weaknesses of each data collection method?



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 Salantera¨ 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,


Accepted for publication 16 February 2005



Katja Heikkinen,

Department of Nursing,

University of Turku,

FIN – 20014,



E-mail: [email protected]

HEIKKINEN   K., SALANTERA¨ S., KETTU M. & TAITTONEN M. (2005) 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 regression 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

2005 Blackwell Publishing Ltd



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.


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 (Bostro¨m 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 evaluate 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 quantitative 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) concluded 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 & 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). Sjo¨stro¨m et al. (2000) investigated the pain assessments of critical care nurses (n ¼ 30), physicians (n ¼ 30) and postsurgical 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’ awareness 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 asleep (Schaufheuthle et al. 2001). Nurses draw their conclusions on the basis of observations and measurements of physiological features such as blood pressure or pulse (McGuire 1992, Salantera¨ et al. 1999), which, however, are unreliable indicators of pain because they are influenced by a large number of other factors (Closs 1996). Nurses’ overestimations tend to increase if a patient has a rising blood pressure and pulse (Teske et al. 1983, Bondestam et al. 1987).

The study


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.


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.


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.

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 descriptions 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 measurement 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 classified into four mutually exclusive categories of pain: 1, none; 2, moderate; 3, intense; and 4, intolerable.

The data were represented with frequencies and percentages. 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.


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









Patient with









Nurse with








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

Table 2 Nurses’ and patients’ pain assessments using the numeric rating scale at five measurement points (%)

Measurement Equivalent Nurses’ Nurses’ point estimations overestimations underestimations Total
































In total






Minimum 1

Minimum 1


Maximum 5

Maximum 6

Table 3 Patients’ and nurses’ pain assessments divided into five groups (%)



No pain


































Total (%)






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


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 overestimated (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 differences 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 numerical 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 assessments 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 assessments 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 categories: 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 4 Sedation levels (%)


Measurement Awake Tired Sleepy

Strong sedation

In sound





































In total





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 assessments).

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.


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 correlated 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’ assessments: 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

What is already known about this topic

• The use of a simple, valid and reliable pain assessment tool in clinical practice would standardize the assessment of pain and contribute to more effective management and evaluation of pain.

• The reliability of visual analogue scales and numeric rating scales has not been widely tested in surgical patients, and there is no evidence on their usability in the recovery room.

What this paper adds

• Patients’ and nurses’ assessments of pain differed, but were generally similar.

• Patients’ verbal assessments can vary widely