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Improvements in nursing knowledge and ability to manage epidural analgesia followed the
reintroduction of an epidural education program using an audit/ guideline/ problem‐based
teaching approach, accompanied by practical assessments (Richardson, 2001 Level III‐3). Pain
documentation in surgical wards (Ravaud et al, 2004 Level III‐1; Karlsten et al, 2005 Level III‐2) and
intensive care units (Arbour, 2003 Level IV; Erdek & Pronovost, 2004 Level III‐3) was also improved
by education programs. Implementation of a quality improvement program led to
improvements in nurses' knowledge and assessment of pain using pain rating scales; however
while the number of patients assessed increased, there was no improvement in pain relief
(Hansson et al, 2006 Level III‐2).
Improvements in postoperative pain relief, assessment of pain, and prescribing practices, can
result from staff education as well as the introduction of medical and nursing guidelines (Gould
et al, 1992 Level III‐2; Harmer & Davies, 1998 Level III‐3). In emergency departments, education of
junior medical staff improved patient pain relief (Jones, 1999 Level III‐3) and implementation of
an education program and guidelines for pain management improved analgesia and patient
satisfaction (Decosterd et al, 2007 Level III‐2). Personalised feedback forms given to anaesthetists
have been shown to increase the use of PCA, non‐steroidal anti‐inflammatory drugs (NSAIDs),
epidural morphine and nerve blocks (Rose et al, 1997 Level III‐3).
A number of studies have shown the benefits of education and/or guidelines on improved
prescribing patterns both in general terms (Humphries et al, 1997 Level III‐3; Ury et al, 2002 CHAPTER 3
Level III‐3) and specifically for NSAIDs (May et al, 1999 Level III‐3; Figueiras et al, 2001 Level I; Ray et
al, 2001 Level II), paracetamol (acetaminophen) (Ripouteau et al, 2000 Level III‐3) and pethidine
(meperidine) (Gordon et al, 2000 Level III‐3). Use of an electronic decision‐support system
significantly improved adherence to guidelines for the prescription of postoperative nausea
and vomiting (PONV) prophylaxis for patients at high risk of PONV (Kooij et al, 2008 Level III‐3).
However, education programs may not always be successful in improving nursing staff
knowledge or attitudes (Dahlman et al, 1999 Level III‐3) or pain relief (Knoblauch & Wilson, 1999
Level IV). In rural and remote settings, distance and professional isolation could impact on the
ability of health care staff to receive up‐to‐date education about pain relief. However,
similarities between urban and rural nurses’ knowledge and knowledge deficits relating to
acute pain management have been reported (Kubecka et al, 1996) and a tailored education
program in a rural hospital improved the management of acute pain (Jones, 1999 Level III‐3). An
education program delivered to nurses in rural and remote locations and focusing on acute
pain, chronic pain and cancer pain, improved understanding of pain management (Linkewich et
al, 2007 Level III‐2).
While the focus of most research has been on the impact of education on efficacy of pain
treatments, there remains much work to be done on establishing the role of education in
patient monitoring and safety.

3.2 ORGANISATIONAL REQUIREMENTS

It is recognised that patients should be able to access best practice care, including appropriate
assessment of their pain and effective pain management strategies (ANZCA & FPM, 2008).
However, effective acute pain management will, to a large extent, depend not on the drugs
and techniques available but on the systems involved in their delivery (Macintyre & Schug, 2007).
Even simple methods of pain relief can be more effective if proper attention is given to
education (see Section 3.1), analgesic drug orders, documentation, monitoring of patients and
the provision of appropriate policies, protocols and guidelines (Gould et al, 1992 Level III‐3). In

Acute pain management: scientific evidence 47