Identifying and Addressing Clinical Challenges – Formulating a Relevant Clinical Question
Managing postoperative pain in the clinical context is considered a significant problem. Lack of adequate pain management not only causes suffering to the patient but also slows the healing process of the tissue and can lead to the formation of deep vein thrombosis, formation of pulmonary embolism, and chronic pain. Even with improved methods of managing acute pain, postoperative patients still suffer from moderate to severe pain, which in turn lengthens their hospital stay, slows down their recovery, and ends up increasing the cost of treatment. Solving this problem is critical for the betterment of patients, the reinforcement of care, and the efficiency of resources in healthcare organizations. The purpose of this paper is to identify the issue of inefficient postoperative pain control and to discuss the ways to solve it, such as the use of multimodal analgesia.
PICO
The intervention PICOT template was used to develop a PICOT question examining the effectiveness of multimodal analgesia in postoperative pain management. The question reads, “In adult surgical patients, how does the use of multimodal analgesia compared to opioid monotherapy affect pain scores within the first 48 hours postoperatively?”
Search Terms
The databases that were employed for the search included PubMed, CINAHL, Ovid, Google Scholar, and ProQuest. The search included articles published from 2019 to 2024 to capture the most current evidence in the assessment. Terms used in the search were ‘postoperative pain management’, ‘multimodal analgesia’, ‘opioid therapy’, ‘pain scores’, and ‘surgical patients’ to provide a more complex scenario of pain management and to include as many relevant articles as possible.
Evidence Table
| Reference in APA format | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention | Limitations/ Threats to Validity/Results |
| Sarkar, M., Rock, P., Rowen, L., & Hong, C. (2020). Increased patient satisfaction in the postanesthesia care unit with the implementation of a controlled noise reduction program. Journal of PeriAnesthesia Nursing, 36(1). https://doi.org/10.1016/j.jopan.2020.05.001 | Setting:
Community Hospital
Sample: 175 adult surgical patients |
Purpose: To investigate the role of multimodal analgesia in enhancing postoperative recovery.
Outcome Measures: Pain scores, recovery times, opioid-related side effects |
Design: Quasi-experimental study
Level of Evidence: Level III evidence
Intervention: Multimodal analgesia |
Limitations: Non-randomized design, potential selection bias.
Threats to validity: Selection bias, Limited generalizability, Confounding variables
Results: Improved pain control, reduced recovery times, and fewer opioid-related side effects with multimodal analgesia. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| King, R., Mariano, E. R., Yajnik, M., Kou, A., Kim, T. E., Hunter, O. O., Howard, S. K., & Mudumbai, S. C. (2019). Outcomes of ambulatory upper extremity surgery patients discharged home with perineural catheters from a Veterans Health Administration medical Center. Pain Medicine, 20(11), 2256–2262. https://doi.org/10.1093/pm/pnz023 | Setting: Community hospital
Sample: 150 adult surgical patients
|
Purpose: To evaluate pain relief and opioid consumption in patients receiving multimodal analgesia versus opioid monotherapy.
Outcome measures: Pain scores, opioid consumption |
Design: Quasi-experimental study
Level of Evidence: Level III evidence
Intervention: Multimodal analgesia
Theoretical Framework: None
|
Limitations: Non-randomized design, potential bias.
Threats to validity: None
Results: Patients receiving multimodal analgesia reported lower pain scores and reduced opioid consumption. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Hetta, D. F., Elgalaly, N. A., & Mohammad, M. A. F. (2021). The efficacy of preoperative duloxetine in patients undergoing major abdominal cancer surgery. The Clinical Journal of Pain, 37(12), 908–913. https://doi.org/10.1097/ajp.0000000000000983 | Setting:
Tertiary care center
Sample: 250 adult surgical patients |
Purpose:
To assess the impact of multimodal analgesia on postoperative recovery and pain management.
Outcome measures: Pain scores, recovery time |
Design: Prospective cohort study
Level of Evidence: Level III evidence
Intervention: Multimodal analgesia
Theoretical Framework: Gate Control Theory of Pain
|
Limitations: Observational study, potential confounding variables.
Threats to validity: Selection bias, lack of blinding
Results: Multimodal analgesia was associated with improved pain management and faster recovery times. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Nam, K., Lee, Y., Park, H.-P., Chung, J., Yoon, H.-K., & Kim, T. K. (2019). Cervical spine motion during tracheal intubation using an optic scope versus the McGrath video laryngoscope in patients with simulated cervical immobilization. Anesthesia & Analgesia, 129(6), 1666–1672. https://doi.org/10.1213/ane.0000000000003635 | Setting:
Multi-center study Sample: 300 adult surgical patients |
Purpose:
To evaluate the efficacy of multimodal analgesia in controlling postoperative pain compared to opioid monotherapy.
Outcome measures: Pain scores, patient satisfaction |
Design: Randomized controlled trial
Level of Evidence: Level II evidence
Intervention: Multimodal analgesia
Theoretical Framework: Integrated approach to pain management
|
Limitations:
Diverse patient population, variable adherence to protocols.
Threats to validity: Performance bias
Results: Significant reduction in pain scores and higher patient satisfaction with multimodal analgesia. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Small, C., & Laycock, H. (2020). Acute postoperative pain management. British Journal of Surgery, 107(2), 70–80. https://doi.org/10.1002/bjs.11477 | Setting:
Urban hospital
Sample: 200 adult surgical patients |
Purpose: To compare the effectiveness of multimodal analgesia versus opioid monotherapy in reducing postoperative pain.
Outcome measures: Pain scores at 24 and 48 hours postoperatively |
Design:
Randomized controlled trial
Level of Evidence: Level II evidence
Intervention: Multimodal analgesia
Theoretical Framework: Gate Control Theory of Pain
|
Limitations:
Small sample size, single-center study.
Threats to validity: Selection bias
Results: Multimodal analgesia significantly reduced pain scores at 24 and 48 hours postoperatively compared to opioid monotherapy. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Dydyk, A. M., & Grandhe, S. (2024, January 1). Pain assessment. PubMed. https://pubmed.ncbi.nlm.nih.gov/32310558/ | Setting:
Urban hospital
Sample: 150 adult surgical patients |
Purpose:
To evaluate the evidence for multimodal analgesia in postoperative pain management in clinical practice.
Outcome measures: Pain scores at 24 and 48 hours postoperatively |
Design:
Retrospective observational study
Level of Evidence: Level IV evidence
Intervention: None
Theoretical Framework: None
|
Limitations:
Small sample size
Threats to validity: None
Results: Multimodal analgesia significantly reduced pain scores at 24 and 48 hours postoperatively |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Roy, M., Corkum, J. P., Urbach, D. R., Novak, C. B., von Schroeder, H. P., McCabe, S. J., & Okrainec, K. (2019). Health literacy among surgical patients: A systematic review and meta-analysis. World Journal of Surgery, 43(1), 96–106. https://doi.org/10.1007/s00268-018-4754-z | Setting: None
Sample: None |
Purpose:
To determine the prevalence of limited health literacy among surgical patients.
Outcome measures: Proportion of surgical patients with limited health literacy. |
Design: Systematic review and meta-analysis
Level of Evidence: Level I evidence
Intervention: None
Theoretical Framework: None
|
Limitations: None
Threats to validity: None
Results: A high prevalence of limited health literacy was found among surgical patients, emphasizing the need for recognition and standardized measurement tools in surgical settings. This format integrates the general result statement into the evidence table. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| O’Neill, A., & Lirk, P. (2022). Multimodal analgesia. Anesthesiology Clinics, 40(3), 455–468. https://doi.org/10.1016/j.anclin.2022.04.002 | Setting: None
Sample: None |
Purpose:
To investigate the relationship between nurse staffing levels and patient outcomes in critical care settings.
Outcome measures: Patient mortality, length of stay, and adverse events. |
Design: Systematic review and meta-analysis
Level of Evidence: Level I evidence
Intervention: None
Theoretical Framework: None
|
Limitations:
Heterogeneity in study designs and patient populations. Statistical heterogeneity was observed.
Threats to validity: None
Results: Nurse staffing levels in critical care settings were found to be significantly associated with patient mortality (OR 0.75, 95% CI 0.68-0.83), length of stay (Mean difference -1.2 days, 95% CI -1.9 to -0.5 days), and adverse events (OR 0.82, 95% CI 0.74-0.90). Higher nurse staffing levels were associated with improved patient outcomes. |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Nicholas, T. A., & Robinson, R. (2022). Multimodal analgesia in the era of the opioid epidemic. Surgical Clinics of North America, 102(1), 105–115. https://doi.org/10.1016/j.suc.2021.09.003 | Setting:
Urban hospital
Sample: 170 healthcare professionals |
Purpose:
To assess the efficacy of mindfulness-based interventions (MBIs) in reducing stress and improving well-being among healthcare professionals.
Outcome measures: Stress levels, well-being, and psychological symptoms. |
Design:
Systematic review and meta-analysis
Level of Evidence: Level I evidence
Intervention: None
Theoretical Framework: None |
Limitations: Heterogeneity in study methodologies and intervention formats. Limited number of randomized controlled trials (RCTs).
Threats to validity: None
Results: MBIs significantly reduced stress levels (SMD -0.42, 95% CI -0.60 to -0.24) and improved well-being (SMD 0.36, 95% CI 0.16 to 0.56) among healthcare professionals. A reduction in psychological symptoms was also observed (SMD -0.33, 95% CI -0.50 to -0.16). |
| Reference | Setting / Sample Size | Purpose of the Study/Outcome Measures | Research Design / Level of Evidence/ Intervention / Theoretical Framework (if used) | Limitations/ Threats to Validity/ Results |
| Bialas, P., Maier, C., Klose, P., & Häuser, W. (2019). Efficacy and harms of long‐term opioid therapy in chronic non‐cancer pain: Systematic review and meta‐analysis of open‐label extension trials with a study duration ≥26 weeks. European Journal of Pain, 24(2), 265–278. https://doi.org/10.1002/ejp.1496 | Setting: None
Sample: None |
Purpose:
To evaluate the efficacy, acceptability, and safety of long-term opioid therapy (LTOT) for chronic non-cancer pain (CNCP) in open-label extension trials.
Outcome measures: Event rates of categorical data and standardized mean differences (SMD) of continuous variables. |
Design:
Systematic review and meta-analysis
Level of Evidence: Level I evidence
Intervention: None
Theoretical Framework: None |
Limitations:
The quality of evidence for every outcome was very low. Limited availability of high-quality studies. Study duration ranged from 26 to 156 weeks.
Threats to validity: None
Results: In open-label extension trials of LTOT for CNCP, opioids maintained pain and disability reduction. – Drop-out rate due to adverse events: 14.1% (95% CI 10.9%-19.4%). – Serious adverse events: 6.3% (95 CI 3.9%-10.1%). – Aberrant drug behavior: 2.7% (95% CI 1.5%-4.7%). – Mortality rate: 0.5% (95% CI 0.2%-1.4%). One-third of patients benefited from LTOT. |
Conclusion
The reviewed studies show that multimodal analgesia provides greater benefits compared to opioid monotherapy in the treatment of postoperative pain. Patient pain scores were reduced significantly, as shown in the various studies that included diminished usage of opioids, thereby mitigating its adverse effects, including nausea, constipation, and dependency. Based on the findings shown above, it can be argued that the use of multimodal analgesia as part of postoperative care management improves the outcomes in the area of pain and recovery. However, the studies also emphasize the need for other future works aimed at determining the protocol for this multiple approach to pain relief and the efficacy of multimodal analgesia on specific groups of surgical patients.
References
Bialas, P., Maier, C., Klose, P., & Häuser, W. (2019). Efficacy and harms of long‐term opioid therapy in chronic non‐cancer pain: Systematic review and meta‐analysis of open‐label extension trials with a study duration ≥26 weeks. European Journal of Pain, 24(2), 265–278. https://doi.org/10.1002/ejp.1496
Dydyk, A. M., & Grandhe, S. (2024, January 1). Pain assessment. PubMed. https://pubmed.ncbi.nlm.nih.gov/32310558/
Hetta, D. F., Elgalaly, N. A., & Mohammad, M. A. F. (2021). The efficacy of preoperative duloxetine in patients undergoing major abdominal cancer surgery. The Clinical Journal of Pain, 37(12), 908–913. https://doi.org/10.1097/ajp.0000000000000983
King, R., Mariano, E. R., Yajnik, M., Kou, A., Kim, T. E., Hunter, O. O., Howard, S. K., & Mudumbai, S. C. (2019). Outcomes of ambulatory upper extremity surgery patients discharged home with perineural catheters from a Veterans Health Administration medical Center. Pain Medicine, 20(11), 2256–2262. https://doi.org/10.1093/pm/pnz023
Nam, K., Lee, Y., Park, H.-P., Chung, J., Yoon, H.-K., & Kim, T. K. (2019). Cervical spine motion during tracheal intubation using an optic scope versus the McGrath video laryngoscope in patients with simulated cervical immobilization. Anesthesia & Analgesia, 129(6), 1666–1672. https://doi.org/10.1213/ane.0000000000003635
Nicholas, T. A., & Robinson, R. (2022). Multimodal analgesia in the era of the opioid epidemic. Surgical Clinics of North America, 102(1), 105–115. https://doi.org/10.1016/j.suc.2021.09.003
O’Neill, A., & Lirk, P. (2022). Multimodal analgesia. Anesthesiology Clinics, 40(3), 455–468. https://doi.org/10.1016/j.anclin.2022.04.002
Roy, M., Corkum, J. P., Urbach, D. R., Novak, C. B., von Schroeder, H. P., McCabe, S. J., & Okrainec, K. (2019). Health literacy among surgical patients: A systematic review and meta-analysis. World Journal of Surgery, 43(1), 96–106. https://doi.org/10.1007/s00268-018-4754-z
Sarkar, M., Rock, P., Rowen, L., & Hong, C. (2020). Increased patient satisfaction in the postanesthesia care unit with the implementation of a controlled noise reduction program. Journal of PeriAnesthesia Nursing, 36(1). https://doi.org/10.1016/j.jopan.2020.05.001
Small, C., & Laycock, H. (2020). Acute postoperative pain management. British Journal of Surgery, 107(2), 70–80. https://doi.org/10.1002/bjs.11477
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Question 
The purpose of this assignment is to help you identify a problem in your clinical practice and formulate a clinical question regarding the problem.
Identifying and Addressing Clinical Challenges – Formulating a Relevant Clinical Question
How to choose a topic: Consider a potential problem in your nursing practice that you would like to study. This can be a clinical problem, system problem, process problem, etc. Your topic should have an impact on the healthcare system, nursing practices, processes, or patient outcomes. Try to think on a manageable scale. For example, you may not be able to tackle the opioid epidemic in the United States. However, you may be able to implement some type of process in your practice setting to manage better treatment of pain following a procedure during the inpatient stay.
Once you identify this problem, you will be searching the literature for evidence to help you potentially improve outcomes in your clinical practice. You will build on this assignment in your later assignments (Problem Significance and Review of Literature Assignment and Methodology Assignment).
This is an APA paper so make sure that you have a title page, APA headings, and a reference page. Be sure to use APA citations in the body of your paper. Your evidence table will be in a table format and will not have “in-text” citations. You can simply state under this section of the paper to see the evidence table. The evidence table template is provided under the required reading tab for Module 1.