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Donabedian model, hospitals, multilevel analysis, nursing, pain, pain management, quality of healthcare, social environment



  1. Van Hecke, Ann
  2. Van Lancker, Aurelie
  3. De Clercq, Bart
  4. De Meyere, Celine
  5. Dequeker, Sara
  6. Devulder, Jacques


Background: Despite an enhanced interest and evolution in pain management, prevalence remains high. Interventions to optimize pain-related care can only be effective if barriers are identified and accounted for.


Aim: To assess pain intensity and examine its association with patient- (including health literacy defined in this study as "requiring help to read health information"), nurse-, and system-related (including social capital defined as "the importance of network and norms at work") barriers/facilitators to pain management.


Methods: A two-center, cross-sectional study was performed between October 2012 and April 2013. The study included patients and nurses of 39 noncritical wards of two hospitals in Belgium. Patients who were 18 years of age or older and without impaired cognition or consciousness were eligible to take part. All nurses working in the included ward were invited to participate. Pain intensity and patient-related barriers were collected by a structured and standardized questionnaire, completed in dialogue with the patient. Nurses completed the questionnaire on the nurse- and system-related barriers and the social capital scale. Multilevel analysis was used to analyze the data because of the hierarchical structure of the data.


Results: The average pain of all patients across all wards on a 0-10 scale was 2.2 (SD = 3.6). The multilevel analysis indicates that pain intensity can be explained by variables at patient and ward levels. A significant independent association was found between higher pain intensity and younger age, receiving pain medication, the conviction of patients that pain medication does not improve pain, inadequate health literacy in patients, nurses without advanced education, and nurse's concerns about side effects. Social capital did not emerge as predictor of pain intensity.


Discussion: Patient and nurse level factors should be taken into account in hospitals when setting up strategies to improve pain management.