Does the Morale of Nursing Staff Affect Delivery of Effective Pain Management?

Currently nursing staff morale is estimated to be at an all-time low due to COVID [2]. The consequences of this are likely to be increased rates of burnout, reduced retention, and potentially worsening patient care [3]. Nursing staff have worked tirelessly throughout the pandemic and the consequences of this have understandably led to feelings of lower morale coupled with increased rates of burnout. Pain is a manifestation of various physiological and psychological factors that requires urgent relief [4]. Administration of timely pain relief and its effect on both patient care and recovery is essential. If pain relief is delayed, this can have an impact on how quickly patients are able to engage with their post-operative rehabilitation, therefore timely administration is essential to ensure a patient’s recovery. When people’s morale in a job is low, their performance often suffers as a consequence [3]. In medicine this can have significant effects on patient care and their subsequent post-operative recovery. Our study sought to identify whether there was any correlation between nursing staff morale and pain relief administration in the post-operative surgical population. As a result, we hypothesized that reduced levels of morale within nursing staff would correlate with lower levels of pain relief and lower rates of appropriate delivery of adequate pain medication delivery post op.

We undertook this qualitative study at a district general hospital. We surveyed 45 patients and 45 nursing staff over a two-week period on post-operative surgical wards requiring post-operative pain relief. We investigated several areas regarding nurse morale, features of burn out and prescribing of appropriate pain relief. The following criteria were examined from a patient perspective and from a nursing perspective (Table 1 & 2).

Table 1: Areas assessed in patient perspective of pain relief administration.

Table 2: Areas assessed in nursing perspective in regard to pain administration and morale.

The patients assessed included a wide range of ages from 18 to 98. The majority of patients reported taking their regular analgesia always. 34 were aware of additional painkillers, 11 were not. Most patients (29) had to ask for additional pain relief on top of their regular analgesia to control their pain. The majority reported that when they asked for additional pain relief it was delivered immediately. Seven patients reported a little delay, and one reported a moderate delay. All patients reported that their pain was reassessed. Patients’ satisfaction of care and pain management were either satisfied or very satisfied (Table 3).
From the results, we found that the job role or experience of nursing staff was not linked to a specific decline or change in morale or risk of burnout. The majority of nurses were either satisfied or very satisfied with their career choice. Only two nurses reported feeling burnt out. Of the nurses that appeared to be suffering low morale and possible burnout, this appeared to be in the context of feeling unsupported at work. All nursing staff were confident at assessing pain and were aware of the need to reassess pain. There were some discrepancies in how frequently they assessed and reassessed pain ranging from 10 minutes to one hour. This could be accounted for by the patients that they were looking after but could also be related to varying opinions as to how frequent pain should be reassessed. The most challenging group of patients to assess pain relief in was the intravenous drug user populations as it was difficult to accurately assess their score and/or the most appropriate pain medication post operatively. Statistical analysis was carried out using a Pearson’s rank correlation analysis. The correlation analysis suggested that there was no correlation (R -0.11) between nursing staff morale, job satisfaction and its link with timely administration of pain relief and pain satisfaction scores.

Table 3: Results of patient experience of pain relief administration post operatively.

The current study supports other studies [3] that nursing staff, regardless of their current morale, continue to do the best that they can for their patients and those lower levels of morale do not correlate with reduced delivery of pain relief. The results highlight that the majority of nursing staff are satisfied with their jobs, regardless of whether they are currently experiencing low morale. The study provides further evidence of the dedication of nursing staff to their patients and their importance to the delivery of care in the health service. The study had a number of limitations. Firstly, it was a relatively small study, and it may be that with larger numbers of both nursing staff and patients there would be higher rates of low morale among nursing staff, which may lead to reduced delivery of timely pain relief. Secondly, this study was conducted at a district general hospital.
If this was carried out at a tertiary centre, there is a higher likelihood that greater rates of burnout and low morale may be encountered leading to impacts upon patient care and subsequent pain relief administration. Thirdly, pain relief and pain scoring are extremely subjective and dependent on the individual patient. Therefore, there is a possibility that less or more stoical patients may have asked for more or less pain relief respectively. Fourthly, due to the period in which this research was carried out, it is possible that during those weeks, the patient population and the operations involved may not be further representative of the pain relief required and subsequent impact of nurse delivery of patient relief may not be representative. Further the nursing staff working during that two-week period may again not be representative of the wider nursing population or the other nurses not on shift during that two-week period. Overall, this study indicates that nursing staff administer timely pain relief medication to their patients regardless of the level of morale of the workforce.
However, this does not negate the fact that nursing staff are under extreme pressures to deliver high quality care at all times and the impact of the COVID pandemic upon their morale has had a significant impact. Further there are increasing studies suggesting that the impact of moral injury upon staff working in the health service, as a consequence of the COVID-19 pandemic is likely to be high and this will only become apparent over the next few years [5]. Therefore, it is highly likely that although nursing staff continue to do their best for patients. In the future, if burnout, moral injury, working conditions and staff morale are not addressed, then this could have a negative impact upon patient care including their management of pain relief post operatively.

1. Yahya AS, Khawaja S, Chukwuma J (2020) Staff morale and well-being during the COVID-19 Prim Care Companion CNS Disord 22(3): 20com02645.
2. Stuijfzand S, Deforges C, Sandoz V, Sajin CT, Jaques C, et al. (2020) Psychological impact of an epidemic/pandemic on the mental health of healthcare professionals: A rapid review. BMC Public Health 20(1): 1230.
3. Numminen O, Katajisto J, Kilpi LH (2019) Development and validation of nurses' moral courage scale. Nurs Ethics 26(7-8): 2438-2455.
4. Ramachandran G, Sangineni DKS, Kiran T, Polapally V (2020) Pain relief is not optional-Choose Indian Journal of anaesthesia 64(6): 453-455.
5. Sriharan A, West KJ, Almost J, Hamza A (2021) COVID-19-related occupational burnout and moral distress among nurses: A rapid scoping review. Nurs Leadersh (Tor Ont) 34(1): 7-19.