Patients’ peri-operative experiences with non-pharmacologic pain care techniques: a secondary qualitative analysis of the NOHARM trial

Abstract

Background

Peri-operative pain management guidelines recommend multimodal strategies, but education on non-pharmacological pain care (NPPC) is lacking. The present study explored patients’ experiences participating in the Healing After Surgery (HAS) initiative as part of a pragmatic clinical trial, designed to provide patients with peri-operative education and support for using NPPC.

Methods

We sought to interview two patients from each of the 31 surgical practices participating in the trial. Interviews were semi-structured, audio-recorded, and transcribed verbatim. We used a rapid analytic approach to summarize interview transcripts. Summaries were uploaded to NVivo and two researchers independently reviewed queries and produced analytic memos with key themes organized according to the Theoretical Framework of Acceptability’s seven constructs.

Results

We analyzed interview transcripts for 71 patients. Findings revealed that patients (1) generally liked the HAS initiative (affective attitude), (2) it aligned with patients’ beliefs about wellness techniques and concerns about opioids (ethicality), and (3) many patients had experience using NPPC (self-efficacy). However, (4) care team education and provision of NPPC was inconsistent (intervention coherence), (5) patients varied on their thoughts about the effectiveness of NPPC and the role of NPPC and medication (perceived effectiveness), (6) some patients found resources repetitive and encountered logistical challenges engaging with resources or using NPPC (burden), and (7) patients cited completing tasks ahead of surgery and competing demands post-operatively (e.g., caring for a spouse or young children) as barriers (opportunity costs). An additional theme, the invisible and individualistic nature of pain, also emerged.

Conclusions

Peri-operative initiatives that educate patients about NPPC may be well-received and remind patients of “wellness techniques” and alert them to their role in pain management. Familiarity with NPPC may contribute to patients’ self-efficacy using these techniques. However, some patients may require additional support to feel comfortable using NPPC in a post-operative context. Emphasizing the care team’s role of directing patients to existing educational recourse or interactive supportive resources may be a low burden way of providing this support. Adding a health coach role to the intervention may also be an option for providing extra support without increasing care teams’ workload.

Trial registration

This study was registered on ClinicalTrials.gov, NCT05166356, https://clinicaltrials.gov/study/NCT05166356?term=%20NCT05166356&rank=1 Patient enrollment began on 3/01/2022.

Background

As the opioid crisis persists and worsens in the United States [1–4], ^, surgical patients may be a vulnerable group, given their potential for new persistent or prolonged opioid use [5–9]. In 2022, the Centers for Disease Control and Prevention released opioid prescribing guidelines specifying prescription of the lowest dose needed for pain management [10]. This has not always occurred in practice [11] despite higher doses carrying greater risks for long-term use [12]. However, changes in opioid prescribing may be insufficient for curbing opioid overuse without appropriate pre-operative education and the availability of other approaches to manage pain. Peri-operative [13, 14] or pre-operative [15–18] patient education may reduce use of opioids, decrease patients’ interest in receiving prescription opioids [19], and promote patient satisfaction [20].

Non-pharmacological pain care (NPPC) techniques are safe and effective at reducing post-operative pain [21–29] and opioid use [22, 27–31], and decreasing anxiety [22, 24, 31, 32]. Moreover, patients may want to know how to manage post-operative pain besides taking medication [33]. However, NPPC is not typically offered as part of routine post-operative care.

Past educational focuses have included post-operative pain expectations, opioid risks, and ways of managing pain without opioids, but from the descriptions of these educational interventions it was unclear whether information on ways of managing pain covered NPPC techniques (and to what extent) or focused on non-opioid medications [13, 14]. One study on the effect of pre-operative education focused on teaching patients about how opioids can interfere with the body’s endorphins, but that non-opioid medications would not interfere [19]. Further, other pre-operative education consisting of a one-page handout that covered pain expectations, goals, medications (opioid and non-opioid) for peri-operative pain management, opioid risks, normalization of pain, and NPPC, limited information about NPPC to a single bullet point [15]. Similarly, another study provided pre-operative education via a brief video and handout on proper opioid use and narcotic risks, but the video contained only a single bullet point and talking point suggesting use of ice and heat, in terms of NPPC [18]. Another study that developed a brief pain management handout to share with patients pre-operatively more prominently featured 10 non-pharmacological techniques for pain management (along with brief information that normalized pain and set pain expectations and information about pharmacologic options and their risks) [20]. However, detailed information about how to use the non-pharmacologic techniques listed was lacking [20]. Thus, existing peri-operative education inconsistently incorporates robust information about using NPPC, despite recommendations to do so [34].

Members of the medical community have called for more active inclusion of patients in post-operative pain management [35]. Educating patients about NPPC techniques and supporting them in choosing and utilizing techniques that work best for them may increase their self-efficacy and encourage them to try different options rather than automatically taking medication, giving them more direct control over their post-operative pain management. There has also been recognition that pre-operative education should be supported by different surgical team members, utilizing a team-based approach [36, 37]. Patient education should also be delivered in multiple formats [16, 37–40] without over-reliance on a single mode [41] and be easily accessible to patients.

As part of the present study, a multidisciplinary team developed the Healing After Surgery (HAS) initiative to provide peri-operative education and to support use of NPPC in post-operative pain management. The HAS initiative incorporates many of the aforementioned components by educating patients about opioid safety, pain medication, and NPPC. The HAS initiative also encourages different surgical care team members to engage in patient-centered discussions to encourage patients to include NPPC modalities in their pain management plan.

The parent trial, Non-pharmacologic Options in post-operative Hospital-based and Rehabilitation pain Management (NOHARM), studied the effect of the HAS initiative on physical function, pain, anxiety, and opioid consumption [42]. This trial was a pragmatic stepped-wedge, cohort cluster randomized trial in which different surgical practices across a multi-state health system were randomized to the HAS initiative at five consecutive seven-month intervals. We adapted the intervention to accommodate site and practice-specific needs and to address feedback from patients and providers. This paper presents findings from patient interviews conducted throughout the trial to elucidate patients’ experiences participating in the HAS initiative and to identify areas for improvement. Findings are organized according to the Theoretical Framework of Acceptability (TFA), which includes the following constructs: (1) affective attitude, (2) burden, (3) ethicality, (4) intervention coherence, (5) opportunity costs, (6) perceived effectiveness, and (7) self-efficacy [43]. This framework centers around patients’ cognitive and emotional reactions, which are thought to influence patients’ feelings of appropriateness of an intervention [43].

Methods

Intervention

Upon surgical scheduling, patients were automatically sent an educational HAS guide via their electronic health record (EHR) patient portal, which discussed opioid safety and introduced 13 validated NPPC techniques. These techniques were categorized as movement (walking, yoga, tai chi), relaxation (relaxed breathing, muscle relaxation, music listening, aromatherapy, guided imagery) and physical techniques (application of cold or heat, acupressure, massage, TENS). Recommendations for use of NPPC have categorized TENS and acupressure as “passively applied physical approaches” [44] and massage therapy under “physical interventions.” [45] We chose to classify cold and heat as a physical approach because these approaches similarly involved something therapeutically applied to the body. We chose our grouping of movement techniques to make clear to patients that these methods involved physical activity. Lastly, grouping techniques as relaxation techniques was done to emphasize their role in helping patients relax (although others have classified meditation as “psychological” [44] or “behavioral/cognitive interventions/psychological,” progressive muscle relaxation as “behavioral/cognitive interventions/psychological,” and music therapy as “environmental-based interventions”) [45]. Moreover, grouping NPPC into a limited number of categories that shared a similar focus was done to facilitate ease of understanding educational materials. Patients were encouraged to select up to three techniques to use in conjunction with any prescribed pain medication for peri-operative pain management. Additional resources that provided information and instruction for NPPC modalities were available via print materials, a website, inpatient hospital TV, and a DVD. Interactive, synchronous support for NPPC use consisted of a toll-free number and group Zoom-based support calls, led by nursing and physical therapy study team members, who possessed expertise in NPPC.

Care team support

During pre-operative outpatient visits, ambulatory nurses were instructed to encourage patients to complete the HAS guide prior to surgery and use it to select their preferred NPPC techniques. Prior to surgery, some patients had a Pre-operative Evaluation (POE) Clinic visit to prepare them for surgery or physical/occupational therapy so POE clinic staff and physical therapists and occupational therapists (PT/OTs) were encouraged to do this as well. Ambulatory nurses, POE clinic staff, and PT/OTs were also instructed to offer patients HAS print materials. Inpatient nurses were instructed to identify the patient’s preferred NPPC techniques in the EHR (or help the patient make selection and enter them into the chart if they had not completed the HAS guide), provide patients with educational materials on their preferences (e.g., print materials, videos on the NPPC techniques available on the televisions in patient rooms or tablets), provide the patients’ NPPC preferences when feasible, and discuss use of NPPC as part of discharge discussions. Inpatient PT/OTs were also instructed to identify the patient’s preferences in the EHR (or direct patients to videos on the televisions in patient room or tablets to assist in making selections), incorporate NPPC techniques into therapy as feasible, and encourage patients to refer to HAS resources (e.g., videos on patient televisions, print materials, website, toll-free number and Zoom-based calls). For patients who had same day procedures and were discharged from the hospital the day of the surgery, post-operative nurses were encouraged to discuss NPPC use as part of the discharge conversation and offer print resources. Information was also included in the after visit summary. Outpatient nurses who had follow-up post-op phone calls with patients were instructed to encourage patients to use NPPC. Clinical decision support elements were built into the EHR to support care teams in delivering the intervention. (For more details, see [42]). Staff supporting delivery of the intervention received training via an online role-specific module, presentations at staff meetings/huddles, and members of the study team stopped by inpatient floors and were available via email and study pager to offer support.

Sample

NOHARM met criteria for a “standard of care” trial, so we received a waiver of consent from our Institutional Review Board (IRB). Patients undergoing a qualifying procedure from one of the 31 participating surgical practices were automatically enrolled in the trial. Participating practices were part of Mayo Clinic and spread across six geographic locations (Rochester, Minnesota; Phoenix, Arizona; Jacksonville, Florida; Mankato, Minnesota; Eau Claire, Wisconsin; and La Crosse, Wisconsin). Surgical practices started delivering the intervention at different times as part of the stepped-wedge trial design [42]. To gather diverse patient perspectives, we recruited surgical patients from each of the 31 diverse surgical practices with varied levels of engagement in the intervention.

To do this, we generated a reported in the Epic EHR that looked at patients who had a surgery in the last 45–59 days and received the intervention. From this report, we were able to see whether the patient had selected NPPC techniques in the portal-based HAS guide prior to the date of their surgery (because responses in the HAS guide auto-populated flowsheet rows in their EHR, which could be extracted as report data) and whether they had reported using any of the 13 NPPC techniques on a questionnaire sent to their patient portal one month post-operatively (which could also be extracted from the EHR via report data). We considered patients more highly engaged if they (1) selected their preferred NPPC techniques in the HAS guide ahead of surgery (because that is what the intervention encouraged them to do) and (2) reported using at least one of the 13 NPPC techniques (indicating adoption of at least one of the NPPC techniques that the intervention provided educational materials on). We considered patients less engaged if they did neither, indicating lower adoption of the intervention. We sought to interview one highly engaged patient and one less engaged patient from each of the 31 participating surgical practices.

Recruitment

We developed an EHR report to identify patients who were 45–59 days post-operation and met criteria for being highly engaged or less engaged. A study coordinator called a random subset of these patients and invited them to participate in a telephone interview. Those who agreed to participate were sent a Health Insurance Portability and Accountability Act (HIPAA) release form that could be signed electronically or as a hard copy returned using a pre-paid envelope.

Procedure

The study coordinator scheduled a ~ 30 min telephone interview between the patient and an experienced qualitative researcher (CT, a nurse scientist, or SM, a research associate), who have routinely used qualitative methods. Both researchers are female and were not familiar with the study participants, although CT and SM had limited interactions with a small subset of the > 40,000 participants who received the intervention as part of the parent trial via their role on the study team. Interviews were conducted using a semi-structured interview guide that probed patients’ experiences with the HAS guide, educational materials, interactive support, and interactions with their care team. Slight modifications were made to the interview guide after early interviews and to capture information related to minor modifications to the intervention over the course of the trial. The interviewer explained the purpose of the interview at the start. All interviews were audio-recorded and transcribed verbatim. Participants received $20 remuneration. Study procedures were approved by the Mayo Clinic Institutional Review Board (IRB) (# 21–007898). Subjects signed a HIPPA release form to provide written consent to have their data used for research.

Analytic strategy

Patient interviews were analyzed using a Rapid Analytic Approach [46, 47] to allow for ongoing learning from patient feedback, and inform potential modifications to the intervention and its delivery. SM created a summary template with domain labels that corresponded to the interview questions. For the first four interviews, CT or SM took thorough notes from the interview audio recording and then populated the summary template. Given the extensive time of note taking, subsequent interview audio-recordings were transcribed verbatim, and summaries were completed from interview transcripts. SM and CT completed secondary reviews of each other’s summaries for the first 10 interviews to achieve uniformity in summary completion [46, 47]. A third researcher, KS, also assisted with preparing summaries; first conducting secondary reviews of several summaries and then receiving feedback on her first summary from SM prior to independent summary completion. CT, KS, and SM met regularly to discuss progress, resulting in minor modifications to the interview guide and summary template; existing summaries were updated accordingly. Completed summaries were uploaded to NVivo [48] qualitative software by a fourth researcher, CA. The domain labels used to prepare the summaries were used as codes so that the text under each domain heading on the summaries could be coded to that domain in NVivo [48] by CA. This step did not require any analysis by CA but enabled us to run a query for each domain that consolidated the text placed under that domain across all summaries into a single document. CA and SM then independently created memos for each domain by reviewing the queried text for that domain, identifying key themes by summarizing the unique thoughts reflected in the queried text, and then recording which of the TFA constructs each theme corresponded to [43]. CA and SM also recorded representative quotes on the memos. CA and SM met regularly to review their memos and arrived at consensus of key themes and how they fit within the TFA via discussion. Key themes were copied and pasted into a data matrix in Microsoft Excel organized by domain by TFA construct.

Results

71 patients participated (at least two from each practice), meeting our recruitment goal. As part of our recruitment efforts, we called or left voicemail messages for 429 patients, resulting in 91 verbally agreeing to participate and 91 verbally declining. Of the 91 who agreed to participate, 5 did not complete their HIPAA release form, 1 withdrew their consent, and 14 were not reachable via telephone for their scheduled interview. Two additional patients were interested in participating, but the interview slots had already been filled. Participants were 59% female, 93% white, and had a mean age of 53 years (SD = 17.24; min = 22, max = 83). Interviews lasted 26 min on average (min = 8 min, max = 85 min). See Table 1 for additional demographic information. Themes are organized below by TFA constructs. One emergent theme from the queried domains that did not fit the TFA, the invisible and individualistic nature of pain, is described below. We also report suggested improvements. Quotes included participant number and whether the quote was from a highly engaged (HE) or less engaged (LE) patient.

Table 1.

Sample demographic information

	Highly Engaged▪ (n = 34)	Less Engaged▪ (n = 37)
Female	67.65% (23/34)	51.35% (19/37)
Male	32.35% (11/34)	48.65% (18/37)
Mean Age (Standard Deviation)	55.18 (16.02)	50.92 (18.05)
Race/Ethnicity
White	100% (34/34)	86.49% (32/37)
African American	-	5.41% (2/37)
Asian	-	8.12%**(3/37)
Hispanic/Latino	5.88%* (2/34)	2.70%*** (1/37)
Age- Minimum, Maximum	25, 78	22, 83
Surgical Practice
Cardiac	4	6
Obstetrics (caesarean deliveries)	4	4
Orthopedic	6	6
Colorectal	6	6
Gynecology	7	6
Pulmonary/Thoracic	4 (3 lung, 1 thoracic)	6 (2 lung, 4 thoracic)
Transplant	3	3
Hospital location
Rochester, Minnesota	10	8
Phoenix, Arizona	6	7
Jacksonville, Florida	6	8
Eau Claire, Wisconsin	5	7
La Crosse, Wisconsin	4	4
Mankato, Minnesota	3	3

Surgical patients from a few practices were overrepresented (e.g., multiple patients agreed to participate, practices were mistakenly recruited from twice). One patient was non-randomly invited to participate because they contacted the study team to provide feedback and were invited to participant in an interview

^*1 participant identified as Hispanic/Latino and 1 identified as South American

^**1 participant identified as Asian Indian and 1 identified as Asian Filipino

^***Participant identified as Central American

^▪Highly engaged patients were classified as those who selected their preferred NPPC techniques in the portal-based decision support tool prior to surgery and reported NPPC use post-operatively. Less engaged patients were classified as those who did not make pre-operative NPPC selections and did not report post-operative NPPC use. Obstetric patients undergoing cesarean deliveries who did notcomplete the decision support tool pre-operatively butdid report post-operative NPPC use were classified as highly engaged because those who underwent emergency cesarean deliveries were sent the decision support tool post-operatively. Further, some obstetric patients who had planned cesareans were not sent the guide until shortly before their scheduled procedure. Additionally, due to a recruitment glitch, four patients in the less engaged group did select their preferred NPPC techniques in the portal-based decision support tool prior to surgery but did not report NPPC use post-operatively. We still included these four patients’ data. However, we also re-recruited less engaged patients from these surgical practices, who met both criteria for being less engaged

Affective attitude

Many patients thought favorably about NPPC, but some were skeptical or actively against using NPPC (e.g., “…if I’m in that much pain, do you think I wanna meditate?” P42, LE). Irrespective of their thoughts about NPPC, many patients wanted to avoid medication. Many patients felt positively about HAS materials. A patient who had undergone a prior surgery for which she had not received the HAS intervention remarked, “… I actually have thought, um, why didn’t I get those the first time. [Laughs] Um, so I-I definitely felt they were helpful,” P38, LE. However, some found them too loaded with information, and others found them not detailed enough. For instance, when asked about the materials, another patient referred to them as “a complete and utter waste of marketing dollars” because “the content itself was too generic,” P50, HE. A few patients mentioned not liking the Zoom format of the HAS group calls, and a couple did not like the group format, sharing “that group conversation about things…that’s not my style,” P25, HE.

Ethicality

The HAS intervention aligned with many patients’ general beliefs about integrative techniques and wellness and concerns about the risks of opioid addiction. One patient shared, “I think that they [non-medication ways of managing pain] are far better than…opiates…one, they don’t really help a lot…and then, like, the risk of addiction with all of them is insane,” P56, LE. Patients noted the importance of diet and exercise and overall health to ease recovery such as “…walking, uh, at least 10,000 steps a day, um, trying to build the strength in my legs to the point where, when I had the surgery, it would be easier to get it back again,” P9, LE. Others discussed the value of physical therapy. Some discussed undertaking these things ahead of time to aid recovery. Other patients wished to focus on getting surgery behind them and were not thinking about “…managing the pain at the time at post-op” but were focused on “just get to post-op” P35, HE.

Intervention coherence

Patients who underwent emergency procedures did not have the opportunity for pre-operative pain planning and pain management discussions. Pre-operative care team discussions about NPPC with patients with planned surgeries occurred inconsistently, despite their potential benefit. Some pain management discussions incorporated NPPC:

“The nurse practitioner went over quite a bit of relaxation techniques and breathing techniques and how to control the pain because it was a very painful surgery, the doctor said. And it helped a great deal knowing that ahead of time, that I can control the pain without the narcotics. And I didn’t use that many narcotics,” P57, LE (completed guide, but didn’t report post-operative NPPC use).

However, sometimes pain management discussions focused more on pain medication, and some patients learned about NPPC via HAS materials alone.

During their post-operative hospital stay, many patients reported receiving pain medication and some reported receiving NPPC, which largely consisted of movement/walking, aromatherapy for nausea, and ice or heat. One patient shared, “During my hospital stay, obviously it was, um, medications…Opioid and non-opioid. Um, and then I’m not sure if walking was part of the pain management. They just said walking earlier will make you recover faster—but they did not specifically say that walking will ease your pain better, or something,” P18, LE Care teams inconsistently discussed other NPPC techniques and shared relevant videos and materials. Some patients also noted their inability to recall conversations with their care team more generally in the immediate post-operative period and whether NPPC was discussed, sharing “…I don’t recall whether or not they mentioned anything else. I don’t recall whether they asked me, you know, ‘What else will you do?’” P13, HE.

Following hospital discharge, many patients used NPPC (e.g., ice, heat, walking, aromatherapy, relaxation techniques, massage, TENS) in conjunction with pain medications. Most patients did not recall pain management being a major focus of post-operative care team discussions. Some patients were not aware of other HAS resources (e.g., website, toll-free number, Zoom calls), but said they might have been interested in them, particularly the toll-free number.

Self-efficacy

Most patients had prior experience using NPPC for medical reasons or general wellness but did not always connect this with pain management:

“At the beginning I thought it was a lot of stuff to go through, and I just didn’t comprehend. It was like learning a whole new situation… but then when I started to actually go through the information it’s like, oh, I know this. I know this. I know this. I know this…when I looked at the non-medication options and I counted through ‘em, I’ve already been doing nine of ‘em,” P68, HE.

Patients commonly selected walking, relaxation, and heat/cold in the guide and reported choosing techniques they were familiar with. A couple patients did not make selections because of their familiarity with NPPC. Several patients were unsure of how to use some of the NPPC techniques (e.g., yoga, TENS, massage) following surgery after reviewing the guide or wanted additional support. Some patients prepared their environment, gathered information, or used NPPC in preparation for their surgery. One shared, “I did some meditation because I was very anxious about the surgery,” P57, LE (completed guide, but didn’t report post-operative NPPC use). Some also engaged the help of a support person. A subset of the patients who did not prepare chose not to do so because they felt confident in their ability to address pain.

Following discharge, many patients did not encounter barriers to pain management or NPPC use. However, pain, other medical concerns, and uncertainty about the appropriateness of certain NPPC were barriers for some. One patient stated, “… if I had a reassurance from a doctor that, ‘Yes, you can do this. Yes, you can do that,’ then I would have been more open to doing those non-medication techniques in an earlier period…” P18, LE. Some did not need to utilize HAS resources (e.g., website, Zoom calls, toll-free number) or seek out additional resources because their pain was well-controlled, or they knew how to manage their pain: “There wasn’t ever, um, a time where I felt like I needed additional support, um, further than, you know, the meds that had been prescribed and then what I was already doing, um, based on the-the guide’s recommendations,” P1, HE. However, others turned to websites or apps, family or friends, or received assistance from physical therapy.

Burden

A few patients found the HAS materials repetitive or too much to review. One patient mentioned being too busy and another too sick to make selections, though they reviewed the guide. Some did not realize they were supposed to make selections in the guide, while others had difficulties using the portal or other technology. One patient described challenges with his computer and limited portal use:

“I didn’t do an online, uh, survey, no…It’s kind of hard because… my computer… I go in there very infrequently… maybe once a week. So my computer is always updating. It’s just a laptop and, uh, so sometimes I’m doing something and then it stops doing it…I have to wait and wait and wait and it’s just—so I’ve-I never, um, uh, I’ve never gone, um, deep into my portal,” P70, LE.

A few also talked about the overwhelming nature of the patient portal and portal-based questionnaires, which was the mode we used to deliver the HAS guide. Some patients found the always available functionality of the HAS guide to be too much: “Even though I completed it, it kept popping up—before the surgery happened and then over and over after the surgery happened,” P45, HE. Some patients attributed not joining a Zoom call to scheduling conflicts, forgetting, or being focused on other things. Some patients noted logistical challenges (e.g., weather, inability to drive, financial limitations) to using NPPC:

“…you’re not allowed to drive for four weeks, or five weeks it was, whatever resources I would have wanted I had no way of getting there. So, you know, that massage, had I found somebody, uh, you know, it’s like, well, doesn’t matter. Because I have no way of getting there. Could I take an Uber? Yeah. But, you know, I’m still walkin’ with a walker, still, you know, all these things that get into your psyche. That it’s not even worth the effort to go out.” P64, HE.

Perceived effectiveness

Patients’ thoughts about the effectiveness of NPPC varied. Some noted the need for medication for acute pain control, but that NPPC could be used supplementally. As was the case for one patient who described how she, “… utilized them the most after my stronger meds ran out…” and that “… it was helpful to have it as…a continuing, um, way to relieve pain after the medications was done,” P1, HE. Others stressed the importance of NPPC for their recovery, while a few patients felt that NPPC was less relevant to them. Patients also noted individual variability in the fit and effectiveness of NPPC, and some found certain NPPC more helpful than others:

“… I think it’s nice they kinda have this f-formal, um, uh, grouping of, you know, here’s a whole bunch of techniques that, you know, you can pick from and they’ve all kinda been researched and known to work to some degree for, you know—maybe not for everybody but, um, at least give ‘em a try and see if you can’t, you know, get off the narcotics,” P54, LE.

Finally, some patients who received HAS materials after their surgery found them less relevant by that point in their recovery.

Opportunity costs

Prior to surgery, a few patients who made selections in the guide discussed how they were busy or focused on getting work done, which took away focus from trialing or preparing for using their NPPC techniques for pain management. One patient shared, “I was very, very busy and was kind of distracted with a lot of things I was tryin’ to take care of at the same time. And so I didn’t probably, you know, put as much emphasis and time on it [incorporating these options into a pain management plan preoperatively] as I normally might have. But, um, I definitely kinda had a mental checklist, and I did order a TENS unit.” P13, HE. Another patient was, “tryin’ to get my business stuff done, tryin’ to look at my taxes for the year,” and although he “did get some exercise…did do some walking ahead a time,” that was not his “entire focus.” P48, HE. Similarly, patients mentioned lack of time (e.g., “…once I get back to work, time is always an issue.” P2, HE) and competing demands (e.g., caring for a spouse, caring for young children, tending to a home) as barriers to pain management or NPPC.

Invisible and individualistic nature of pain

Patients emphasized the subjective nature of pain and needing to find what works best for oneself. Many patients suggested others should try NPPC instead of relying on medications. Patients wanted others to understand the goal should not be to get rid of pain entirely:

“Not all of it will be taken away a 100%. And to utilize other resources, uh, or other methods other than narcotics to control your pain. Just with the opioid epidemic that’s, uh, going on, and people with telepharmacy, they get themselves in trouble and they, I feel like, rely too much on medication. They rely on that little pill to take e—to make everything better, but to know that there’s other methods that are proven are effective such as, you know, those non-pharmacologicals from aromatherapy to movement to music to ice and heat and stuff. So the—and like don’t knock it until you try it, ‘cause it might work for some, but it might not work for others. So just you gotta find what works for you,” P43, HE.

Patients discussed the mental component of pain and needing to push through it. A few mentioned taking pain medications as needed and that over-the-counter medications can be helpful. They also discussed the challenge of others not being able to understand others’ pain, especially when others have not undergone the same surgery: “…let’s say you’re, you know, you’re talkin’ to somebody about your pain and managing it and whatnot and how you feel and all these things, and it’s somebody who’s never had surgery…they—like, the words comin’ out of your mouth may mean absolutely nothing to them…” P54, LE.

Improvements

Many patients were satisfied with the support they received and suggested no improvements. However, some wanted more discussion about pain medications and NPPC, with differing opinions on whether use of pain medications should be more encouraged or discouraged. Many patients would have also liked HAS to be more integrated with their care team and wanted more discussion about NPPC during their hospital stay and following discharge. Patients would have also liked additional resources or greater access to NPPC options in the hospital. Suggestions for improving the portal-based HAS guide included making it clear when it has been completed, providing more support if a patient indicates needing help with the techniques, and orienting questions to techniques patients are familiar with and focusing in on those. Patients also noted the individual nature of pain management; some were more comfortable figuring out what works best for them and using the resources, while others thought the lack of personalization of this program was a deficit.

Discussion

The present study gathered surgical patients’ perspectives on receiving support for using NPPC for peri-operative pain management as part of the NOHARM trial. The idea behind the intervention was compatible with many surgical patients’ preferences and beliefs. Many patients thought favorably of and were familiar with some of the NPPC techniques, although some were familiar with these techniques in the context of general wellness. Many patients also wanted to avoid or limit medication use, but some affirmed its role in managing pain. However, some patients were focused on getting the surgery behind them or getting work done ahead of their surgery, which shifted their attention away from pre-operative pain planning, suggesting the need for flexibility and ongoing support for NPPC use from care teams with possible coaching and availability of educational materials.

Interviews revealed that from patients’ perspectives, care teams did not always support delivery of the intervention as intended. Patients’ surgical care teams had been instructed to encourage patients to select and utilize NPPC techniques for peri-operative pain management and direct patients to educational resources (e.g., print materials, website, DVDs) and additional interactive support (e.g., telephonic and group Zoom-based support). However, care team conversations about NPPC techniques did not always occur, and per several patients reports, hospital-based NPPC provision was largely limited to techniques already encouraged prior to the intervention (e.g., walking, heat/cold, aromatherapy). Further, discussions with hospital teams about post-discharge pain management were often focused on medications, and some patients were not aware of the additional resources available to them through the HAS initiative. Thus, the amount of education and support patients received from care teams regarding NPPC varied, and as a result, some patients received a lower dose of the intervention than intended. In response to this feedback in earlier interviews, we compiled individual educational handouts into a single workbook in an attempt this facilitate care team provision of key education. However, it was not evident that this made much of a difference in patients’ receipt of education on NPPC from their care team.

Differences in the dose of the intervention received is a common challenge of large-scale pragmatic trials delivered in a real-world setting [49], and may impact the effect of the intervention on patient outcomes. However, we were able to deliver the intervention to over forty-thousand surgical patients, potentially providing more net benefit than carrying out the intervention with higher fidelity on a smaller scale [50]. Moreover, it is unclear what dose of the intervention is needed to achieve the desired patient outcomes (and outside the scope of the present study to explore). For instance, although patients highlighted the need for more discussion about how to integrate NPPC and medications, as well as for greater access to NPPC in the hospital, many patients did not report any barriers to post-operative pain management or NPPC use. Further, although we observed low utilization of interactive support (e.g., toll-free number and Zoom-based group calls), some said they did not need these resources because their pain was under control, or they knew what to do.

However, some thought the information provided in the HAS guide was too much, while others thought the information provided was not specific enough. Some were also confused by the fact that the HAS guide remained available even after they had selected their preferred NPPC techniques. In response to this, once a patient made their selections, we assigned a new version of the HAS guide to them in their portal with a title indicating that no response was required. Additionally, several patients were unsure how to use certain techniques presented in the guide or thought they might not be appropriate in the context of their surgical recovery (despite a few of these patients having prior experience with them), and some patients mentioned logistical barriers to NPPC use. In these instances, we may reinforce the care team’s role in helping patients navigate these barriers by steering them towards modalities they deem safe and high yield, and by making them aware of web-based and print resources that neutralize access challenges (e.g., a webpage with videos and other resources to support modality use). However, care teams’ requirement to address immediate patient needs may impede directive conversations about NPPC use, and a balance must be struck between greater care team engagement in NPPC delivery and the risk of overburdening time-limited staff. Moreover, care team members may lack knowledge about certain modalities [51], making them feel underprepared to have these conversations.

We had instructed care teams to direct patients to the HAS toll-free number and Zoom-based group calls in instances when care teams felt they lacked the time or expertise to discuss specific NPPC techniques with patients. However, this likely did not always occur in practice, as some patients interviewed reported being unaware of these resources, but thought the toll-free number, especially, may have been helpful. This suggests an opportunity to further reinforce care teams’ ability to direct patients to these resources as a low burden way of supporting patients. Furthermore, there may be an opportunity to incorporate a health coaching role into the intervention to help guide and individualize interventions and approaches for patients who need more support.

Strengths and limitations

The present study took a patient-centered approach to understanding patients’ education and support needs for incorporating NPPC into their peri-operative pain management plan. Such efforts can complement other strategies that have been employed to combat the opioid crisis, which often target clinicians’ prescribing behaviors. Thus, our findings may help others who wish to implement educational initiatives on NPPC use for peri-operative pain management that are compatible with patients’ interests and proactively address the types of shortcomings reported by patients in our study. This adds to the limited research exploring surgical patients’ educational interests, which included patients undergoing limited types of procedures [39]. A strength of our study was evaluating diverse surgical patients’ perceptions of a multi-faceted educational initiative. Patients interviewed underwent procedures from one of seven surgical practices across six geographic locations and varied in level of engagement and age; both sexes were also represented. We also sought to recruit patients who varied on their level of engagement (e.g., made NPPC selections in the HAS guide ahead of surgery and reported using NPPC vs. those who did neither) from each surgical practice to recruit a more balanced sample in case level of engagement was tied to patients feeling more positively or negatively about the intervention. Because we did not aim to recruit patients who engaged more moderately with the intervention (e.g., made NPPC selections in the HAS guide or reported NPPC one month post-operatively), we may have failed to capture the perspectives of those with more moderate engagement with the intervention. However, some of the less engaged patients did discuss using NPPC post-operatively (despite not reporting doing so on the one-month post-operative questionnaire sent to their patient portal) suggesting we may have had some diversity in engagement in our group defined as less engaged.

Furthermore, our recruitment efforts were imperfect. Some surgical practices were overrecruited from, one patient was not selected at random (because she contacted the study team to provide feedback and was invited to participate in an interview), and a data glitch resulted in us interviewing four patients who were thought to meet the less engaged criteria but had made NPPC selections in the HAS guide ahead of surgery. Further, we had more difficulty recruiting patients classified as less engaged, so it is possible that our findings did not capture the perspectives of patients who were least interested in the HAS initiative and refused participation. Moreover, we encountered difficulty recruiting patients who had undergone cesarean deliveries - likely due to the competing demands of caring for a newborn– particularly those who met the highly engaged criteria. Patients who had unplanned cesareans were not sent the HAS guide until after the cesarean and some planned cesarean procedures were scheduled outside of the EHR and later entered into the EHR, resulting in little time for these patients to review and enter NPPC selections into the HAS guide before their procedure. This reduced the number of obstetric patients who might meet the highly engaged criteria. However, we thought it was important to capture the perspectives of obstetric patients, who may especially benefit from this type of educational intervention, particularly if they are breast feeding and wanting to reduce prolonged use of opioids for post-operative pain management. Thus, we modified the recruitment criteria for highly engaged obstetric patients to also include those who did not make NPPC selections in the HAS guide prior to surgery, but did report post-operative NPPC use.

We chose to include all interview data collected in the analysis because our goal was to gather diverse patient perspectives about their experiences with the intervention. However, it is unclear to what extent our sample is reflective of the over 40,000 patients who received the intervention. We also cannot make inferences about how the findings apply to a specific surgical patient population included in our sample because of the relatively small number of patients recruited from each surgical practice. It is also unclear to what extent our findings can be generalized to other surgical patient populations outside of our hospital enterprise, particularly patients belonging to minoritized groups, because our sample was mostly White, non-Hispanic. Moreover, this paper did not explore patient outcomes of the trial (e.g., pain, anxiety, physical functioning, opioid use), which will be reported elsewhere, so the present paper does not make inferences about the effect of the intervention on patient outcomes. Our findings do, however, offer general insights into patients’ thoughts about an EHR-based educational intervention designed to teach them about and facilitate NPPC use for managing post-operative pain and how such an intervention could be improved.

There is also some concern for recall bias because we identified patients for recruitment 45–59 days post-operatively, and interviews were typically scheduled within a month after that for those who agreed to participate. It is likely that some patients had forgotten about conversations they had with their care team about NPPC or HAS resources they had used by the time we spoke to them. Shorter lengths of stay combined with prolonged effects of anesthesia may have also influenced their recall. However, similar research has conducted interviews and focus groups with patients up to a year post-operatively [39]. It is possible that interviewing patients earlier during their acute post-operative recovery phase may have resulted in more negative perceptions of the educational initiative if patients were actively experiencing expected post-operative pain. However, patients may have been less receptive to participating in an interview during the early stages of their recovery.

Lastly, the study was conducted, in part, during the COVID-19 pandemic. It is unclear how this may have impacted patient engagement with the intervention because this was not explicitly asked about in the interviews and patients did not discuss pandemic related challenges to engaging with the intervention or using NPPC. However, patients’ reports of inconsistent discussions of NPPC from their care teams and provision of limited NPPC modalities inpatient may have been influenced by short staffing and larger patient to staff ratios that reduced that amount of time nurses had to provide patients with education on NPPC.

Conclusions

The Healing After Surgery initiative was generally well received by patients, but some patients may need more care team reinforcement and support for NPPC use to fully benefit. A challenge of similar support initiatives will be working with care teams to identify ways they can feasibly support and incorporate discussion of this type of educational content in patient care. Our team conducted interviews and administered surveys to care team members to better understand facilitators and barriers to implementing the intervention (which is reported elsewhere) [52, 53]. However, each hospital organization aiming to implement such an initiative will likely need to evaluate their own readiness and available resources for implementation to determine how to best incorporate such a practice into existing workflows. This research takes an important step towards helping address the opioid use epidemic by including patients in the discussion surrounding how to best help them create peri-operative pain management plans that incorporate NPPC in addition to prescribed medication. Future research many consider testing similar initiatives with more diverse patient populations to determine whether the intervention needs to be adapted for different patient populations.

Abbreviations

NPPC

Non-pharmacological pain care

HAS

Healing After Surgery

NOHARM

Non-pharmacologic Options in post-operative Hospital-based and Rehabilitation pain Management

EHR

Electronic health record

TFA

Theoretical Framework of Acceptability

IRB

Institutional Review Board

HIPPA

Health Insurance Portability and Accountability Act

POE

Pre-operative Evaluation

PT/OTs

Physical therapists and occupational therapists

HE

Highly engaged

LE

Less engaged

Authors’ contributions

SM, JT, AC, SC, and CT contributed to the conceptualization of the manuscript. SM and CT collected the data. SM, CT, KS, and CA contributed to the data analysis. CA assisted with preparing Table 1. SM prepared the first draft of the manuscript, and all authors provided their feedback on subsequent drafts. All authors have reviewed and agreed on the final version.

Funding

This work was supported within the National Institutes of Health (NIH) Pragmatic Trials Collaboratory through the NIH HEAL Initiative under award number UH3 AG67593-04 administered by the National Institute on Aging (NIA) and the National Institute of Neurological Disorders and Stroke (NINDS). This work also received logistical and technical support from the PRISM Resource Coordinating Center under award number U24AT010961 from the NIH through the NIH HEAL Initiative. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIA, NINDS, or the NIH or its HEAL Initiative.

Data availability

The datasets generated and analyzed during the current study, consisting of interview transcripts, are not publicly available to protect the privacy of individual patients, who participated in interviews.

Declarations

Ethics approval and consent to participate

Study procedures were approved by the Mayo Clinic IRB (# 21-007898). Subjects signed a HIPAA release form to provide written consent to have their data used for research.

Consent for publication

Participants provided consent and a signed a HIPAA release for their de-identified health information to be used for research, which covers the use of de-identified quotes per IRB policy.

Competing interests

The authors declare no competing interests.