Nursing Care Omissions in Postoperative Pain Management: Secondary Analysis of a Multimodal Analgesia Implementation Study.

PURPOSE: To examine how omissions in pain-related nursing care occur during the implementation of a multimodal analgesia protocol and to identify contributing factors and targets for improvement.

DESIGN

Secondary qualitative analysis of interviews from a larger descriptive study conducted across three university hospital sites.

METHODS

Fifteen individual and focus-group interviews with nurses, physicians, and pharmacists were held approximately 3 years after protocol implementation. Selected verbatim transcripts were independently coded by two analysts. Codes related to pain-related care omissions were extracted and organized using thematic analysis, with team review to enhance consistency.

RESULTS

Three domains of omission were prominent: (1) inconsistent medication monitoring and pain reassessment after administration; (2) underuse of interdoses and co-analgesic strategies despite protocol availability; and (3) incomplete or missing pain-related documentation. Reported drivers included insufficient staffing and time pressure, role ambiguity between disciplines, variable familiarity and comfort with the protocol, and communication lapses that complicated medication changes. Patient characteristics-such as opioid tolerance, frailty, cognitive impairment, language barriers, and values-also shaped decision-making and contributed to missed care, undertreatment, or delays.

CONCLUSIONS

Omissions in pain-related nursing care arise from an interplay of organizational conditions, team processes, and patient factors. Protocols alone are insufficient; effectiveness depends on local capacity, clear roles, reliable communication, and individualized application.

CLINICAL IMPLICATIONS: Health systems should pair multimodal analgesia protocols with actions that strengthen staffing and workload management, clarify professional responsibilities, standardize and streamline documentation, and provide targeted training and decision support. Interdisciplinary routines (for example, brief pain rounds) and patient-centered assessment strategies can enhance adherence, reduce omissions, and improve postoperative pain outcomes.