When the Number Falls Short: Nurses, Postoperative Pain Discordance, and Opioid Stewardship.

PURPOSE: To explore how surgical-ward nurses experience and interpret patient-nurse discordance in postoperative pain assessment and how this discordance shapes pain management and opioid stewardship in practice.

DESIGN

Qualitative study using Interpretive Description.

METHODS

Nineteen registered nurses providing direct postoperative care in adult surgical wards were purposively recruited from two hospitals in southern Saudi Arabia to maximize variation across sites, experience, roles, and specialties. Individual semi-structured interviews were audio-recorded, transcribed verbatim, and analyzed concurrently using Interpretive Description.

RESULTS

Four interpretive themes were identified: Reading pain beyond the number; negotiating credibility in a relational and cultural space; practicing caution under the shadow of opioids; and carrying discordance within organizational constraints. Discordance was described not as a simple mismatch between pain scores and clinical observation, but as an interpretive challenge shaped by trust, family dynamics, multilingual communication, workload, and hierarchical decision-making. Participants described it as influencing whether analgesia was administered, delayed, questioned, or escalated, and intensifying the tension between relieving suffering and avoiding opioid-related harm.

CONCLUSIONS

Patient-nurse discordance in postoperative pain assessment is a clinically consequential phenomenon that extends beyond numeric pain scoring and was described as shaping analgesic decision-making and opioid stewardship in surgical wards. Nurses navigate this discordance through interpretive, relational, and organizational work not fully captured by standard pain assessment tools alone.

CLINICAL IMPLICATIONS: Postoperative pain management may be strengthened by approaches that support nurses' clinical judgement, communication across linguistic and cultural differences, structured team-based decision-making, and opioid stewardship practices responsive to uncertainty in pain assessment.