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INTERVENÇÕES NÃO FARMACOLÓGICAS NO MANEJO DA DOR PÓS-OPERATÓRIA: CONCEPÇÃO DE ENFERMEIROS NON-PHARMACOLOGICAL INTERVENTIONS IN POSTOPERATIVE PAIN MANAGEMENT: NURSES’ CONCEPTION INTERVENCIONES NO FARMACOLÓGICAS EN EL TRATAMIENTO DEL DOLOR POSTOPERATORIO: CONCEPCIÓN DE LOS ENFERMEROS

Objective: to assess nursing care in non-pharmacological interventions in postoperative pain. Method: descriptive and qualitative study with nurses from the general surgical clinic of a public hospital in Recife. Data were collected from July to September 2019, through semi-structured interviews recorded and assessed through the thematic content analysis proposed by Bardin. Results: six nurses with an average age of 45.3 years took part in the study, with time of training between 3 and 24 years. Three categories emerged from the statements: 1) Nurses’ sensitivity and knowledge in the adequate pain management; 2) Thermotherapy and comfort massage for pain relief for the surgical patient; and 3) Alternative practices associated with drugs in postoperative pain control. From the reports, the subjectivity characteristic of pain was verified as a factor that influences its assessment. Conclusion: it was identified that nurses have autonomy, playing a key role in recognizing the benefits that integrative and complementary health practices can promote to the patient, regarding the quality and comfort in postoperative pain relief, such as thermotherapy, comfort massage and dialogue to divert the focus of attention. Other techniques are difficult due to lack of resources. Descriptors: Pain, Postoperative; Pain Management; Nursing.

Pain is conceptualized as an experience of the senses at the emotional and tactile level, with an uncomfortable and subjective sensation, which is characterized as a multidimensional experience, either in quality or intensity, from the sensory, affective, autonomic and behavioral point of view. 1-2 Pain is configured as a common phenomenon, identified by all human beings, which can manifest itself in different ways. Thus, its assessment and measurement are important parameters of control and patient care. 3 Significant scientific advances have occurred in pain assessment in recent years, bringing to light the effectiveness of adequate pain management for quality patient care. 3 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) understands pain as the fifth vital sign, identifying it as a priority in assessment, intervention and reassessment during comprehensive care in the patient's hospitalization. 4 Inadequate control of pain sensation can be related to the absence of criteria or unpreparedness in the use of assessment and recording methods. 3-5 Generally, the knowledge, technical man-  6 This may be due to the lack of knowledge about what type of therapy would be most effective in controlling pain, partly due to a deficit in their professional training or due to difficulties in accepting workers and patients because of the hospital culture of resistance to using integrative and complementary practices (ICPS) in the field of pain management or by insufficient scientific evidence. 7 It is noteworthy that nursing is able to expand its field of action and assume some integrative and complementary practices as components of care. Within this perspective, one should analyze the possibility of the empowerment of nursing in the National Policy on Integrative and Complementary Practices (PNPIC, as per its Portuguese acronym) and in the SUS regarding the insertion of integrative practices in the act of nursing care. 10 The protagonism and empowerment of nursing staff are necessary in relation to the use of ICPS in their care practices, but, for this, they need professionalization and knowledge about ICPS in their work context, thus providing autonomy for patients and reducing costs for the SUS. 11 It is understood the role of the nursing professional as a mediator of acute pain relief methods for postoperative patients. Therefore, it is justified to question why non-pharmacological interventions in the management of postoperative pain are little explored in nursing care?

INTRODUCTION
To assess nursing care in non-pharmacological interventions in postoperative pain.

Applied methodology
This is a descriptive and exploratory research, with a qualitative approach, conducted in the general surgical clinic unit of a public hospital in the metropolitan region of Recife.
The recruitment of individuals was done by convenience according to the following inclusion criteria: being a nurse in the institution and in the surgical clinic sector with a minimum experience of 1 year in surgical patient care. Professionals on maternity leave, on sick leave or on vacation were excluded. The interview was conducted, previously scheduled so as not to disrupt the progress of the service, in a private room, free of possible interruptions and recorded on digital audio with the interviewee's consent. The sample was closed due to saturation of responses, i.e., when there is no new information in the statements, resulting in six interviewees.

Data collection elaboration
In order to ensure anonymity, participants were identified by the letter E, followed by Arabic numerals in the order of the interviews (E1, E2, E3...). The transcribed data were assessed using the thematic modality content analysis technique, which uses content as a set of communication analysis techniques from three sequential phases of pre-analysis, material exploration and treatment of results, with inference and interpretation. Therefore, the statements were grouped according to the similarity of meanings, categorizing them later. 12

Ethical aspects
The research was conducted within the standards required by Resolution 466/12, produced Six on-duty nurses (three from daytime and three from nighttime) composed the sample, they were female (100%), with an average age of 45.3 years. The time of training ranged from 3 to 24 years. In total, they worked in more than one institution, with an average workload of 42.22 hours per week.
The description and analysis of the statements presented contextual meaning in the way nurses performed their assessment and management to minimize the effects of pain from the emergence of three categories described below:

Nurses' sensitivity and knowledge in the adequate pain management
When answering about the nurses' conception in the management of pain in the postoperative phase of patients, the interviewees defined that postoperative pain is natural, which requires professional sensitivity and empathy for its best management. However, although the use of drugs is preferred, there is a need for the provision of non-pharmacological material for this practice to be RESULTS stimulated by providing alternative routes of relief and comfort to the surgical patient with postoperative pain: "When the patient arrives from the operating room, normally, he is still a little sedated due to anesthesia, so his pain appears more in the following hours, but it decreases over time. After

Thermotherapy and comfort massage for pain relief for the surgical patient
As for the types of non-pharmacological nursing interventions that are used for postoperative pain relief, nurses highlighted that they adopted comfort measures in positioning, relieved patient anxiety with qualified listening, thermotherapy and massage therapy, and also stimulated the patient for self-care:

Alternative practices associated with drugs in postoperative pain control
In order to improve the quality of nursing care, the suggestions given by the interviewees to minimize the excessive use of drugs in postoperative pain management as facilitators of health actions were based on minimizing these dosages and implementing non-pharmacological therapies in the sector, for example, the use of aromatherapy, Reiki, music therapy, deep breathing, chromotherapy and shiatsu: Effective pain management depends on an accurate and comprehensive assessment of the patient's symptoms, functional status and clinical history, by means of tools that tend to locate and quantify, in a reliable and valid manner, the client's experience of pain, in order to facilitate communication between the client and the health professional. [13][14][15][16] In the post-operative period, its control is fundamental to provide quality care to the individual. 13

DISCUSSION
The professional must be based on scientific evidence that supports his/her practice as a nurse, in the search for improvement in nursing care, so that pain control measures can be part of his/her daily routine in providing care to patients. [13][14] The subjectivity characteristic of pain as a factor that influences its assessment was verified through the professionals' statements. In this sense, a research conducted in São Paulo with patients undergoing orthognathic surgery showed that each individual's experience of pain can be influenced by his/her own history, his/her understanding of pain and the presence of anxiety. Thus, people in identical or similar conditions may behave differently due to the variation in their personality and experience. This was highlighted by the conception assessed in the involved professionals. 13 Although it is understood that postoperative pain control is essential in the provision of highquality patient care, the ability to understand and appreciate its adverse consequences demonstrates that health professionals can employ non-pharmacological measures associated with drugs, provided they are appropriately trained in postoperative pain relief, and thus improve the ability to produce effective analgesia. [15][16][17] On some occasions, professionals with some knowledge of pain assessment and treatment, due to misguided concerns about the side effects of analgesics or fear of their dependence, may restrict the use of these medications. 15,18,19 During the postoperative period, if the medical team is not attuned to actively assessing the level of pain experienced by the patient, appropriate treatment may be delayed. 19 In the treatment for pain relief and control, the nurses reported that medication approaches are the most recommended, with the prescription of routine drugs in the first 24 hours after surgery. However, they also emphasized the adoption of some measures or alternatives independent of medical intervention that aim at promoting relaxation and focal pain distraction and, consequently, allow the patient to feel more comfortable with the situation being experienced.
Non-pharmacological intervention measures for surgical patients should be used with the purpose of controlling and relieving postoperative pain. [13][14] This casuistry allowed the identification of action strategies adopted by nurses in the assessment and management of postoperative pain and how they develop their activities to minimize the excessive use of pharmacological analgesia.
Quality of life is one of the benefits most cherished by those who use Integrative and Complementary Health Practices, because it is reflected in all the other benefits. Non-pharmacological interventions, such as the use of plants and teas, constitute a factor that greatly helps patients' quality of life, providing a more autonomous type of care, for example. ICPS aim to increase the patient's quality of life, through practices that stimulate physical and mental well-being, as well as reducing harm from worsening conditions, promoting a better treatment environment. 11 In the interviewees' speeches, the understanding about the application of non-pharmacological interventions in pain management and its effectiveness in postoperative care was highlighted.
Moreover, the difficulty in using non-pharmacological techniques was identified due to the lack of financial resources and support of hospital supplies, which are not always available in the institution, which sometimes makes it impossible to develop an assistance with improved quality in pain relief aimed at the implementation of integrative practices.
Non-pharmacological interventions are adjuvant to pharmacological treatment and should have their use discussed with patients and their relatives as part of perioperative care planning, with the recommendation on the importance of organizational structure that allows for policies and procedures for postoperative pain control to be developed and enhanced. [14][15] The nurses' autonomy and knowledge are of fundamental importance in the promotion and implementation of alternative practices based on scientific evidence in pain relief for surgical patients. 7 Studies have shown that the inadequate training of health professionals on many aspects of pain management interferes with the quality of care. 15,20,21 It is necessary to identify the needs of each patient and plan according to the benefits that a particular alternative measure to be adopted may contribute to his/her surgical recovery.
Sometimes, it is identified a lack of investment by the hospital institution, whether in the perspective of public or private hospitals, which do not have financial investments aimed at the applicability of alternatives, for example, the use of aromatherapy or, still, the lack of sensitivity of the management in promoting certain practices in the hospital environment, such as Reiki, music therapy, chromotherapy and shiatsu, which would help to promote more options of feasible nonpharmacological alternatives to the management of acute postoperative pain and the benefits of improvement in patient care. 15 Some limitations were observed in this study, since the nurses had to leave their workplace for a few minutes, as well as the environment chosen for the interview was not adequate for not maintaining isolation from external noises. There were also some interruptions for problem solving by the professional participant, which affected the conduction of data collection.
This study corroborated and showed that non-pharmacological measures associated with medication can be employed in postoperative pain relief by nurses, provided they have the proper CONCLUSION training. Interfering with quality of life is one of the benefits most esteemed by those who use Integrative Complementary Health Practices, as it is reflected in all the other benefits, which was evident in this research.
The participants recognized that integrative and complementary practices, such as thermotherapy, comfort massage, relaxation techniques, music therapy, among others, can be applied as a care model in perioperative nursing care, with good results in pain reduction and surgical recovery of patients, but there are still some difficulties and resistance to be implemented in the hospital environment.
The authors related to the study effectively participated in the preparation of the manuscript.
Principal researcher Kerrolayne Christtine Jacob was responsible for preparing the research project, collecting, analyzing and discussing the data/results. The authors: Lais Bezerra da Silva, Eder Dourado Martins da Costa and Iago Vieira Gomes, also helped in the collection, tabulation and analysis of data, in addition to the creation of tables and general formatting of the manuscript. The review of methodological procedures, results and discussion and textual writing was accompanied by supervisor Solange Queiroga Serrano.
There is nothing to declare.