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Nursing care of patients in pain: an age-old problem

Ramon Pediani
RN BSc(Hons) PhD
Former Clinical Nurse Specialist for Acute Pain
Victoria Hospital
Blackpool

The author did a presentation ­entitled "The Nurse's Role in Pain Management" in the "Pain and Chronic Wounds" section of the 12th Conference of the European Wound Management Association in May 2002

This article purposefully draws on many of the early papers on the topic of pain to show that the problems of pain management have long been recognised and understood, but that the solutions have not spread into practice. Nurses are in a unique position to improve the patient's experience of wound pain, but to have a positive impact on outcomes they must see the nurses' role in its wider context, and identify deficiencies in their own knowledge and skills.

Definitions of pain
McCaffery stated that pain is what the patient says it is,(1) and although this may be true, it does not in itself offer any practical solutions. Sofaer commented that pain is a complex phenomenon, known to many, but defying definition.(2) Pain has, however, been described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage,(3) and as a unique, highly subjective, multidimensional experience encompassing many sensory and affective components.(4)
The duration of wound pain is often wrongly assumed to be limited to the healing time of the damage.(5) Potter defined acute pain as that which is present for less than four weeks, and chronic pain as that which is present for longer than six months.(6) Prechronic pain is present for between one and six months, and presents a window of opportunity for the prevention of chronic pain resulting from unrelieved acute pain episodes. Crombie et al illustrated this when they surveyed the initial cause of pain in 5,130 patients attending chronic pain clinics and found that over 40% of problems resulted from earlier inadequate pain control.(7) Callesen et al surveyed 400 patients who had a groin hernia repair and found that, at one year, 19% still had wound pain.(8) Krasner makes a distinction between noncyclic wound pain, such as sharp debridement or drain removal, and cyclic pain, such as daily dressing. All of the above suggests that with the potential to develop chronic pain problems the level of priority afforded to procedural pain management now needs to be re-evaluated.(9)

Historical inadequacies of pain management
A review in 1979 claimed that pain management techniques had not advanced in the past 25 years or more,(10) and some 15 years later a major review concluded that nurses' lack of knowledge undermined appropriate nursing interventions.(11) In a seminal piece of research in 1980, Cohen found that over 75% of surgical patients (n=109) had experienced "moderate" or "marked pain distress".(12) A lack of formal pain assessment, it was suggested, resulted in miscommunication between patients and nursing staff, and it was claimed that "choices of analgesic medications seemed irrational; and knowledge of the drugs was inadequate".
Nurses' lack of knowledge was seen as one of the main obstacles to good patient care by Hosking,(13) who reported that nurses were not giving analgesia until patients were already in considerable pain, rather than keeping them comfortable and pre-empting painful activities. Kuhn et al conducted a questionnaire study into patients' pain experiences and contrasted this with their nurses' and doctors' attitudes.(14) This study showed that nurses underestimated the amount of analgesia required to control patients' pain, and did not assess or evaluate the drugs that they had given. This led the authors to state wryly that: "Patients expect ineffective pain relief and their carers ensure that they are not disappointed." This was adequately illustrated by Bruster et al in a recent study of 5,150 hospital patients, 2,755 (53%) of whom experienced moderate to severe pain.(15)

The fear of opioid addiction
Among medical and nursing staff there has been a persistent fear of causing addiction in patients supplied with opioid drugs for the relief of their pain,(16) and this overestimation of the addiction risk leads to an underestimation of the harm of untreated pain.(17) Porter and Jick in 1980 reported one of the largest review studies on 11,882 medical inpatients receiving at least one opioid analgesic, and estimated the addiction risk to be less than 1%.(18) Saxy found that 77% of nurses did not understand the pharmacology of opioids,(19) which may have contributed to Seers' finding that 85% of nurses overestimated the risk of addiction.(20) Wallace et al  have argued that if knowledge of addiction is an accurate barometer of other pain management knowledge, then there is little evidence that knowledge is improving.(21)

Factors affecting patients' experiences of pain
Patients' perceptions of pain are complicated and bound up with their cultural background, age, sex and past experience,(1,22,23) although each of these factors may be seen to work in different directions in different people. For example, men have been found to under-report their pain to female researchers,(24) while nurses have been shown to select less medication for female patients.(12) Greenwald found differences in the interpretation of pain within different ethnic cultures,(25) although Hosking and Welchew found pain thresholds to be little different between ethnic groups,(26) but the way in which pain was accepted or expressed varied. Predicting or evaluating the pain experience in any given individual therefore is not a simple activity.
The cause of the pain may play a part in the perception of its severity. For example, the pain of a chronic leg ulcer wound may be viewed differently from the pain of cosmetic surgery. While one patient may under-report their pain to appear stoical, avoid a painful injection or to please nurses, another patient may need to overemphasise their pain in order to receive adequate analgesia. There is no substitute for involving the patient directly in the assessment and recording of the level of pain being experienced and the degree of relief being obtained from any analgesics given.

The challenges of accurate pain assessment
There is immense variability between individual patients and nurses, presenting opportunities for miscommunication. Since assessment is an interactive process between the nurse and the patient, the responsibility is on nurses, as a professional group, to recognise these difficulties and find strategies for overcoming them. In Zalon's research, surgical patients and their nurses were asked to rate the level of pain being experienced, and it was found that nurses overestimated mild discomfort but failed to recognise more severe pain.(27) Zalon's study would suggest that it is not enough simply to make a professional judgement about how much pain someone is, or ought to be, in. To say that "pain is whatever the patient says it is" makes the assumption that we have either asked the question or the patient has volunteered the information.
The barriers to pain management were discussed throughout the 1970s and 1980s, and two of the difficulties for nurses attempting to titrate analgesia against a measured effect was that there had been no easily defined endpoint,(5) and medical and nursing staff held different values when it came to setting standards for pain control.(28) Patients may believe that nurses will know how much pain they are in,(12,29) but nurses may believe that if the patients were in pain they would say so.(30) Jacox has suggested that patients associate a social stigma with being seen to complain of pain, and nurses may mistakenly interpret the patients' behaviour as coping.(31) This lack of dialogue creates a formidable barrier to pain relief. Patients who use a pain assessment tool have, however, found it easier to communicate their pain levels, felt more informed, and were given analgesia more readily.(32)
Research over many years has shown that nurses considerably underestimate severe pain,(12,20,27,33-35) and this begs the question of why it is that experienced, caring, professional nurses can get the assessment of something so seemingly universal as pain so wrong? Turrill offered the opinion that employees generally are doing their best to achieve a high quality of service, it is just that often they are doing the wrong thing to the best of their ability!(36)
The way in which nurses make judgements about a person's pain will be affected by many of the same factors that affect the patient's perception.(22) Nurses have their own personal experience of pain and sense of cultural norms, but in addition the subculture of the nursing profession gives a particular view of the world of pain and its importance in the clinical setting. Research by Dudley and Holm indicated that the only really significant factor in a nurse's mind when gauging how much pain a patient is experiencing is the category of illness or injury - that is, the bigger the incision, the more pain allowed.(37) Such knowledge could lead to education strategies focused on giving nurses a greater appreciation of patient individuality.
Using pain assessment tools where the patient has the opportunity to rate their own pain sounds ideal, and yet the way in which pain tools are applied is another source of confusion, as a proportion of patients will not be able to use a verbal, numerical or visual scale - they simply will not be able to categorise their pain in that way.(38,39) Whatever tool is used, it is essential that the patient is informed as to the purpose of pain assessment and analgesia provision. They should never be made to feel they are being weak to need pain relief, but see it as part of their treatment and be encouraged to become involved and participate actively in their own recovery.

Summary
Nurses must appreciate that pain can cause serious harm to their patients, both physically and psychologically, and if allowed to persist it can result in chronic pain that lasts long after any sign of physical injury has healed. There are difficulties in defining what pain is; there is great variability in the experience of pain, and this is further complicated by the complexity of professionals as individuals, each with their own individual biases, levels of preparation and fears of causing drug addiction. Add to this the likelihood of having an effect on the very thing nurses are trying to measure just by asking the questions and pain assessment appears to be a pointless exercise. There is, however, a psychological advantage for the patient having their pain assessed: when consulted about how they feel, when a nurse spends time other than carrying out tasks, the patient feels respected and cared for. This can help break the helplessness- or hopelessness-pain cycle that can arise when pain is perceived to be being ignored and undertreated.(40)
The evidence of the past 30 years has shown that nurses need to be aware of their own knowledge, skills and competency to practice. Being accountable for practice relates not only to the actions we perform on patients, such as the standard of our wound dressing technique, but also to those acts we omit, such as neglecting to assess fully the patient's pain or to take action to minimise it. We may never entirely relieve pain, but as professionals we must expect to be judged on our ability to assess, plan, carry out and evaluate the care that we give.

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