Nursing and Supporting Patients With Chronic Pain

By Shaw, Susan M

Summary

Nurses in all settings are likely to be working with patients in chronic pain on a regular basis. Although there is much information available about chronic pain, there is evidence that nurses find patients with chronic pain difficult to work with. This article assists nurses to maintain and develop their practice by addressing these issues.

Keywords

Pain and pain management; Pain: measurement

These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For related articles and author guidelines visit our online archive at www.nursing-standard.co.uk and search using the keywords.

Aim and intended learning outcomes

Chronic pain is experienced by an increasing number of people. This means that nurses in all settings are likely to be working with patients in chronic pain on a regular basis. There is much information available about chronic pain. However, there is evidence that nurses find patients with chronic pain difficult to work with. This article aims to assist nurses to maintain and develop their practice by addressing these issues.

After reading this article you should be able to:

* Explain the prevalence of chronic pain.

* Describe how chronic pain differs from other types of pain.

* Develop an appreciation of patient experience.

* Identify misconceptions held by health professionals about patients experiencing chronic pain.

* Reflect on your practice and ask ‘How can I work differently in the future?’

* Consider skills and knowledge which may be developed further.

Introduction

Pain is a universal part of human experience and is defined as an emotional and sensory experience resulting from actual or potential damage (Merskey and Bogduk 1994). Chronic pain is pain that has been present for a significant length of time, is disabling and may interfere with physical functioning (Price 1996, Simon 1996). Chronic pain is common, increasing in prevalence and is a leading cause of disability. The experience of this type of pain is complex for health professionals and patients, and as a result it is not always well understood or managed. One explanation for this is that the models of diagnosis and treatment that are used for other categories of pain are not appropriate for describing or responding to patients experiencing chronic pain.

Time out 1

Consider five patients you have nursed recently and try to answer the following questions:

* How many were affected by pain?

* Of these, how many had pain identified as a problem?

* Were there other patients who may have benefited from a pain assessment?

Types of pain

The pain that people experience may be divided into categories. These determine how the pain is defined by patients, treated by health professionals and responded to by society. Acute pain is generally caused by trauma such as surgery or inj ury. The cause of acute pain is obvious, and the experience of it may be severe, but generally it can be treated effectively. Once the trauma has been resolved the pain subsides. This is a type of pain that is easy for people to recognise and the treatment of it is well understood by professionals. Because the origin of acute pain is obvious it is usually remedied in a short period of time and does not usually continue to be a problem for patients, professionals or resource agencies.

Pain that is related to terminal illness is also quite well understood by patients and health professionals. As with acute pain, there is an obvious or understandable cause. The desire to ensure that people do not suffer needlessly underpins responses to those with terminal pain. As a result this pain is treated in a more comprehensive manner than other types of pain, partly because there is less concern about potential negative effects of treatment if the patient is already seriously unwell (Melzack 1990).

Procedural pain is experienced by patients during treatment or diagnostic investigations. This category of pain has always existed but has only recently received recognition in nursing. Procedural pain poses a fundamental conflict for health professionals and patients, because health care is generally associated with the concept of providing comfort rather than causing pain. There is considerable evidence that this type of pain is poorly understood and managed by health professionals (Madjar 1998).

Chronic pain

Chronic pain, like procedural pain, is often unrecognised and inadequately treated by health professionals. It is a long-term experience of pain that often continues beyond the presence of identifiable causes of trauma, making the cause of it more difficult to isolate than other types of pain (McCaffery and Pasero 1999). Chronic pain by definition is not usually cured but is often manageable. The concept of chronic pain is difficult for many health professionals to understand because generally they are educated and work in clinical settings where they encounter patients who are experiencing acute pain. As a result it is common for them to treat chronic pain as if it were acute (seers and Friedli 1996).

Chronic pain is a common cause of disability (Chapman and Gavrin 1999) and is experienced by an increasing number of people (Burckhardt 1990, Davis and Magilvy 2000). It is difficult to know what proportion of the population experiences chronic pain. However, some studies have estimated that approximately 45 per cent of the population may experience this type of pain (Elliott et al 1999). In the United States it has been estimated that 25 per cent of the population experience pain more than 50 per cent of the time (Wilson etal 1992), and a World Health Organization study reported that approximately 22 per cent of people experience persistent pain (Gureje et al 1998). These studies have generally been based on samples of patients enrolled with healthcare providers and therefore the estimations of how many people experience chronic pain do not include those who are not engaging with health professionals (Crook etal 1984). Despite the prevalence of chronic pain there is evidence that it is not effectively treated by health professionals (Hitchcock etall994), and society feels it is not well managed (Norton etal 1999). Chronic pain syndrome Many people with severe pain manage their lifestyles in spite of their pain (Risdon etal 2003), while others stop searching for cures and lead satisfying lives despite constant pain (Howell 1994). A small proportion of patients with chronic pain display maladaptive behaviour, which is referred to as chronic pain syndrome (CPS) (Wall and Melzack 1989, McCaffery and Pasero 1999). CPS is a psychosocial disorder and is characterised by the experience of chronic pain becoming the central focus of the patient’s life. Patients with this disorder engage in dependent relationships with family members and health professionals. These patients tend to be depressed, anxious, and no longer able to maintain employment or other responsibilities. They frequently seek radical interventions despite the limited likelihood of success. Some of these maladaptive behaviours may be iatrogenic as a result of previous inadequate symptom management (Bates et al 1997), or an inaccurate belief that the pain may be able to be cured. The features of CPS should not be used to define patients with chronic pain.

Time out 2

Consider patients you have nursed who have experienced various types of pain (acute, terminal, procedural, chronic or chronic pain syndrome).

* What was it about these patients that you remember?

* What skills and knowledge did you draw on?

* What were the challenges that you experienced?

* What did you learn from these patients/situations?

Management of pain

While knowledge about pain, and specifically chronic pain, has continued to advance and become widely available since the 1980s, this has not led to an overall improvement in the way patients experiencing it are treated or understood. However, it is estimated that the knowledge and resources exist to adequately manage 90 per cent of the pain that people experience (McCaffery and Pasero 1999).

The reasons why pain is not effectively managed have been grouped into three main areas: the healthcare system, health professionals and patients (McCaffery and Pasero 1999). The healthcare system encompasses the cultural contexts of patients and professionals, the processes for diagnosing and treating pain, and the general environment in which health care is offered. The practice of health professionals contributes to inadequate pain management because deficits in knowledge, skill, attitudes and values towards pain and people who experience it influence practitioners. Patients also pose barriers to the effective management of pain. In particular, they have been found to have fears about medication and addiction (McCaffery and Pasero 1999). Concerns that the public have about health care can be directly related to the inaccurate and inadequate knowledge that is held by health professionals (French 1994).

The values of Western medicine require health practitioners to identify objective information in the assessment of patients and the evaluation of health care that is provided (Galvin 2002). There is evidence that such an objective approach is not appropriate when dealing with pain in general and even less appropriate in the management of chronic pain. One example of this is th\e finding that health professionals regularly assess pain and evaluate the treatment of it in terms that are different to those of patients (Ecclestoneia/1997). These objective values lead health professionals to treat pain by separating the symptoms from the person who is experiencing them. Health professionals tend to consider pain as a symptom that needs to be supported by evidence (McCaffery and Pasero 1999), even though chronic pain is not necessarily accompanied by physiological evidence of tissue damage or expressions of pain (Portenoy and Kanner 1996). Patients with chronic pain frequently do not display behaviour that communicates that they are in pain (Turner and Clancy 1986).

This search by health professionals for objectivity is demonstrated in attempts to quantify pain. There is evidence that professionals treat patients differently once clear pathology is found that can account for the pain that they experience, and assume that when there is no obvious cause of pain, it either does not exist or is not very severe (Halfens et al 1990). Assessment of chronic pain is a challenge for professionals because it is a situation where they have to rely on information from the patient, more than observable symptoms, to provide an assessment of the condition (McCaffery and Pasero 1999). It is important to realise that relatively minor experiences of pain can have a considerable impact on patients. In studies where patients have been asked to rate their pain on a scale of one (minor pain) to ten (severe pain), scores of four to five were found to affect patients’ daily functioning, and scores of six to seven were found to interfere with enjoyment of life (Twycrosseia/1996). The search for objective evidence to confirm the existence of pain is further complicated, and the subjective nature of it confirmed, by the tendency of patients’ current level of pain to cloud their memory of pain they have previously experienced (Eichetal 1985).

Time out 3

Reflect on what comes to mind when patients say they are in pain, when colleagues report during handover that a patient is in pain and when you have difficulty managing a patient’s pain.

Patients’ experience of chronic pain

Despite stereotypes of people with chronic illnesses and disabilities as dependent and passive (French 1994), there is evidence that many people in this situation are active and otherwise healthy. In an overview of research in the field of chronicity, Thorne and Paterson (2000) report that research based on the experience of patients with chronic illness presents them as active and thinking analysts. In a review of 300 nursing references, Dluhy (1995) identified demands and challenges, emotional and cognitive responses, day-to-day tasks of living with illness, being chronically ill in the culture of a healthy society, changing patterns with family and healthcare providers, and potential life outcomes as issues for patients. Patients who manage their lives in spite of the presence of chronic pain may either choose to no longer engage with health professionals providing their care, or be selective about those with whom they have contact (Richardson and Poole 2001). In fact many patients actively seek to conceal that they are in pain (Niv and Kreitler 2001). For patients with chronic pain the dynamic and subjective nature of pain is the basis of their experience, and the interactions they have with health professionals are of great importance to them (Reid et al 1991, seers and Friedli 1996). Establishing a positive relationship with health professionals, based on equitable power relations and dynamics, is particularly important for people with chronic health issues because they often have ongoing relationships with those who treat them.

Patients with chronic pain feel under pressure to prove that the pain they experience is real when they interact with health professionals. They feel a responsibility to provide evidence that the pain exists, so that health professionals may be able to find a cause and validate it (Johansson et al 999). There is also pressure on them to explain the pain in terms that professionals will understand (Price and Cheek 1996). This raises the issue of using objective measures to assess a subjective experience, because patients with chronic pain often do not demonstrate behavioural or physiological signs of pain. In a study of the experience of 75 people with chronic non-malignant pain and how it affected their lives, seers and Friedli (1996) identified that patients experienced the need to feel that professionals believed they were in pain. In addition to being believed, finding a cause for pain and having pain legitimised are vital tasks for patients. In a study that researched 52 Australian women with repetitive strain injury, similar issues were identified. This has been termed the ‘burden of proof which rests with patients as they interact with, and receive treatment from, health professionals (Reid et al 1991).

Time out 4

Consider what you hear colleagues say about patients with chronic pain. Are these comments stereotypes? What do you think they may be influenced by?

Misconceptions about chronic non-malignant pain

Margo McCaffery is one of the most prolific writers and researchers in the field of pain and pain management. In collaboration with colleagues (McCaffery and Beebe 1989, McCaffery and Pasero 1999) she has documented many misconceptions held by health professionals about people experiencing pain. These misconceptions are presented as beliefs, values, attitudes and ‘exaggerated fears’ (McCaffery and Pasero 1999). Evidence that they are incorrect is the basis for them being referred to as misconceptions. There are several sets of misconceptions relating to the assessment and treatment of patients with various kinds of pain. The misconceptions identified as being held by health professionals towards people experiencing chronic non-malignant pain are shown in Box 1.

Time out 5

Make a list of the information and practices in your organisation that address or reinforce each of the misconceptions highlighted in Box 1.

Nursing practice

Practitioners bring beliefs and values from their individual cultural heritage to their practice (Westbrook et al 1984). Studies have found that the background of health professionals affects their ethical and moral decision making (Green etal 2003), and the manner in which they interact with patients (Paris 1993). This is an important issue because patients with chronic pain most frequently evaluate the care that they receive according to the attitudes, rather than the skills and knowledge, that they perceive in health professionals (McCracken et al 1997, Sherwood et al 2000).

BOX 1

Misconceptions held by health professionals towards people experiencing chronic non-malignant pain

For more than 20 years research has identified knowledge deficits among nurses about pain in general, and chronic pain specifically, and resulting deficiencies in nursing practice regarding pain management (Brunier et al 1995).

In a study of the knowledge, attitudes and clinical pain management practice of 150 nurses in five different countries, McCaffery and Ferrell (1995) identified knowledge deficits that were likely to affect the care of patients. They observed that the longer a nation had been deliberately engaged in educating professionals and the public about pain management, the better informed were the nurses.

A lack of knowledge about pain management and assessment was also identified in a study of 318 nurses in Canada (Hamilton and Edgar 1992), which found a lack of understanding of the differences between chronic and acute pain to be prevalent, as well as poor knowledge about pain management interventions.

In a study of the knowledge and attitudes of 120 nurses about pain management, Clarke et al (1996) discovered knowledge about the differences between acute and chronic pain were inadequately addressed in the education of nurses and identified ‘a persistence of inaccurate, negative attitudes about patients in pain’.

Time out 6

Reflect on the ways you think patients with chronic pain are perceived within your personal cultural context and organisational and multidisciplinary boundaries.

Conclusion

The role of nurses in the management of pain is particularly important because they are often responsible for patient assessment, administration of pain relief interventions and evaluation of their effectiveness (Lisson 1987). Nurses are also regularly responsible for deciding which, if any, pain relief measures are offered to patients, and are often involved in the design and evaluation of healthcare services (Davis and Magilvy 2000). The management of pain is considered to be one of the most important technical and moral tasks in nursing (Hunter 2000). However, the widespread lack of knowledge that nurses have about pain management, and the attitudes, values and misconceptions that they hold about pain and the people who experience it, have a detrimental effect on their practice (McCaffery andPasero 1999)

Time out 7

Write down some questions that yon would like to explore about working with patients who are experiencing chronic pain. Consider how you might extend your knowledge of this area, for example, by identifying articles from the reference list.

Time out 8

Now that you have completed this article, you might like to write a practice profile. Guidelines to help you are on page 68.

NS325 Shaw SM (2006) Nursing and supporting patients with chronic pain. Nursing Standard. 20,19, 60-65. Date of acceptance: August 10 2005.

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Author

Susan M Shaw is principal lecturer, Centre for Educational and Professional Development, Auckland University of Technology. Email: susan.shaw@aut.ac.nz

Copyright RCN Publishing Company Ltd. Jan 18-Jan 24, 2006