Adequate control of pain is only achieved in 50% of patients in Western societies. This emphasizes that pain control is a serious problem for a great number of patients. Health care professionals, patients and the health care system itself all contribute to this problem. Other factors that add to this undesirable situation include the following:
Poor decision making on part of health care professionals myths and misconceptions about pain and opoids patients non compliance with treatment and their reluctance to report pain Problems within the organization of health care
Pain assessment and management is an integral part of the daily nursing routine. Health care professionals must strive to overcome the barriers to effective pain management in practice. The tendency to under medicate older adults may be related to several factors, including misguided beliefs, fears regarding complications, and a failure to assess ant treat confused older adults. It is imperative that nurses dont act upon false misconceptions in delivering patient care.
The management of pain in the elderly represents a considerable nursing challenge. This is because the elderly are more likely to experience both acute and chronic pain than their younger counterparts. Age related factors may also complicate the assessment and management of the individuals pain. Failing sight and hearing, cognitive impairment, confusion and dementia create communication difficulties and therefore pose significant barriers to pain assessment particularly in the use of the measurement tools.
Lack of knowledge of the Doctor and nurse / poor communication:
An individuals pain is complex, the management should not rely on one professional clinical judgment and action. The pain control process should be interwoven between numerous health care professionals. The nurse must strive to exercise their communication skills in discussing aspects of patient care with the MDT team. A lack of confidence and knowledge are the common reasons for poor communication and teamwork.
There is ample evidence to demonstrate that both nurses and doctors have poor knowledge about pain and its management. It is also known that contemporary nursing and medical education programs do not equip health care professionals with significant information on the nature of pain, the methods of pain assessments and the principles of pain management.
With a lack of knowledge and basic fundamental management skills, nurses may feel unprepared to care for patients suffering from pain, and consequently make incorrect decisions regarding the management of patients pain. Poor decision making on behalf of the nurse can reflect on the following:
âž¢ Underestimation of the severity of the illness âž¢ Overestimation of the effectiveness of the interventions âž¢ Reluctance to administer parental analgesia âž¢ Administering a low dose of opoid rather than the required dose needed to control the severity of patients pain. âž¢ Nurses rarely employing non pharmacological strategies
In addition, the lack of knowledge and confidence of the nurse may interfere with his or her ability to effectively communicate aspects of patient care to other health care professionals. The under educated nurse has a tendency to underestimate the MDT and doctors involvement in pain assessment and management. However, it is imperative that the doctor carriers out a physical examination of the patient on admission to identify the pathological causes of the patients pain. This is an imperative part of pain management and is much needed to facilitate the planning of care.
The more experienced the nurse is the more inclined they are to underestimate severe pain. The less experienced nurse is more inclined to overestimate an individuals pain.
The doctors lack of confidence and knowledge may result in him or her avoiding discussions relating to analgesia and changing the drug or dose of the opoid, irrespective of the nurses belief that it for the best interest of the patient. Doctors that are lacking in knowledge have a tendency to prescribe analgesia below the therapeutic level of the pain and are often reluctant to act upon the nurse. This is a serious issue that must be addressed as the nurse is often the person who knows the most information about the patient as they provide a 24 hour round the clock care to the patient.
It is clear that these poor practices arise from a number of inter- related reasons. However the lack of knowledge and effective team work seems to be the central issue. In order to assure effective communication is brought to the clinical practice, efforts to increase group learning and confidence of health care professions is much needed. Role play may improve health care professionals knowledge and collaboration skills. Interpersonal education may be effective at allowing health care professionals understand each others roles in practice. Regular education sessions in the hospital with numerous health care professions from different specialties may be a great opportunity for nurses and other health care professionals to learn together.
The collection of information at assessment is dependent on the nurses ability to communicate effectively. However, nurses commonly lack the skills required in this area.
Health care professionals often expect the patients to complain spontaneously of pain and patients often assume the nurse will enquire about their pain. This is one significant issue within communication that is commonly demonstrated in practice. Certain nurses dont even ask the patient if they are experiencing pain. This is a serious issue as patients may be reluctant to report their pain because they dont want to appear unpopular or dont want to distract the health care professionals from treating their condition. The omission of verbal assessment may result in these patients suffering unnecessary pain for a prolonged period of time. This can have devastating long term consequences to an individuals health.
A quantity of nurses may employ some form of verbal communication to the patients pain assessment. However, they usually confine the assessment to asking one question only, such as, are you experiencing any pain at present? This can be misinterpreting as the patient may be pain free lying still in bed, yet the patient may be experiencing pain on activity. In order to improve the management of pain in practice, continuous education of improving communication skills must be enforced into the clinical setting.
A number of communication barriers such as deafness, blindness, and disorientated, confused and cognitive impaired persons can further complicate the assessment process. It is important to compensate for the auditory and visual impairments that the individual may have. While assessing and monitoring the patient, the nurse must position her/his face in view of the patient, speak in a slow and normal tone of voice, use large print size, and provide written instructions and aids such as glasses or hearing aids.
Pain assessment should be considered a greater challenge amongst the elderly as these patients more commonly present with communication barriers. Such barriers include deafness, blindness, and cognitive impaired, unconscious and disorientated individual. Pain assessment tools are designed to suit patients with various communication barriers. Health care professionals must choose the appropriate assessment tool that would best suit the individual in pain. For example, a visual analogue scale may be more suitable for a deaf individual. The abbey scale is specially designed for the cognitive impaired individual.
The nurse must validate the pain and believe that the pain is as bad as the patient reports it to be. Nurses have a tendency not to validate the patients pain. They tend to overestimate lower levels of pain and underestimate more severe pain. If the nurse places him or herself in the role of the family member, they may become more sensitive to the patients needs and his or her experience of pain. Commonly the nurses distance themselves from the patient which results in the nurses failing to recognize the patients needs.
Nurses have a tendency to block communication with patients who are terminally ill or patients who have chronic pain. This is because they believe they cannot do much for the patient. Efforts to improve professionals collaboration skills with the terminally ill patients and chronically ill is fundamental.
Clearly continuing education that integrates helping nurses become more sensitive to patient pain may have an important role in facilitating nurses to develop better assessment skills.
Health care professionals poor pain assessment
A good assessment is the cornerstone of good control of distressing symptoms. Yet, current pain assessment practices leave much to be desired. The underestimation of the patients pain seems to be problematic in current practice. Nurses have developed a tendency to interfere about a persons pain on a basis of what they observe. This may be acceptable if they confirm the validity of the interferences with the patient, however this is not happening.
Poor use of verbal cues
Health care professionals frequently observe patients behaviors and activities when assessing pain and consider non verbal cues as being reliable indicators of pain intensity. However, it is easy to misinterpret non verbal cues. For example the nurse tends to only regard pain as intense or severe if the patients show real intense behavioral signs. The nurse assumes the patient is pain free if such intense behavior signals are absent. Nurses need to take into account that each patient will have a unique response to pain which will be influenced by many factors including cultural beliefs and religious morals.
Such patients will exhibit expressive pain behaviors such as crying and moaning, where others may adapt a stoical approach and will not express their suffering outwardly. The presence of pain is therefore not always obvious from the patients facial expression and non verbal cues should not be regarded as reliable indicators of pain.
If health care professionals place emphasizes on non verbal cues and make interferences on the basis of what they observe, it is not surprising that they yet tend to underestimate the intensity of patients pain and over estimate the effectiveness of interventions.
The use of measurement tools which provide patients with a means of quantifying their pain experience is one way of overcoming this problem in practice. However, the under use of assessment tools is a problem that needs to be addressed. Interviewing the patient who is experiencing pain is a critical component of assessment since it provides patients with an opportunity to express not only intensity of their pain but also what it means to them and the effect it has on their lives.
Constraints to developing a therapeutic relationship with the patient
Pain assessment should be viewed as a unique opportunity for the nurse to use effective communication skills and spend time to build a relationship with the patient. This may encourage patients to express their fears or concerns, enhancing patient assessment and therefore improving the overall goals of care. However, staff shortages and time constraints often make it difficult for the nurse to spent time with the patient and hence it is difficult to build a thrusting relationship with the patient. The fact that there is a high turnover of patients in the hospital means that nurses have little opportunity to establish and sustain a good therapeutic relationship with the patient and family.