Pain with no cause! Nurses' perception.

CONTEXT: Nurses are called upon to assess chronic pain in health settings and their perceptions about chronic pain are likely to influence the pain assessment and pain relief. SETTINGS AND
DESIGN: This survey as a part of chronic pain education workshop was conducted at National Institute of Mental Health and Neurosciences, Bangalore, India, by pain education group. Here we present the observations collected during the workshop on chronic pain held for nurses.
MATERIALS AND METHODS: A semiqualitative method was used to survey the perceptions about chronic pain among nurses. The survey form consisted of 28 statements about chronic pain with options of agree and disagree to be marked prepared by the pain education group. STATISTICAL ANALYSIS USED: The data were computed and frequency distribution of different statements was derived.
RESULTS: The total number of participants was 44. Two-thirds of the nurses had good knowledge about pain behaviors. About 70% of the nurses reported that severity of pain to be assessed by observing patient's behavior and felt that if a house wife complains of pain it is to avoid work. Only 11% of the nurses provided correct responses related to discussion on pain being psychological; 90% had poor knowledge about pain communication on pain to be treated only for the underlying cause.
CONCLUSIONS: These observations highlight the fact that inadequacies in knowledge about chronic pain exist among nurses; the main areas include pain communication and pain treatments. It is important to include proper pain curriculum and training for chronic pain assessment and management.

INTRODUCTION

Chronic pain is a common condition that affects various aspects of individual life. It impairs quality of life, productivity, and increase health care burden. Nurses are involved in the care of the patients with chronic pain. It is pertinent to have a comprehensive knowledge about the assessment and management of chronic pain among them. The attitudes of the health professionals will influence the treatments provided and hence it is important to be aware of the attitudes of the health professionals. Pain is considered as a fifth vital sign and is expected to be assessed routinely by nurses. The current nursing curriculum does not prepare the nurses for effective assessment and management of chronic pain.

Inadequate knowledge and practice among nurses were identified and found to negatively affect the care of patients.[1] Fontana has commented that very little focus has been given to chronic non-malignant pain in nursing.[2] A cross-sectional study investigated the misconceptions held by student nurses, of adults experiencing chronic non-malignant pain demonstrated that they held misconceptions to a considerable degree.[3] Nurses and physicians have been found to hold the misconception that chronic pain is caused by psychological disturbance. This occurs when professionals, unable to find an objective cause of pain, attribute symptoms to psychological causes.[45]

Nurses and physicians have more positive responses toward patients in whom pathologic or physiologic evidence is found to support the existence of their pain.[6]

Misconceptions related to chronic pain have already been reported like chronic pain patients are tolerant to pain, chronic pain is caused by psychological disturbance, and fear of addiction to pain medication among health professionals.[7] Nurses are called upon to assess chronic pain in health settings and their perceptions about chronic pain will influence the pain assessment and pain relief. A report on nurses’ perception about chronic pain is presented here.

MATERIALS AND METHODS

This survey as a part of chronic pain education workshop was conducted at National Institute of Mental Health and Neurosciences, Bangalore, India, by the pain education group. A series of workshops were conducted on chronic pain assessment and management on various themes like hypnotherapy, fibromyalgia, neuropathic pain, cancer pain, cognitive behavior therapy, phantom pain, and somatoform pain disorders. Here we present the observations collected during the workshop on chronic pain held for nurses. A semiqualitative method was used to survey the myths and misconceptions about chronic pain. Nursing professionals attending this program on chronic pain formed the sample for the survey. The survey form consisted of 28 statements about chronic pain prepared by the pain education group. Each statement had two options namely agree and disagree. Participants were asked to indicate their options. The participants were also asked to give in their details like name (optional), years of experience in health profession, gender, and educational qualification. The participants were assured about confidentiality and the use of this data only for academic purpose. Informed consent was sought for this purpose.

The data were computed and frequency distribution of different statements was derived.

RESULTS

The total number of participants was 44. The mean age of the participants was 42.18 ± 10.123 and the mean years of experience 17.64 ± 10.086. The responses of the statements on pain behaviors, pain communication, and pain treatment are given in Tables 1–3, respectively.

Table 1

Pain behaviors

Table 3

Pain treatment

Two-thirds of the nurses had good knowledge about pain behaviors. Most of the nurses agreed that pain should be assessed irrespective of the coexisting psychiatric illness, site of pain to be examined irrespective of the cause and the number of sites. About 70% of the nurses reported that severity of pain is to be assessed by observing patient's behavior and felt that if a house wife complains of pain, it is to avoid work [Table 1].

Nurses had adequate knowledge (75%) on pain communication about discussion of causes and imaginary pain. Only 11% of the nurses provided correct responses related to discussion on pain being psychological; 90% had poor knowledge about pain communication on pain to be treated only for the underlying cause [Table 2].

Table 2

Pain communication

75% of the nurses had good knowledge about the advice on over-the-counter medication for patients with chronic pain. Nurses had inadequate knowledge (60-70%) on hypnotherapy, addiction to analgesics, and psychological treatments for chronic pain [Table 3].

DISCUSSION

These observations on perception about chronic pain highlight many important issues. Despite the pain being defined as a subjective experience (IASP), 23% of them still considered that pain is not a subjective experience. This finding is in accordance with our earlier study on the rating of pain by nurses[8] wherein the nurses despite pain being subjective reported pain rating based on objective pain behaviors. Majority of them did agree that if pain and psychiatric illness exist one still needs to address pain. The common myth that if no obvious cause is found then it is psychological was endorsed by 75% of the nurses. Myths related to the pain communication predominantly were on discussing treatment and casual factors. There were inadequacies in knowledge about pain communication more so in the area of causal factor, discussing treatment options. There is sparse literature on pain communication in the Indian setting.

The perceptions held by nurses were predominantly in the area of psychological aspects of chronic pain, use of psychological treatments for chronic pain. Hypnotherapy to be used only for non-organic pain was endorsed by majority of the nurses. However, hypnotherapy has been used in organic pain conditions and this finding is similar to the survey conducted by the authors on myths about hypnotherapy among health professionals.[9] The perception of health professionals on addiction to analgesics prevails in this observation too and in accordance with our earlier study on perception and knowledge about narcotics among nurses.[10] These observations highlight the fact that inadequacies in knowledge about chronic pain exist among nurses; the main areas include on-pain communication and pain treatments. It is important to include proper pain curriculum and training for chronic pain assessment and management. The findings are important as many patients may be deprived of certain effective treatments and may continue to suffer. It is pertinent to include chronic pain education in the curriculum.

It is also essential to study the same in other health professionals to be able to address the need for emphasizing the need the for pain education.