A study of nurses' inferences of patients' physical pain

Aim. The aim of this study was to establish if postregistration education and clinical experience influence nurses’ inferences of patients’ physical pain. Background. Pain is a complex, subjective phenomenon making it an experience that is elusive and difficult to define. Evaluation of an individual's pain is the product of a dynamic, interactive process that frequently results in ineffective pain management. Educating nurses should address the deficit, however the clinical environment is thought to be most influential in the acquisition of knowledge. Design. A series of vignettes was used to consider nurses’ inferences of physical pain for six hypothetical patients; these were employed within a self‐administered questionnaire that also addressed lifestyle factors of patients in pain, general attitudes and beliefs about pain management and general knowledge of pain control. Method. One hundred questionnaires were distributed; 86 nurses returned the questionnaire giving a response rate of 86%. Following selection of the sample 72 nurses participated in the study: 35 hospice/oncology nurses (specialist) and 37 district nurses (general). Data analysis was carried out using SPSS and qualitative analysis of the written responses. Results. The specialist nurses tended to infer lower levels of physical pain than the general nurses when considering the patients in the vignettes. Conclusion. Education and clinical experience influence nurses’ knowledge, attitudes and beliefs about pain. However, it would appear that the specialist nurses’ working environment and knowledge base engenders a practice theory divide, resulting in desensitization to patients’ physical pain. Relevance to clinical practice. It is suggested that the specialist nurses use defence mechanisms to protect them from the conflict that arises from working within the clinical environment. These cognitive strategies have the potential to ease cognitive dissonance for the nurse, but may increase patient suffering.     

A comparison of adolescents' and nurses' postoperative pain ratings and perceptions

Purpose: To examine the relationship between adolescents' subjective and nurses' objective pain ratings and their perceptions of each other's evaluation. Methodology: Twenty-two adolescent patients admitted for elective surgical procedures and the registered nurses responsible for their nursing management rated pain on a visual analog scale. Pearson Product Moment Correlation, Spearman Rank-Difference Correlation, and T-Test were used to analyze the results. Results: The correlation between patients' and nurses' pain rating was significant (r = .62; p less than .001). Nurses expected patients to rate pain higher than the nurses would (t = 3.467; p = .0005). There was no significant difference between adolescents' rating and their expectations of nurses' ratings. Conclusion: The relationship between patients' and nurses' pain assessment was moderate. Adolescents perceived that nurses' know how much pain they were experiencing. Nurses expected adolescents to rate pain higher than the nurses themselves would rate it.     

Patient participation in clinical decision-making in nursing: A comparative study of nurses' and patients' perceptions

Aims and objectives. The aim of this study was to compare the degree of concordance between patients and Registered Nurses’ perceptions of the patients’ preferences for participation in clinical decision‐making in nursing care. A further aim was to compare patients’ experienced participation with their preferred participatory role. Background. Patient participation in clinical decision‐making is valuable and has an effect on quality of care. However, there is limited knowledge about patient preferences for participation and how nurses perceive their patients’ preferences. Methods. A comparative design was adopted with a convenient sample of 80 nurse–patient dyads. A modified version of the Control Preference Scale was used in conjunction with a questionnaire developed to elicit the experienced participation of the patient. Results. A majority of the Registered Nurses perceived that their patients preferred a higher degree of participation in decision‐making than did the patients. Differences in patient preferences were found in relation to age and social status but not to gender. Patients often experienced having a different role than what was initially preferred, e.g. a more passive role concerning needs related to communication, breathing and pain and a more active role related to activity and emotions/roles. Conclusions. Registered Nurses are not always aware of their patients’ perspective and tend to overestimate patients’ willingness to assume an active role. Registered Nurses do not successfully involve patients in clinical decision‐making in nursing care according to their own perceptions and not even to the patients’ more moderate preferences of participation. Relevance to clinical practice. A thorough assessment of the individual's preferences for participation in decision‐making seems to be the most appropriate approach to ascertain patient's involvement to the preferred level of participation. The categorization of patients as preferring a passive role, collaborative role or active role is seen as valuable information for Registered Nurses to tailor nursing care.     

Relationships between nurses' observations and patients' self-reports of pain

Pain researchers and clinicians alike are often troubled by a lack of correspondence between non-verbal behavior and patients' self-reports of level of pain. This paper discusses some of the variables which can effect the relationship between these measures. In addition, the paper reports on the reliability of nurses' observations of pain behavior and of their inferences about the intensity of a patient's pain. In general, though these observations and inferences have adequate reliability, the correspondence between such inferences and patients' reports of pain intensity are modest, though significant. Discrepancies between observers' and patients' ratings of pain are greater in a chronic pain sample (N = 37) than in an acute pain sample (N = 34). Theoretical implications of these results are discussed.     

Chronic pain and distress among elderly in the community: comparison of patients' experiences with enrolled nurses' assessments

AIM: This study compared elderly patients' reported experiences of pain and distress with enrolled nurses' assessments and related potential differences to patient and enrolled nurse characteristics. BACKGROUND: Many elderly suffer from chronic pain but few studies have focused on this group of patients. METHODS: Data were collected through personal interviews with 38 patients and questionnaires completed by 38 enrolled nurses. FINDINGS: Enrolled nurses underestimated patients' experiences of physical pain, physical discomfort, breathing problems, resignation, and dependency. Pain and distress were overestimated by enrolled nurses who had lower scores on three of the five personality scales used. In contrast, enrolled nurses who had higher scores on these personality scales tended to underestimate the patients' pain and distress. CONCLUSIONS: There is a need to develop staff training programmes in order to optimize the care for elderly patients with chronic pain in the community.     

The effect of rapid induction analgesia on subjective pain ratings and pain tolerance

The effect of Rapid Induction Analgesia (RIA) on pain tolerance and ratings of mechanically induced pain in the pain-sensitized forearm was investigated in 58 undergraduates. Posthypnotic suggestions of relaxation and analgesia did not influence pain ratings or tolerance, but relaxation ratings increased after RIA. When suggestions for analgesia were made throughout pain testing, ratings of pain unpleasantness at the pain tolerance point decreased more in the RIA group than in the attention control group. However, RIA did not influence pain threshold or tolerance. It was concluded that RIA was more effective in reducing subjective reports of pain (particularly the affective component) than in altering pain tolerance, and that maintenance of hypnotic suggestions was more effective than posthypnotic suggestions of comfort and relaxation in alleviating the affective component of pain.     

The effect of Rapid Induction Analgesia on subjective pain ratings and pain tolerance

The effect of Rapid Induction Analgesia (RIA) on pain tolerance and ratings of mechanically induced pain in the pain-sensitized forearm was investigated in 58 undergraduates. Posthypnotic suggestions of relaxation and analgesia did not influence pain ratings or tolerance, but relaxation ratings increased after RIA. When suggestions for analgesia were made throughout pain testing, ratings of pain unpleasantness at the pain tolerance point decreased more in the RIA group than in the attention control group. However, RIA did not influence pain threshold or tolerance. It was concluded that RIA was more effective in reducing subjective reports of pain (particularly the affective component) than in altering pain tolerance, and that maintenance of hypnotic suggestions was more effective than posthypnotic suggestions of comfort and relaxation in alleviating the affective component of pain.     

A comparison of patients' and nurses' assessments of pain intensity in patients with coronary artery disease

Self-report of pain is the single most reliable indicator of pain intensity. The purpose of this study was to compare patients' and nurses' ratings of patients' pain. The sample comprised 76 patients and 65 nurses in coronary care units that rated the patient's pain intensity on a 0-10 numeric rating scale. Results showed that the mean scores of nurses were lower than their patients significantly (P < 0.01). Also, nurses assessed patients' pain intensity accurately 60% of the time. Overestimations and underestimations were 12.4% and 27.6% respectively. In addition, there were positive, moderate and significant correlations between patients' and nurses' ratings (r = 0.41, P < 0.001). Underestimation of patient's pain can have negative effects if appropriate treatment is withheld. This emphasizes the importance of a systematic assessment and acceptance of the patient's self-reported of pain.     

Congruence between health professionals' and patients' pain ratings: a review of the literature

The literature suggests that health professionals have a tendency to underestimate pain when performing clinical assessments. In addition, it appears that the more clinical experience one has, the greater will be the underestimation of pain. Pain assessment is difficult because of the complex interaction between environment, patient and practitioner variables. Although there is a need for further research in this area, there are clinical implications worthy of consideration. Health professionals need to use a variety of valid and reliable measures, use measures of pain behaviour and disability to complement self-report measures and examine how their own biases and values may influence pain judgements.     

Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries

In order to provide burn patients with adequate pain relief, the nurses must be able to accurately evaluate the patients' pain levels and to assess whether sufficient analgesia is achieved or not. The present study examined this issue by comparing the pain ratings in 42 patients hospitalized for burn injuries and 42 nurses. The patient and the attending nurse were asked to rate, independently of each other, the intensity of the pain felt by the patient during a therapeutic procedure and at rest. When analgesic medication was given prior to the procedure, both the patients and the nurses were asked to estimate the degree of pain relief. All ratings were obtained using visual analogue and verbal scales. The results revealed significant but small correlations between the nurses' and patients' ratings. Frequently, the nurses underestimated or overestimated the patients' pain. Discrepancies were also observed in the evaluation of pain medication efficacy, the nurses showing a tendency to overestimate the degree of pain relief. The accuracy of the nurses' perception did not vary as a function of the patients' age, socioeconomic status or burn severity. However, the number of years of experience in burn-nursing had a significant influence on the nurses' estimation of the patients' pain during therapeutic procedures. Theoretical and clinical implications of these results are discussed with a particular emphasis on the need to implement systematic procedures to assess pain and success of analgesia. Additional recommendations to optimize pain management in burn patients are also made.     

Altering gender role expectations: effects on pain tolerance, pain threshold, and pain ratings.

The literature demonstrating sex differences in pain is sizable. Most explanations for these differences have focused on biologic mechanisms, and only a few studies have examined social learning. The purpose of this study was to examine the contribution of gender-role stereotypes to sex differences in pain. This study used experimental manipulation of gender-role expectations for men and women. One hundred twenty students participated in the cold pressor task. Before the pain task, participants were given 1 of 3 instructional sets: no expectation, 30-second performance expectation, or a 90-second performance expectation. Pain ratings, threshold, and tolerance were recorded. Significant sex differences in the "no expectation" condition for pain tolerance (t = 2.32, df = 38, P <.05) and post-cold pressor pain ratings (t = 2.6, df = 37, P <.05) were found. Women had briefer tolerance times and higher post-cold pressor ratings than men. When given gender-specific tolerance expectations, men and women did not differ in their pain tolerance, pain threshold, or pain ratings. This is the first empirical study to show that manipulation of expectations alters sex differences in laboratory pain.     

Factors influencing nurses' decisions to use non-pharmacological therapies to manage patients' pain.

This study investigated nurses' beliefs and attitudes toward the use of non-pharmacological therapies as adjunct pain management strategies. Registered nurses (RNs) (n=37) from the medical, surgical, oncology/palliative care and critical care areas of two Australian hospitals participated in a series of focus group discussions that explored the use of non-pharmacological therapies to help manage patients' pain in a hospital setting. Results from the discussions identified that nurses believe non-pharmacological therapies offer several advantages to the management of patients' pain and general well being. For example non-pharmacological therapies were recognised to be useful as adjuncts while waiting for medications to take effect. However significant barriers such as lack of organisational and professional support were also identified as hindering nurses' current usage of non-pharmacological therapies. Further investigation of the key issues from this study is recommended to improve non-pharmacological pain management and enhance patient outcomes.     

Effects of a continuing education program on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports

A hospital-based quasi-experimental (pretest and post-test) study was conducted in Kaohsiung Veteran General Hospital, Taiwan. This study was to evaluate a continuing education program (CEP) on nurses' practices of cancer pain assessment and their acceptance of patients' pain reports with respect to four types of misconceptions. A questionnaire was sent to on-duty nurses or head nurses with patient care responsibilities before the implementation of CEP (n=645) and six months after the program (n=630). The response rates were 92.6% and 91.3% for pretest and post-test surveys, respectively. The CEP was implemented in 8 weeks with four-repeated sessions of 4-hour lectures. A one-day workshop focused on cancer pain assessment and treatment was held 3 months after the four-repeated sessions. Several educational strategies and teaching materials were used in the CEP. The results showed that CEP made statistically significant yet moderate improvement in nurses' practices of pain assessment using pain rating scales (pretest 3.29+/-0.76 vs. post-test 3.48+/-0.75, P<0.001) and acceptance of patient's pain reports without misconceptions on addiction (3.12+/-0.80 vs. 3.39+/-0.90, P<0.001), phantom pain (3.91+/-0.96 vs. 4.07+/-0.92, P=0.005), and placebo testing (3.63+/-0.72 vs. 3.81+/-0.73, P<0.001), except on patient gender-age-related doubts (3.60+/-0.72 vs. 3.67+/-0.77, P=0.109). In order to achieve further improvement, additional follow-up CEP combined with a hospital-wide institutionalization of pain assessment should be promoted and implemented in the future.     

Effect of attitudes, subjective norms and perceived control on nurses' intention to assess patients' pain

This study examines the underlying determinants of nurses' behaviour regarding the conduct of pain assessments One hundred nurses in a variety of health care facilities were invited to complete an Attitude Intention Questionnaire based upon the theory of planned action which is an extension of the theory of reasoned action Results provide some support for the theory of planned action, as nurses' intention to conduct pain assessment was shown to be predicted by attitude, subjective norms and perceived control, although the latter was the only variable to make an independent contribution to intention Additional support for the importance of perceived control was provided by the analysis of 'intenders' and 'non-intenders'(to conduct pain assessments), as perceived control was the only variable which differed significantly between the groups The findings are consistent with earlier studies which showed that the variables in the theory of planned behaviour provided reasonably accurate predictions of behavioural intention