Categories of congruence between inpatient self-reported pain and nurses evaluation

Observed and Perceived Pain: Findings of a Cross-Sectional Study in Hospitalized Subjects

BACKGROUND

Pain constitutes a serious problem of a health, economic, ethical, and social equity nature affecting negatively quality of life. Its assessment is often subjected to overestimation or underestimation.

AIM

The aim of this study is threefold: (1) to estimate the prevalence of pain in hospitalized patients; (2) to assess the grade of correlation between the level of pain observed by the nurses and the pain perceived by the patients; and (3) to examine the level of scientific knowledge among the healthcare professionals.

DESIGN

Cross-sectional study.

METHODS

The intensity level of observed and perceived pain has been evaluated in 401 patients with validated scales. Analyzed data have been extracted from the electronic medical record and integrated into the data-collection sheet. A questionnaire has been submitted to nurses to investigate their level of knowledge on pain assessment and management.

RESULTS

The study included 350 patients out of 401; for 51 patients the "pain" data was missing. Prevalence of perceived pain was 40.15%. Nurses overestimated pain in 7.43% of cases and underestimated it in 24.9%. The majority of the nursing staff claimed to be aware of the pain topic, however, they showed some uncertainties in clinical practice.

CONCLUSIONS

The differential variation between the observed pain and the perceived one resulted in 43.71% of cases, highlighting the dependence on the two variables: "area of hospitalization" and "intensity level". The observation and monitoring of pain did not appear to be a consolidated practice, thus representing an important area for investments in the nursing profession.

Pain assessment and management among adult patients in a gynecology ward: a best practice implementation project

OBJECTIVES

This project aimed to improve compliance with evidence-based practice in pain assessment and management in a gynecology ward.

INTRODUCTION

Effective pain control is important to prevent the negative consequences of pain that is poorly managed. However, it remains undervalued and inadequately treated. Applying evidence-based practices to correctly evaluate and manage pain is essential to improve pain relief.

METHODS

This project followed the JBI Evidence Implementation Framework. A baseline audit of 41 women admitted to the gynecology ward was conducted and measured against 5 best practice criteria, along with a patient satisfaction questionnaire. Targeted strategies were then implemented and a follow-up audit was conducted using the same criteria, methods, and sample size as the baseline audit.

RESULTS

The baseline audit revealed gaps between current and best practice. Barriers to implementation were identified and strategies to resolve the barriers were designed and implemented (nurse education, informative materials, electronic patient records system improvements). Comprehensive pain assessment, including dynamic and static pain assessment, use of a validated tool, and education provided to patients and carers, improved in the follow-up audit. There was no change in patient satisfaction levels; however, the discrepancy between pain measured by nurses and pain measured by patients was reduced.

CONCLUSIONS

The JBI methodology was useful in improving compliance with evidence-based practice criteria. It also facilitated adaptation to new barriers, such as the COVID-19 pandemic. Improving nurses' knowledge of pain assessment can lead to more accurate assessment. Inadequate records systems also made it difficult to record the care that was provided. Subsequent audits will assess sustainability and the project will be escalated to other wards.

Classism in pain assessment and management: the mediating role of female patient dehumanization and perceived life hardship

ABSTRACT

Compared with racism and sexism, classism in pain assessment and management practices (PAMPs) has been less investigated, and its mediating mechanisms are still unknown. Drawing on a social psychological model of dehumanization, this research aimed to test (1) the effect of patient socioeconomic status (SES; a proxy of social class) on PAMPs and (2) whether patient dehumanization and perceived life hardship mediated these effects. Two online experimental studies were conducted, in which patient SES was manipulated (low vs high) within-subjects. One-hundred sixty-two female medical students (study 1) and 105 female nurses (study 2) were presented with vignettes/images depicting 2 cases of women with chronic low-back pain, followed by videos of them performing a pain-inducing movement. Participants reported on patient dehumanization, perceived life hardship, and PAMPs. The low SES patient was perceived as less pain sensitive (medical students alone) but more disabled, credible, and her pain more attributed to psychological causes (by nurses alone). Medical students recommended less nonpharmacological treatments but prescribed slightly stronger medication. Medical students were less willing to provide individualized care to the low SES patient, whereas nurses showed the opposite pattern. Patient mechanistic dehumanization mediated SES effects on pain disability (medical students alone). Perceived life hardship mediated SES effects on pain disability, credibility (nurses alone), and intentions of providing individualized care (nurses alone). These finding bear novel contributions to the fields of pain, health service research, and social psychology and have important implications to the development of more effective future interventions to reduce classism in PAMPs.

Congruence between nurses' and patients' assessment of postoperative pain: a literature review

Postoperative pain remains poorly managed for many patients. Effective pain management begins with accurate pain assessment, with patient self-reporting considered the most accurate measure of pain. This literature review aimed to identify how congruent nurses' assessments of pain were with patients' self-reporting. A search identified six observational studies and one quasi-experimental study that met the inclusion criteria. The findings from these studies were summarised under two themes: nurses' underestimation of patients' pain and nurses' knowledge and understanding of pain assessment. Some nurses' pain management knowledge was deemed inadequate, with evidence of negative attitudes towards managing pain in certain groups of patients. Educational interventions have so far had limited impact on correcting the ethical and professional problem of inadequate pain relief in many patients postoperatively. Randomised controlled trials are required to identify effective education interventions that can contribute to ending this avoidable suffering.

Pain assessment in native and non-native language: difficulties in reporting the affective dimensions of pain

Background and aims The language in assessing intensity or quality of pain has been studied but the results have been inconsistent. The physicians' language skills might affect the estimation of the severity of pain possibly leading to insufficient use of analgesics. Several interfering cultural factors have complicated studies aimed at exploring the language used to detect the quality of pain. We aimed to compare native and non-native language related qualitative aspects of pain chosen by Swedish speaking patients with diabetes. Methods In the study participated 10 Finnish and 51 Swedish speaking patients with diabetes. The Pain Detect-questionnaire was used for clarifying the patients' pain and the mechanism of their pain (neuropathic or not) and for assessing the intensity and quality of pain. In addition, the patients completed the short-form McGill Pain Questionnaire (sfMPQ) in Finnish (test I). After 30 min the subjects completed the sfMPQ a second time in their native language (test II). The Swedish speakers estimated their second language, Finnish, proficiency on a 5-graded scale. Results There were significantly more discrepancies between sfMPQ test I and test II among the Swedish speaking respondents who reported poor (hardly none) Finnish language proficiency compared with those with good Finnish proficiency. Discrepancies occurred especially between the affective qualities of pain. Conclusions Poor second language proficiency exposes Swedish speakers to pain communication difficulties related to the affective aspects of pain. Consequently, discordant language communication could cause underestimation of the severity of pain and pain undertreatment. Implications To ensure adequate pain treatment measuring the affective dimension of pain in the patient's native language is crucial.

Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses’ Pain Assessment and Management Practices

Objective

Research on social disparities in pain care has been mainly focused on the role of race/racism and sex/sexism. Classism in pain assessment and management practices has been much less investigated. We aimed to test the effect of patient socioeconomic status (SES; a proxy of social class) on nurses’ pain assessment and management practices and whether patient SES modulated the effects of patient distress and evidence of pathology on such practices.

Design

Two experimental studies with a two (patient SES: low/high) by two (patient distress or evidence of pathology: absent/present) between-subject design.

Subjects

Female nurses participated in two experimental studies (N = 150/N = 158).

Methods

Nurses were presented with a vignette/picture depicting the clinical case of a female with chronic low back pain, followed by a video of the patient performing a pain-inducing movement. Afterwards, nurses reported their pain assessment and management practices.

Results

The low-SES patient’s pain was assessed as less intense, more attributed to psychological factors, and considered less credible (in the presence of distress cues) than the higher-SES patient’s pain. Higher SES buffered the detrimental impact of the presence of distress cues on pain assessment. No effects were found on management practices.

Conclusions

Our findings point to the potential buffering role of SES against the detrimental effect of certain clinical cues on pain assessments. This study contributes to highlighting the need for further investigation of the role of SES/social class on pain care and its underlying meanings and processes.

Medical Evidence Influence on Inpatients and Nurses Pain Ratings Agreement

Biased pain evaluation due to automated heuristics driven by symptom uncertainty may undermine pain treatment; medical evidence moderators are thought to play a role in such circumstances. We explored, in this cross-sectional survey, the effect of such moderators (e.g., nurse awareness of patients' pain experience and treatment) on the agreement between n = 862 inpatients' self-reported pain and n = 115 nurses' pain ratings using a numerical rating scale. We assessed the mean of absolute difference, agreement (κ-statistics), and correlation (Spearman rank) of inpatients and nurses' pain ratings and analyzed congruence categories' (CCs: underestimation, congruence, and overestimation) proportions and dependence upon pain categories for each medical evidence moderator (χ² analysis). Pain ratings agreement and correlation were limited; the CCs proportions were further modulated by the studied moderators. Medical evidence promoted in nurses overestimation of low and underestimation of high inpatients' self-reported pain. Knowledge of the negative influence of automated heuristics driven by symptoms uncertainty and medical-evidence moderators on pain evaluation may render pain assessment more accurate.

Healthcare providers' accuracy in assessing patients' pain: A systematic review

OBJECTIVE

Healthcare providers satisfy an important role in providing appropriate care in the prevention and management of acute and chronic pain, highlighting the importance of providers' abilities to accurately assess patients' pain. We systematically reviewed the literature on healthcare providers' pain assessment accuracy.

METHODS

A systematic literature search was conducted in PubMed and PsycINFO to identify studies addressing providers' pain assessment accuracy, or studies that compared patients' self-report of pain with providers' assessment of pain.

RESULTS

60 studies met the inclusion criteria. Healthcare providers had moderate to good pain assessment accuracy. Physicians and nurses showed similar pain assessment accuracy. Differences in pain assessment accuracy were found according to providers' clinical experience, the timing of the pain assessment, vulnerable patient populations and patients' pain intensity.

CONCLUSION

Education and training aimed at improving providers with poor pain assessment accuracy is discussed especially in relation to those with limited clinical experience (<4 years) or a great deal of clinical experience (>10 years) and those providing care for vulnerable patient populations.

PRACTICE IMPLICATIONS

More research on characteristics that influence providers' pain assessment accuracy and trainings to improve pain assessment accuracy in medical and continuing education may improve pain treatment for patients.

Older people and barriers to self-reporting of chronic pain

Too many older adults live with the negative consequences of chronic pain and its detrimental impact on quality of life. To explore this, an extended literature review was conducted to identify barriers the older person encountered in the self-reporting of their chronic pain. Four themes were found to mediate help-seeking behaviour. Attitudes such as stoicism, beliefs such as pain being a necessary part of ageing, and the external barriers generated by health professionals, all have a multidimensional relationship with the 'decision' to seek help for pain. Personality and the perceived importance of independence were found to influence these responses. The findings imply that communication between the health professional and patient needs to improve during the more comprehensive assessment of chronic pain. To achieve such improvements, it is first necessary to eradicate ageist attitudes held both by the elderly and within health care.

[Postoperative pain assessment after middle ear surgery]

BACKGROUND

The purpose of this work was to assess postoperative pain management after middle ear surgery.

MATERIALS AND METHODS

In a prospective clinical study, 73 adults were evaluated on the first postoperative day after middle ear surgery using the questionnaire of the Germany-wide project QUIPS (quality improvement in postoperative pain management). The main outcome measures were patients' characteristics, pain parameters, outcome, and pain therapy process parameters.

RESULTS

Overall, pain on the first postoperative day was mild. Pain management consisted predominately of premedication with midazolam, remifentanil intraoperatively, metamizole in the recovery room and on the ward. Otherwise healthy patients suffered significantly more from pain than patients with reduced general condition in univariate and multivariate analyses. About half of the patients demanded pain relief on the ward. Despite immediate pain management with nonopioids and/or opioids, these patients had significantly more maximal pain and were less satisfied with overall pain therapy than patients not demanding pain therapy.

DISCUSSION

QUIPS is a simple tool to evaluate the quality of in-hospital postoperative pain management following ear surgery. Pain on the first postoperative day seems to be moderate but should be improved for patients demanding more analgetics despite baseline pain therapy on the ward.

Postoperative pain assessment after functional endoscopic sinus surgery (FESS) for chronic pansinusitis

Postoperative pain after functional endoscopic sinus surgery (FESS) and its optimal management has not been described in detail. The objective was to evaluate pain, its influencing factors and its management on the first postoperative day following FESS. In a prospective case study, 101 FESS patients were examined after removal of the nasal packing within the Quality Improvement in Postoperative Pain Management (QUIPS) project allowing a standardized assessment of patients' characteristics, pain parameters, outcome and process parameters. The influence of these parameters on the patients' postoperative pain was estimated by univariate and multivariate statistic analysis. Pain during the first postoperative day after FESS was moderate. Younger patients reported significantly more pain than did older patients. Specific counseling about the possibilities of postoperative pain management reduced pain intensity highly significantly in univariate and multivariate analysis. Patients demanding for pain relief in the recovery room and on the ward predominantly received acetaminophen as non-opioid and piritramide as opioid. This pain management was obviously insufficient as these patients still reported significantly more from pain on the first postoperative day than patients not demanding for pain relief. We conclude that QUIPS could help to optimize the quality of postoperative pain management following FESS.

The Impact of Daylight and Views on ICU Patients and Staff

Objective:

Using a pre-test/post-test quasi-experimental study in two New Hampshire ICUs, the impact of daylight and window views on patient pain levels, length of stay, staff errors, absenteeism, and vacancy rates were examined. One ICU was operational until 2007, the second opened in 2007. ICU patients were randomly selected from cardiac surgery, pneumonia, and chronic obstructive pulmonary disease admissions of one or more days, 58 from the old ICU, and 52 from the new. Regular medical staff members assigned to the unit between October 2006 and September 2007 (old unit) and March 2008 and February 2009 (new unit) were included.

Results:

Variables other than unit design had a more significant impact on relative pain levels in each unit. Comparing light levels independent of ICU assignment supported the hypothesis that increased light levels reduce pain perception and length of stay, but the relationship was not statistically significant. One trend, not statistically significant, suggested that view was associated with reduced pain perception. A decrease in incident filings supported the hypothesis that improved natural light and views reduced errors, but results were not statistically significant. Some subcategories demonstrated significance. Mean absenteeism per person decreased from 38 to 23 hours from the old unit to the new (p = 0.05). Average vacancy rates decreased by 25% (from 10.12% to 7.49% staff openings per year) in the old and new units (p = 0.04).

Conclusion:

High levels of natural light and window views may positively affect staff absenteeism and staff vacancy. Factors such as medical errors, patient pain, and length of stay require additional research.

Postoperative pain assessment after septorhinoplasty

Postoperative pain after septorhinoplasty and its optimal management has not been described in detail. Fifty-two adult septorhinoplasty patients were included in a prospective cohort single center study. Patients' and surgical characteristics were evaluated. Outcome and process parameters were analyzed using the questionnaires of the German-wide project Quality Improvement in Postoperative Pain Management (QUIPS) on the first postoperative day. Pain during the first operative day after septorhinoplasty was moderate. Pain management predominately consisted of remifentanil intraoperatively, metamizole in the recovery room, in combination with piritramide in one-third of the patients, and metamizole on ward. Patients younger than 31 years were less satisfied with pain management (P = 0.018). Open rhinoplasty was associated with less satisfaction with pain management (P = 0.007). Use of rib grafts led to more mobility, breathing, sleeping and mood disturbances (P = 0.003, 0.047; 0.047; 0.022, respectively). Preoperative pain counseling was followed by higher satisfaction, less breathing and mood disturbances after surgery (P = 0.021; 0.004; 0.046, respectively). Opioids in the recovery room in addition to non-opioids and treatment with non-opioids on ward led to less maximal pain (P = 0.027 and 0.040, respectively). We conclude that QUIPS is an easy tool to evaluate the quality of postoperative pain management following rhinoplasty. Preoperative pain counseling, specific care for patients with rib grafts, consequent use of opioids in the recovery room in addition to non-opioids, and use of non-opioids on ward seem to be effective to improve pain management after septorhinoplasty.