Carl C Ineffective Management of Chronic and Acute Pain

Ineffective management of chronic and acute pain by nursing and other medical staff because of inadequate treatment, education and cultural misconceptions, is a continuing barrier to achieving client wellness. This situation is not a recent development and can be mitigated through the implementation of several strategies of which the nursing cohort is the prime driver.
These strategies include educating nurses to perform adequate and regular pain assessments. These assessments require that the nurse listen to what the client is saying about their pain levels and experience. In addition, the nurse needs to develop awareness in others of cultural and social constructs that create misconceptions surrounding pain and pain treatment therapies. Lastly, the nurse must have the ability to formulate effective strategies to break down these misconceptions of all the involved parties and ultimately, help the client.

Pain is described as;“ A sensation in which person experiences discomfort, distress or suffering due to the provocation of sensory nerves.” (Thomas, 1973) Taber’s then goes on to describe ninety seven different types of pain, demonstrating that pain is a highly complicated subject matter ranging from the metaphorical to sequlae of a specific medical condition. Regardless of the neurological response generated, pain impacts wellness. Acute pain is generally short in duration but severe, such as the pain generated from a surgical procedure or accident. It is expected to abate or at worst convert to chronic pain. Chronic pain is long term and constant, such as the pain of arthritis or cancer. Pain can impact an individual’s ability to lead a participatory life or a patient’s ability to recover from an illness. Pain can impact mental health, acuity and, pain can result in a lifetime of searching for relief (Fine & MacLow, 2006). In her article Managing Chronic Pain (2002), Michelle Meadows relates the story of a woman’s 30 year search for relief from pain resulting from injuries received in a skiing accident. Her search involved multiple surgeries, some of dubious value, therapies, depression and numerous healthcare workers who offered little help or hope.

One strategy for improving outcomes is educating nurses. A qualitative study conducted in a series of Colorado Long Term Care (LTC) facilities found that 25-33% of the residents experience moderate to severe pain on a daily basis (Clark, Fink, Pennington & Jones 2006). Data from this study indicates that this issue is related to inadequacies of the care staff involving training, basic philosophies and communication among the staff and clients, all correctable factors (Clark, Fink, Pennington & Jones 2006). Education of the nursing and support staff caring for these individuals is critical to improving this situation. Regular and complete assessments for pain must be completed on all clients under care. There are numerous tools available to make these assessments complete and in a common format that all care providers coming in contact with these clients can understand and use to the client’s benefit. The most common tool in use is the very effective 0-10 scale. This tool needs to be augmented with observations made by the managing nurse and include input from support staff who may very well have more contact with the client. Proper communication of the client’s reaction to the multitude of stimuli encountered is as important as the formal assessments and needs to be part of the treatment plan.

Another strategy involves specific cultural issues surrounding how a client may deal with or express pain. Strategies that resolve these issues need to be understood and incorporated into daily care. A known example of this is individuals from some Asian cultures will readily accept pain relief if they are asked several times. They simply feel it is impolite to accept the offering immediately and expect that it will be offered a second time. In this instance, offering pain relief to this client one time and walking away under the assumption they are able to tolerate their pain is an error in care. An adjunct to this is having this specific knowledge and not communicating it to other care staff. In some ways this is no different than ignoring the client’s pain altogether. Key information such as this needs to be available to all the care givers requiring clear and adequate communication are part of the routine of daily care.

A third strategy involves the clarification of misconceptions surrounding pain in general and treatments for pain. In addition to factors elucidated in the LTC study regarding how social constructs impact how pain is treated another issue involves direct treatments for pain. Often times the most effective therapies for pain is the use of opioid drugs or narcotics. While their proper use is known and accepted in much of the medical community, societal controls over these substances places blocks to their proper and effective application. Physicians and practitioners wanting to prescribe these materials are faced with regulations governing their use that are so onerous these professionals physicians often use less effective therapies (Berry & Dahl 2007). Patients and family members often question the use of these therapies based on a fear of addiction and place a self imposed stigma on their use, a situation largely derived from their own ignorance (Mercadante 2007).

The technology and techniques to effectively manage pain already exist. Through the implementation of strategies that include educating nursed in proper assessments, secondly improve social and cultural awareness and lastly that address misconceptions that hinder treatment these techniques can be better utilized. In many instances the barriers to their implementation are created by the very professionals meant to administer these therapies (Berry & Dahl 2007). As primary caregivers the ranks of professional nurses are in an ideal position to make these changes across the entire spectrum of healthcare.

Intervention One

Educate professional care giving staff to adequately assess and treat pain

Disadvantage 1

Currently there are multiple tools in use to measure or attempt to quantify pain. This includes the visual analogue scale (VAS), the numeric rating scale (NRS), the verbal rating scale (VRS), the category ratio (CR-10 scale) and McGill pain questionnaire (Ergun et al, 2005). What is to be taught and how is it to be taught. Are the existing tools up to the task of providing a universal description of pain and quantifying it. Are the existing tools up to the task interpreting across the breadth of cultural and educational diversity that health care professionals are required to address. At this point in time the answers for these questions is not a definitive yes, there are still tools in development that may be more effective. So the question is what is to be taught.

Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Disadvantage 2

Pain and its assessment is by nature subjective, what is tolerable to one person is not to another. Pain is also a symptom of a condition that may or may not be identified. In this case therapies for pain relief mask the existence of underlying pathology which may go untreated. With these instances in mind, is it even reasonable to assume that effective assessments for pain and the implementation of effective therapies can be adequately taught. A simple 0-10 scale is may not be adequate to the task at hand. (Vallerand et al, 2007).

Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Intervention 2

Removal of barriers to effective pain control

Disadvantage 1

Many of the most effective therapies for pain relief involve the use of opiates, the ability to use these medications more freely would improve pain control. The vast majority of the governments in the world place heavy regulation on the use and distribution of these dangerous chemicals for good reason. Reducing the control mechanisms already in place over these materials would reduce the responsibilities associated with their prescription and dispensing(Mercadante 2007). Given the potential for abuse and danger here facilitating their use is unwise.

Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>

Disadvantage 2

Fear of addiction is a very legitimate fear and a distinct possibility where the regular use of strong pain medications is involved. A patient’s or their family’s concern over this matter is well placed. In many instances the populations of not only inner city but urban hospitals display drug seeking behaviors (McCaffery et al, 2007). Are these individuals in pain or are they seeking an alternate source to better serve their additions. Is it the job of the medical community and the population of those responsibly insured to support these actions. Can a medical system that is not capable of providing services to the population as a whole afford to support addictive behavior (Levine et al, 2007).

McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>

Bibliography

Berry, P.; Dahl, J., Advanced Practice Nurse Controlled Substances Prescriptive Authority: A Review of the Regulations and Implications for Effective Pain Management at End-of-Life. Medscape Nurses. Released October 30, 2007. Retreived November 6, 2007 from Medscape Nursing Search.

Clark, L, Fink, R, Pennington, K & Jones, K, (2006) Nurses' reflections on pain management in a nursing home setting. Pain Management Nursing 7(2) pp 71-77, Retrieved April 13, 2007 from Medscape Today Database.

Ergun, U et al, Trial of a New Pain Assessment Tool in Patients With Low Education: The Full Cup Test. International Journal of Clinical Practice 63(3) 2005, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Fine, P. & MacLow, C., (2006). Principles of effective pain management at the end of life. Medscape CME/CE Activity. Released October 5, 2006. Retrieved April 19, 2007 from Medscape Today Search. <>

Hazard Vallerand et al, Knowledge of and Barriers to Pain Management in Caregivers of Cancer Patients Receiving Homecare. Cancer Nursing, 2007, 30(1):31-37, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Levine et al, Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform. The Hasting Center Report, 2007;37(5):14-19. Retrieved February 2, 2008 from Medscape Nursing Search. <>

McCaffery et al, On the Meaning of "Drug Seeking" Pain Management Nursing 8(3) 2007, Retrieved February 2, 2008 from Medscape Nursing Search. <>

Meadows, M. (2004, March-April ). Managing chronic pain. FDA Consumer Magazine. Retrieved April 13, 2007. <>

Mercadante, S. (2007). Why are our patients still suffering pain? National Clinical Practice Oncology 4(3) pp 138-139. Retrieved April 19, 2007 from Medscape Today Search. <>

Thomas, C. L. (Ed.). (1973). Taber’s cyclopedic medical dictionary (12th ed.) p-4. Philadelphia, PA: Davis.