Dr Patricia Schofield, PhD, RN, DipEd, DipN.
Professional Nurse 2003 Jan;18(5):276-9.
Pain assessment is increasingly being accepted in practice as a key aspect of the nurse’s role. This paper highlights common instruments, and discusses current practice and issues raised by nurses attending the ENB N53 pain education programme at the University of Sheffield.
Historically, criticism has been levelled at the lack of formal pain assessment in many areas of health care. In one review, of 353 hospitalised patients, not one recalled a member of the health-care team even asking about their pain (Donovan, 1983). Where pain assessment was used, there were big differences between nurses’ assessments and the patients’ own (Camp and Sullivan, 1987). Health professionals were reported to underestimate patients’ pain experiences, especially as pain intensified (Grossman et al, 1991; Field, 1996). The patient is the most reliable source of assessment (Carr 1997a, 1997b; Allcock, 1996). A review of pain assessment was recently commissioned by the European Association of Palliative Care (Caraceni et al, 2002).
The role of the nurse and of education
In 1990 a working party reviewed postoperative pain management within the UK (Royal College of Surgeons, 1990). One recommendation was that pain assessment should be recorded along with other routine postoperative observations of temperature, pulse and respiration, and blood pressure, thus appearing to recognise the nurse’s involvement in these assessments. A few years later the Audit Commission (1997) recommended recording pain levels alongside other routine vital signs, with corresponding guidelines. It acknowledged the individuality of patients’ pain by recommending ‘evidence-based … personally tailored care’ with the nurse occupying the key role and responsibility. These days pain is more readily assessed (Neighbor et al, 1999; Lynch, 2001).
Pain education for nurses has helped move practice forward. For example, the pre-registration curriculum for the Advanced Diploma in Nursing Studies (University of Sheffield) contains learning outcomes that advocate the role of the nurse as the pain assessor. Various options are explored with students so that they arrive in the wards with a knowledge of the most used pain assessment tools.
The Effective Management of Patients in Pain course at the same university was the first pain course in the UK for nurses, set up in 1989. It offers education on various assessment tools, including those for more challenging groups such as elderly or confused people, or younger patients.
Legal and professional issues
Pain assessment leads to obvious improvements in patient care. But there are also moral and legal reasons for it. This was highlighted by a court case in the USA (Shapiro, 1994). A patient in a nursing home with cancer of the prostate died in pain. His relatives sued the nursing home and the primary nurse for their failure to control his pain. The judge awarded $15 million against the nurse and the home on the grounds that, as there was no documented evidence regarding pain assessment, he could only assume it had never occurred.
In the UK the nurses’ own professional body assumes that if something is not documented it has not been done (NMC, 1998) Documentation is an essential part of nursing practice and must be performed adequately or disciplinary action will ensue. A nurse does not administer insulin without measuring blood sugar, so why administer powerful narcotics without first measuring a patient’s pain score? It is clear that from a legal, professional and ethical point of view that pain should be assessed, with nurses instigating this procedure.
Since many nurses believe in the principles of advocacy, they should consider Fordham’s view (1988) that believing a patient’s report of pain and documentation are essential components of this.
It could be argued that pain relief is a fundamental human right and that nurses, as accountable practitioners, must support the patient’s self-report or face the prospect of litigation. The Human Rights Act 1988 could be used as a vehicle for future litigation in the area of pain control.
Assessment: acute or chronic
Which assessment tool to use depends on the type of pain. People experiencing acute pain need to be assessed as quickly and efficiently as possible (Bonica, 1990). Chronic or cancer pain may need a longer assessment that takes into account the many factors involved in a multidimensional experience (Black, 1975). The pain may be part of other problems such as anxiety, coping or quality of life.
While using an appropriate tool for clients, nurses should be aware of other measures, too. For example, a nurse in a surgical ward needs to be able to use simple intensity measures but may encounter patients with underlying chronic pain. The key principles are simplicity and flexibility.
Common pain assessment tools
This section describes the most common pain assessment tools.
Visual analogue scales (Figure 1) - Developed by Scott and Husskisson (1976), this scale consists of a 10cm line with the anchor words ‘no pain’ and ‘worst pain imaginable’ at either end. The patient indicates the point along the line that represents their pain experience and this can subsequently be measured providing a pain score, such as 2.5cm.
The scale is simple to use and analyse. It has been adapted for children, with smiley faces (Aradine et al, 1988). The scale can be obtained from various sources in a ruler format that acts as a prompt or reminder to nursing staff. Finally, the scale fits in with the three-step analgesic ladder (WHO, 1996).
Problems are, however, encountered when the scale is adapted. This has been seen when numbers or words are added - such as ‘1-5’, or ‘none, mild, moderate, etc’ - as this can alter the patient’s decision on where to place their mark, not giving a true reading (Scott and Husskisson, 1976; Seymour et al, 1985).
A further problem relates to using the scale at a vertical angle, which the patient may assume represents the head and feet. In terms of reliability and validity, the scale fulfils most of the criteria of an assessment tool (Price and Harkins, 1992) unless the original format is altered.
The Wong Baker FACES rating scale has initial validity and reliability compared to other instruments and consists of a range of faces from very smiling to very sad, which are assigned a rating from 0-5, 0 being no pain with increasing intensity up to 5 (Wong and Baker, 1988).
Verbal descriptors (Figure 2) - This scale consists of boxes representing none, mild, moderate and severe pain, numbered 0-3 (Gracely and Dubner, 1981). The patient is asked to tick the box or to verbally indicate their level of pain. Again this scale is simple to analyse and complete and fits with the analgesic ladder for management.
However, if adapted, its validity and reliability can be compromised (Cicchetti et al, 1985). For example, extra boxes with extra descriptors can confuse patients. The tool does consistently demonstrate validity (Jenson et al, 1986), but it assumes equal distances between the descriptors; and the difference between mild and moderate can vary between 10 and 50%, depending on the perceived interval between the words (Rasmussen, 1989).
McGill pain questionnaire (Figure 3) - This is one of the most validated and reliable measures of pain (Melzack, 1975), developed over many years with many trials in practice and laboratory settings and translated into 18 languages (Melzack and Katz, 1992). The scale provides a rapid way to measure the subjective pain experience and is valid, reliable, consistent and useful (Chapman, 1985).
The scale takes around five minutes to administer, while the nurse reads the 78 descriptors aloud, and then around the same time to analyse. Information can be gained about the sensory, affective and evaluative qualities of the pain experience and small changes can be detected as a result of treatment. This tool is widely used in pain clinics for people with chronic pain, although it can be used when the cause is undiagnosed (Melzack and Katz, 1992).
Registered nurses are accountable, so to what extent should support workers be involved in pain assessment (NMC, 1992)? Warr and Gobbi (1998) surveyed the work of various grades of registered nurses and NVQ Level III support workers in an acute hospital and found that the support workers were responsible for much care delivery.
The then Health Secretary Frank Dobson (Waters 1999) acknowledged the Government’s backing for support workers taking on some nursing tasks. Factors that influence pain assessment must be considered (Figure 4). Does the support worker have knowledge and skills to identify these? It is unlikely that they do, in our opinion.
The Audit Commission (1997) recommended that acute pain teams be set up to train staff. It acknowledged the spectre of pain beyond the surgical ward, for example, accident and emergency departments, and for radiological procedures, where the anaesthetist can play a role.
All patients’ pain should be assessed on admission, regardless of whether they are undergoing surgery or having potentially painful procedures. Pain, whether acute, chronic or palliative, exists across all medical inpatient and outpatient specialties. The Pain Society (Latham, 2001) says that assessment should be ongoing throughout any patient episode. The society recommends that the pain nurse should be skilled in:
- Providing patient information
- History taking
- Appropriate physical examination
- Physical observation of the patient and interpretation of indicative vital signs
- Administration and interpretation of validated assessment tools, such as the visual analogue scale.
However, 24-hour access to a pain nurse is not always an option, and the pain team must educate and develop these skills among direct care givers.
Are the tools too rigid?
A single pain assessment tool for all across a trust may not recognise the varied needs of patients or staff. Assessment must be appropriate for the individual, taking into account age, cognitive development and physical or conscious state. Education is an important aspect of the pain team’s role (Audit Commission, 1997).
Pain is routinely assessed while patient-controlled analgesia or epidural devices remain in situ, as reported by students attending a pain management programme, and discontinued when these devices are removed.
However, Gehling et al (1999), in a prospective research study of 201 trauma surgery patients, found a positive link between patients who had increased pain on day four after surgery with later chronic pain symptoms. This study suggests pain assessment should continue after an intervention such as intravenous patient-controlled analgesia or epidural has stopped. It is difficult to prove that prolonged acute pain is a direct cause of chronic pain, but continued pain post-surgery does need treating, as untreated pain can result in further tissue damage (Bonica, 1990).
Not everyone speaks English or can communicate for other reasons yet the most reliable indicator of a person’s pain experience is the verbal report (Davies and McVicar, 2000). Observing a patient’s physiological and behavioural responses is no substitute for their verbal descriptions, but it can be useful in a patient with communication difficulties. Nurses attending the ENB N53 pain education programme at the University of Sheffield are encouraged to develop a tool suitable for use in non-verbal patients (Figure 5). Assessing and documenting the patient’s normal pain-free state, with co-operation from family members or carers, helps identify changes (Simons and Malabar, 1995). Tied in with this are issues such as age, gender and personality (Seers, 1988).
Not only treatment, but also the pain assessment strategy, should be reviewed if there is a disparity between the nurse-assessed pain and the patient’s own self-report. Cultural background can also affect people’s experience of pain (Zborowski, 1952), which reinforces the need for the patient to be involved in any assessment.
Validated pain assessment tools play a key role, but their limitations in practice for individualised care must be acknowledged. Preventing pain is better than trying to reduce it, but where this cannot be achieved, pain assessment is a care priority.
After auditing pain assessment and prescribing habits from 136 prescription charts in hospital wards, Maclellan (1997) questioned the usefulness of analgesics when required, and recommended regular pain assessment, along with regular doses of analgesia. Marks (1999) suggests nurses choose to see only perceived physical symptoms of pain, when listening to individuals should be an option.
Nurses need to know about the various assessment strategies to make an informed care choice. They need to be aware of how their own attitudes may inhibit their understanding of another individual’s experience. They need to accept pain assessment as the norm.
Melzack (1975) wrote: ‘To describe pain solely in terms of intensity is like specifying the visual world only in terms of light flux, without regard to pattern, colour, texture and the many other dimensions of the visual experience.’
Pain assessment is, however, only one of many things nurses are expected to do in a working day. To encourage them to perform documented assessments the process needs to be as simple as possible.
Pain must be seen as a vital sign - a necessary part of basic nursing care. Being heard and believed is a patient’s essential human right. Pain assessment and treatment strategies must be evidence-based and taught in the core curriculum, with regular reinforcement from pain team members and professional educators on post-basic courses. Above all, nurses need to remember: pain is what the patient says it is.
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