VOL: 98, ISSUE: 44, PAGE NO: 51
Helen Hollinworth, RGN, MSc, BA, RNT, is senior teaching practitioner, Suffolk College, Ipswich
Pain during dressing changes is such an important aspect of practice that the European Wound Management Association chose this topic for its first position document (European Wound Management Association, 2002). The vision for this document, published in English and four other languages, was to provide clear clinical advice on the assessment and management of pain during wound dressing changes.
Assessing and managing wound pain and tissue trauma is complex, and therefore the limited evidence to support current professional practice is particularly worrying. Our current understanding of wound pain is based on the physiology of acute and chronic pain and the literature relating to other conditions, including burns.
While there are tools available to assess pain, there is very little evidence of how to assess wound pain effectively, and even less relating to tissue trauma. A further problem is managing the pain of wounds and preventing tissue trauma; again research evidence is limited. This lack of evidence compounds the difficulties experienced in practice and underlines the importance of this position document (European Wound Management Association, 2002).
Pain is a frequent symptom of patients with a wide range of wounds (Enflorgo, 1999), and there is growing concern that patients are often subjected to painful dressing changes. These professional issues provided the springboard, first for a UK survey and then an international collaboration. Understanding what is happening internationally enables nurses to reflect on their own knowledge and practice and then to contribute to the debate so that patient care really improves.
Wound pain and tissue trauma: an international perspective
Based on the questionnaire used for a recent large UK survey of nurses’ views on pain and tissue trauma (Hollinworth and Collier, 2000), 11 countries (mainly from western Europe) took part in the international survey. Of the 14,657 questionnaires distributed to practitioners, 3,918 were returned (a 27% response rate). The survey aimed to identify nurses’ primary considerations in their approach to pain and tissue trauma at wound dressing changes and the strategies used in the selection of products and treatment choices for their patients. The questionnaires, translated into the appropriate language for each country, consisted of structured questions. Data was analysed by a statistical agency and collated by Moffatt et al (2002).
Findings and discussion points
Preventing trauma was the most important factor to consider at wound dressing change for seven of the 11 countries surveyed. Pain prevention was the next most important.
- Leg ulceration was perceived as the most painful wound type for nine of 11 countries, and superficial burns were ranked the second most painful. While other wounds, such as infected wounds, cavity and fungating wounds were considered less painful, this may reflect nurses’ lack of assessment and experience rather than the pain actually perceived by patients;
- Dressing removal was consistently rated to be the time of patients’ greatest pain. Wound cleansing was identified as the second most important situation when patients experience wound pain, with respondents from four countries confirming that wound cleansing was the most important factor. This clearly raises questions about the methods used to cleanse wounds and demonstrated the significant differences in wound care internationally;
- Pain assessment results demonstrated that respondents made a general assessment of pain rather than specifically assessing patients’ pain at the time of wound dressing changes. Talking to the patient was the most important factor for eight countries, but for other countries facial expression and body language were the most important. While this probably reflects cultural differences, there was minimal evidence that practitioners were using their previous experience of treating similar patients when ranking the significance of wound pain;
- The most important factors causing wound pain during dressing changes were very clearly identified as dried-out dressings and products that adhered to the wound. It is surprising, therefore, that gauze packing - probably the most adherent product in wound care - was considered of little importance. It may be that, in line with best practice (Thomas, 1990), gauze packing is infrequently used;
- Trauma during dressing changes was again recognised to be caused by adherent products and drying out of dressings. Although gauze has a major traumatic effect during removal (Grocott, 2000), practitioners did not consider this cause of tissue trauma as an important issue. Perhaps this is because, contrary to best practice, some countries still advocate the use of wet to dry gauze dressings for debridement;
- The most common strategies to manage pain at dressing changes were to soak old dressings, choose non-traumatising dressings and select dressings that do not cause pain during removal. However, soaking dry dressings is contrary to recommendations and may compromise the current principles of moist wound healing (Hollinworth and Collier, 2000). In addition, involving patients in strategies to avoid pain and supporting the surrounding skin during removal were not considered important, despite evidence that adhesive wound care products lead to skin stripping and potential pain and skin trauma (Gotschall et al, 1998; Dykes et al, 2001);
- Only respondents from the UK and France considered giving analgesia before dressing change as an important factor. Respondents from Spain, Austria and Germany only ranked this as their last but one option, even though the prolonged inflammatory response in chronic wounds can lead to increased sensitivity in the wound and surrounding skin (Briggs and Torra i Bou, 2002);
- There was complete agreement by all countries that tissue trauma could be avoided by selecting non-traumatic dressings. Soaking and avoiding adhesive products were less important in avoiding tissue trauma;
- Painfree dressing removal was the most highly desired characteristic of a dressing, with non-adherence the second most important priority. A worrying theme for all countries involved in this study was the lack of importance attached to research evidence to support dressing choice. Dressings that often cause pain and tissue trauma at dressing changes were consistently identified as gauze, knitted viscose, film dressings and paraffin tulle. Products least likely to cause pain and tissue trauma were hydrogels, hydrofibres, alginates and soft silicones.
Practitioners in the UK had the greatest freedom to select dressings for their patients, but in Spain and France medical staff restricted choice of dressings, and respondents from Switzerland acknowledged that a lack of knowledge was the most important factor. There was considerable variation between countries as to practitioners’ knowledge of dressings specifically designed to prevent pain and tissue trauma. These latter points illustrate the complexity of interpreting international practice.
While research over the past decade has concentrated on wound healing and how this can be improved using evidence-based practice, studies repeatedly demonstrate that the pain of chronic wounds has a major impact on patients’ quality of life (Charles, 1995; Franks and Moffatt, 1998). In addition, wound pain and tissue trauma - especially at wound dressing changes - has been marginalised as an issue by health care professionals (Hollinworth, 1999).
The results of the multinational collaborative survey summarised here very clearly confirm that understanding wound pain and trauma is an international problem. It is therefore entirely appropriate that the European Wound Management Association position document offers guidance to practitioners by reviewing pain theory and management of pain at wound dressing changes. Both sections are insightful, aid our understanding and have immediate relevance to practice. However, if patient care is to improve internationally there needs to be open debate and collaborative research on this very important topic.
- The EWMA position document Pain at Wound Dressing Changes can be downloaded as a pdf file from www.tendra.com
The document is available in English, French, German, Italian and Spanish.