|Year : 2016 | Volume
| Issue : 2 | Page : 12-18
Pain assessment: Can a number meaningfully describe the pain experience?
Associate Professor, College of Nursing, CMC, Vellore, India
|Date of Web Publication||9-Jun-2020|
Source of Support: None, Conflict of Interest: None
Pain as the ‘fifth vital sign’ highlights the significance of pain assessment in patient care, but has often been found to be mechanistic and devoid of meaningful significance in clinical settings. Due to the complex nature of pain experience, nurses and doctors rarely depend on the patient self-report of Numerical Rating Scale (NRS) alone to initiate, modify, supplement or discontinue analgesia. Hence, there is a need to supplement the existing pain assessment using NRS with more clinically-relevant strategies in pain assessment. The article depicts the issues with using NRS and encourages nurses to use clinically meaningful pain assessment methods, citing an example of Clinically Alligned Pain Assessment tool (CAPA©), a new pain assessment tool.
Keywords: fifth vital sign, pain assessment, Numerical Rating Scale, CAPA©
|How to cite this article:|
Solomon A. Pain assessment: Can a number meaningfully describe the pain experience?. Indian J Cont Nsg Edn 2016;17:12-8
| Introduction|| |
Pain assessment is now a universally accepted component of patient care. The journey of considering pain assessment as an important mandate in patient care evolved aver the last five decades. It was almost forty seven years ago, when, McCaffery introduced the now conventional maxim that “Pain is what the person says it is and exists whenever he ar she says it does” (as cited in Newton, Southall, Raphael, A.shford & LeMarchand, 2013). This concept catapulted the patients into the forefront and made them the experts in assessing their pain experience. Moreover, the emphasis on personal experience also helped to lay the foundation for what was argued to be the ‘gold-standard’ for pain assessment: self-report. In 1995, the American Pain Society (APS) for the first time, set out guidelines describing that the first step in improving the treatment of pain is assessment and recording af patients’ reports of pain (American Pain Society, 1999; American Pain Society Quality of Care Committee, 1995). However, it was through the Veterans Health Administration (VHA) initiative in 1998, that pain was considered as the ‘fifth vital sign’ and the use of the numeric rating scale (NRS) for pain assessment was mandated (as cited in Cleeland et al., 2003). The Joint Commission on Accreditation of Healthcare Organization’s (JCAHO) requirement, that accredited hospitals and clinics must routinely assess all patients for pain, also contributed to considering pain assessment as an important indicator for quality patient care (Krebs, Carey & weinberger,2007, Mularskiet al..,2006).
In adults, self-report of pain intensity is most frequently assessed using unidimensional scales, expressed either numerically (e.g., ranging from 0 or ‘no pain,' to 10 or ‘the worst pain’) or through the use of a visual analog scale (e.g., a 10 cm line anchored at extremes of’no pain’ and ‘pain as bad as it could be’) or by using a descriptive, categorical scale (e.g., adjectives of’no pain’ to ‘extremely intense pain’). These scales, currently at the frontline of clinical practice, focus upon the subjective experience of the person and consider patients as the primary source for deciding the presence or absence of pain. When appropriately used, they can provide valid and reliable information. Among all the scales, the NRS has been widely used in almost all clinical settings to assess self-report of pain intensity. The NRS has potential advantages as a pain screening tool. It is short, easy to administer, and has been validated as a measure of pain intensity in populations with known pain (Jensen, Turner, Romano & Fisher, 1999; Mularski et al., 2006; Schiavenato & Craig, 2010; Veterans Health Administration, 2005).
However, over the years, it was realized that sell report (pain scores) were not being used in clinical practice with as much seriousness and appropriateness as advocated (Mularski et al., 2006; Schiavenato & Craig, 2010; Wadensten, Frojd, Swenne, Gordh & Guingberg, 2011). Also, the use of a unidimensional scale to assess a multidimensional experience such as pain was questioned and studied by researchers and physicians (Clark, Yang, Tsui, Ng & Clark, 2002; Donaldson & Chapman, 2013; Gordon, 2015; Krebs et al., 2007). Since it is widely accepted that pain has at least two dimensions: somatosensory qualities and affect (as cited in Clark et al., 2002), studies suggest that pain scores on unidimensional pain intensity scales reflect the emotional qualities of pain much more than its sensory intensity or other qualities. Accordingly such scales were reported to be poor indicators of analgesic requirement. Some of these issues are highlighted in the next section.
| Why is NRS not meaningful enough?|| |
Pain is a complex phenomenon, including both sensory and emotional experiences. For pain assessment to be clinically relevant, it should include not only assessing the presence or absence of pain and its severity, but also the psychological, social and functional consequences of pain (Zacharoff, Katz, & Pujol, 2010). When patients are asked to rate their pain on a numerical scale, they need to use their cognitive and emotional abilities to perceive and assemble the somatosensory input, feelings, and thoughts involved with pain and reduce it to a number. Often, this process is influenced by a variety of unrelated personal and social factors, which in return, influence their self-report on NRS.
Patients have been observed either to suppress or exaggerate their self-report of pain. Various reasons have been reported for patients suppressing or masking their report of pain. Some of them include patients considering increased pain as worsening of their condition, concern about causing inconvenience to doctors, and unwillingness to be perceived as whining or complaining unnecessarily (Ameringer, Serlin, Hughes, Frierdich & Ward, 2006; Schiavenato & Craig, 2010). Their cultural beliefs that stoic behavior will let them be in control of their pain or that pain cannot be relieved completely also mask their report of pain (Ameringer et al., 2006). Patients have also been found to have tendencies to ‘fit’ their clinical symptoms to an expected pattern, in an attempt to establish credibility with their doctors (Werner & Malterud, 2003). Most of them are reluctant to express their pain, and typically assume that doctors / nurses will know they are in pain, as evident from studies on self-report of pain (as cited in Schiavenato & Craig, 2010). On the other extreme, patients might exaggerate purposely or unwittingly, their report of pain. Sometimes, seeking an empathetic response from providers, they exaggerate their self- report of pain (Werner & Malterud, 2003). At other times, reasons for exaggeration may include efforts to obtain opioids and malingering or avoiding responsibilities (Mendelson & Mendelson, 2004; Vukmir, 2004). Some other factors are described in [Table 1] (Watt-Watson, Stevens, Garfinkel, Streiner, & Gallop, 2001). It can therefore, safely be concluded that the assumption that the patient invariably is ‘speaking the truth’ in the self-report is not reasonable. Patients’ modulated pain behaviors and self-report may be based on their perception of their best interest.
In clinical practice, it is also observed that few patients do not understand the concept of ‘rating’ despite addressing the linguistic, social and intellectual concerns. Some of the patients find it difficult to remember their previous pain scores and in spite of being reminded, are not able to meaningfully convey about change in their pain status. For e. g., the author has observed few instances where patients rate their pain score as 8 or 9 on a particular day. On being assessed at a later time-point on the same day, they had expressed increased pain than the preceding observation but had given the same pain score again. While comparing and discussing the previous pain scores with them, they would then say that the previous score was 5 or 6 and not 8 as previously mentioned. An empirical evidence of this clinical observation is reported in a study that evaluated the accuracy of the NRS as a screening test to identify primary care patients with clinically important pain (Krebs et al., 2007). It was found that NRS has only modest accuracy for identifying patients with clinically important pain. Nearly one third of the patients with pain-related functional interference had an NRS score of 0. Twenty-one percent of patients who reported pain as the main reason for the clinician visit and 28% of those with any pain reason for the visit had a pain screening NRS score of 0. These findings and clinical observations lead the author to conclude that the practice of forcing a patient to give a number to their pain has very limited clinical relevance.
Health care provider issues
The two main reasons for assessing pain are to determine the effectiveness of analgesia and to implement analgesic dosing changes if required. However, in clinical practice, drug modifications are seldom made solely on the basis of pain score. The health care providers - nurses or doctors, rarely use the self-report alone to choose or modify pain interventions. They typically use a broader range of resources in arriving at their judgment (Donovan, 2002; Odhner, Wegman, Freeland, Steinmetz & Ingersoll, 2003). For instance, it has been found that nurses use four categories of criteria to assess pain in surgical patients namely, how the patient looks, what the patient says, the patient’s way of talking, and experience with similar circumstances. The leading strategy in assessing pain was not what the patient says (i.e. self-report), but rather how the patient looked (behavioral observation, facial expression, and vital signs). Nurses used their past experiences to form associations between disease states and extent of pain and formed conclusions about pain intensity (Kim, Schwartz-Barcott, Tracy, Fortin, & Sjostrom, 2005). Another study reported that the more experienced the nurses were, the less likely they were to believe the patient’s self-report (Katsma & Souza, 2000). Even among non-intubated patients in critical care setting, it was found that behavioral and physiological pain indicators were used 97% of the time as compared with 29% for self-report (Gelinas, Fortier, Viens, Fillion, & Puntillo, 2004). In another study, physiological and behavioral indicators (36%) were more frequently used to determine the effectiveness of the pain interventions rather than self- report (1%) (Ayasrah, O’Neill, Abdalrahim, Sutary, & Kharabsheh, 2014). Some of the reasons why providers do not depend on a pain score alone are listed in [Table 1] (Schiavenato & Craig, 2010; Watt-Watson et al., 2001).
McCaffery, the ‘godmother’ of nursing care of patients in pain (Ferrell, 2005), documented the lack of trust of nurses in patient’s self-report in her review of studies spanning three decades (McCaffery & Ferrell, 1997). There is strong evidence to suggest that healthcare providers attached greater importance to behavioral displays of pain than patients’ verbal report of pain. If a patient’s self-report does not lead the nurse or the doctor to alter analgesic dosing and other pain interventions, then its utility remains limited. The pain score just becomes an objective representation of an integration of subjective pain experience at that moment, along with the perception as to how one should behave at that moment in time. It can be said then, that patients are asked to tell a number for their pain which may or may not be taken to account for managing their pain. The providers are demanding for an oversimplification of a complex experience.
| Implications on pain management|| |
The issues concerning self-report, therefore, have far-reaching implications on efficacy of pain management and patient satisfaction. If nurses and doctors are not influenced by the patient’s self-report of pain but by the ‘pain- presentation’, the decisions about opioid titration will be biased. In a study among surgical cardiac patients, it was observed that patients reported moderate to severe pain but received only 47% of their prescribed analgesia. Due to these experiences, patients’ perceptions of their nurses as resources with their pain were not positive (Watt-Watson et al., 2001). Another study suggested that nurses undertreated pain in the smiling patient simply because they did not believe the patient had severe pain (McCaffery, Ferrell & Pasero, 2000). In another survey among inpatients, it was found that too many patients were suffering from pain and that the NRS was not used to the extent it should be. The study recommended efforts to overcome under-implementation of pain assessment (Wadensten et al., 2011). In a retrospective study comparing providers’ pain management before and after implementing the initiative of ‘Pain as the 5[th] vital sign, requiring the use of NRS’, it was found that the routine measurement of pain as the 5[th] vital sign did not increase the quality of pain management and that patients with substantial pain documented as the 5[th] vital sign often had inadequate pain management (Mularski et.al., 2006).
| What is the solution?|| |
In light of these issues, it is evident that although the pain assessment using NRS is methodologically convenient, it is not practically efficient. The routine documentation of pain intensity, while necessary for quality care, may not be sufficient by itself to improve the quality of pain management especially in inpatient surgical settings. Pain assessment needs to incorporate other factors that give a better picture of patients’ pain experience than NRS alone which only focuses on current pain and also misses intermittent symptoms. There is therefore, an urgent need to employ pain assessment methods wherein, the pain that patient reports drives how that pain is to be managed. An example of how a new pain assessment tool was developed is given below to illustrate the point.
| CAPA© - Clinically Aligned Pain Assessment tool|| |
The need for a conceptual shift away from simple pain intensity ratings has resulted in at least one new tool named the Clinically Aligned Pain Assessment (CAPA©) tool. Patient and staff frustration with repeatedly having to associate the experience of pain as a number from 0 to 10 at the University of Utah was the impetus for designing the tool. It was observed that having patients repeatedly rate their pain from 0-10 presents a number of issues including additional distress and inconsistent pain rating (Donaldson & Chapman, 2013; Gordon, 2015). In order to address these concerns, a pilot project was started in 2012 to replace conventional NRS (0-10 scale). The project, involving a team of nurses, pharmacists, physicians, educators, advanced practice nurses, researchers, and physical therapists, aimed to develop a pain assessment model that brings out the pain experience and its functional implications in a clinically relevant manner.
They introduced ‘CAPA©' tool, where the patient is asked about pain in a casual and natural manner, rather than using a strict checklist format. At no point, does the patient rate any scale or checkboxes of responses. The tool provides a framework for the nurse / clinician to elicit questions with a distinct focus on five aspects namely comfort, change in pain severity, adequacy of pain control, functioning, and sleep. Each of these categories has descriptor coding to help the nurses to document the pain assessment findings (see [Table 2]. Each category in the tool is to be assessed every shift. Ongoing assessments throughout the shift do not require each category to be completed and the Comfort, Change, and Pain Control categories are used to reflect the patient’s pain experience and effectiveness of pain management interventions. For example, a nurse assessing her patient’s pain would ask how comfortable a patient is, whether discomfort is improving or worsening, whether the current pain medications are adequate or not, whether the patient is able to participate in recovery activities, and if pain is interfering with sleep. The nurse would then document the assessment findings as follows:
Comfort : Intolerable
Change : Getting worse
Pain Control : Inadequate
Functioning : Can’t do anything because of pain
Sleep : Awake most of night
After administering an analgesic, she re-assesses patient’s pain and would document as follows:
Comfort : Comfortably manageable
Change : Getting better
Pain Control : Effective pain control
| Why using CAPA© is better than NRS alone to assess pain?|| |
After introducing the CAPA© tool, in a 4-week quality improvement study at the University of Utah on four inpatient units that covered surgery, medicine, cancer, and orthopedic services with more than 12, 000 total pain assessment observations, statistical data analysis revealed that both patients and nursing staff strongly preferred CAPA© to NRS. The probability of correctly classifying clinical pain states (defined as severity and effectiveness of pain management) was 81 % for CAPA© compared with 42% with NRS. After implementing the new assessment tool, the researchers at the University of Utah found that their Press Ganey© satisfaction scores increased from 18[th] percentile to 95[th] percentile. To the question on Press Ganey© pain care satisfaction, “Did the staff do everything they could to help manage my pain?” the hospital scored in the 92[nd] percentile as against 45[th] percentile earlier. The study also revealed improvements in staff satisfaction and the patient satisfaction, including the post-discharge survey question ‘How well was your pain controlled’. The creators of the CAPA© tool concluded that having brief natural conversations about what patients were feeling using a specific tool seems to have greater pragmatic validity and acceptance, thus providing more precise, consistent, and accurate measurement than the NRS (Donaldson & Chapman, 2013; Gordon, 2015).
The CAPA© , addresses several key questions, including patient comfort, pain control, change in pain status, daily functioning, and sleep quality, all of which are not part of NRS system. Culturally relevant interpretations of pain are also better captured by CAPA© than NRS because using conversation as an alternative form of pain measurement allows patients to freely discuss their pain without feeling as though they are being clinically assessed. Another advantage is that the CAPA© tool may be used with both adult and pediatric patients who are able to participate in a basic conversation. Patient’s responses can be converted to the descriptor codes and documented, providing a clinically relevant pain assessment as compared to just a number alone depicting pain severity. Clearly, more study is needed to validate the tool among various populations. Also, since it is a new tool, its use and efficacy among other healthcare settings are yet to be reported. Despite these limitations, it can be agreed that the CAPA© offers a pragmatic addition to one- dimensional pain intensity ratings and that it is definitely a significant step towards clinically-relevant pain assessment.
| Conclusion|| |
Although a pain self-report using NRS focuses upon the subjective experience of the person and brings patient to the fore-front, for a gold standard, it is fraught with limitations. It gives limited information on the nature of pain in a particular patient. The new pain assessment tool, CAPA©, offers abetter forum for patients to express pain, transcending their personal and social beliefs regarding pain. Since it does not require the patient to score their pain, but express it in terms of descriptive aspects like sleep, comfort, adequacy of pain control etc., they are able to provide clinically meaningful data on efficacy of pain interventions. While the NRS might still be useful in providing a score depicting the pain intensity, the CAPA© tool can be used in combination to augment pain assessment and management strategies in a hospital. Since it is a relatively newer pain assessment tool, its cultural-specific validity is yet to be ascertained. However, using the tool along with the existing NRS for pain assessment will go a long way in improving patient satisfaction with the pain experience.
Conflicts of Interest: The author has declared no conflicts of interest.
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[Table 1], [Table 2]