Nurses Often Underestimate Pain
The current treatment of acute pain is unsatisfactory and can result in chronic pain. This has emerged from research being carried out by Jorien Pierik, a doctoral candidate at the University of Twente. Once pain has become chronic, it can no longer be treated effectively and could have a serious impact on the quality of life of the patient. Pierik has identified two risk factors for chronic pain: the presence of severe pain when leaving the Accident and Emergency Department and the exaggeration of pain. The improvement and prevention of chronic pain can be achieved through the proper treatment of pain and more attention being given to pain through efficient pain protocols.
Chronic pain is a significant social issue that is experienced by twenty per cent of the population of the Netherlands. Chronic pain is the result of disruption to the pain receptors in the brain. This is different from acute pain which is caused by unhealed wounds. Once pain has become chronic, it can no longer be treated effectively. ‘At this point, something in your pain system has become irreparably damaged,’ explains Pierik. ‘The development of chronic pain can have a serious impact on the quality of life of a patient, as it doesn’t only affect quality of life but also creates exorbitant medical expenses.’
Jorien Pierik will be awarded her doctoral degree at the University of Twente on 1 December for her research on chronic pain. She investigated the risk factors for the development of chronic pain and the ways in which this can be prevented. For an entire year, Pierik monitored 450 patients aged between 18 and 69 who suffer from acute pain as a result of injuries to the arms and legs caused by blunt trauma such as fractures, sprains, or dislocated joints. After six months, 44 of these individuals still suffered pain and just over ten per cent experienced moderate to serious chronic pain.
The research identified six predictive factors that play a role in the development of chronic pain. Two of these risk factors can be influenced: the presence of severe pain when leaving the Accident and Emergency Department and the exaggeration of pain. The other four factors cannot be influenced: advanced age, a poor physical condition prior to the injury, the presence of other chronic pain, and the extent of the injury.
Patients who leave the Accident and Emergency Department with severe pain and have long-term severe acute pain are at a higher risk of developing chronic pain. ‘This suggests that timely and proper treatment of pain can reduce the progression from acute to chronic pain and thus diminish the risk of developing chronic pain,’ states Pierik. ‘A long-term and intense pain stimulus can deregulate the normal pain signalling mechanisms, causing them to continuously transmit these pain stimuli without any direct cause. This can be compared to an alarm system that keeps going off even though there is no burglar. In this case, the cause for the malfunction is an incorrect setting of the alarm system.’
While sixty per cent of patients used pain medication somewhere in the emergency care chain, it appeared that more than two-thirds of patients still experienced moderate to severe pain when leaving the Accident and Emergency Department. According to Pierik, ‘This means that you need to ensure pain relief at as early a stage as possible. More attention also needs to be given to effective pain alleviation in cases of acute pain.’ Patients also need to be properly informed about the importance of pain relief. Currently, one in five patients refuses to take painkillers.
Nurses Often Underestimate the Pain
An accurate assessment of pain is vital for effective pain treatment. Nevertheless, the pain experienced by patients is often underestimated by nurses in different settings, including in emergency care. In more than 63% of patients, their pain was underestimated by a clinically relevant value. In this research, the pain was predominantly underestimated in women, people with a lower level of education, patients who had already been given pain medication, fearful patients, and patients with small injuries. Nurses need to be aware that these patient groups are at a high risk of having their pain underestimated. An underestimation of pain may result in unsatisfactory pain treatment when policy is based on a pain assessment by the nurses. ‘The pain is as severe as the patient says it is,’ highlights Pierik. ‘Pain is subjective and differs for each individual.’
Effectiveness of a Pain Protocol
Research has shown that the implementation of a pain protocol in the Accident and Emergency Department will result in an increase in the prescription of pain medication, shorter administration time, and less pain. Patients will be administered a particular type of medication based on their pain score. Because this is protocolized, nurses can administer strong pain medication such as opioids without a doctor having to prescribe them. According to Pierik, ‘This is one of the most important points of such a protocol, as patients with an injury often have to wait for hours before seeing a doctor.’
People who exaggerate or dramatize pain and are pessimistic towards the pain are at increased risk of developing chronic pain. ‘Pain is not just a sensory experience,’ explains Pierik. ‘It is a very emotional experience as well.’ This risk factor can be limited in the future through new approaches such as cognitive behaviour therapy. This could reduce the risk for developing chronic pain or teach people to handle the pain more effectively.This type of research is also being conducted at the University of Twente.