Chronic pain: how to support patients by asking the right questions
What you need to know about assessing an individual’s experience of pain
What you need to know about assessing an individual’s experience of pain
Wherever you practise, the likelihood is you’ll be dealing with a high percentage of patients in pain, whether chronic, acute or a combination of both.
‘It’s so prevalent,’ says Emma Davies, an advanced pharmacist practitioner at Abertawe Bro Morgannwg University Health Board in Swansea. ‘In around 90% of hospital admissions, pain is an associated presenting symptom. As many as 50% of the population may be living with pain.’
Pain management role
As nursing staff spend so much time with patients, they can play a major role in its management. ‘Nurses are in a really good position to be able to support people,’ says Ms Davies. ‘They’re the professionals who have the most one-to-one time with patients on a daily basis, so they’re very likely to pick up on the impact of pain on their patients.’
But identifying when someone is in pain can be complicated. ‘When someone says “describe your pain to me”, even as a professional who works in this field, I’d find it very hard to find the right words,’ says Ms Davies. ‘And if what you’re experiencing is distress at being in a different environment, concern about what is happening, being prodded and poked and asked lots of questions, it’s difficult for someone who has no cognitive impairment, let alone those who have problems communicating.’
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Fortunately, there are a variety of tools that healthcare professionals can use to help their patients express their level of pain, including those for people with learning difficulties or cognitive impairment. ‘But you need to know where they are and how to interpret them,’ says Ms Davies. ‘Education is so important.’
Range of assessment tools
The choice of pain assessment tool is usually decided organisationally. Visual analogue and numerical rating scales are commonly used to assess acute pain, and are widely regarded as reliable and straightforward for patients who can verbalise. Alternative tools, such as the Abbey Pain Scale or the Pain Assessment in Advanced Dementia (PAINAD) Scale, can help patients who have cognitive impairment or find communication challenging.
Another difficulty is that patients who are used to living with pain are more likely to feel a new pain more intensely, says Ms Davies, adding that healthcare professionals need to understand the individual’s emotional response, alongside their physical symptoms. ‘These patients can be much more anxious than someone who doesn’t have chronic pain,’ she says. ‘They worry about what any increase in their pain might mean. As they already have pain and are struggling, they feel very anxious about how they’ll cope if the new pain doesn’t go away.’
Pain in the UK: the facts
- According to the British Pain Society, around ten million people in Britain suffer pain almost daily. However, a study published in 2016 suggests a much higher figure of just under 28 million adults in the UK having chronic pain – between a third and half of the population
- Acute pain is defined as lasting 12 weeks or less
- Poorly managed acute pain may result in the development of chronic pain – known to have strong associations with anxiety, depression, and reduced quality of life and ability to sleep, communicate and work, says the RCN
- Chronic pain is continuous long-term pain lasting beyond 12 weeks, or after the time it’s anticipated healing should have happened, following trauma or surgery
- Common conditions that cause chronic pain include lower back pain and osteoarthritis
For those who are already taking medication to control their pain, it can be tricky deciding what else to prescribe, particularly because there are relatively few medicines used in pain relief. These are grouped as non-opioids, including paracetamol and non-steroidal anti-inflammatory drugs, and opioids such as codeine phosphate, tramadol hydrochloride and morphine.
‘Reviewing is often seen as the job of the pharmacist, but it should be any healthcare professional who interacts with the patient, including nursing staff’
Emma Davies, advanced pharmacist practitioner, Abertawe Bro Morgannwg University Health Board
‘For practitioners, there are concerns about doing harm to someone who is already on a lot of medication,’ says Ms Davies. ‘It’s a crucial role for nurses because they are so involved in monitoring the patient.’
But hospital admission can also provide an ideal opportunity to review someone’s medication, enabling clinicians to observe closely the effects of making any changes, in a safe environment.
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‘Reviewing is often seen as the job of the pharmacist, but in my view, it should be any healthcare professional who interacts with the patient, including nursing staff, who need the support to ask questions,’ says Ms Davies. ‘Even as a more junior nurse, you can raise the issue with other professionals, including pharmacists, if you identify that someone seems to have been on a high dose of something for a long time.’
Ask about drug effects on everyday life
A good starting point is to ask how the person manages with their drugs and whether they affect their normal day-to-day activities, advises Ms Davies. ‘Patients will often continue to take medicines, even if they don’t think they’re helping them. If no one asks whether it’s making a difference to their life, often they won’t volunteer that information,’ she says.
In other cases, patients will decide for themselves that a medication does nothing or makes them feel worse, so they stop taking it, but don’t tell anyone. In hospital, they may even experience side effects because they’re now taking medicines that they’d stopped taking at home.
‘Nurses are usually the first person a patient sees when they come into hospital and the last they see on their way home,’ says Ms Davies. ‘They are in such a good place to give information about pain management, whether it’s a leaflet or signposting to other services. It’s also really important to acknowledge to those patients living with chronic pain that we do care. They fear not being believed, so this makes a huge difference to them on a personal level.’
Tips for assessing a patient’s pain
- Ask about pain, urges advanced pharmacist practitioner Emma Davies. ‘It sounds obvious, but we’ve found it may not always be done well or consistently, and that’s often due to lack of training about its importance. If we don’t ask, we may not be told,’ she says
- Think carefully about the kind of questions you ask. ‘For someone who lives with pain all the time, asking about their pain may not be enough,’ says Ms Davies. ‘There may be other ways you can help to make them more comfortable.’ For those in hospital, find out how they usually manage their pain at home. ‘If being active helps, try to replicate that as much as you can,’ she says
- Be wary of assuming that distress or anxiety indicates pain. ‘It’s worth spending a few minutes chatting to your patient about their worries, rather than reaching for medicines immediately,’ advises Ms Davies. ‘But it’s also worth remembering the greater the level of pain, the more anxious and distressed we become’
- Follow guidance on next steps. For acute pain, while it’s important to assess, report and document, there must be clear guidance on what happens next, when a patient is reporting mild, moderate or severe pain, says Cardiff University programmes director Sue Jenkins
- Don’t just assess patients at rest, says Ms Jenkins. ‘And if they have had surgery, make sure you’ve seen them taking a deep breath,’ she says
- Find out what resources are available locally and be prepared to signpost patients. ‘Acute hospitals will have a pain service, often with link nurses, which can be a good source of knowledge, information and support,’ says Ms Davies
- Make sure you’re up-to-date and understand local policies and procedures, says Ms Jenkins. ‘Attend any study days you’re offered’
- Get to know your physio and occupational therapists if you work on a ward, says Ms Davies. ‘Learn when to refer someone to them,’ she says. Shadowing can pay dividends. ‘Hearing how they ask certain questions can enhance your own practice,’ she adds
Building a nursing specialty
Increasing numbers of nurses are becoming pain specialists, says Sue Jenkins, programmes director at Cardiff University, which offers an MSc in pain management. ‘They are clearly needed,’ she says. ‘Our local service started with one nurse and now they have about seven, covering both acute and chronic pain.’
Nurses bring several important attributes, including the ability to network with other professionals. ‘As nurses, we are taught and trained to be holistic, so we look beyond someone’s pain score, at the impact it has on them as a person,’ says Ms Jenkins, who has worked in the field for more than two decades. ‘For patients, pain can be the worst thing they’re experiencing and the most significant problem for them.’
Yet despite the knowledge that most patients will experience pain at some point, education, including at preregistration level, is still lacking. As part of her work with the British Pain Society, guidance on an undergraduate curriculum was launched last year. ‘We’re working hard to try to provide a template,’ she says. ‘But trying to fit it into a timetable is difficult because they’re so full.’ At postregistration, although many hospitals with pain services run in-house staff training, there can be difficulties getting time off to attend.
For Ms Jenkins, putting the patient at the centre is fundamental. ‘None of us want to suffer unrelieved pain,’ she says. ‘My advice is act on pain that is not being treated appropriately as soon as possible – and don’t forget to re-assess.’
Lynne Pearce is a health journalist