Pain is an unpleasant biopsychosocial experience associated with tissue injury, described in terms of such damage as being always subjective. It has no borders and can affect any individual. It affects activities of daily living and can meaningfully diminish quality of life for those who experience it. Since pain is such a universal condition, capacity to assess and manage it is vital for healthcare professionals. Nurses have always had an advocacy relationship with their patients. Their constant exposure to them during normal activities allows for observation of pain experiences that can be different than those described to the physician. Patients rely on nurses for benevolence, empathy, and decision making skills not only to interpret their symptoms but also manage pain effectively.
Pain relief is progressively seen as a rudimentary human need and right, therefore, it is more ethical than medical concern for healthcare workers to address. Inadequate relief of pain is recognized in most countries for many years. Lack of awareness and understanding is the key issue in ineffective pain management. Nurses and doctors, being at the forefront, exhibit insufficient grasp of medications and misconstructions about opioids, linking not only to addiction, dependence and tolerance risks but also problems with adverse effects. It is strongly believed that immediate and effective pain relief for comfort is one of the primary objectives in providing high quality care for the patient.
To begin with, one of the few commonalities in human nature is pain. However, there are variances in how it is conveyed and construed but it signifies a similar experience for most people. In order to understand this phenomenon roots back to the specific cultural or ethnic background of the individual. For instance, most parts of the western hemisphere are very communicative with regards to pain unlike with the eastern hemisphere where expression is impassive. More common with the Americans, expressivity denotes articulation of what is in their mind and emotional state. On the other hand, stoicism manifests more with Asians, particularly in the Philippines. Filipinos tend to endure pain trusting it is the will of God and that He will provide strength to bear it. These cultural dissimilarities greatly affect expression of pain as well as understanding and managing it. Such as an American patient may verbalize pain piercingly and be interpreted by a Filipino nurse as just an exaggeration to the situation. It is therefore felt that understanding cultural differences will greatly improve management of pain.
On the other hand, from the time of Hippocratic days, doctors have gone lengths to impede and supersede patient’s preferences in their own treatment. Patients on the other hand have to believe their doctors, abundant in knowledge and training, without question. This paternalistic, on occasion autocratic doctor-patient relationship has been in existence for quite some time. Traditionally, physicians took care of families to the extent that he is considered a genuine member of the family, caring for the infant to the elder generations until their final illnesses. Therefore, the degree of trust given by a patient variably increased the extent doctor’s go to uphold health.
However, changes in periods happen, increasing awareness and autonomy have led patients to want to know more about their conditions and consequently participate in their own care. Gone were the days of unquestioned judgment by the doctors. Increasing patient involvement along with the physician contributes to a more acceptable and productive decision making process. Conversation with the patient paved way to decisions that will mutually benefit both parties. The advent of informed consent strengthened this doctor-patient communication process. What used to be “we need to do this to you” became “this is what we want to do, what do you suggest”. Consent meant a degree of autonomy as well as self-determination for the patient nowadays.
Lastly, physicians solely managed pain for the patients conservatively. Traditionally, pain relief has been controlled in the emergency room to circumvent misdiagnosis or any other treatment for the patient. Numerous researches have revealed inadequate pain relief given in the emergency room (Muntlin, Gunningberg & Carlsson, 2006). Inadequate pain relief has been linked to limited understanding with regards to pain assessment and management, communication gaps between healthcare workers and patient, as well as limitations of the institution (Layman Young, Horton & Davidhizar, 2006). Studies carried out in ED’s have shown that emergency nurses and emergency physicians assess pain as being of lower intensity than the patients do (Marinsek, Kovacic, Versnik, Parasuh, Golez & Podbregar, 2007). However, with the increasing pace of healthcare development, advances in practices paved way for nurses to initiate pain relief for the patient. Kelly, Brumby & Barnes (2005) defined nurse-initiated analgesia as “the initiation of analgesia by nursing staff, using a pre-defined protocol, prior to the patient being seen by a medical officer” (p. 151). The same research (Kelly, et. al., 2005, p. 153) presented that patients’ who received nurse-initiated pain relief prior any interaction with a doctor obtained analgesic on average 26 minutes earlier than those seen by a doctor first. Patients’ perceptions of the care they receive are often seen as an indicator for quality of care. Improvement of pain management protocols requires healthcare workers, especially nurses, to pay attention to the patients who will be given the actual care (Elder, Neal, Davis, Almes, Whitledge & Littlepage, 2004). Pain management is not only limited to analgesia administration but also a systematic nursing assessment of the patient. Evidenced-based practice examining nurse-initiated pain protocols are, nonetheless, limited. Most are found only in developed countries like Australia, United Kingdom and United States of America.
This essay aims to:
Explore pain beliefs across diverse cultures.
Review traditional approach in lieu of patient management
Describe patient participation in pain management
Discuss clinical pathways registered nurses follow to promote pain relief for the patient.
Multicultural perceptions of pain
Pain is a ubiquitous feature of the human experience; it is one of the few universals of human existence (Free, 2002, p. 143).
The Differences in ways physical and emotional pain was experienced and expressed gives support to the view that cultural background determines how pain is experienced and communicated to others (Lovering, 2006, p. 392).
Filipinos believe that pain is the will of God and an opportunity for forgiveness of sins. Acceptance of faith-determined destiny may lead to abstinence from health treatment to leave fate in the hands of God (Schmit, 2005 pp. 348-349).
The doctor-patient relationship model
Paternalistic model: the doctor utilises his skills to choose the necessary interventions and treatments most likely to restore the patient’s health or ameliorate pain (Kaba & Sooriakumaran, 2007).
The physician is readily recognised and accepted as the guardian who uses his specialised knowledge and training to benefit patients, including deciding unilaterally what constitutes a benefit (Chin, 2002, p. 152).
Participating in own pain management
Increasing patients’ involvement in the medical decision-making process is one potentially fruitful means of improving pain management (Borders, Xu, Heavner & Kruse, 2005).
Patient-driven health care can be characterized as having an increased level of information flow, transparency, customization, collaboration and patient choice and responsibility-taking, as well as quantitative, predictive and preventive aspects (Swan, 2009, p.492).
Paradigm shift in pain relief
Triage nurse initiated pain management protocol required the nursing staff to play a central role. It is logical for nursing staff to take on this role as they are the first HCW that an ED patient will come into contact (Goh, Choo, Lee & Tham, 2007, p. 20).
Enabling an ED nurse to assess a patient’s pain at the point of presentation to ED and then administer analgesia according to a pre-approved protocol simply makes sense, given the goal to reduce time to analgesia (Finn, Rae, Gibson, Swift, Watters & Jacobs, 2012, p. 34).
Nurse-initiated analgesia is defined as ‘the initiation of analgesia by nursing staff, using a pre-defined protocol, prior to the patient being seen by a medical officer’ (Kelly, Brumby & Barnes, 2005, p. 40).
The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in patients perceived lower pain intensity and improved quality of care in pain management (Muntlin, Carlsson, Säfwenberg & Gunningberg, 2011, p. 20).
Multicultural beliefs affect expression, perception and action towards pain. Knowledge and understanding of these beliefs will greatly assist in pain management.
Doctor-patient relationships offer a great deal in pain control outcomes. Excessive authority by the physician or autonomy by the patient decreases meaningful choices to pain relief.
Expansion of nursing scope of practice encourages nurses to be more active in patient care. Nurse-initiated pain relief promotes an immediate response to pain presented by the patient.