Improving the Nurses' Understanding of Pain Perception

Pain is the fifth vital sign. Many practitioners find it difficult to assess pain. There are no definitive tests or measurements to provide objective data regarding pain perception. This article explores the perception of pain and information to improve the nurses' understanding of this concept.


The perception of pain can be complex for nurses to comprehend. Patients who have chronic pain may not appear to be in distress. Pain is known as the fifth vital sign; however, it is subjective data, and there are no objective measurements readily available to quantify levels of discomfort. This subjective data is unlike the objective data for other vital signs such as heart rate, blood pressure, and respiratory rate.

Pain can be acute or chronic. Individuals with diagnoses such as cancer and sickle cell disease may exhibit acute on chronic pain as their conditions typically carry an underlying level of continuous discomfort. These patients may present to the emergency department describing levels of pain that are difficult for the nurse to understand.

Patients in pain may have methods to cope with their situation through means that staff may misinterpret. They may appear happy and laughing, with no signs of distress. Patients may be using their phones for gaming or holding a video conversation. When asked about their pain, they state the level is high. This presentation is confusing for the nurse, who may need help comprehending what they are seeing versus what the patient is reporting.

Patient experience surveys can contain questions regarding pain management. Staff may describe patients with chronic pain who experience acute episodes requiring hospitalization as "drug seekers" or "frequent fliers.” These derogatory terms negatively impact the patient experience and can delay future care. These scores are often lower for patients with sickle cell disease or other chronic pain conditions.

As a medical oncology department leader, I often round on our patients, including those with sickle cell disease.  Nurses would report challenges with patients regarding pain management, and I would address these issues. Patients described interactions in the emergency department with nurses as dismissive of their complaints of pain. Many heard nurses speaking about them with statements such as "they are here again" and "they can't be in that much pain; they have eaten two trays of food already.” It was very disheartening to hear of these interactions.  Many patients described waiting until they could no longer bear the pain before coming to the emergency department due to their negative experiences. These patients felt like they were a burden to others and were frustrated with their experiences.

Nurse education regarding pain perception and management is crucial to addressing these patient concerns. Taking the time during daily huddles and monthly meetings to review patient experiences proved beneficial in improving nurses' understanding of pain perception.  Formal education sessions on these topics are also helpful.

Nurses caring for individuals with acute and chronic pain should understand perception as the patients' reality. While the nurse may not understand how the patient can be experiencing high levels of pain and not show signs of distress, they must be aware of the differences in individual perceptions. Understanding is incredibly challenging when the patient has a history of acting out towards the staff when they feel ignored.

When speaking with nurses caring for the more challenging patients, it is evident that these interactions hurt job satisfaction. Many felt overwhelmed while caring for chronic pain patients who required higher doses of medication. Often these doses resulted in frequent, sometimes hourly, requests and interventions for pain management.  Fatigue from these frequent requests often led to delays in call-light response and further patient dissatisfaction. Some nurses cited the care of challenging chronic pain patients as a reason for transferring to other departments.

Perception of pain is challenging for patients and nurses. Nurses' understanding of pain perception may improve their care through education and follow-up. Providing education regarding pain perception during daily huddles, monthly meetings, or formal presentations may prove successful in increasing this understanding, resulting in improved patient satisfaction. Patient rounding helps gauge the nurses' knowledge of pain perception and reveals opportunities for improvement. 

Dr. Steven Marshall, DNP, MSN, BSN, RN, has been a nurse since 1993. He has experience in critical care, emergency departments, air and ground transport, oncology, and infectious disease. He hopes to educate others through health and medical writing.

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Candi Williams

1 Article; 5 Posts

Specializes in Perioperative Nurse. Preop and discharged patients. Has 25 years experience.

I sometimes found it challenging caring for patients with pain. Nurses have been trained to respond to objective data such as elevated or low blood pressures, respiratory rates, SpO2 levels, and temperatures. But our response to subjective data seems more difficult. I have heard nurses say those exact statements and I am sure I've thought or probably even said them myself.

Over the years whenever those thoughts crossed my mind when caring for a chronic or acute pain patient who showed no signs of pain, but gave me a high pain level, I had to remind myself that pain is subjective and yes that people deal with pain differently. I felt it was my responsibility to listen to the patient, accept the pain level given, chart it, and use sound judgement to treat the patient's pain.

I think when nurses are caring for such patients, if at all possible, management should consider lowering the nurse's patient load to prevent fatigue because those patients can be challenging and preventing fatigue improves nursing care and patient satisfaction.

Erin Lee, BSN, RN

3 Articles; 17 Posts

Specializes in Critical Care, Procedural, Care Coordination, LNC. Has 11 years experience.

Pain is a challenging thing to measure. I agree that it is important to consider the patient's perspective, just because they don't appear to be in pain doesn't mean they are not. Pain tolerance is real. I have been disregarded multiple times when showing up to the emergency room for severe injuries because I don't "look" like I am in pain. Example: I broke my back and was completely ignored until they got the initial imaging, I went from sitting in an overcrowded ED on the floor of the hallway to being fast-tracked to an MRI and given pain medicine. Or the time more recently when I broke my foot and was provided with zero pain medicine for breakthrough pain during my recovery. 

On the other hand, I do think our healthcare system is so quick to administer pain medications. While they are absolutely necessary, people also need to learn alternative methods to deal with and work through the pain. I wish nurses had more time to help patients with these alternative methods so we can adjunct them with pain medications and help people wean from them sooner. Taking pain medications is not always the answer. 

I do realize that caring for sickle cell patients or oncology patients are entirely different than someone with an orthopedic issue though. Pain is so complex, and caring for people with it is truly an art. 

Thank you for sharing.