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.

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Improving the Nurses' Understanding of Pain Perception

Pain is Subjective

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 Surveys

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.

Individual Perceptions

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.

Education / Follow-Up

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. 

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Steven Marshall

About Steven Marshall, BSN, MSN, DNP, RN

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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Specializes in Perioperative Nurse. Preop and discharged patients.

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.

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Specializes in Critical Care, Procedural, Care Coordination, LNC.

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. 

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Specializes in Public Health, TB.

A few years ago I had an outer/middle ear infection that my provider described as "impressive" and predicted rupture at some point and would feel much better. I started oral antibiotics. Well, it ruptured and I eventually went to the ED at 2 am on a Saturday and the pain was a 10. I was shuddering and sobbing with pain. The triage nurse got me back quickly, because she sensed I was accurate in my pain rating. The next nurse who saw me told me not to expect any pain meds, other than perhaps, a topical. My ear was irrigated for copious amounts of purulent drainage, and both nurse and MD said that it was indeed impressive. I was never give any pain meds, topical or oral in the ED. I was given home prescriptions for 4 vicodin tablets and antibiotic/steroid ear drops. 

This was my only time ever, in an ED. I suspect that because the triage nurse knew me and identified me as a nurse, that I was labeled as seeking opiates. 

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Specializes in Critical Care.
nursej22 said:

A few years ago I had an outer/middle ear infection that my provider described as "impressive" and predicted rupture at some point and would feel much better. I started oral antibiotics. Well, it ruptured and I eventually went to the ED at 2 am on a Saturday and the pain was a 10. I was shuddering and sobbing with pain. The triage nurse got me back quickly, because she sensed I was accurate in my pain rating. The next nurse who saw me told me not to expect any pain meds, other than perhaps, a topical. My ear was irrigated for copious amounts of purulent drainage, and both nurse and MD said that it was indeed impressive. I was never give any pain meds, topical or oral in the ED. I was given home prescriptions for 4 vicodin tablets and antibiotic/steroid ear drops. 

This was my only time ever, in an ED. I suspect that because the triage nurse knew me and identified me as a nurse, that I was labeled as seeking opiates. 

Thanks for sharing - unfortunately your experience is all too common.  Many individuals with acute or chronic pain are mislabeled as "drug seekers" and do not have their pain treated adequately.  I am hopeful that this trend will decrease over time with appropriate pain management education for providers and clinicians. 

Candi Williams said:

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.

Well said.  Many clinicians feel that if there are no changes in the vital signs then the patient cannot be experiencing the level of pain which they report.  Unfortunately, this leads to inadequate pain treatment in many settings.  We need to understand that pain is a perception and is what the patient says it is and not something we can measure ourselves. 

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Specializes in Critical Care.
nursej22 said:

A few years ago I had an outer/middle ear infection that my provider described as "impressive" and predicted rupture at some point and would feel much better. I started oral antibiotics. Well, it ruptured and I eventually went to the ED at 2 am on a Saturday and the pain was a 10. I was shuddering and sobbing with pain. The triage nurse got me back quickly, because she sensed I was accurate in my pain rating. The next nurse who saw me told me not to expect any pain meds, other than perhaps, a topical. My ear was irrigated for copious amounts of purulent drainage, and both nurse and MD said that it was indeed impressive. I was never give any pain meds, topical or oral in the ED. I was given home prescriptions for 4 vicodin tablets and antibiotic/steroid ear drops. 

This was my only time ever, in an ED. I suspect that because the triage nurse knew me and identified me as a nurse, that I was labeled as seeking opiates. 

 

Erin Lee said:

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. 

Thanks, Erin. While there are multiple causes of pain, it is essential never to discard the patient's subjective data.  Since we cannot objectively measure pain, the patient must be considered the source of truth. 

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Specializes in orthopedic/trauma, Informatics, diabetes.

I have chronic pain and work with mostly ortho/trauma pts and deal with a LOT of pts that have pain. Sometimes it is a fight with some providers to get a pain management regimen that works. With the current war on opioids, they have gotten stinigier with pain meds. On the other side, I have had to fight to keep my current regimen. 

Over time, I have learned to assess pain and help newer nurses/doctors (teaching hospital) with some ideas that I have seen work. We also have a pain team to help with acute on chronic pain, and a team to deal with pts that hx of opioid use disorders. And a sickle cell crisis management team. 

I feel that where I work is more willingly to address pain management most of the time. 

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Specializes in CRNA, Finally retired.
nursej22 said:

A few years ago I had an outer/middle ear infection that my provider described as "impressive" and predicted rupture at some point and would feel much better. I started oral antibiotics. Well, it ruptured and I eventually went to the ED at 2 am on a Saturday and the pain was a 10. I was shuddering and sobbing with pain. The triage nurse got me back quickly, because she sensed I was accurate in my pain rating. The next nurse who saw me told me not to expect any pain meds, other than perhaps, a topical. My ear was irrigated for copious amounts of purulent drainage, and both nurse and MD said that it was indeed impressive. I was never give any pain meds, topical or oral in the ED. I was given home prescriptions for 4 vicodin tablets and antibiotic/steroid ear drops. 

This was my only time ever, in an ED. I suspect that because the triage nurse knew me and identified me as a nurse, that I was labeled as seeking opiates. 

I wish every practitioner in training could buy an incision as part of the educational process.  Not only is pain a personal experience for the patient, it is for the practitioners who bring all their prejudices to the table.  As long as I'm wishing for the impossible, I wish every patient could have a professional massage too.  And yet, my husband was prescribed 4 Vicodins for oral surgery and out drug store chain had NONE in stock!  This is how stupid we are.

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Specializes in Med-Surg.
Steven Marshall said:
 

 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.

I'm glad this is acknowledged.  When a patient with chronic pain issues is injured or has surgery it is very stressful to manage them because they hit the floor in pain and we have to address this before we can get them settled.  Often it takes many hours to get them under control.

Often their ordered regimen is inadequate and multiple calls to the MD needs to be made.  Doctors sometimes could use a lesson.  When a patient's home medication includes oxycodone 30 mg q4h and you order 5 mg q6h for a broken femur, you're going to be hearing from me.

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Specializes in Tele, ICU, Staff Development.

Thanks for sharing an informative article, and I'd be curious how you feel about "pain as the 5th vital sign" being removed by many medical organizations?

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Specializes in CRNA, Finally retired.
Candi Williams said:

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.

Considering this was an acute episode positive for pus, IMHO, this is malpractice.

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