Steven Marshall

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.

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. 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.

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.