The purpose of this analysis is to clarify the use of the term ‘pain management’ in relation to practice, with the aim of aiding effective communication and enabling the development of knowledge and tools to evaluate the quality of pain management. Walker and Avant (2005) suggest that performing concept analysis helps clarify those overused or vague concepts that are prevalent in nursing practice so that everyone who subsequently uses the term will be speaking of the same thing and results in a precise operational definition. McKenna, (1997) purports that concept analysis permits the operationalisation of variables for testing a hypothesis via research studies which will assist in the aims of developing knowledge tools to evaluate the quality of pain management.
Uses of the concept.
In addition to definitions and uses of pain management from dictionaries and nursing literature, definitions from professionals and patients from my practice area are presented.:-
The Collins dictionary and thesaurus (2004) notes three uses of the term manage; (i) to be in charge of, (ii) to succeed in being able (to do something), (iii) to exercise control or domination over, and four uses of the term pain; (i) the sensation of acute physical hurt or discomfort caused by injury; illness etc., (ii) emotional suffering or mental distress, (iii) to cause hurt, grief, anxiety, (iv) to annoy, irritate. One dictionary definition of the term pain management was found; ‘ the alleviation of pain or a reduction in pain to a level that is acceptable to the patient,’ Mosby’s (2002, p.1263)
From a search of the clinical databases, Medline, CINAHL, Embase, AMED and British Nursing Index 41940 ‘hits’ were retrieved for the term pain management demonstrating its wide use.
Davis, (1992) defined the concept of pain management as success in taking care of or handling the pain by using certain actions and by directing and controlling one’s own use of these actions. Day, (2002) argues that as pain is a multi-modal experience it needs a multi-professional approach. Loeser and Turk (2001) in their principles of multidisciplinary pain management cite the single most important ingredient is the existence of healthcare providers who are willing to work together as a team. Carr and Mann, (2000) suggest that the effective management of pain relies on the teamwork of different professionals, each with a valuable contribution.
Oliver and Ryan (2004) cite a holistic assessment, therapeutic and non-therapeutic options, education and information giving as components of pain management for arthritis patients.
McCaffery and Pasero (1999) in a summary of pain management for patients with osteo or rheumatoid arthritis suggest that patients’ should be taught how to rest, exercise, adapt their lifestyle, maintain adequate nutrition, recognise and treat fatigue and take advantage of community resources. Care and education on the patient with OA or RA are multifaceted, multidisciplinary tasks, involving a combination of pharmacological, physical, surgical and other approaches.
Davis and Atwood (1996) suggest that assisting the individual to identify, develop and use appropriate strategies is a major goal of healthcare professionals concerned with the interdisciplinary assessment and treatment of chronic pain related to arthritis.
A pain specialist nurse defined pain management as the “multidisciplinary and multimodal treatment of the distressing symptom that is defined as pain by the individual. It is essential that the person who has pain is involved in the planning and evaluation of their treatment. Part of the treatment has to be appropriate education, information and discussion of options.”
A rheumatology specialist nurse defined pain management as “the application of pharmacological and non-pharmacological strategies that relieves pain or reduces pain to a manageable level of severity and to enable the patient to use these strategies so that they are enabled to effectively manage their pain to maintain optimum levels of independence.”
A ward nurse suggested that pain management meant giving analgesia and making the patient comfortable. Another, that pain management meant instructing patients with pain how to cope.
A patient with a chronic orthopaedic disease defined pain management as “pain management to me means two things both equally important. Intervention to reduce the pain using medication and other skills, e.g. operation, physiotherapy, meditation etc. Helping, teaching, showing, counselling me to help me have a high quality life while I live with the pain.”
Walker and Avant (2005) argue that determining the defining attributes is the heart of concept analysis. “The effort is to try to show the cluster of attributes that are the most frequently associated with the concept that allow the analysis the broadest insight into the concept,” (Walker and Avant, 2005, p.68).
In examining the various uses and meanings of the term ‘pain management’ in nursing the following words emerged as being the most commonly used or implied and are grouped to ascertain the defining attributes: -
‘Alleviation’, ‘reduction’, ‘taking care of’, ‘handling the pain’ imply modulation of the pain or response to it. ‘Multiprofessional’, ‘working as a team’, ‘holistic’ imply a multiprofessional approach. ‘Multimodal’, ‘therapeutic/non-therapeutic’, ‘pharmacological/ non-pharmacological’, ‘medication and other skills’ imply a multimodal approach.
‘One’s own use of’, ‘the person who has the pain is involved’, ‘enables patient to use these strategies’, ‘effectively manage their own pain’, ‘help me to have a high quality of life while I live with the pain,’ imply self-efficacy.
‘Education’, ‘teaching’, ‘information giving’, ‘discussion’, ‘helping’, ‘counselling’ imply that there must be an active participatory relationship with the patient.
Therefore I propose that the defining attributes of pain management in nursing are: -
(i)the intention to modulate the patients pain or the response to it, (ii) using a multiprofessional and multimodal approach to pain, (iii) in a participatory relationship with the patient in pain, (iv) with the aim of self-efficacy of the patient in pain.
It is not always possible to achieve pain relief. Modulation refers to altering the pain (e.g. intensity) or changing the patient’s response to it. A holistic team approach is required using a variety of interventions both pharmacological and non-pharmacological. Nurses must ensure that the patient has the appropriate information from which to make an informed decision. It is incongruous that misinformed patients can meaningfully participate in their own pain management, in order to achieve self-efficacy.
The separate definitions of ‘pain’ and ‘management’ do not provide a complete sense of the meaning of the term ‘pain management.’
‘A model case is an example of the use of a concept that demonstrates all the defining attributes of the concept,’ (Walker and Avant, 2005, p.69).
The presented model case is drawn from a ‘real life’ situation.
Mr. X was admitted to the ward suffering from complex regional pain syndrome for pain management. A holistic assessment was taken from the patient regarding the sites; intensity, duration and types of pain experienced, previous pain experiences and previously tried methods for pain modulation. The nurse, doctor, physiotherapist and occupational therapist agreed goals with the patient for modulating the pain and Mr.X’s response to it. Mr. X was given information on which with the multidisciplinary team multimodal strategies were decided upon and included opioid therapy, hydrotherapy, relaxation techniques, an exercise regime and pacing. Mr. X was taught how to use each of the multimodal strategies. The nurse with agreement from Mr. X. co-ordinated the treatment regime. The nurse and Mr. X built up a rapport in which Mr. X felt able to tell the nurse how he felt, the problems his pain was causing him in his roles in life and how it affected activities of daily living, as well as being able to express his evaluation of the pain management process. This meant that the treatment regime could be tailored specifically for Mr. X. The multidisciplinary team communicated regularly with Mr. X and each other. After two weeks Mr. X had reached the goals agreed and was able to use the multimodal strategies independently.
In this case the patient presented with pain and during a holistic assessment communicated how it affected him to the multidisciplinary team and in a participatory relationship decided upon multimodal strategies for pain modulation. An individualised and collaborative approach was taken. Mr. X was given sufficient information from the skilled professionals on using the strategies enabling self-efficacy. Mr.X’s quality of life improved as he attained his own goals.
Walker and Avant (2005) recommend that clarity can be further enhanced through identifying alternative cases.
Mrs. P had been admitted to the ward with an exacerbation of rheumatoid arthritis. Following assessment by the nurse, doctor, physiotherapist and occupational therapist a multimodal strategy to try to modulate the pain was decided and Mrs.P was informed. The nurse told Mrs.P that they knew best how to treat her pain. Mrs. P was told to use the strategies and after three weeks was discharged. Following discharge Mrs. P stopped using the strategies and was later re-admitted to hospital.
In this case there is evidence of a multiprofessional and multimodal approach taken to modulate the patients pain, however there is no evidence of this being done in participation with Mrs.P. Mrs. P was the recipient of rather than an active participant in the pain management process. The aim of self-efficacy was not fulfilled as Mrs.P was not invited to take part in the process by agreeing goals, or given any information or education on how to use the strategies which would make a difference to her ability to deal with the pain, both of which may have contributed to her non-compliance.
Mr.C had severe osteoarthritis to his spine. Following a discussion between the consultant and a nurse Mr.C. was told there was nothing that could be done to help him and that he would just have to put up with the pain. Mr.C. felt that the nurse and doctor did not believe his expressions of the pain, felted annoyed, irritated and anxious and his pain increased.
This case clearly demonstrates what pain management is not. There was no intention to modulate the patients pain or response to it, the multiprofessional team were not involved, no strategies were employed, there was no relationship with the patient and no attempt to enable self-efficacy. In fact the anxiety caused seems to have caused Mr.C. more harm; clearly not what the concept is.
‘Ancedents are those events or incidents that must occur prior to the occurrence of the concept,’ (Walker and Avant, 2005, p. 73). A number of antecedents facilitate the occurrence of pain management.
The patient must believe they are in pain and be believed. The patient must express their pain. Patients’ may unintentionally create a barrier to effective pain management by their reluctance to report pain. This may be due to fear of ensuing diagnosis and treatment, believing that pain is to be expected at their age or with their disease or because they do not want to bother staff. In line with the nursing philosophy pain management requires a holistic approach. By the very subjective nature of pain and idiosyncrasies of people, pain management requires an individualised approach. Multidisciplinary team members need to work together collaboratively in a non-hierarchical structure. As well as facts (empirical evidence), personal values and beliefs inform decision-making. Briggs (1995) proposed that successful assessment and control of pain ultimately depends on a positive, trusting relationship between nurse and patient and that effective communication is essential to help people express their pain. Resources are essential. Pain management as a process takes time. Access to a multidisciplinary team and multimodal strategies are essential for pain management to occur. Members of the team must be educated in pain management. Using the skills of professionals can help to address physical, psychological and social difficulties and result in improved pain management strategies overall, (Brown, 2004). The patient requires cognitive ability. This is not to say that pain assessment and control is impossible in cognitive impairment but that for pain management as defined in this concept analysis would be difficult to achieve in cognitively impaired patients.
Walker and Avant (2005) suggest that consequences are the outcomes of the concept and are useful in determining often-neglected ideas, variables, or relationships that may yield new research directions. In this concept analysis the consequences may help develop hypothesis relating to the quality of pain management.
Because of the subjective nature of pain the consequences of pain management should be defined by the patient’s own measurement of their emotional, physical and social wellbeing.
A consequence of pain management is that the patient with pain is able to cope with the demands both physical and emotional made upon them. ‘Pain is the most frequent cause of suffering and disability that seriously impairs the quality of life for millions of people throughout the world,’ (Bonica and Loeser, 2001, p.3). Therefore a consequence of achieving pain management is improved quality of life. When patients’ have actively been involved in deciding upon strategies to deal with their pain or response to it and know how to use them compliance is an outcome. Pain and anxiety are closely related. A reduction in anxiety is a consequence of achieving pain management.
Walker and Avant (2005, p. 73) define empirical referents as classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself, and suggest that they are useful in practice because they provide the clinician with clear observable phenomena by which to determine the existence of the concept in particular clients.
During this concept analysis four defining attributes where identified; the intention to modulate the patients pain or the response to it, using a multiprofessional and multimodal approach to pain, in a participatory relationship with the patient in pain, with the aim of self-efficacy of the patient in pain.
Many tools exist to measure the modulation of pain, for example, the Brief Pain Inventory (Daut et al, 1983) and the McGill pain questionnaire (Melzack,1987).
Surveys can be helpful to measure intentions, i.e. the intention to use a multiprofessional, multimodal approach, but do not actually tell you with certainty whether this approach is used in practice. Observation of practice might give more realistic answers. Noting the barriers to effective pain management would provide essential information on how best to change practice to enable optimum pain management.
Surveys could also determine patient satisfaction with pain management but would only elicit superficial information.
Phenomenology seeks to discover the essence and meaning of a phenomenon as it is experienced by people, (Polit et al, 2001). Using this research approach from the naturalistic paradigm could ascertain the quality of pain management from the point of view of patients and professionals. Interviews could reveal whether patients feel that a participatory relationship existed, if not why not and how important it was.
Tools based in the positivist paradigm, such as the arthritis self-efficacy scale (Lorig et al, 1989) could be employed. Self-efficacy could also be tested in the naturalist paradigm using interviews.
Concept analysis is a useful tool in defining the concept of pain management and has provided a tentative definition of pain management using the defining attributes.
Pain management could be viewed as a process and an outcome as a result of this analysis. To manage pain nurses need to have an understanding of each of the defining attributes of pain management. The nurse-patient relationship has been highlighted throughout the concept analysis as pivotal in pain management. The antecedents- pain, resources, a knowledgeable team, holistic assessment, individualised approach, communication in a trusting relationship and cognitive ability provide areas for development to improve the existence and quality of pain management. The consequences of pain management – compliance, improved quality of life, coping and a reduction in anxiety provide areas for measuring the quality of pain management in local practice. Identifying the defining attributes, antecedents and consequences gives a basis for discovering the barriers to pain management and areas for knowledge development in local practice. Improving pain management begins with reflection on our reactions, values and beliefs surrounding pain and how these have the potential to influence the care we provide (Briggs, 2003). The consequences identified have important implications in providing indicators for the clinical and cost-effectiveness of pain management.
Cronin and Rawlings-Anderson (2004) suggest that the outcomes of any analysis can only be tentative, as concepts can change with use and as situations and practice develop and two people may draw different conclusions when investigating the same concept, owing to the realm of data analysed, their skills of critical thinking and the manner in which they synthesise the material. Kitson (1993) suggests that the most effective use of concepts is when people pool them and all the different concepts of a thing coincide.
The concept of pain management whilst frequently used in nursing has not been extensively defined. A shared understanding of pain management is important in nursing to aid effective communication, develop knowledge and enable the development of tools to evaluate the quality of pain management in practice for use and is necessary if all those professionals involved are to resolve problems associated with it. This concept analysis enabled the development of an operational definition; pain management is the intention to modulate the patient’s pain or the response to it, using a multiprofessional and multimodal approach to pain, in a participatory relationship with the patient in pain, with the aim of self-efficacy of the patient in pain. This definition of pain management will aid effective communication. The defining attributes and consequences have provided a basis for research hypothesis to test the quality of pain management in local practice. The antecedents give clear indicators for what needs to be in place before pain management can be achieved. The empirical referents provide strategies to determine the existence of pain management, the quality of pain management and could reveal areas for knowledge development and aid in identifying barriers to progress in pain management for this patient group. Pain management will be most auspicious when the patient is acknowledged as an equal partner in the process.
This concept analysis of pain management is open to further development and a collective consensus of the meaning of pain management.
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