In this 2007 article, Dr Eloise Carr provides an in-depth discussion of the numerous barriers that have contributed to acute pain after surgery persisting as a significant problem. Despite the fact that this article is 14 years old, these barriers continue to exist to one degree or another. These barriers include:
- patient barriers
- inadequate knowledge of healthcare professionals
- organisational practices which impede the administration of analgesics and non-
- lack of assessment
Let's jump right into a description of the barriers present and provide some of my insights as to how to overcome these barriers.
Anxiety and pain - high levels of anxiety are know to influence the level of pain. Patients often have low expectations about pain relief.
-->what you can do
- make preoperative visits / have conversations with patients; these serve to set
realistic expectations regarding pain management and functioning and can allow the
patient to share their concerns. This is an important step in validating their
feelings and expressing your interest and commitment to manage pain in
a safe and effective manner.
Patients may not report their pain for a number of reasons
- thinking the healthcare professional is the authority on their pain
- distracting the surgeon from his or her job in treating the problem
- a fear of injections
- worried about being 'unpopular'
- thinking that pain isn't harmful and can be endured
--> what you can do
- encourage the patient to speak about their pain particularly if they feel it is
interfering with their ability to be mobile
-- Not mentioned in the article my own thought...
Some patients may expect they will not have any pain. If a provider does not intentionally discuss pain that will be experienced as a result of a procedure, it might lead the patient to believe they will not experience any pain. Pain is an emotional experience and has several confounders. Pain often signals to the patient that 'something went wrong' when that might not be the case at all.
--> what you can do
- ask the patient 'what did your doctor tell you to expect after this procedure /
with this medical condition regarding pain?
- say, 'some pain is expected and that is normal. We will do everything we can
to safely minimize pain while getting you to return to being functional.'
Assessing pain - 'we may not see (realize) that routine actions may elicit intense pain and discomfort for many patients' (who are intubated / sedated) and cannot verbalize.
- wound drain removal
- tracheal suctioning
- femoral catheter removal
- placement of CVC
- changing of non-burn wound dressings
Also, it is challenging to assess pain in patients who are unable to communicate and observational scores in these patients commonly underestimate the intensity of their pain experienced.
--> what you can do
- use validated pain scales for children and non-communicative individuals; ask their
caregivers how they demonstrate pain. Caregivers often provide valuable insights in
- consider the intensity of the procedure or intervention and let that be a guide
to beginning your pain management plan (check out my PreEmpt Pain app for
more information for a practical guide)
WHO Pain Management Ladder
Treatment based on expected intensity of pain.
Pain education - 'While knowledge levels have improved, the actual practice or management showed less improvement'.
In other words 'recommendations from research regarding best practice for pain management are not consistently applied for several years'.
Improvement in education surrounding pain management starts with improving the relationships with the nursing providers who spend a great deal of time with the patient and best understand how pain may impede the patient from increasing their mobility, taking deep breaths, or resting comfortably.
Dr Carr ponders why education has failed to equip healthcare professionals with good knowledge about pain management.
- variability in duration of pain management education varies widely between
medical schools; however, medical students receive an average of 16 hours over the
duration of their training dedicated to pain management. Veterinary students