Enablers and Barriers to Effective Pain Assessment and Management - Essay Example

Introduction Pain is an indicator that arises to flag out that a sense or an emotion has been traumatized or has been injured, this is especially so when blood, marrow or skin tissue has been damaged (Francoeur, et al, 2007). Pain is an experience that is subject to a particular individual and therefore not transferable to any other person, this aspect makes hard for one to put themselves in the shoes of the sufferer since they cannot understand the pain. The ability to feel pain is important in order to prevent one from injurious situations (Kikwilu, et al, 2008). Pain is usually what one would feel when they cut a finger, pour an antiseptic on a wound or even when a muscle clumps up. In order for a physician to diagnose an illness, assessing pain is crucial in prescribing, proper and efficient management of pain (Upshur, et al, 2006). There are no universal tools to determine the levels or severity of pain, therefore, a physician relies majorly on indicators in both physical and in behaviour. There are various steps and techniques that can be used to identify barriers, how to assess pain (Ward, et al, 2009). These are significant in the process of ensuring proper and efficient assessment of pain. Pain is the first indicator that a patient experiences, it notifies them that everything is not alright, physically, psychologically, spiritually and even emotionally and thus seeking medical attention and opinion. This can be affirmed by more than 35 million medical visits that are done to physicians as recorded in 1984 by Knapp and Koch (Geertzen, et al, 2006). According to International Association for the Study of Pain i.e. (IASP), pain is the unpleasant experience of the senses and emotions that is associated with real or potential damage to the tissues. There has been extensive research as to the understanding of pain in a particular individual’s experience, and the aspects of pain, and how they are influenced by various elements. Therefore, the reasoning is that there is no single physiological contributor to pain as other factors as psyche and issues in society has a part to play in factors that contribute to pain (Upshur, et al, 2006). The sufferer is the only one who can describe what they are undergoing at that particular time since they are the only one experiencing the actual and real pain. There are however, other sources of pain. These include among others, lesions formed after surgeries, and chronic tumours that are non-malignant. In all these scenarios, it is reasonably common for the patient to suffer, complain n report of experiencing acute pain to the physician (Sorkin, 2005) Researchers in the field of pain have traditionally categorized pain as a) acute pain. B) Pain related to cancer and c) Pain groups associated with chronic non-malignant tumours. Acute pain is described and identified as the reaction to trauma or an attack of a disease. In this case, symptoms of pain are seen as a direct proportionate to the extent of the disease or injury, or damage to the tissues (Francoeur, et al, 2007). More often than not, researchers have observed over time that symptoms tend to gradually, follow a certain trend over an expected period. This is so to ailments or conditions that may are known to stretch over long periods of time, be it weeks, months and sometimes years. Sorkin (2005) indicates that acute pain may happen in a sudden and are caused by trauma, surgeries or as a result of an acute disease which may go on and on for days and even into weeks. Among examples of acute pains are the unvarying pains like burns, regular or irregular pains i.e. as is in cases where cuts have been made to the stomach. Barriers to pain management There have been identified various barriers or hinderances to effective and efficient management of pain. Among them problems associated with the physician. This may be in form of lack of know how in dealing with pain, physician being prejudiced when he is prescribing oipioids. The physician may be inadequate in his ability to assess pain thereby overdosing or under dosing in his prescription (Francoeur, et al, 2007). All these are hindrances to effect proper assessment of pain in clinical setups caused by physicians. This has been duly noted and has been attributed to placing low or no priorities at all to treatment of pain in most of medical institutions and schools, and medical programmes when practicing (Mehta & Chan, 2008). Physicians have cited that low capability or lack of know how in pain assessment, as the major contributing factor to poor management of pain and as the barrier to effective management of pain(Hemming and David, 2005). They also cited that reluctance to prescribe opioids as another contributing factor. The barriers described above, are heavily contested more especially where the cases at hand are the treatment of chronic non-malignant pains (Jordan, et al, 2006). Patient-Related Barriers Apart from the physicians having a role to play as a barrier to effective and proper management of pain, patients are barriers too. This is made so by problems of contact related issues, psychological, emotional problems, and even prejudice and attitude, seems to make matters worse than they previously were (Geertzen, et al, 2006). A survey done on patients suffering from cancer who went to outpatient social service agencies for their treatment, discovered that poor or lack of communication between the physician and the patient caused part of the complications that caused pain (McCluskey & Middleton, 2010). There are particular psychological and emotional issues that have been known to have an impact during assessment and its treatment. Psychological and emotional issues include distress, patients being anxious, anger management issues, dementia, stress that develops to depression (Jordan, et al, 2006). These conditions have been known to cover and camouflage the original pain symptoms, thus complicating management of pain and pain assessment. Researchers have over time, evaluated the level at which a patient’s attitude in relation to pain and the intake of opioids may be a hindrance to pain treatment (Kikwilu, et al, 2008). They discovered that the fear of being addicted to the drugs, level of tolerance and the ensuing side effects were in fact barriers to management of pain. Respondents interviewed during the research indicated fatalism and the need to please the physician (Jordan, et al, 2006). Patients have been led to believe or have assumed that pain is part and parcel of the process of healing, or that pain is a component of the disease they are suffering from. This inclines them to expect no medication to help ease or relieve pain (Locher, et al, 2009). Patients are known to believe that as the pain increases, it directly means that their conditions are worsening. Ultimately, patients are always unwilling to report pain or hold the belief that they cannot relieve pain unless they are prescribed regimen with opioids (McCluskey & Middleton, 2010). Health Care System Barriers The health care sector has posed as a barrier to efficient and effective management of pain. This is mostly presented in constraints in practicality (Geertzen, et al, 2006). These includes lack of pharmaceutical shops nearing patients, lack of good infrastructural facilities like good transport to the physician, pharmacy or medical centres, lack of enough doses of opioids at medical centres, and lack of home nurses or caregivers to help in drug administration, are obstacles that do hinder effective pain relief. The changes in medical and health insurance policies are barriers (Locher, et al, 2009). This is especially so to older patients whose healthcare benefits do not cover the costs incurred when ordering for outpatient prescription drugs (Jordan, et al, 2006). Furthermore, patients are unable to cover extra costs required to pay caregivers due to increasing co-payments and out of pocket expenditures, do limit the amount of prescriptions a patient may order for monthly, thus limiting on refills (Steven, 2006). Such predicaments can force a patient to seek less efficient or effective analgesics and thereby causing improper or under treatment of pain in patients (Kikwilu, et al, 2008). Enablers to effective pain assessment and management Proper and efficient pain assessment and pain management do require the medical personnel to know and understand the nature of pain from the physical aspect, the factors that influence the intensity of pain, emotional aspect, mental aspect, and spiritual aspects (Hemming and David, 2005) Critical analysis of Enablers and Barriers to effective pain assessment and management in cancer patients Pain is caused by a variety of elements, which may be mental, social and physical and may influence greatly the intensity of pain. When a physician allows his patients to explain what they are feeling and experiencing, believing, respecting and assuring them, that they are able to take control of their situation is an important step in assessing pain and managing it (Kikwilu, et al, 2008). This can be achieved by the clinician listening to their patients, who use words to explain what they are feeling and experiencing. Medical professionals can understand the pain felt from the language the patient is using, and classify it as a) neuropathic or b) nociceptive. Physicians however, do lack enough experience of the described pain and the patients are sometimes unable to describe their pain, therefore, health care provider is unable to conclusively assess and treat the pain. This is regardless of various tools like the Brief Pain Inventory, The Memorial Pain Assessment Card and The McGill Pain Questionnaire, which were specifically formulated to help health professionals in effective assessment of pain, which then allows proper pain management. This is because they are seldomly used. Although these tools are particularly effective, they involve the patient undergoing lengthy assessment thus unlikely to be used where immediate pain relief is needed, or when the patients are under intense turmoil of pains. Spiritual perspective of pain is sometimes hard to evaluate to treat since there is a thin line between spiritual matters and religious concerns of the patient may even be flatly unclear (Locher, et al, 2009). Patients may consider questions concerning their spirituality as invasion of privacy and an abomination. Selectivity can also be cited as a factor that may cause ineffective pain assessment if used during the assessment process. (Hemming, David 2005) Assessing pain in patients that are cognitive should help indicate the location of pain, its intensity , its quality, radiation and the factors that may increase or reduce pain and the temporal aspects associated with the pain (McCluskey & Middleton, 2010). The physician should seek to establish how pain and the cause of terminal illness are co-related. Proper establishment of these elements enables the health care giver to establish and learn about the pathophysiology behind the pain (Jordan, et al, 2006).This can help the clinician choose the most appropriate prescription to give and the ways to be used in the administering the drug (Locher, et al, 2009). Valid and good participation of the patient in accounting of their pain is very significant and helps the clinician in quantifying the severity of the pain being felt and experienced by the patient. Psychological/ mental pain assessment should pay closer attention to stress and depression, anxiety, confusion and anger, delusions and cognitive state of the patient. To also be considered is the patient’s actions r reactions to their situations. The knowledge of these mental factors and aspects in relation to pain can help clinicians in effective and proper management of pain in patients (Friedman, et al, 2002). Understanding a patient’s family structures, relations, patterns of communication with their families is essential for the health professional. This is important because understanding the influences of family relations to the patient helps during assessment of pain. The social perspective of pain may help in treating pain and managing patients well by offering appropriate spiritual care and comfort. For terminally ill patients who are in their final hours, it is advised that intimacy and confidentiality be maintained, and that medical care, be provided for by a widely consulted psychosocial professional (Ferell, et al, 2008). According to Ferell, et al, (2008), patients are sometimes unable to explain and describe their pain well due to their language, their culture, due to cognitive impairment, and intensity of pain. Confusion, their own physical condition, lack of conducive environment, being powerless, immersion of patients, inaccessibility to knowledgeable physicians, and lack of enough time for assessment are factors that hinder effective pain assessment and treatment. Patients with cognitive impairment and dementia are hard to treat (Geertzen, et al, 2006). Therefore, someone who knows and understand him or her well should carry out the process. Pain assessment should be done by observing their behaviour which consides with pain e.g. reluctance of the patient to move their limbs (Fahey, et al, 2008). In case the patient does not recover as anticipated by the physician or respond well to the prescription, the physician should review the validity of the assessment. There are various ways of administering drugs to patients. It may be by the clock, orally or by the ladder. These administration methods often result in effective treatment of pain (Rasche, et al, 2006). When using by the ladder method, it initially relieves the pain effectively with use of drugs that do not contain opioids, then the physician may administer a dose that has mild contents of opioids, if pain persists, the physician administers a dose with strong opioids (Steven, 2006). For intense pains, physicians are advised to consider combining adjuvant drugs and opioids in their administration. Be it as it may, prescription of adjuvant drugs, as an initial drug during pain treatment is a point of contention. Researchers who are pro opiods argue that opioids should be used prior to use of adjuvant drugs in treatment of pain. However, others debate that use of adjuvant drugs in treating cancer in its late stages is futile or does not help the patients, since the drugs take longer time to be absorbed. This indicates that therapeutic doses administered through the blood stream require to be maintained in the optimal, and given regularly to avoid troughs and peaks occurring every now and then (Fehey, et al, 2008). The oral method of administration is the most commonly used, thus should be encouraged by physicians, if the patient is willing to (Mehta & Chan, 2008). Physicians can also administer the drugs through the rectum, but it is not a favourite of many patients. If patients are unwilling or unable to take the drugs as described above, the physician can use an injection. It is done by injecting into the subcutaneous layer through the skin (Hemming and David 2005). There are difficulties in managing or treating pain in the late stages of cancer. This hinders effective pain relief in patients. It is caused by various factors or conditions. Due to enormous spread of the ailment to most of the body tissues, distension that is usually because of retention of fluids in the body, swelling, the disease penetrating into the bone marrow and nerve tissues (Fahey, et al 2008). In new interventions to pain relief should be used especially in late stages of cancer since, it is usually difficult to treat bone pain and neuropathic pain. However, it is hard to find a drug that may specifically treat a particular pain since other drugs causes pain in patients. Physicians should not only consider treating the physical pain only but seeks to efficiently treat mental, spiritual and emotional perspectives to pain, which are contributors the whole pain (Locher, et al, 2009). Neglect of treating these other aspects of pain by the physician leads to improper use of management of pain tools and concepts, which may leave the patient experiencing more pain than they initially had. Conclusion Pain is an indicator that arises to flag out that a sense or an emotion has been traumatized or has been injured. Patients, who are terminally ill and experiencing pain, need a physician to understand their mental, spiritual, physical and emotional aspects in order to treat their pain. This allows effective pain assessment and its proper management. Dwelling so much on the physical pain, has hindered medical practitioners from understanding underlying causes of the pain leading to ineffective pain management in patients. Understanding what the patient feels and experiences when they are describing their pain is integral on the part of the physician, helps in proper administration of drugs, offering the necessary comfort to the patients thus effectively managing the pain. Lack of proper communication, cognitive impairment of the patient, lack of use of effective assessment and management of tools, and cultural and personal issues. Physician’s inability to understand other issues related to pain like influence of family to the patient, and the physiological, mental, social perspectives in regards to medications and use of inappropriate drug administration are just but a few of barriers to effective pain assessment and its treatment. Reference Fahey, K., Rao, S., Douglas, M., Thomas, M., Elliott, J. & Miaskowski, C. (2008). Nurse coaching to explore and modify patient attitudinal barriers interfering with effective cancer pain management. Oncology Nursing Forum, 35(2), pp. 233-240. Francoeur, R., Payne, R., Raveis, V. & Shim, H. (2007). Palliative care in the inner city: patient religious affiliation, underinsurance, and symptom attitude. Cancer, 109(2), pp. 425-434. Ferrell, B., Levy, M. & Paice, J. (2008). Managing pain from advanced cancer in the palliative care setting. Clinical Journal of Oncology Nursing, 12(4), pp. 575-581. Geertzen, J.H., Van Wilgen, C.P., Schrier, E. & Dijkstra, P.U. (2006). Chronic pain in rehabilitation medicine. Disability and rehabilitation, 28(6), pp. 363–7. Hemming, L. & Maher, D. (2005). Cancer pain in palliative care: Why is management so difficult? British Journal of Community Nursing, 10(8), pp. 362-367. Jordan, K., Jnks, C. & Croft, P. (2006). A prospective stu of the consulting behaviour of older people with knee pain. Br J Gen Pract., 56(525), pp. 269-276 Kikwilu, E., Masalu, J., Kahabuka, F. & Senkoro, A. (2008). Prevalence of oral pain and barriers to use of emergency oral care facilities among adult Tanzanians. BMC Oral Health, 8(28) Locher, J., Ritchie, C., Roth, D., Sen, B., Douglas, K. & Vailas, L. (2009). Food choice among homebound older adults: motivations and perceived barriers. J Nutr Health Aging, 13(8), pp. 659-664 Mehta, A. & Chan, L. (2008). Understanding of the concept of “total pain”: A prerequisite for pain control. Journal of Hospice and Palliative Nursing, 10(1), pp. 26-32 McCluskey, A. & Middleton, S. (2010). Delivering an evidence-based outdoor journey intervention to people with stroke: barriers and enables experienced by community rehabilitation teams. BMC Health Serv Res., 10(18) Rasche. D., Ruppolt, M., Stippich, C., Unterberg, A. & Tronnier, V.M. (2006). Motor cortex stimulation for long-term relief of chronic neuropathic pain: a 10-year experience. Pain, 121(1-2), pp. 43–52. Sorkin, L. S. (2005). Basic physiology. In M. S. Wallace & P. S. Staats (Eds.), Pain medicine and management: Just the fact (pp. 7-14). New York: McGraw- hell. Steven H. (2006). Behavioural Conceptualization and Treatment for Chronic Pain. The Behaviour Analyst Today, 7(2), pp. 253 – 275 Upshur, C., Luckmann, R. & Savageau, J. (2006). Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med, 21(6), pp. 652-655. Ward, E., Clark, L. & Heidrich, S. (2009). African American women’s beliefs, coping behaviours, and barriers to seeking mental. Qual Health Res., 19(11) pp. 1589-1601 Read More