Study Highlights Need For More Knowledge of Pain Management

BUFFALO, N.Y. -- Undermedication is the most important problem of pain management in hospitals, one of the first studies to investigate how nurses assess their knowledge of pain and their skill in alleviating it has shown.

The pilot study, conducted by University at Buffalo nursing researchers, also revealed that nurses think they are adequately informed about managing pain, despite research showing they aren't.

The nurses interviewed, on the other hand, believed physicians were ill-informed about pain management, and that this lack of knowledge interfered with nurses ability to provide adequate treatment.

The study appears in the May issue of The Journal of Pain and Symptom Management. Kathleen G. Wallace, Ph.D., assistant professor in the UB School of Nursing, post-doctoral nurse fellow at the Buffalo Veterans Affairs Medical Center and lead author of the study, says much of the problem lies with nursing and medical school curricula.

"Nurses and physicians are not taught enough about pain management," she said. "Schools have not made the commitment to teach it. In the meantime, the knowledge base of pain management is exploding."

Wallace said nurses in a baccalaureate program typically spend about four hours studying pain management, with students in two-year programs most likely spending less.

"But even if nurses know more about pain, they may not be able to practice it," Wallace stated. "If physicians aren't well informed, or if administration doesn't support spending more time with the patients, it won't matter if nurses know more."

The pilot project involved 108 staff nurses selected from a random sample of hospitals in Georgia, Louisiana, New York and Washington. Staff nurses are usually first on the scene when a patient is in pain. Their sensitivity to, and skill in dealing with, pain problems is critical for effective pain management, Wallace said.

Study participants were asked to rate themselves in several areas relating to pain management -- educational preparation, practice skills, and knowledge of financial, legal, political and ethical issues -- and to rate the importance of each area. They also listed the three most important problems of pain management in their facility.

The researchers found that most of the nurses interviewed thought their pain-management skills were adequate, even though other studies repeatedly had found the opposite to be true. Wallace said this finding may be the root of the problem.

"Perhaps one of the reasons why pain management has been so impervious to change is that many practitioners don't recognize their own inadequacy and don't see the need for change," she said.

Findings showed participants were aware that they needed more information about political, legal, financial and ethical issues -- the position of insurers on paying for epidural catheters, long-acting morphine and other new techniques of pain management; procedures of multiple-copy prescription programs; appropriate use of high-tech machines, and legal definitions of addiction.

Wallace said not knowing their state's definition of addiction, in particular, could have serious consequences, especially in states such as New York where the definition is very broad.

"In New York, an addict means a person who habitually uses a narcotic drug and who by reason of such use is dependent thereon," said Wallace, citing the definition's wording. "Obviously, nurses in this state would care for many patients who fit this description, patients with cancer in particular. They are involved in the delivery of medications to these patients and, under this definition, they may be at some legal risk if they continue to give medications to physically dependent individuals. Nurses, as well as physicians, need to get their state's definition, as well as many other regulations, changed," she said.

Undermedication surfaced as the most important problem of pain management in their institutions. This finding is a step forward, Wallace said, because previous reports have shown nurses and physicians generally did not believe patients were being undermedicated. Inadequate knowledge of physicians and certain problems with pain-management teams were also cited as barriers.

If the pilot study's findings are confirmed by further research, they would indicate several courses of action, Wallace said.

"If nurses and physicians don't see themselves as lacking in knowledge and practice of pain management, researchers need to devise ways to develop awareness. As awareness is heightened, we need to find ways to educate practitioners. Finally, researchers need to investigate how bureaucratic systems support or inhibit the use of this new knowledge in pain management."

Other investigators in the study were Barbara A. Reed, Emory University Hospital, Atlanta, Ga.; Chris Pasero, formerly with Schumpert Medical Center in Shreveport, La., and Gayle L. Olsson, Virginia Mason Medical Center in Seattle, Wash.