Considering patients’ pain holistically
Our clinical nurse specialist, Liz Morgan, draws from her own experience of pain to argue that if we are to help patients manage their pain better we need to consider people as whole individuals rather than a set of symptoms.
Having been a cancer nurse for more than 12 years, I have assessed hundreds of patients’ pain and have seen how my assessment and actions have brought about improvements in what they are feeling. I have prescribed interventions for patients’ pain using recognised assessment tools and the World Health Organization Cancer Pain Ladder . Yet, my experience as an orthopaedic patient over the past 12 months has changed how I approach pain assessments and reminded me that pain is more complex than I realised.
In October 2016, I was persuaded to go to the GP due to a deteriorating gait. In November 2017, after a year of diagnostic tests and treatments, I had a total left hip replacement owing to osteoarthritis.
My family told me that I was limping but my behaviour had alerted me to that a long time before they did. My gait had changed. I had difficulty bending over, putting socks on and tights were impossible. Yet fear stopped me from visiting the GP; a fear that I wouldn’t be believed. How could a 33-year-old healthy adult who could work all day on her feet as a nurse not be able to put tights on? It didn’t make sense.
We often forget patients are fearful – fearful that they won’t be believed or understood. Fear affects what patients divulge and therefore the validity of our assessments. Patients want to be listened to and believed, and for their pain to be acknowledged as a legitimate reason for a change in behaviour (Yelland 2011).
As a palliative care nurse I was familiar with the concept of total pain. Pain affecting the whole person: physically, psychologically, spiritually and socially (Saunders 1964). Nurses strive to treat patients holistically yet commonly only use pain assessment tools that generally measure pain intensity and little else (Telford 2017). As a patient, I was never asked how my pain was affecting me or what it was preventing me from doing. In an attempt to comfort me, my surgeon once kindly promised me he would ‘get me back walking over Derbyshire’. If asked what activity I was missing, I would have replied ‘playing with my daughter’. If promised I would achieve this again it would have provided comfort, hope and determination. This made me reflect how often I had replaced patients’ individual goals and motivations for something that I wrongly assumed they desired.
I considered pain in relation to fear. How could I continue some tasks but not others? I worked until the day of my surgery, partly because the perceived fear of being unable to work was greater than the fear of the pain. If we fall in the street it hurts, yet that pain becomes insignificant if we see a bus coming towards us. The fear of the bus is greater than the fear of the initial pain and we overcome it to move away. As nurses, we need to understand what patients are fearful of losing and their goals so we can help individuals achieve what is important to them.
As a nurse, I knew pain was complex, but as a patient I experienced the complexity. If we continue to focus on using tools that solely assess patients’ pain physically, we will fail to see patients as individuals and be unable to respond to peoples’ pain and fears effectively.
Clinical Nurse Specialist
Saunders C (1964) Care of patients suffering from terminal illness at St Joseph’s Hospice, Hackney, London. Nursing Mirror. 14, vii-x.
Telford A (2017) Approaches to acute pain management in older people. Nursing Older People. 29, 9, 32-40.
Yelland M (2011) What do patients really want? International Musculoskeletal Medicine. doi 10.1179/175361511X12965803070667.