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Adult patients' perceptions of pain management at triage: a small exploratory study
Accident and Emergency Nursing ( 2002) 10, 78–86 ° C 2002 Elsevier Science Ltd. All rights reserved doi:10.1054/yaaen.2001.0324, available online at http://www.idealibrary.com on
Adult patients’ perceptions of pain management at triage: a small exploratory study J. Graham
Research studies reveal that pain management in Accident and Emergency (A&E) is often sub-optimal. The administration of simple oral analgesics at triage in a large teaching hospital provided the rationale to explore pain management in A&E from the patient’s perspective in a small-scale exploratory study using a broadly qualitative approach. Structured interviews using open-ended questions and lasting no longer than 20 minutes explored patients’ experiences and opinions of pain assessment, and pain management at triage. A sample of convenience produced a group of 65 patients from which 18 patients; 9 males and 9 females participated. Analysis of the data revealed that 16 patients presented in pain. Triage nurses trained to administer analgesics were available for 7 patients; 2 patients received analgesia. Six patients did not receive a pain assessment and in 3 cases the triage nurse was trained to administer analgesia. Sixteen patients considered pain management at triage to be important. The study reinforces the subjective and complex nature of pain, raises pragmatic questions regarding triage, the need for sustained education and training with any advance in nursing practice and further research regarding patients’ perceptions of C 2002 Elsevier Science Ltd pain management in A&E. °
Introduction
Jane Graham RGN, MSc, Health Lecturer, School of Nursing, The University of Nottingham, Queen’s Medical Centre, B Floor, Nottingham NG7 2UH, UK
In Accident and Emergency (A&E) patients in pain are a daily occurrence. Over 15 million patients attend A&E in England and Wales each year (Audit Commission 2001) and of these patients it is estimated that 75% are likely to be experiencing some level of pain (Illingworth & Simpson 1998). The prompt control and reduction of pain is a fundamental role for health care professionals and a core service of A&E possessing a moral, ethical, legal and clinical dimension (The Royal College of Surgeons 1990, British Association for Accident and Emergency Medicine 1998, Dimond 1995, Carr & Goudas 1999). A collaborative project between A&E and the Acute Pain Service to improve pain management at triage resulted in an advance to nursing practice, enabling the triage nurse to
78 Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 7 8 – 8 6
administer three simple oral analgesics: paracetamol, ibuprofen and dihydrocodeine. Prior to this patients requiring analgesia were taken into the department to wait for a doctor’s assessment and prescription. A scope of practice package was devised including a standing order protocol (UKCC 1992, Department of Health 1998, Atkinson et al. 1998), now a Patient Group Direction (NHS Executive 2000). The impetus for the study arose from my involvement with this practice development and anecdotal reports regarding the benefit to patients of analgesic administration at triage.
Study aim and objectives The aim of the study was to explore adult patients’ perceptions of the pain management process at triage. This was by:
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Adult patients’ perceptions of pain management at triage
• Establishing the level of pain experienced on arrival in A&E using a verbal descriptor scale and descriptive words used by the patient. • Exploring pain relieving strategies used by patients before attending A&E. • Identifying patients’ experiences of pain management at triage. • Determining patients’ perceptions of the effectiveness of pain management at triage using a verbal descriptor scale and descriptive words. • Determining patients’ perceptions regarding the need for pain management at triage.
Literature review Databases: CINAHL, MEDLINE, BIDS, OMNI, national and international research sites and reference lists provided the mechanisms of retrieval for the search. Twenty-five terms relating to emergency care, triage, pain, analgesia and qualitative research were used in isolation and in combination to provide a broad and subsequently specific focus. Four themes emerged from the study objectives and were used to structure the literature review. The nature of pain Pain is a subjective, individual and highly complex phenomenon (Baillie 1993, Bourbonnais 1981, Briggs 1995, Carr 1997, Hawthorn & Redmond 1998, Illingworth & Simpson 1998, McCaffery & Beebe 1994). Affective, motivational and cognitive factors contribute to the pain phenomenon (Melzack & Katz 1994) and the ability to discern the existence of pain will depend on the individual’s personality (Carr & Goudas 1999) and ‘pain behaviour’ (Fordyce 1983). Accurate assessment and appropriate management of pain in the emergency environment is a challenge (Boisaubin 1989, Cooper 1994, Dempster 1995) relying on an effective method of communication between patient and caregiver. Pain assessment and measurement is essential to determine the nature of the pain, therapeutic intervention and evaluation of the therapy (Melzack 1975, Melzack & Katz 1994). Huskisson (1993), Skevington (1995) and Williams (1988) debate
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the relative merits and effectiveness of pain assessment tools, however, whatever assessment tool is used the process is potentially redundant unless the principle of subjectivity is accepted and adhered to by all caregivers. Pain management for adult patients in A&E Within the broad context of pain management five categories emerged: management, age, gender, ethnicity and knowledge. Management refers to the treatment of pain (Wilson & Pendleton 1989, Ducharme & Barber 1995, Goodacre & Roden 1996, Chan & Verdile 1998, Guru & Dubinsky, 2000) and with the exception of Chan & Verdile (1998) the studies in this group found pain management to be inadequate. Four studies used age as a focus. Elderly patients ( > 70 years) were less likely to receive analgesia (Jones et al. 1996); whilst Lewis et al. (1994) and Selbst & Clark (1990) found elderly patients received analgesia as often as younger adults. A Costa Rican study (Jantos et al. 1996) found that adults were more likely to receive analgesia than children in a study of two emergency departments. From a perspective of gender and ethnicity, female patients are more likely to receive pain relief (Raftery et al. 1995) as were white non-Hispanic patients (Todd et al. 1993). Yet ethnicity was not found to be a factor in a replication of the study in a London hospital (Choi et al. 2000). The need for education and training regarding pain management for medical staff in A&E was established by Reichl and Bodiwala (1987). Prior experience and trauma training influences pain management practice; better results in the choice of route and dose of analgesic administered by those with previous A&E or anaesthetic experience and possession of an Advanced Trauma Life Support certificate was established by Sandhu et al. (1998). Triage in A&E Four main areas of focus emerged: effectiveness, perceptions, pain management and characteristics. The effectiveness of triage in reducing waiting times was noted in three
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Adult patients’ perceptions of pain management at triage
studies (Bailey et al. 1987, Mallet & Woolwich 1990, Burgess 1992). In contrast George et al. (1992) found waiting times lengthened when triage was in operation. Cook & Jinks (1999) studied the effectiveness of the Manchester Triage System and noted the importance of training for effective triage. Patient perceptions and satisfaction with care is related to the urgency with which they are seen (Hansagi et al. 1992). Nursing perceptions of the patient’s need to be seen could influence the triage assessment, with problems more than 24 hours old eliciting less sympathy and more irritation (Crouch & Dale, 1994). The use of oral analgesics at triage was evident in 17 of the 24 A&E departments surveyed by Larsen (2000) in the Greater London area. In contrast, pain management is not mentioned among the 44 skilled tasks of the triage nurse in a survey of 185 departments in five North American states (Purnell 1991). Adult patients’ perceptions of pain management in A&E The link between pain, anxiety and fear is well documented by Byrne & Heyman (1997) and Walsh (1993). Walsh (1993) notes the responsibility of the triage nurse in recognizing anxiety in the context of pain. Patients in all triage categories (Nash-Huggins et al. 1993) identify the importance of pain relief, however, delivery of pain management often fails to meet patient expectations (Cave 1994, Tanabe & Buschmann 1999). Johnston et al. (1998) found that the severity of pain experienced was related to the body system affected. All the research studies identified in the literature review adopted a quantitative approach and many studies identified limitations and confounding factors associated with research activity in a busy, acute area with a mobile and unpredictable population. The difficulties inherent with research activity in A&E was acknowledged, however, the need to explore the patient’s perspective influenced the research approach adopted in this study.
Method The study employed a broadly qualitative approach using a descriptive exploratory
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non-emergent design. Data analysis takes place after data collection in a non-emergent design and the results do not influence the research process, in contrast to an emergent design when data is analysed immediately (Maykut & Morehouse 1994). Qualitative research is concerned with the individual’s perspective within a natural surrounding (Holloway & Wheeler 1996) and practice within a practice area (Silverman 1997). A qualitative approach is appropriate when little is known about the subject, or the subject requires exploration for the first time (Bowling 1997). Ethical approval was granted by the hospital Ethics Committee and senior medical and nursing staff approved department access. The exact nature of the study was not divulged to nursing staff working in the area to eliminate potential for bias. Pain relief was offered to all patients participating in the interview and the researcher referred any patient for medical assessment if the patient’s condition caused concern. The convenience sample is the preferred method of sampling in qualitative research (Bowling 1997) and the availability and access to potential participants (Parahoo 1997) influenced the choice of a non-probability sample of convenience in this study. Eighteen patients participated in the study from a target group of 65 patients; demographic details are summarized in Table 1. The sample is evenly divided with 9 male and 9 female patients. Forty-seven patients did not participate (Table 2). On completion of the triage assessment ambulant or wheelchair-bound patients required to wait in the main waiting area were approached and asked to read the patient information sheet providing information about the study and the researcher. The patient was approached again 1 hour after triage and invited to participate. If the patient refused or was not eligible (see exclusion criteria Box 1), the next triaged patient was approached and the process repeated. The sample was drawn from patients attending A&E during a week in June 2000. Each participant was interviewed by the researcher using a structured approach; 7 open-ended questions relating to opinion, experience and feelings concerning pain and
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Adult patients’ perceptions of pain management at triage
Table 1 Demographic information of patients participating in the study Patient
Male
Female
18–40
•
1 2
•
3
•
41–64
65 & over
TOA***
WT hours**
Triage Nurse*
•
10.43
2.5
Yes
•
11.06
2.5
Yes
09.48
4
Yes
12.03
2
No
19.30
1
No
•
4
•
5
•
• •
6
•
•
09.28
1.5
Yes
7
•
•
20.43
5
No
8
•
•
13.11
2
No
9
•
•
21.33
3
Yes
20.44
3.5
Yes
10
•
11
•
•
17.06
2-3
No
12
•
•
15.05
2.5
No
•
12.37
2
No
•
16.43
5
No
•
15.04
4
No
13.14
3
No
•
11.13
3
Yes
•
10.22
1.5-2
No
13
• •
14 15
• •
16 17
•
•
•
18
•
Time of arrival TOA*** Waiting time to be seen by a doctor WT hours** Triage nurse trained to administer analgesia Triage Nurse*.
Table 2 Reasons for patients not participating in the study <18 years
7
Mental health problem
1
Alcohol/drug ingestion
2
Refused
3
Left after triage, did not wait to be seen
8
Medical assessment within 1 hour
17
Taken into department after triage
5
Circumstances of the injury/condition
3
Circumstances changed within 1 hour
1
Total
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47
Box 1 Exclusion criteria • Inability to give informed consent • Head injury with loss of consciousness • Alcohol and drug ingestion • Mental health problem • Inability to participate in an interview due to communication difficulties pain management (see Appendix 1). Exploring and recording the individual’s perspective is a goal of qualitative research (Holloway & Wheeler 1996, Black 1994) and the structured interview provided an opportunity to explore patients’ perspectives without compromising access to medical assessment, an important ethical consideration of the study. Each
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interview took no longer than 20 minutes. The interviews were recorded, transcribed, and data analysis was carried out by analysing the content (Silverman 2000, Mason 1994) in the context of themes identified by the study and interview schedule; pain perception, pain assessment and management, and the need for pain management. A small pilot study was conducted 2 weeks beforehand to expose potential problems with the process and environment. The structured interview format and evidence of comprehension of the interview questions controlled the consistency of data collection. The threat to validity was reduced by the use of a single interviewer using the interview schedule. The main threat to reliability lay in the use of a convenience sample. However, the study was exploratory in nature and not intended to generalize to all patients in A&E. The use of a convenience sample and exclusion criteria provided a sample of adult patients willing to discuss their perceptions of pain management at triage.
action. Nine patients did attempt to relieve the pain using: analgesia (6), ice pack (1), pressure (1), dressing (1). Pain assessment and management Eight patients expressed the way in which their pain was assessed as: ‘ok’ (1), ‘efficient’ (1), ‘fine’ (2), ‘quite good’ (1), ‘very good’ (1), ‘good’ (1), ‘all right’ (1). Six patients identified that no pain assessment took place, for example: . . .[the nurse] didn’t even ask if it hurt just squeezed it. I think [the nurse] realised it hurt when I nearly kicked [him/her]. (Patient 1)
Five patients in this group experienced mild or moderate pain, and in three cases the triage nurse was trained to administer analgesia. Pain management intervention was completed for four patients, in one case the researcher intervened to elevate a lower limb. Ten patients who complained of pain did not receive any intervention, and in four cases the triage nurse was trained to administer analgesia.
Results
The need for pain management
Pain perception
Sixteen patients identified the importance of pain management at triage. Some patients described pain management in terms of waiting time for treatment:
All of the patients interviewed presented to A&E with injuries sustained to upper and lower limbs and in two cases isolated injury to the face. Words used to describe the reason for their attendance involved direct references to pain such as ‘hurt’ (4) and ‘pain’ (2), or broadly descriptive terms of the incident and its effect such as ‘accident’ (5), ‘injury’ (2), ‘broken’ (1), ‘damaged’ (1), ‘gashed’ (1). Patients were asked to describe the level of pain experienced on arrival in A&E and 1 hour after triage using a verbal descriptor scale (Appendix 1) and/or descriptive terms. The verbal descriptor scale was used by 16 patients to describe pain on arrival and by 9 patients to describe pain 1 hour after triage. Analysis of all the patients revealed that 16 patients presented in pain; after 1 hour 6 patients experienced an increase in the level of pain, 3 patients a decrease and for 9 patients the pain level remained the same. Nine patients did not attempt to relieve the pain before attending A&E; 2 patients believed it to be the wrong
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. . .I think it is quite important because (pause) I’ve sat out there before without painkillers, and it gets extremely difficult, and stressful as well. (Patient 16) Well, if I had two paracetamol, on me at the moment, I would take it, and I suppose I could have asked for it. But I didn’t realise how long it would be then before I was seen. (Patient 16)
Waiting for treatment also prompted speculation about the condition of other patients in the waiting area and their apparent need for pain relief: It seems to me that they are all dumped in together, and some of them look in a lot worse state than others. (Patient, 15)
Some patients perceived pain management at triage from the perspective of medical assessment and believed that pain relief could
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Adult patients’ perceptions of pain management at triage
not be given until the medical assessment took place. For other patients, pain management is an individual responsibility; the dilemma exists for each patient as to whether and when they should ask for pain relief.
Discussion Sixteen patients (89%) presented in pain, and this figure correlates with the assertion that 75% of patients presenting to A&E experience some degree of pain (Illingworth & Simpson 1998). For some patients the reduction of the pain experience to one word proved inadequate. The sophistication of the verbal descriptor scale is critical because the patient will choose the word that most accurately reflects the pain experience, a finding exposed by psychologists investigating ‘semantic relations among word groupings’ (Gracely 1993). The limited choice of descriptors arguably limits the patient’s response and is further compounded when the patient is asked to compare the pain experience retrospectively on arrival, and 1 hour after triage. The precursor to effective pain management is pain assessment. Six patients did not receive a pain assessment, and in three cases the nurse was trained to administer analgesia. Similarly, of the 10 patients complaining of pain who received no intervention, triage nurses trained to give analgesia assessed 4 patients. Explanations for these findings may lie in triage training, the scope package (Atkinson et al. 1998), or the management of triage. It is beyond the scope of this study to attribute causal relationships, however, the prevailing conditions in the department; workload, geography, location and resources at triage in relation to the rest of the department may affect the process and provide barriers to effective pain management. Experience of pain management at triage was limited to 4 patients, 12 patients did not receive any intervention corresponding closely with the number of nurses unable to administer analgesics (11). Pain management is not restricted to analgesics and prompts consideration of factors affecting decision-making in triage; experience, skill, perception of pain and pain assessment, and attitude to different patient groups. From the
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patient’s perspective there is an overwhelming perception that pain management at triage is both important and necessary. The environment both outside and inside the department exposed the unavoidable and confounding factors affecting the process, reliability and validity of the study. Situations arose in the waiting area that demanded the researcher’s attention, resulting in a temporary halt to data collection, reinforcing the unpredictable nature of research activity in an acute environment. The size and unrepresentative nature of the sample threaten the reliability of the study, and the effect on participant responses of a single researcher who worked in the department is unknown. The relatively short interview time was influenced by the structured nature of the interview and the need to reassure patients that access to medical assessment would not be adversely affected by participation in the study. Fontana & Frey (1994) discuss the ethical responsibility of researchers to protect the patient from harm; in this study the researcher ensured that all patients understood the researcher could administer analgesia if required. A larger study with a longer interview would provide an opportunity to explore the unknown effect of the interaction at triage regarding offers and refusal of pain relief, and the effect of waiting times on the patient’s response.
Conclusion The findings of this single centre, exploratory study confirm the ubiquity of pain in A&E, the individual nature of the pain experience and provides evidence of patients’ experiences of pain assessment and management, an area of A&E nursing that is currently underrepresented in the literature. Inconsistencies of pain assessment and management at triage contrast with the consistent view of patients that pain management is both necessary and important. Patients express satisfaction with pain management in the face of continuing pain (Ward & Gordon 1996, McNeill et al. 1998) and the patient’s perception of personal control may be the link between pain and satisfaction
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with pain relief (Pellino & Ward, 1998). Further research is needed to explore the complex factors affecting patients’ perceptions of pain management, because the timely recognition and care of the patient in pain is fundamental to nursing practice in A&E. Acknowledgements
My thanks to the staff in Accident and Emergency, Dr Nick Allcock and Dr Sian Maslin Prothero for their support and advice. References Atkinson J, Savoury J, Dobson F 1998 Administration of Simple Oral Analgesics to Adults and Adolescents by Triage Nurses Working in Adult A&E. Unpublished Queen’s Medical Centre, Nottingham Audit Commission 2001 Acute Hospital Portfolio: Review of National Findings – Accident and Emergency. Audit Commission Publications, Wetherby Bailey A, Hallam K, Hurst K 1987 Triage on trial. Nursing Times 83, 44: 65–66 Baillie L 1993 A review of pain assessment tools. Nursing Standard 7, 23: 25–29 Black N 1994 Why we need qualitative research. Journal of Epidemiology and Community Health 48: 425–426 Boisaubin EV 1989 The assessment and treatment of pain in the Emergency Room. The Clinical Journal of Pain 5 Supplement 2: S19–S25 Bourbonnais F 1981 Pain assessment: development of a tool for the nurse and the patient. Journal of Advanced Nursing 6: 277–282 Bowling A 1997 Research Methods in Health. Open University Press, Buckingham Briggs, M 1995 Principles of acute pain assessment. Nursing Standard 9, 19: 23–27 British Association for Accident & Emergency Medicine (BAAEM) 1998 The Way Ahead. BAAEM, London Burgess K 1992 A dynamic role that improves the service: combining triage and nurse practitioner roles in A&E. Professional Nurse February: 301–303 Byrne G, Heyman R 1997 Patient anxiety in the accident and emergency department. Journal of Clinical Nursing 6: 289–295 Carr E 1997 Overcoming barriers to effective pain control. Professional Nurse 12, 6: 412–416 Carr DB, Goudas LC 1999 Acute pain. The Lancet 353: 2051–2058 Cave I 1994 Pain in A&E: the patient’s view. Emergency Nurse 2, 2: 19–20 Chan L, Verdile VP 1998 Do patients receive adequate pain control after discharge from the Emergency Department? American Journal of Emergency Medicine 16, 7: 705–707 Choi DMA, Yate P, Coats T, Kalinda P, Paul EA 2000 Ethnicity and prescription of analgesia in an accident and emergency department: cross sectional study. British Medical Journal 320: 980–981
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Cook MW, Jinks J 1999 Does the Manchester triage system detect the critically ill? Journal of Accident and Emergency Medicine 16: 179–181 Cooper AD 1994 Pain assessment in Accident and Emergency. Accident and Emergency Nursing 2: 103–107 Crouch R, Dale J 1994 Identifying feelings engendered during triage assessment in the accident and emergency department: the use of visual analogue scales. Journal of Clinical Nursing 3: 289–297 Dempster E 1995 Pain relief in Accident and Emergency? Accident and Emergency Nursing 3: 3–6 Department of Health 1998 A Report on the Supply and Administration of Medicines under Group Protocols (Chairman June Crown). Department of Health, London Dimond B 1995 Pain relief and the Accident and Emergency Nurse: the legal aspects. Accident and Emergency Nursing 3: 158–159 Ducharme J, Barber C 1995 A prospective blinded study on emergency pain assessment and therapy. Journal of Emergency Medicine 13: 571–575 Fontana A, Frey JH 1994 Interviewing the art of science. In: Denzin, NK Lincoln, YS Ed, Handbook of Qualitative Research. Sage Publications, London pp 361–376 Fordyce WE 1983 The validity of pain behaviour measurement. In: Melzack, R (ed), Pain Measurement and Assessment. Raven Press, New York pp 145–153 George S, Read S, Westlake L, Williams B, Fraser-Moodie A, Pritty P 1992 Evaluation of nurse triage in a British accident and emergency department. British Medical Journal 304: 876–878 Goodacre SW, Roden RK 1996 A protocol to improve analgesia in the Accident and Emergency department. Journal of Accident and Emergency Medicine 13: 177–179 Gracely RH 1993 Pain language and ideal pain assessment. In: Melzack, R (ed) Pain Measurement and Assessment. Raven Press, New York pp 71–77 Guru V, Dubinsky I 2000 The patient vs caregiver perception of acute pain in the emergency department. Journal of Emergency Medicine 18: 7–12 Hansagi H, Carlsson B, Brismar B 1992 The urgency of care need and patient satisfaction at a hospital emergency department. Health Care Management Review 17, 2: 71–75 Hawthorn J, Redmond K 1998 Pain Causes and Management. Blackwell Science Limited, Oxford Holloway I, Wheeler S 1996 Qualitative Research for Nurses. Blackwell Science, Oxford Huskisson EC 1993 Visual analogue scales. In: Melzack, R (ed) Pain Measurement and Assessment. Raven Press, New York pp 33–37 Illingworth KA, Simpson KH 1998 Anaesthesia and Analgesia in Emergency Medicine. 2nd Edn. Oxford University Press, Oxford Jantos TJ, Paris PM, Menegazzi JJ Yealy DM 1996 Analgesic practice for acute orthopaedic trauma pain in Costa Rican Emergency Departments. Annals of Emergency Medicine 28: 145–149 Johnston CC, Gagnon AJ, Fullerton L, Common C, Ladores M, Forlini S 1998 One-week survey of pain intensity on
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admission to and discharge from the emergency department: a pilot study. The Journal of Emergency Medicine 16, 3: 377–382 Jones JS, Johnson K, McNinch M 1996 Age as a risk factor for inadequate Emergency Department analgesia. American Journal of Emergency Medicine 14: 157–160 Larsen D 2000 An investigation into the assessment and management of pain by triage nurses in Greater London A&E departments. Emergency Nurse 8, 2: 18–24 Lewis LM, Lasater LC, Brooks CB 1994 Are Emergency Physicians too stingy with analgesics. Southern Medical Journal 87: 7–9 McCaffery M, Beebe A 1994 Pain: Clinical Manual for Nursing Practice. Mosby, London McNeill JA, Sherwood GD, Starck PL, Thompson CJ 1998 Assessing clinical outcomes: patient satisfaction with pain management. Journal of Pain and Symptom Management 16, 1: 29–40 Mallett J, Woolwich C 1990 Triage in accident and emergency departments. Journal of Advanced Nursing 15: 1443–1451 Mason J 1994 Qualitative Researching. Sage Publications, London Maykut P, Morehouse R 1994 Beginning Qualitative Research A Philosophic and Practical Guide. The Falmer Press, London Melzack R 1975 The McGill pain questionnaire: major properties and scoring methods. Pain 1: 277–299 Melzack R, Katz J 1994 Pain measurement in persons in pain. In Wall, PD Melzack, R Ed Textbook of Pain. 3rd Edn. Churchill and Livingstone, Edinburgh pp 337–351 Nash-Huggins K, Gandy WM, Kohut CD 1993 Emergency department patients’ perceptions of nurse caring behaviours. Heart & Lung 22, 4: 356–364 NHS Executive 2000 Patient Group Directions. Department of Health, London Parahoo K 1997 Nursing Research. Principles, Process and Issues. Macmillan, Basingstoke Pellino TA, Ward SE 1998 Perceived control mediates the relationship between pain severity and patient satisfaction. Journal of Pain and Symptom Management 15, 2: 110–116 Purnell LDT 1991 A survey of emergency department triage in 185 hospitals: physical facilities, fast-track systems, patient-classification systems, waiting times, and qualification, training and skills of triage personnel. Journal of Emergency Nursing 17, 6: 402–407
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Raftery K, Smith-Coggins R, Chen A 1995 Gender associated differences in Emergency Department pain management. Annals of Emergency Medicine 26: 414–421 Reichl M, Bodiwala G 1987 Use of analgesia in severe pain in the Accident and Emergency department. Archives of Emergency Medicine 4: 25–31 Sandhu S, Driscoll P, Nancarrow J, McHugh D 1998 Analgesia in the Accident and Emergency department: do Senior House Officers have the knowledge to provide optimal analgesia? Journal of Accident & Emergency Medicine 15: 147–150 Selbst SM, Clark M 1990 Analgesia use in the Emergency Department. Annals of Emergency Medicine 19: 1010–1013 Silverman D 1997 The Logics of Qualitative Research. In: Miller, G Dingwall, R (eds) Context and Method in Qualitative Research. Sage Publications, London pp 12–25 Silverman D 2000 Doing Qualitative Research: A Practical Handbook. Sage Publications, London Skevington S M 1995 Psychology of Pain. John Wiley and Sons, Chichester Tanabe PT, Buschmann M 1999 A prospective study of Emergency Department pain management practices and the patient’s perspective. Journal of Emergency Nursing 25, 3: 171–177 The Royal College of Surgeons of England The College of Anaesthetists 1990 Report of the Working Party on Pain after Surgery. The Royal College of Surgeons, London Todd K, Samaroo N, Hoffman J 1993 Ethnicity as a risk factor for inadequate Emergency Department analgesia. Journal of the American Medical Association 269, 12: 1537–1539 United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) 1992 The Scope of Professional Practice. UKCC, London Ward SE, Gordon DB 1996 Patient satisfaction and pain severity as outcomes in pain management: a longitudinal view of one setting’s experience. Journal of Pain and Symptom Management 11, 4: 242–251 Walsh M 1993 Pain and anxiety in A&E attenders. Nursing Standard 7, 26: 40–42 Wilson JE, Pendleton JM 1989 Oligoanalgesia in the Emergency Department. American Journal of Emergency Medicine 7, 6: 620–623 Williams RC 1988 Toward a set of reliable and valid measures for chronic pain assessment and outcome research. Pain 35: 239–251
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Appendix 1 Pain Management at Triage – Structured Interview 1. Why did you come to A&E today? 2. How would you describe your pain when you arrived in A&E?
¤ None Mild ¤ Moderate ¤ Severe ¤ Other words used to describe the pain 3. Can you tell me about anything you did or took to relieve the pain before you arrived in A&E? 4. How would you describe your feelings about the way in which your pain was assessed in triage? 5. Can you tell me about any methods that were used to manage your pain in triage? 6. How would you describe your pain now?
¤ None Mild ¤ Moderate ¤ Severe ¤ Other words used to describe the pain 7. What are your thoughts regarding the need for pain management in triage? Male Female 18–40 years 41–64 years 65 years and over Time of arrival in A&E Waiting time in department Triage nurse trained to administer analgesia in triage
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Yes
No
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Adult patients’ perceptions of pain management at triage: a small exploratory study J. Graham
Research studies reveal that pain management in Accident and Emergency (A&E) is often sub-optimal. The administration of simple oral analgesics at triage in a large teaching hospital provided the rationale to explore pain management in A&E from the patient’s perspective in a small-scale exploratory study using a broadly qualitative approach. Structured interviews using open-ended questions and lasting no longer than 20 minutes explored patients’ experiences and opinions of pain assessment, and pain management at triage. A sample of convenience produced a group of 65 patients from which 18 patients; 9 males and 9 females participated. Analysis of the data revealed that 16 patients presented in pain. Triage nurses trained to administer analgesics were available for 7 patients; 2 patients received analgesia. Six patients did not receive a pain assessment and in 3 cases the triage nurse was trained to administer analgesia. Sixteen patients considered pain management at triage to be important. The study reinforces the subjective and complex nature of pain, raises pragmatic questions regarding triage, the need for sustained education and training with any advance in nursing practice and further research regarding patients’ perceptions of C 2002 Elsevier Science Ltd pain management in A&E. °
Introduction
Jane Graham RGN, MSc, Health Lecturer, School of Nursing, The University of Nottingham, Queen’s Medical Centre, B Floor, Nottingham NG7 2UH, UK
In Accident and Emergency (A&E) patients in pain are a daily occurrence. Over 15 million patients attend A&E in England and Wales each year (Audit Commission 2001) and of these patients it is estimated that 75% are likely to be experiencing some level of pain (Illingworth & Simpson 1998). The prompt control and reduction of pain is a fundamental role for health care professionals and a core service of A&E possessing a moral, ethical, legal and clinical dimension (The Royal College of Surgeons 1990, British Association for Accident and Emergency Medicine 1998, Dimond 1995, Carr & Goudas 1999). A collaborative project between A&E and the Acute Pain Service to improve pain management at triage resulted in an advance to nursing practice, enabling the triage nurse to
78 Accident and Emergency Nursing ( 2 0 0 2 ) 1 0 , 7 8 – 8 6
administer three simple oral analgesics: paracetamol, ibuprofen and dihydrocodeine. Prior to this patients requiring analgesia were taken into the department to wait for a doctor’s assessment and prescription. A scope of practice package was devised including a standing order protocol (UKCC 1992, Department of Health 1998, Atkinson et al. 1998), now a Patient Group Direction (NHS Executive 2000). The impetus for the study arose from my involvement with this practice development and anecdotal reports regarding the benefit to patients of analgesic administration at triage.
Study aim and objectives The aim of the study was to explore adult patients’ perceptions of the pain management process at triage. This was by:
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Adult patients’ perceptions of pain management at triage
• Establishing the level of pain experienced on arrival in A&E using a verbal descriptor scale and descriptive words used by the patient. • Exploring pain relieving strategies used by patients before attending A&E. • Identifying patients’ experiences of pain management at triage. • Determining patients’ perceptions of the effectiveness of pain management at triage using a verbal descriptor scale and descriptive words. • Determining patients’ perceptions regarding the need for pain management at triage.
Literature review Databases: CINAHL, MEDLINE, BIDS, OMNI, national and international research sites and reference lists provided the mechanisms of retrieval for the search. Twenty-five terms relating to emergency care, triage, pain, analgesia and qualitative research were used in isolation and in combination to provide a broad and subsequently specific focus. Four themes emerged from the study objectives and were used to structure the literature review. The nature of pain Pain is a subjective, individual and highly complex phenomenon (Baillie 1993, Bourbonnais 1981, Briggs 1995, Carr 1997, Hawthorn & Redmond 1998, Illingworth & Simpson 1998, McCaffery & Beebe 1994). Affective, motivational and cognitive factors contribute to the pain phenomenon (Melzack & Katz 1994) and the ability to discern the existence of pain will depend on the individual’s personality (Carr & Goudas 1999) and ‘pain behaviour’ (Fordyce 1983). Accurate assessment and appropriate management of pain in the emergency environment is a challenge (Boisaubin 1989, Cooper 1994, Dempster 1995) relying on an effective method of communication between patient and caregiver. Pain assessment and measurement is essential to determine the nature of the pain, therapeutic intervention and evaluation of the therapy (Melzack 1975, Melzack & Katz 1994). Huskisson (1993), Skevington (1995) and Williams (1988) debate
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the relative merits and effectiveness of pain assessment tools, however, whatever assessment tool is used the process is potentially redundant unless the principle of subjectivity is accepted and adhered to by all caregivers. Pain management for adult patients in A&E Within the broad context of pain management five categories emerged: management, age, gender, ethnicity and knowledge. Management refers to the treatment of pain (Wilson & Pendleton 1989, Ducharme & Barber 1995, Goodacre & Roden 1996, Chan & Verdile 1998, Guru & Dubinsky, 2000) and with the exception of Chan & Verdile (1998) the studies in this group found pain management to be inadequate. Four studies used age as a focus. Elderly patients ( > 70 years) were less likely to receive analgesia (Jones et al. 1996); whilst Lewis et al. (1994) and Selbst & Clark (1990) found elderly patients received analgesia as often as younger adults. A Costa Rican study (Jantos et al. 1996) found that adults were more likely to receive analgesia than children in a study of two emergency departments. From a perspective of gender and ethnicity, female patients are more likely to receive pain relief (Raftery et al. 1995) as were white non-Hispanic patients (Todd et al. 1993). Yet ethnicity was not found to be a factor in a replication of the study in a London hospital (Choi et al. 2000). The need for education and training regarding pain management for medical staff in A&E was established by Reichl and Bodiwala (1987). Prior experience and trauma training influences pain management practice; better results in the choice of route and dose of analgesic administered by those with previous A&E or anaesthetic experience and possession of an Advanced Trauma Life Support certificate was established by Sandhu et al. (1998). Triage in A&E Four main areas of focus emerged: effectiveness, perceptions, pain management and characteristics. The effectiveness of triage in reducing waiting times was noted in three
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studies (Bailey et al. 1987, Mallet & Woolwich 1990, Burgess 1992). In contrast George et al. (1992) found waiting times lengthened when triage was in operation. Cook & Jinks (1999) studied the effectiveness of the Manchester Triage System and noted the importance of training for effective triage. Patient perceptions and satisfaction with care is related to the urgency with which they are seen (Hansagi et al. 1992). Nursing perceptions of the patient’s need to be seen could influence the triage assessment, with problems more than 24 hours old eliciting less sympathy and more irritation (Crouch & Dale, 1994). The use of oral analgesics at triage was evident in 17 of the 24 A&E departments surveyed by Larsen (2000) in the Greater London area. In contrast, pain management is not mentioned among the 44 skilled tasks of the triage nurse in a survey of 185 departments in five North American states (Purnell 1991). Adult patients’ perceptions of pain management in A&E The link between pain, anxiety and fear is well documented by Byrne & Heyman (1997) and Walsh (1993). Walsh (1993) notes the responsibility of the triage nurse in recognizing anxiety in the context of pain. Patients in all triage categories (Nash-Huggins et al. 1993) identify the importance of pain relief, however, delivery of pain management often fails to meet patient expectations (Cave 1994, Tanabe & Buschmann 1999). Johnston et al. (1998) found that the severity of pain experienced was related to the body system affected. All the research studies identified in the literature review adopted a quantitative approach and many studies identified limitations and confounding factors associated with research activity in a busy, acute area with a mobile and unpredictable population. The difficulties inherent with research activity in A&E was acknowledged, however, the need to explore the patient’s perspective influenced the research approach adopted in this study.
Method The study employed a broadly qualitative approach using a descriptive exploratory
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non-emergent design. Data analysis takes place after data collection in a non-emergent design and the results do not influence the research process, in contrast to an emergent design when data is analysed immediately (Maykut & Morehouse 1994). Qualitative research is concerned with the individual’s perspective within a natural surrounding (Holloway & Wheeler 1996) and practice within a practice area (Silverman 1997). A qualitative approach is appropriate when little is known about the subject, or the subject requires exploration for the first time (Bowling 1997). Ethical approval was granted by the hospital Ethics Committee and senior medical and nursing staff approved department access. The exact nature of the study was not divulged to nursing staff working in the area to eliminate potential for bias. Pain relief was offered to all patients participating in the interview and the researcher referred any patient for medical assessment if the patient’s condition caused concern. The convenience sample is the preferred method of sampling in qualitative research (Bowling 1997) and the availability and access to potential participants (Parahoo 1997) influenced the choice of a non-probability sample of convenience in this study. Eighteen patients participated in the study from a target group of 65 patients; demographic details are summarized in Table 1. The sample is evenly divided with 9 male and 9 female patients. Forty-seven patients did not participate (Table 2). On completion of the triage assessment ambulant or wheelchair-bound patients required to wait in the main waiting area were approached and asked to read the patient information sheet providing information about the study and the researcher. The patient was approached again 1 hour after triage and invited to participate. If the patient refused or was not eligible (see exclusion criteria Box 1), the next triaged patient was approached and the process repeated. The sample was drawn from patients attending A&E during a week in June 2000. Each participant was interviewed by the researcher using a structured approach; 7 open-ended questions relating to opinion, experience and feelings concerning pain and
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Adult patients’ perceptions of pain management at triage
Table 1 Demographic information of patients participating in the study Patient
Male
Female
18–40
•
1 2
•
3
•
41–64
65 & over
TOA***
WT hours**
Triage Nurse*
•
10.43
2.5
Yes
•
11.06
2.5
Yes
09.48
4
Yes
12.03
2
No
19.30
1
No
•
4
•
5
•
• •
6
•
•
09.28
1.5
Yes
7
•
•
20.43
5
No
8
•
•
13.11
2
No
9
•
•
21.33
3
Yes
20.44
3.5
Yes
10
•
11
•
•
17.06
2-3
No
12
•
•
15.05
2.5
No
•
12.37
2
No
•
16.43
5
No
•
15.04
4
No
13.14
3
No
•
11.13
3
Yes
•
10.22
1.5-2
No
13
• •
14 15
• •
16 17
•
•
•
18
•
Time of arrival TOA*** Waiting time to be seen by a doctor WT hours** Triage nurse trained to administer analgesia Triage Nurse*.
Table 2 Reasons for patients not participating in the study <18 years
7
Mental health problem
1
Alcohol/drug ingestion
2
Refused
3
Left after triage, did not wait to be seen
8
Medical assessment within 1 hour
17
Taken into department after triage
5
Circumstances of the injury/condition
3
Circumstances changed within 1 hour
1
Total
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47
Box 1 Exclusion criteria • Inability to give informed consent • Head injury with loss of consciousness • Alcohol and drug ingestion • Mental health problem • Inability to participate in an interview due to communication difficulties pain management (see Appendix 1). Exploring and recording the individual’s perspective is a goal of qualitative research (Holloway & Wheeler 1996, Black 1994) and the structured interview provided an opportunity to explore patients’ perspectives without compromising access to medical assessment, an important ethical consideration of the study. Each
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interview took no longer than 20 minutes. The interviews were recorded, transcribed, and data analysis was carried out by analysing the content (Silverman 2000, Mason 1994) in the context of themes identified by the study and interview schedule; pain perception, pain assessment and management, and the need for pain management. A small pilot study was conducted 2 weeks beforehand to expose potential problems with the process and environment. The structured interview format and evidence of comprehension of the interview questions controlled the consistency of data collection. The threat to validity was reduced by the use of a single interviewer using the interview schedule. The main threat to reliability lay in the use of a convenience sample. However, the study was exploratory in nature and not intended to generalize to all patients in A&E. The use of a convenience sample and exclusion criteria provided a sample of adult patients willing to discuss their perceptions of pain management at triage.
action. Nine patients did attempt to relieve the pain using: analgesia (6), ice pack (1), pressure (1), dressing (1). Pain assessment and management Eight patients expressed the way in which their pain was assessed as: ‘ok’ (1), ‘efficient’ (1), ‘fine’ (2), ‘quite good’ (1), ‘very good’ (1), ‘good’ (1), ‘all right’ (1). Six patients identified that no pain assessment took place, for example: . . .[the nurse] didn’t even ask if it hurt just squeezed it. I think [the nurse] realised it hurt when I nearly kicked [him/her]. (Patient 1)
Five patients in this group experienced mild or moderate pain, and in three cases the triage nurse was trained to administer analgesia. Pain management intervention was completed for four patients, in one case the researcher intervened to elevate a lower limb. Ten patients who complained of pain did not receive any intervention, and in four cases the triage nurse was trained to administer analgesia.
Results
The need for pain management
Pain perception
Sixteen patients identified the importance of pain management at triage. Some patients described pain management in terms of waiting time for treatment:
All of the patients interviewed presented to A&E with injuries sustained to upper and lower limbs and in two cases isolated injury to the face. Words used to describe the reason for their attendance involved direct references to pain such as ‘hurt’ (4) and ‘pain’ (2), or broadly descriptive terms of the incident and its effect such as ‘accident’ (5), ‘injury’ (2), ‘broken’ (1), ‘damaged’ (1), ‘gashed’ (1). Patients were asked to describe the level of pain experienced on arrival in A&E and 1 hour after triage using a verbal descriptor scale (Appendix 1) and/or descriptive terms. The verbal descriptor scale was used by 16 patients to describe pain on arrival and by 9 patients to describe pain 1 hour after triage. Analysis of all the patients revealed that 16 patients presented in pain; after 1 hour 6 patients experienced an increase in the level of pain, 3 patients a decrease and for 9 patients the pain level remained the same. Nine patients did not attempt to relieve the pain before attending A&E; 2 patients believed it to be the wrong
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. . .I think it is quite important because (pause) I’ve sat out there before without painkillers, and it gets extremely difficult, and stressful as well. (Patient 16) Well, if I had two paracetamol, on me at the moment, I would take it, and I suppose I could have asked for it. But I didn’t realise how long it would be then before I was seen. (Patient 16)
Waiting for treatment also prompted speculation about the condition of other patients in the waiting area and their apparent need for pain relief: It seems to me that they are all dumped in together, and some of them look in a lot worse state than others. (Patient, 15)
Some patients perceived pain management at triage from the perspective of medical assessment and believed that pain relief could
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Adult patients’ perceptions of pain management at triage
not be given until the medical assessment took place. For other patients, pain management is an individual responsibility; the dilemma exists for each patient as to whether and when they should ask for pain relief.
Discussion Sixteen patients (89%) presented in pain, and this figure correlates with the assertion that 75% of patients presenting to A&E experience some degree of pain (Illingworth & Simpson 1998). For some patients the reduction of the pain experience to one word proved inadequate. The sophistication of the verbal descriptor scale is critical because the patient will choose the word that most accurately reflects the pain experience, a finding exposed by psychologists investigating ‘semantic relations among word groupings’ (Gracely 1993). The limited choice of descriptors arguably limits the patient’s response and is further compounded when the patient is asked to compare the pain experience retrospectively on arrival, and 1 hour after triage. The precursor to effective pain management is pain assessment. Six patients did not receive a pain assessment, and in three cases the nurse was trained to administer analgesia. Similarly, of the 10 patients complaining of pain who received no intervention, triage nurses trained to give analgesia assessed 4 patients. Explanations for these findings may lie in triage training, the scope package (Atkinson et al. 1998), or the management of triage. It is beyond the scope of this study to attribute causal relationships, however, the prevailing conditions in the department; workload, geography, location and resources at triage in relation to the rest of the department may affect the process and provide barriers to effective pain management. Experience of pain management at triage was limited to 4 patients, 12 patients did not receive any intervention corresponding closely with the number of nurses unable to administer analgesics (11). Pain management is not restricted to analgesics and prompts consideration of factors affecting decision-making in triage; experience, skill, perception of pain and pain assessment, and attitude to different patient groups. From the
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patient’s perspective there is an overwhelming perception that pain management at triage is both important and necessary. The environment both outside and inside the department exposed the unavoidable and confounding factors affecting the process, reliability and validity of the study. Situations arose in the waiting area that demanded the researcher’s attention, resulting in a temporary halt to data collection, reinforcing the unpredictable nature of research activity in an acute environment. The size and unrepresentative nature of the sample threaten the reliability of the study, and the effect on participant responses of a single researcher who worked in the department is unknown. The relatively short interview time was influenced by the structured nature of the interview and the need to reassure patients that access to medical assessment would not be adversely affected by participation in the study. Fontana & Frey (1994) discuss the ethical responsibility of researchers to protect the patient from harm; in this study the researcher ensured that all patients understood the researcher could administer analgesia if required. A larger study with a longer interview would provide an opportunity to explore the unknown effect of the interaction at triage regarding offers and refusal of pain relief, and the effect of waiting times on the patient’s response.
Conclusion The findings of this single centre, exploratory study confirm the ubiquity of pain in A&E, the individual nature of the pain experience and provides evidence of patients’ experiences of pain assessment and management, an area of A&E nursing that is currently underrepresented in the literature. Inconsistencies of pain assessment and management at triage contrast with the consistent view of patients that pain management is both necessary and important. Patients express satisfaction with pain management in the face of continuing pain (Ward & Gordon 1996, McNeill et al. 1998) and the patient’s perception of personal control may be the link between pain and satisfaction
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with pain relief (Pellino & Ward, 1998). Further research is needed to explore the complex factors affecting patients’ perceptions of pain management, because the timely recognition and care of the patient in pain is fundamental to nursing practice in A&E. Acknowledgements
My thanks to the staff in Accident and Emergency, Dr Nick Allcock and Dr Sian Maslin Prothero for their support and advice. References Atkinson J, Savoury J, Dobson F 1998 Administration of Simple Oral Analgesics to Adults and Adolescents by Triage Nurses Working in Adult A&E. Unpublished Queen’s Medical Centre, Nottingham Audit Commission 2001 Acute Hospital Portfolio: Review of National Findings – Accident and Emergency. Audit Commission Publications, Wetherby Bailey A, Hallam K, Hurst K 1987 Triage on trial. Nursing Times 83, 44: 65–66 Baillie L 1993 A review of pain assessment tools. Nursing Standard 7, 23: 25–29 Black N 1994 Why we need qualitative research. Journal of Epidemiology and Community Health 48: 425–426 Boisaubin EV 1989 The assessment and treatment of pain in the Emergency Room. The Clinical Journal of Pain 5 Supplement 2: S19–S25 Bourbonnais F 1981 Pain assessment: development of a tool for the nurse and the patient. Journal of Advanced Nursing 6: 277–282 Bowling A 1997 Research Methods in Health. Open University Press, Buckingham Briggs, M 1995 Principles of acute pain assessment. Nursing Standard 9, 19: 23–27 British Association for Accident & Emergency Medicine (BAAEM) 1998 The Way Ahead. BAAEM, London Burgess K 1992 A dynamic role that improves the service: combining triage and nurse practitioner roles in A&E. Professional Nurse February: 301–303 Byrne G, Heyman R 1997 Patient anxiety in the accident and emergency department. Journal of Clinical Nursing 6: 289–295 Carr E 1997 Overcoming barriers to effective pain control. Professional Nurse 12, 6: 412–416 Carr DB, Goudas LC 1999 Acute pain. The Lancet 353: 2051–2058 Cave I 1994 Pain in A&E: the patient’s view. Emergency Nurse 2, 2: 19–20 Chan L, Verdile VP 1998 Do patients receive adequate pain control after discharge from the Emergency Department? American Journal of Emergency Medicine 16, 7: 705–707 Choi DMA, Yate P, Coats T, Kalinda P, Paul EA 2000 Ethnicity and prescription of analgesia in an accident and emergency department: cross sectional study. British Medical Journal 320: 980–981
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Appendix 1 Pain Management at Triage – Structured Interview 1. Why did you come to A&E today? 2. How would you describe your pain when you arrived in A&E?
¤ None Mild ¤ Moderate ¤ Severe ¤ Other words used to describe the pain 3. Can you tell me about anything you did or took to relieve the pain before you arrived in A&E? 4. How would you describe your feelings about the way in which your pain was assessed in triage? 5. Can you tell me about any methods that were used to manage your pain in triage? 6. How would you describe your pain now?
¤ None Mild ¤ Moderate ¤ Severe ¤ Other words used to describe the pain 7. What are your thoughts regarding the need for pain management in triage? Male Female 18–40 years 41–64 years 65 years and over Time of arrival in A&E Waiting time in department Triage nurse trained to administer analgesia in triage
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Yes
No
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