- Email: [email protected]
Pain description by nurses and physicians
VoL 5 ~¢0. I t ~ b , ~ 7 199o
jen,,~o/e~,,on~sy,,q~n M ~ , ~ , , ~
tt
Pain Description by Nurses and Physicians Kristine Turner Norvell, RN, Fannie Gaston-Johansson, Dr Med So, and Lani Zimmerman, PhD
College of Nursing, Uaiversit3 of Nebraska Medical Center, Omaha,Nebraska
Abstma The purpose of this study was to determine ~'nurses and physiciausselectedsimilar words to describepainlike experiencesand to determine how they rated terms commonly used to describepain. Thirty.seven registerednurses and 21 physiciaus comprised the sample. The Visual Analogue Scale (VAS) was used to measure the terms ache, hurt, and pain. The McGill Pain Questionnaire (MPO~ provided a list of word descriptorsfrom which the subjectsselected words that best representedthe terms ache, hurt, and pain. There was no s~gn~6cantd~erence between the nurses and physicians in the mean rating of any of the pain terms on the VAS. The nurses and physicians chose very similar word descriptorsfrom the MPQ to discriminate one pain termfrom another. Thesefindings ,u~fgest th~ nurses and physicians may have a common understandiag of the language used to d~cribe painlihe experiences. J Pain Symptom Manage 1990;5:11-17.
Pain language, semantics,pain intensity
lntroduct/on Accurate assessment of a patient's pain is the basis for appropriate treatment. Also important is a common under.~,4nding of the meaning of various pain descriptors, if a patiem says he has an ache, the physicians and nurses caring for him should have a common understanding of what is meant by "ache" in order to intervene appropriately. The purpose of this study was (a) to describe how health care p~fe~i,)nal~ (HCP~) r~e th~ intettsity of basic pain terms (i.e., pain, harg, and ache), (b) to identify which word descriptors are selected by HCPs to describe these pain terms,
Address reprint requeststo: Fannie Oaston-Johaasson. Dr. Med. Sc., Universityof Nebraska MedicalCenter. College of Nursing, 42nd amd Dewey Aveaue. Omaha, NE 68105. Atypicalf0r/ndd/cat/0n: March 29, 1989. @ U.S. CancerPainReliefCommittee,1990
Publishedby Elsevier,NewYork,NewYork
and (c) m determine if there is a commonality in description of pain among HCPs. The International Association for the Study of Pain (IASP)t has defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage." While many authors concur with this definkion, there is disagreement as to the words used to describe pain. The words cbosey, :o describe pare usually reflect both a sensory and an emotional (affective) coml~oec, t. &~jeedves used to describe both components of pain are often imt~rtam in the diagnosis of disease and are used by both patients and HCPs to describe the pain experience. A variety of words have been identified as use[ul for describing pain~ Pain, ache, and hurt were words identified by Fabrege and Tyma* and Gaston-Johamson s as common terms used
088~$~,1~0~S,S0
12
Norvdl et al.
to describe painlike experiences. These terms have been found to have different intensity values and different meanings in relation to quality, s-s Typically, there is little thought given to the use and meaning of pain terms. However, they are freely used to describe pain by both those experiencing the pain, and by persons responsible for assessing and treating a parson in pain. A common understanding of the use and meaning of pain terms is important in the assessment and treatment of pain. Therefore, k seems essential to know if nurses and physicians are communicating when they confer with each other about a patient's pain. The following questions were investigated in this study: !. How did nurses and physicians rate the intentities of the terms ache, hurt, and pain? 2. Were there similarities in how nurses and physicians rated the intensity of these pain terms? 8. What word descriptors did nurses and physicians select to describe the tecots ache, hurt, pain with respect to their sensory and affecfive components? 4. Were there similarities in the description of the~e pain terms by nurses and physicians?
]our~,l ~ Pain and SymJ~oraMam~eraet~
provides only a unidimensional rating of pain intensity and has been shown to be difficult for some parsons to understand, s.n The VAS was used in this study to obtain intensity ratings of the three pain terms. MPQ. The MPQ consists of 78 word descriptor's that represent sensory, affective, evaluative, and miscellaneous components of pain. The word descriptors were used in this study for subject selection of words that describe pain terms. Several authors have completed reliability and validity testing of the MPQ. Both Melzackr and Graham and colleagues 's found high intercorrelations among several measures on the MPQ. Kremer and Atkinson Is found support for the construct validity of the affective dimension of the MPQ. Byrne and coUeagues 14 and Prieto and colleagues m subjected the MPQ to factor analysis, each resulting in four factors that were highly simUar, with significant correlations occurring across studies in throe o! the four f~ctors (r ~ ,74 to .g3), Dm,wgrap~ D~a. Demographic data were collected using a questionnaire developed by the investigators. Data obtained included age, sex, educational level, length of employment, and specialty area.
Methods
s,~eas
Proc~lure
The subjects for this study consisted of 58 conveniently selected nurses and physicians working at a teach!r,g hospital in a midwestern city. Thirty-seven licensed registered nurses and 21 physicians comprised the sample. Permission to conduct the study was granted by the lnstimtinnal Review Board of the study hospital.
Informed consent was ,~btained. and each subject was given a VAS with the three pain terms pain. ache. and hurt alphabetized and printed horizontally across the top of the page. The words were presented this way in an attempt to avoid ranking the intensities of the words. The subjects were then asked to mark on the VAS where they perceived the intensities of pain, ache, and hurt to be represented. A list of the word descriptors was then given to the subjects. The descriptors from the MPQ were placed randomly on the data collection sheet in an effort to eliminate any bias that might have occurred by presenting the words according m classifications. The su~ects were asked to identify which of the descriptors were associated with the terms pain. ache, or hurt. A separate list was used for each term, and the terms were presented in a random manner.
Insmmm~ T~voestablished instruments were used in the stnd~, d~e Visual Analogue Scale (VAS)' and the blcGill Pain Questionnaire (MPQ), r
VA& The VAS consists of a 10-cm line with anchors on each end that represent no pain and pain as bad at it can be. The VAS is commonly used for rating pain intensity and is generally reported as valid and reliable, s-H However, it
Vol. 5 No. 1 F d ~
1990
Pain Descripgonby Nursesmul P ~
13
Worst p o s s i b l e
An analysis of variance (ANOVA) for repeated measures was used to calculate differences in VAS ratings of the pain terms. Posthoc Tukey tests were conducted to determine where the pairwise differences were located. A Student's t test was used to determip.e differences in VAS ratings by nurses and physicians. Frequencies and percentages were computed for each word descriptor. A discriminative power index (DP1) wa~. calculated as a ratio of each of the 78 word descriptors with each pain term. Once words with DPIs above 0.50 were identified for each pain term, they were divided into two categories: sensory and affective.
Pain x - 74.96 + 16.59
0
Rendts The mean age of both nurses and physicians was 35 yr. The nurses had practiced a mean of 12.9 yr, while the physicians had practiced a mean of 7.7 yr. The majority (07%) of the nurses were female, as compared to 26% of the physicians. A variety of educational levels were represented in the nurse sample, with the BSN being most common (45%). Among physicians, 36% were surgeons or pathologists; 33% of the nurses practiced in medical/surgical areas. There were no significant differences in the mean ratings of the terms pain, ache, and hurt on the VAS by nurses and physicians (Figure 1). Therefore, the groups were combined, and an ANOVA for repeated measures was used to determine differences between the ratings of the pain terms. A statistically significant difference occurred between the mean ratings of ache, hurt, and pain [F(53, 105) = 8.81, p < 0.0001], with ache having the lowest mean intensity (P~3.92) on the VAS followed by hurt (45.21), and pain having the highest value (74.96) (Figure 2). Posthoc Tukey tests indicated significant differences between all pairwise comparisons ~e < 0.01).
se~
o/Word~ . f o r
Pm
8mm~ Wera~. Nurses and physicians chose similar sensory words (n = IS) to discriminate the word pain from the words hurt and ache (Table 1). The nurses chose four words with
pain
100
--
Hurt ~t - 43.21 +_ 12.40
--
Ache
x
-
23.92
+
1~.55
~ m
pain Fig. 1, The mcinraenss of paintermsby healthcare professional~(nursesand physicians)on the VisualAnalogue Scale(VAS). l~o
DPls of at least .64 that the physician~ did not choose ~ound/ng, spread/ng, squee~g, and bmt/ng). The physicians, in turn, chose three words with a DPI of at least 0.73 that were not chosen by the nurses (quive~ng, ra.vping,andflash/ng). A I e ~ Words. The nurses chose the same affective words (n ffi 15) as the physicians (except for the word v/r/eas) to discriminate the word pain from the words hurt ~ad ache. Additional affective words chosen by physicians were ~.//nd/ng, o-uel, and dreadful (Table 1).
endAd~ Hurt. The sensory words jumping, hurting, sore, and tender were chosen by all subjects to represent die term hurt. The physicians chose no additional words; however, the nurses selected six more word descriptors to represent hurt (Table 2)~ No affective words were identified to represent the word hurt by either group of subjects. Adw. The sensory word descriptor~ ~k/ng and numb were chosen by both nurse~- and physicians to represent the word ache. In addition, nurses also chose the word du//, whereas physlclans chose the word /~h/ng. The affective
~es
Profellsioft
14; SO
~
NurNa
m
Phyei©lono
7O
'!I
SO 2O I0 nl i
./
ACHE HURT PAIN POIn Terrnn FiB.~. l)iffetencesin meanvalacsof ache,hurt and pain betweennursesand phyJicia~
words nagg/ng and ~ were chosen by both 8roups of subjecO. The nurses also chose the
wordaeno~g (Table2). D/smss/on The subjects in this study were ,dl conveniently chmen and may not be representative of HCPs working in the midwestern United State,. The sample size was small and was limited to practitioners from one institution. While there was a wide range of educational levels and specialties inclnded, caution must be taken in interpredng the results because of the small number of participants.
z,,tms~ sae~cs No signffic, m differences occurred between the intensity rating of the three pain terms between the nurses and physicians. Significant differences did occur, however, in the placemere of the terms on the VAS. These findings indicate a consenms among the subjects in this study m to the relative intensity values of these terms. "l~tls llndinll m y be important when HCPs are d~cusdn~ appropriate treatment o1~ dons, sa they should have a common understanding u to the intensity of a particular term.
~
of P r o Tr,~
As was expected, the term pai~ had the highest intensity value, The DPrs of the words selected to describe pain were also higher than those selected for ache or hurt. Additionally, a greater number of sensory and affect/ve w~rds were chosen to describe pain than either of the other two terms. Several subjects indicated difficulty in choreing descriptors tl'mt defined a particular pain term. For example, several subjects commented that they could have beth a nagging ache and a nagging hurt. Subjects seemed m have the most difficulty describing the term hurt and could find no affective words m describe it. This was not true with the term pain, which tended m have well-defined descriptors attached m it, such as ~ and crushing. One possible explanation for this finding is that HCPs often associate pain intensities wim diagnose~ and procedures. Several authors have found that new surgical patients, burn patients, and trauma patients consisuendy are assessed as having higher levels of pain than other types of patients, m-re Many of the words chosen to describe pain were also analogous with the use of certain medical instrumentS, and correspond with a
Vd. ~ No. i F e b , ~ l~90
P,en ~
~ N~
~
Pk~ns
1~
Tabie l Semory and Affecfive Words Clumm by the Subje~ as Discrlmimedvefro-the Term pc/8 NurseJ De,criptor
Physkiam DPI
Des~ptor
DPi
0.89 0.89 0.86
tearing lancina~g
0.89 0.87
0.83 0.8S 0.83 0.79 0.76 054 0,72 0.71 0.70 0.70 0.68 0.67
shooO.,g crushing w~ncinn 8 stabbing p~g drilling
0.8~' 0.8O 0.78 057 0.77 0.75
0.64
ramping radiating cutting sharp penetrating
0.73 0.73 0.08 0.67 0.65 0.65
g suffocating tortudnmg
1.00 1.00 0.88
blinding fearful terrif~ng
unstable
0.8~t
cruel
0,68
dreadful
See~.. piercing crushing tearing
"
" 0.83
lacerating shooting stabbing w~nchin 8 splitting pounding squeezing beating radiating penetrating ~ndnating spreading cutting
terrifying ago~ng w~e~,d intense
fearful frightful punishing grueling nameatin8 sickening exhamdng
0.03
0.83 0.70 0.70 0.77 0,77 0.75 0.71 0.71 0.68
suffocating unbe-amhle grueling punb,~'ng agomzmg killing ~ghff.l wretched nameatin8
0.61
torturing
0,60
classification of pain terminology developed by Gaston-Johansson and Allwood.s Perhaps the familiarity o f dealing with patients who have more intense ~Pain allowed these subjects to describe more adequately that level of pain. The majority of word~ chceen by this group of nurses and physicians to describe pain terms were the same, with a few discrete differences occurring between the groups. It appears, then, that not only do these HCPs have a common understanding of the intensity of these pain terms, they also describe them in a similar manner. By having a shared understanding of these terms, the auassmant and communication
interne
~ickening exhausting
1.00 1.00 0.9'2 0.91 0.89 0.85 0.85 0.85 0.82 0.81 0.78 0.78 0.75 0.75 0.72 0.72 0.67 0,61
of a patient's pain should be more consistent between the two groups.
C ~ The sample size in this study was small and fimited to one institution, and, therefore, it may be difficult to generalize the results to other groups or settings. Nonetheless, the findings of this study suggest that HCPs have a common understanding of the level of intensity that is meant by the terms ache, hurt, or pain. In adclifton to rating the intensity values of pain terms similarly, the subjects used nearly identi-
16
Non~ll ~ al.
.
Tabb 2 ~mm7 md AffecttveWns&Cheun by the Subjec~as ~ t i v e
~eumal of Pain and ~ p t o m Mcmagm~t
get the Pain TermJ Adtt and H ~
Nurses D~r
Physicians DPI
De'~ptor
DPI
0.7,~ 0.75 0.67 0.6,5 0.64 0.6S 0.60 0.70 0.56 o.ss
jumping hurting sore tender
0.07 0.59 0.55 0.55
dull se.hiog numb
0.71 0.71
itching numb aching
0.60 0.58 0.55
nagsing tiring wnm/ing
0.64 0.56 0.56
nagging thing
0.60 0.55
Huigr jumping rare hurling freezing met unarting cool
itchy tender mUlng .At~g
Sa~ 4f,a ~
0,62
cal word modifiers to represent these terms, These findings lend support to the belief that nurses and physiclam may have a common undemanding of pain language used to describe painllke experiences. Previous studies have shown inconsistencies between patient and health care professional ratings of pain. A replkation of thi, study with a larger sample is rec. ommended to determine if other groups describe ache, hurt, and pain in a similar manner, In addition, fmther research into the similar. ities and differences between health care professionah' and patknts' pain descriptors may lead m a more common understanding of pain terms, in turn .tending to improved assessment and treatment of pain.
/~fmes 1. IASPSelgommlttecon Taxonomy, Pain terms: A Iltt with defialtiom and notes on etap, Pain 1~9;6:149-tSa, ~, gltbrqla H, Tyma S, Culture, lansuage, and the Idmpiolgof Ulmm:An illmtrminnhated on pain. J
Pt~hmom i~t 1976;20:$2g-357.
3, Gltston-JohansmnF. Pain assessment: Differences in qualityand intensityof the words pain, ache, and hurt, Pain 1984;20:69-76. 4. Gasmn-Jobansson F, Asldund-Gustahson M. A baseline study for the developmentof an instrument for the assesmlentof pain.J Adv Nuts 1985;10:5395. C,aston-Johansmn F, AIIwoodJ. Pain assessment: Model construction and analysisof words used to describe pain-like exl~rienres. J Int Assoc Semiotic Stud 1088. 6. Hnskisson E. Measurement of pain. Lancet 1974;9:1127-1131. 7. Mel~ck R. The McG~ pain quesdonnsJre: Major properties and scoring methods. Pain 1975;1:277299. 8, ReadingAE. A comparison of pain rating scales.J Paychmom Res 1980;94:119-124. 9. ScouJ, Huakisson EC. Graphic representation of pain. Pain 1076;2:175-104. 10. Downie WW, Lnstham PA, Rhlnd VM, et aL Studies with pain rating ~ales. Ann Rheum Dis 1978;$7:$78-$81, I I. Ohnham E, Adler R. Methodologicalproblems in the measurel.ent of pain: A c u m i n between the verbal rating scale and the visualanalogue scale. Pain 1975;1:$79-384.
Vol. $ No. 1 ¥ ~
1990
Pain l~viptian b~ Nurs~ and P.19sletms
12. Kremer E, Atldnmn JH. Pail, meamremera: Construct validity of the affective dimension of the McGill Pain Questionnaire with chronk benign pain patients. Pain 1981;11:95-100. 13. Graham D, Bond SS, Geekovich MM, et aL Use of the McGiII pain questionnaire in the asse~ment of cancer pain: Replicability and consistency. Pain 1980;8:377-387. 14. Bryne M, Troy A, Bradley LA, et al. Cross-validation of the factor structure of the McC,ill pain questionnaire. Pain 1982;13:193-201. 15. Prleto EJ, Hopson L, Bradley LAS, et al. The lan-
17
guage of low back paln: Facet ~ucture of the McGiI] pain quesdonnaire. Pain 1980;8:11 - 19.
16. Daeitz LJ, Pendleton SH. Nurses inferences of suffering. Nurs Res 196~,18:100- I07. 17. Dudley SR, Holm K. Assessment of the pain experience in relation to selected nurse characterlsdcs. Pain 1984;18:179-186, 18. perry SW. Undermedication for pain on a bum unit. Gen Hcop Psychiatry 1984;6:308-316. 19. Taylor AG, Skelton JA, BuW.herJ. Duration of pain condition and physical pathology as delerminares of nurses' assessment of patient's pain. Nuts Res 1984;33:4-8.
jen,,~o/e~,,on~sy,,q~n M ~ , ~ , , ~
tt
Pain Description by Nurses and Physicians Kristine Turner Norvell, RN, Fannie Gaston-Johansson, Dr Med So, and Lani Zimmerman, PhD
College of Nursing, Uaiversit3 of Nebraska Medical Center, Omaha,Nebraska
Abstma The purpose of this study was to determine ~'nurses and physiciausselectedsimilar words to describepainlike experiencesand to determine how they rated terms commonly used to describepain. Thirty.seven registerednurses and 21 physiciaus comprised the sample. The Visual Analogue Scale (VAS) was used to measure the terms ache, hurt, and pain. The McGill Pain Questionnaire (MPO~ provided a list of word descriptorsfrom which the subjectsselected words that best representedthe terms ache, hurt, and pain. There was no s~gn~6cantd~erence between the nurses and physicians in the mean rating of any of the pain terms on the VAS. The nurses and physicians chose very similar word descriptorsfrom the MPQ to discriminate one pain termfrom another. Thesefindings ,u~fgest th~ nurses and physicians may have a common understandiag of the language used to d~cribe painlihe experiences. J Pain Symptom Manage 1990;5:11-17.
Pain language, semantics,pain intensity
lntroduct/on Accurate assessment of a patient's pain is the basis for appropriate treatment. Also important is a common under.~,4nding of the meaning of various pain descriptors, if a patiem says he has an ache, the physicians and nurses caring for him should have a common understanding of what is meant by "ache" in order to intervene appropriately. The purpose of this study was (a) to describe how health care p~fe~i,)nal~ (HCP~) r~e th~ intettsity of basic pain terms (i.e., pain, harg, and ache), (b) to identify which word descriptors are selected by HCPs to describe these pain terms,
Address reprint requeststo: Fannie Oaston-Johaasson. Dr. Med. Sc., Universityof Nebraska MedicalCenter. College of Nursing, 42nd amd Dewey Aveaue. Omaha, NE 68105. Atypicalf0r/ndd/cat/0n: March 29, 1989. @ U.S. CancerPainReliefCommittee,1990
Publishedby Elsevier,NewYork,NewYork
and (c) m determine if there is a commonality in description of pain among HCPs. The International Association for the Study of Pain (IASP)t has defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage." While many authors concur with this definkion, there is disagreement as to the words used to describe pain. The words cbosey, :o describe pare usually reflect both a sensory and an emotional (affective) coml~oec, t. &~jeedves used to describe both components of pain are often imt~rtam in the diagnosis of disease and are used by both patients and HCPs to describe the pain experience. A variety of words have been identified as use[ul for describing pain~ Pain, ache, and hurt were words identified by Fabrege and Tyma* and Gaston-Johamson s as common terms used
088~$~,1~0~S,S0
12
Norvdl et al.
to describe painlike experiences. These terms have been found to have different intensity values and different meanings in relation to quality, s-s Typically, there is little thought given to the use and meaning of pain terms. However, they are freely used to describe pain by both those experiencing the pain, and by persons responsible for assessing and treating a parson in pain. A common understanding of the use and meaning of pain terms is important in the assessment and treatment of pain. Therefore, k seems essential to know if nurses and physicians are communicating when they confer with each other about a patient's pain. The following questions were investigated in this study: !. How did nurses and physicians rate the intentities of the terms ache, hurt, and pain? 2. Were there similarities in how nurses and physicians rated the intensity of these pain terms? 8. What word descriptors did nurses and physicians select to describe the tecots ache, hurt, pain with respect to their sensory and affecfive components? 4. Were there similarities in the description of the~e pain terms by nurses and physicians?
]our~,l ~ Pain and SymJ~oraMam~eraet~
provides only a unidimensional rating of pain intensity and has been shown to be difficult for some parsons to understand, s.n The VAS was used in this study to obtain intensity ratings of the three pain terms. MPQ. The MPQ consists of 78 word descriptor's that represent sensory, affective, evaluative, and miscellaneous components of pain. The word descriptors were used in this study for subject selection of words that describe pain terms. Several authors have completed reliability and validity testing of the MPQ. Both Melzackr and Graham and colleagues 's found high intercorrelations among several measures on the MPQ. Kremer and Atkinson Is found support for the construct validity of the affective dimension of the MPQ. Byrne and coUeagues 14 and Prieto and colleagues m subjected the MPQ to factor analysis, each resulting in four factors that were highly simUar, with significant correlations occurring across studies in throe o! the four f~ctors (r ~ ,74 to .g3), Dm,wgrap~ D~a. Demographic data were collected using a questionnaire developed by the investigators. Data obtained included age, sex, educational level, length of employment, and specialty area.
Methods
s,~eas
Proc~lure
The subjects for this study consisted of 58 conveniently selected nurses and physicians working at a teach!r,g hospital in a midwestern city. Thirty-seven licensed registered nurses and 21 physicians comprised the sample. Permission to conduct the study was granted by the lnstimtinnal Review Board of the study hospital.
Informed consent was ,~btained. and each subject was given a VAS with the three pain terms pain. ache. and hurt alphabetized and printed horizontally across the top of the page. The words were presented this way in an attempt to avoid ranking the intensities of the words. The subjects were then asked to mark on the VAS where they perceived the intensities of pain, ache, and hurt to be represented. A list of the word descriptors was then given to the subjects. The descriptors from the MPQ were placed randomly on the data collection sheet in an effort to eliminate any bias that might have occurred by presenting the words according m classifications. The su~ects were asked to identify which of the descriptors were associated with the terms pain. ache, or hurt. A separate list was used for each term, and the terms were presented in a random manner.
Insmmm~ T~voestablished instruments were used in the stnd~, d~e Visual Analogue Scale (VAS)' and the blcGill Pain Questionnaire (MPQ), r
VA& The VAS consists of a 10-cm line with anchors on each end that represent no pain and pain as bad at it can be. The VAS is commonly used for rating pain intensity and is generally reported as valid and reliable, s-H However, it
Vol. 5 No. 1 F d ~
1990
Pain Descripgonby Nursesmul P ~
13
Worst p o s s i b l e
An analysis of variance (ANOVA) for repeated measures was used to calculate differences in VAS ratings of the pain terms. Posthoc Tukey tests were conducted to determine where the pairwise differences were located. A Student's t test was used to determip.e differences in VAS ratings by nurses and physicians. Frequencies and percentages were computed for each word descriptor. A discriminative power index (DP1) wa~. calculated as a ratio of each of the 78 word descriptors with each pain term. Once words with DPIs above 0.50 were identified for each pain term, they were divided into two categories: sensory and affective.
Pain x - 74.96 + 16.59
0
Rendts The mean age of both nurses and physicians was 35 yr. The nurses had practiced a mean of 12.9 yr, while the physicians had practiced a mean of 7.7 yr. The majority (07%) of the nurses were female, as compared to 26% of the physicians. A variety of educational levels were represented in the nurse sample, with the BSN being most common (45%). Among physicians, 36% were surgeons or pathologists; 33% of the nurses practiced in medical/surgical areas. There were no significant differences in the mean ratings of the terms pain, ache, and hurt on the VAS by nurses and physicians (Figure 1). Therefore, the groups were combined, and an ANOVA for repeated measures was used to determine differences between the ratings of the pain terms. A statistically significant difference occurred between the mean ratings of ache, hurt, and pain [F(53, 105) = 8.81, p < 0.0001], with ache having the lowest mean intensity (P~3.92) on the VAS followed by hurt (45.21), and pain having the highest value (74.96) (Figure 2). Posthoc Tukey tests indicated significant differences between all pairwise comparisons ~e < 0.01).
se~
o/Word~ . f o r
Pm
8mm~ Wera~. Nurses and physicians chose similar sensory words (n = IS) to discriminate the word pain from the words hurt and ache (Table 1). The nurses chose four words with
pain
100
--
Hurt ~t - 43.21 +_ 12.40
--
Ache
x
-
23.92
+
1~.55
~ m
pain Fig. 1, The mcinraenss of paintermsby healthcare professional~(nursesand physicians)on the VisualAnalogue Scale(VAS). l~o
DPls of at least .64 that the physician~ did not choose ~ound/ng, spread/ng, squee~g, and bmt/ng). The physicians, in turn, chose three words with a DPI of at least 0.73 that were not chosen by the nurses (quive~ng, ra.vping,andflash/ng). A I e ~ Words. The nurses chose the same affective words (n ffi 15) as the physicians (except for the word v/r/eas) to discriminate the word pain from the words hurt ~ad ache. Additional affective words chosen by physicians were ~.//nd/ng, o-uel, and dreadful (Table 1).
endAd~ Hurt. The sensory words jumping, hurting, sore, and tender were chosen by all subjects to represent die term hurt. The physicians chose no additional words; however, the nurses selected six more word descriptors to represent hurt (Table 2)~ No affective words were identified to represent the word hurt by either group of subjects. Adw. The sensory word descriptor~ ~k/ng and numb were chosen by both nurse~- and physicians to represent the word ache. In addition, nurses also chose the word du//, whereas physlclans chose the word /~h/ng. The affective
~es
Profellsioft
14; SO
~
NurNa
m
Phyei©lono
7O
'!I
SO 2O I0 nl i
./
ACHE HURT PAIN POIn Terrnn FiB.~. l)iffetencesin meanvalacsof ache,hurt and pain betweennursesand phyJicia~
words nagg/ng and ~ were chosen by both 8roups of subjecO. The nurses also chose the
wordaeno~g (Table2). D/smss/on The subjects in this study were ,dl conveniently chmen and may not be representative of HCPs working in the midwestern United State,. The sample size was small and was limited to practitioners from one institution. While there was a wide range of educational levels and specialties inclnded, caution must be taken in interpredng the results because of the small number of participants.
z,,tms~ sae~cs No signffic, m differences occurred between the intensity rating of the three pain terms between the nurses and physicians. Significant differences did occur, however, in the placemere of the terms on the VAS. These findings indicate a consenms among the subjects in this study m to the relative intensity values of these terms. "l~tls llndinll m y be important when HCPs are d~cusdn~ appropriate treatment o1~ dons, sa they should have a common understanding u to the intensity of a particular term.
~
of P r o Tr,~
As was expected, the term pai~ had the highest intensity value, The DPrs of the words selected to describe pain were also higher than those selected for ache or hurt. Additionally, a greater number of sensory and affect/ve w~rds were chosen to describe pain than either of the other two terms. Several subjects indicated difficulty in choreing descriptors tl'mt defined a particular pain term. For example, several subjects commented that they could have beth a nagging ache and a nagging hurt. Subjects seemed m have the most difficulty describing the term hurt and could find no affective words m describe it. This was not true with the term pain, which tended m have well-defined descriptors attached m it, such as ~ and crushing. One possible explanation for this finding is that HCPs often associate pain intensities wim diagnose~ and procedures. Several authors have found that new surgical patients, burn patients, and trauma patients consisuendy are assessed as having higher levels of pain than other types of patients, m-re Many of the words chosen to describe pain were also analogous with the use of certain medical instrumentS, and correspond with a
Vd. ~ No. i F e b , ~ l~90
P,en ~
~ N~
~
Pk~ns
1~
Tabie l Semory and Affecfive Words Clumm by the Subje~ as Discrlmimedvefro-the Term pc/8 NurseJ De,criptor
Physkiam DPI
Des~ptor
DPi
0.89 0.89 0.86
tearing lancina~g
0.89 0.87
0.83 0.8S 0.83 0.79 0.76 054 0,72 0.71 0.70 0.70 0.68 0.67
shooO.,g crushing w~ncinn 8 stabbing p~g drilling
0.8~' 0.8O 0.78 057 0.77 0.75
0.64
ramping radiating cutting sharp penetrating
0.73 0.73 0.08 0.67 0.65 0.65
g suffocating tortudnmg
1.00 1.00 0.88
blinding fearful terrif~ng
unstable
0.8~t
cruel
0,68
dreadful
See~.. piercing crushing tearing
"
" 0.83
lacerating shooting stabbing w~nchin 8 splitting pounding squeezing beating radiating penetrating ~ndnating spreading cutting
terrifying ago~ng w~e~,d intense
fearful frightful punishing grueling nameatin8 sickening exhamdng
0.03
0.83 0.70 0.70 0.77 0,77 0.75 0.71 0.71 0.68
suffocating unbe-amhle grueling punb,~'ng agomzmg killing ~ghff.l wretched nameatin8
0.61
torturing
0,60
classification of pain terminology developed by Gaston-Johansson and Allwood.s Perhaps the familiarity o f dealing with patients who have more intense ~Pain allowed these subjects to describe more adequately that level of pain. The majority of word~ chceen by this group of nurses and physicians to describe pain terms were the same, with a few discrete differences occurring between the groups. It appears, then, that not only do these HCPs have a common understanding of the intensity of these pain terms, they also describe them in a similar manner. By having a shared understanding of these terms, the auassmant and communication
interne
~ickening exhausting
1.00 1.00 0.9'2 0.91 0.89 0.85 0.85 0.85 0.82 0.81 0.78 0.78 0.75 0.75 0.72 0.72 0.67 0,61
of a patient's pain should be more consistent between the two groups.
C ~ The sample size in this study was small and fimited to one institution, and, therefore, it may be difficult to generalize the results to other groups or settings. Nonetheless, the findings of this study suggest that HCPs have a common understanding of the level of intensity that is meant by the terms ache, hurt, or pain. In adclifton to rating the intensity values of pain terms similarly, the subjects used nearly identi-
16
Non~ll ~ al.
.
Tabb 2 ~mm7 md AffecttveWns&Cheun by the Subjec~as ~ t i v e
~eumal of Pain and ~ p t o m Mcmagm~t
get the Pain TermJ Adtt and H ~
Nurses D~r
Physicians DPI
De'~ptor
DPI
0.7,~ 0.75 0.67 0.6,5 0.64 0.6S 0.60 0.70 0.56 o.ss
jumping hurting sore tender
0.07 0.59 0.55 0.55
dull se.hiog numb
0.71 0.71
itching numb aching
0.60 0.58 0.55
nagsing tiring wnm/ing
0.64 0.56 0.56
nagging thing
0.60 0.55
Huigr jumping rare hurling freezing met unarting cool
itchy tender mUlng .At~g
Sa~ 4f,a ~
0,62
cal word modifiers to represent these terms, These findings lend support to the belief that nurses and physiclam may have a common undemanding of pain language used to describe painllke experiences. Previous studies have shown inconsistencies between patient and health care professional ratings of pain. A replkation of thi, study with a larger sample is rec. ommended to determine if other groups describe ache, hurt, and pain in a similar manner, In addition, fmther research into the similar. ities and differences between health care professionah' and patknts' pain descriptors may lead m a more common understanding of pain terms, in turn .tending to improved assessment and treatment of pain.
/~fmes 1. IASPSelgommlttecon Taxonomy, Pain terms: A Iltt with defialtiom and notes on etap, Pain 1~9;6:149-tSa, ~, gltbrqla H, Tyma S, Culture, lansuage, and the Idmpiolgof Ulmm:An illmtrminnhated on pain. J
Pt~hmom i~t 1976;20:$2g-357.
3, Gltston-JohansmnF. Pain assessment: Differences in qualityand intensityof the words pain, ache, and hurt, Pain 1984;20:69-76. 4. Gasmn-Jobansson F, Asldund-Gustahson M. A baseline study for the developmentof an instrument for the assesmlentof pain.J Adv Nuts 1985;10:5395. C,aston-Johansmn F, AIIwoodJ. Pain assessment: Model construction and analysisof words used to describe pain-like exl~rienres. J Int Assoc Semiotic Stud 1088. 6. Hnskisson E. Measurement of pain. Lancet 1974;9:1127-1131. 7. Mel~ck R. The McG~ pain quesdonnsJre: Major properties and scoring methods. Pain 1975;1:277299. 8, ReadingAE. A comparison of pain rating scales.J Paychmom Res 1980;94:119-124. 9. ScouJ, Huakisson EC. Graphic representation of pain. Pain 1076;2:175-104. 10. Downie WW, Lnstham PA, Rhlnd VM, et aL Studies with pain rating ~ales. Ann Rheum Dis 1978;$7:$78-$81, I I. Ohnham E, Adler R. Methodologicalproblems in the measurel.ent of pain: A c u m i n between the verbal rating scale and the visualanalogue scale. Pain 1975;1:$79-384.
Vol. $ No. 1 ¥ ~
1990
Pain l~viptian b~ Nurs~ and P.19sletms
12. Kremer E, Atldnmn JH. Pail, meamremera: Construct validity of the affective dimension of the McGill Pain Questionnaire with chronk benign pain patients. Pain 1981;11:95-100. 13. Graham D, Bond SS, Geekovich MM, et aL Use of the McGiII pain questionnaire in the asse~ment of cancer pain: Replicability and consistency. Pain 1980;8:377-387. 14. Bryne M, Troy A, Bradley LA, et al. Cross-validation of the factor structure of the McC,ill pain questionnaire. Pain 1982;13:193-201. 15. Prleto EJ, Hopson L, Bradley LAS, et al. The lan-
17
guage of low back paln: Facet ~ucture of the McGiI] pain quesdonnaire. Pain 1980;8:11 - 19.
16. Daeitz LJ, Pendleton SH. Nurses inferences of suffering. Nurs Res 196~,18:100- I07. 17. Dudley SR, Holm K. Assessment of the pain experience in relation to selected nurse characterlsdcs. Pain 1984;18:179-186, 18. perry SW. Undermedication for pain on a bum unit. Gen Hcop Psychiatry 1984;6:308-316. 19. Taylor AG, Skelton JA, BuW.herJ. Duration of pain condition and physical pathology as delerminares of nurses' assessment of patient's pain. Nuts Res 1984;33:4-8.