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Survey of Pain Among Veterans in Western New York
Original Articles Survey of Pain Among Veterans in Western New York yyy Frances E. Crosby, EdD, RN,* Janice Colestro, DNS, RN,† Marlene R. Ventura, EdD, RN,‡ and Kathy Graham, MS, RN, AOCN†
From the *Niagara University Department of Nursing, Niagara University, New York; †Veterans Health Administration, Buffalo, New York; and ‡Clemson University, Clemson, South Carolina. Address correspondence and reprint requests to Frances E. Crosby, EdD, RN, Niagara University Department of Nursing, Dunleavy Hall, PO Box 2026, Niagara University, NY 14109. E-mail: [email protected] This research was supported by the Veterans Administration Western New York Healthcare System, Health Services Research and Development Special Project. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. 1524-9042/$32.00 © 2006 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2005.12.001
ABSTRACT: Recent emphasis on pain and its impact on the health and well-being of individuals evoked the interest of health care providers about services needed for effective and efficient pain management. This study was undertaken to examine the feasibility of using a mailed survey to determine the prevalence, nature, and extent of pain being experienced by Western New York Veterans. The specific aims were to (1) determine the feasibility of using a mailed survey to obtain information about pain in a population of Veterans; (2) estimate the extent of pain in the sample; and (3) describe the nature and impact of the pain experienced by the respondents. A comprehensive survey was prepared by modifying preexisting, widely used pain-assessment tools to describe a Veteran group’s pain experience. It was mailed to a randomly selected sample of 150 Veterans registered at a primary care clinic at the Western New York Veterans Administration Health System. A 76% response rate (n ⴝ 114) was obtained. Respondents declared a wide variety of health problems, and 71% reported having pain. The average number of body parts affected was 4.4 of a possible 11. The average intensity of pain was moderate; 35% reported constant pain, and 85% reported the pain to be occurring for years. Seventy-nine respondents described their pain to be interfering with their life and well-being. Medication was the primary treatment approach and was reported as ineffective by 48%. Veterans’ satisfaction with specific aspects of pain treatment was mixed. © 2006 by the American Society for Pain Management Nursing
Pain has received increasing attention in health care, especially in relationship to patient well-being and quality of life. In 1997, the World Health Organization published as its sixth priority, “the alleviation of pain, the reduction of suffering and the provision of palliative care for those who cannot be cured” (Montrey, 1999). Concurrently, the Veterans Administration (VA) advocated pain as the fifth vital sign, encouraging its assessment for all clients. The VA recognized the need to address pain within its services to promote the health and well-being of its clients. In 1998, a national VA task force charged with examining the role of pain in the care of the Veteran patient concluded that pain and its management were significant issues and that more information about Veterans’ pain was needed (Department of Veteran Affairs, Veterans Pain Management Nursing, Vol 7, No 1 (March), 2006: pp 12-22
Veterans’ Pain Experience
Health Administration, 2003). They noted that Veterans had some unique issues that influence pain, such as increased homelessness, posttraumatic stress disorder, war injuries, and substance abuse (VA Strategic Healthcare Group Report, 1998). At the local level, the question of what kind of services to offer emerged. It became apparent that the resources needed for managing pain in a given population could best be determined by assessing the nature of pain in that respective population. An effective method to ascertain the quality and scope of pain was needed. Acello (2000) noted that pain-assessment tools are important and need to be appropriate to age, condition, and culture, recognizing that patients’ beliefs regarding pain modify their behavior and response. Although individual assessment was recognized as key to treating a person’s pain, group assessment was sought to guide program planning.
STATEMENT OF THE PROBLEM Before extensive planning and implementation of costly services for pain treatment were undertaken by the Veterans Administration Western New York Healthcare System (VA WNY HS), a more specific description of the extent and kind(s) of pain that groups of Veterans were experiencing was needed so that services could be planned responsively. Some questions that arose were as follows: What percentage of a given group of Veterans served by the medical center was experiencing pain? Was the pain predominantly acute, chronic, or mixed? Was chronic pain simple or complex, and what portion might be considered chronic pain syndrome? The purpose of this study was to provide greater understanding of Veterans’ pain as a group to guide the planning and implementation of pain-management services that would be tailored to the population’s needs.
BACKGROUND The International Association for the Study of Pain (1994) defined pain as the unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It reduces quality of life and impairs functional status (Serlin, 1995). Pain crosses all ages, socioeconomic strata, and diagnostic categories; it is a concern in all health care settings. It is not a single dimension phenomenon. Pain can be a direct symptom of acute sources, such as a surgical procedure or a chronic condition such as cancer and arthritis. Pain can also result from a combination of conditions with a complex origin (Navas, et al., 1999). Pain can be a perva-
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sive experience that interferes with daily life, referred to as chronic pain syndrome or “nonmalignant” pain (McCaffey & Pasero, 1999). Matteson (2002) asserted that, of the hundreds of words used to describe painful experiences, consensus emerged on three best descriptors: pain (high intensity), ache (less intensity), and hurt (low intensity). Relief from pain is advocated as a human right (Brennan & Cousins, 2004). Yet, pain management is a major health care challenge that impacts patients’ health status, treatment decisions, service use, resource allocation, and costs of health care. In developed countries chronic pain afflicts approximately 20% of the adult population (Bond, 2004), and severe chronic pain prevalence was found to be approximately 11.8% (Harstall & Ospina, 2003). Acute pain in the United States is estimated to affect 23 to 25 million people annually (Foley, 1999). Pain is attributed to various sources such as backache (16 million people), trauma (4 million), burns (2 million), and herpes zoster (400,000 people) (Foley, 1999). Approximately 9% of the U.S. population is reported to have moderate to severe non– cancer-related chronic pain, often longer than 5 years in duration, and its prevalence increases with age (American Pain Society, 1998). It is predicted that 80% to 85% of persons aged more than 65 years will experience a serious health problem predisposing them to pain (Leland, 1999). Loeb (1999) reported that up to 80% of residents of long-term care facilities have significant pain. Pain is thought to be underreported, underdetected, and undertreated (Loeb, 1999; Montrey, 1999; Strevy, 1998). Untreated pain is a costly burden to society. It is estimated that the cost of disability associated with pain nationally is approximately $80 billion (VA Strategic Healthcare Group Report, 1998). Pain is a concern of the VA Healthcare System. Kazis et al. (1999; 1998) reported that Veterans’ pain, as measured on a quality of life instrument, was impaired and significantly worse than the pain of the general public. Approximately 700,000 Veterans reported chronic pain and approximately 500,000 Veterans experienced acute pain annually (VA Strategic Healthcare Group Report, 1998). A higher incidence of pain in Veterans was anticipated compared with the general public because of the greater exposure to trauma and psychologic stress (Arnstein et al., 1999), both of which increase pain and confound therapy. Escalante and Fishback (1998) reported that joint pain was widespread in Gulf War Veterans, and that their health-related quality of life was poor. At the VA WNY HS, a quality improvement chart review of 1334 Veterans who visited a primary care clinic at a specific time point revealed that approxi-
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mately 56.6% were experiencing pain. In fact, pain was the predominant concern identified, compared with weight, sleep, sexual functioning, finances, exercise, and general health. In addition, a snapshot record review of 132 acute care inpatients determined that 53% were experiencing pain. In contrast, others have reported that 22% of primary care patients reported persistent pain (Gureje et al., 1998). Pain and its management are of relevance to nursing practice. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) set standards for pain management as accreditation criteria (Acello, 2000). Nurses play a key role in meeting these standards and are often the caregivers responsible for assessing and documenting a patient’s pain (O’Connor, 2003). The JCAHO criteria include the following (JCAHO, 1999): ● ● ● ● ● ●
Patients have the right to appropriate pain assessment, treatment, or referral; Patients’ pain should be regularly assessed and reassessed; Patients should be taught the importance of effective pain management as part of care; Patients should be involved in decisions; Routine and prn analgesics should be administered as needed; Discharge planning should include pain management plans.
Because treatment strategies can be guided by better understanding of the nature of pain (American Pain Society, 1998), and more effective services with better use of resources could result from describing Western New York (WNY) Veterans’ pain, this study was undertaken.
RESEARCH QUESTIONS Five specific research questions were explored in this study to examine Veterans’ pain: What percentage of Veterans in WNY are experiencing pain? What are the characteristics of their pain? How does pain impact on Veterans’ quality of life? What kinds of treatment did WNY Veterans seek/receive for pain? How do Veterans perceive the effectiveness of pain treatment they received?
STUDY METHODS Procedure A written survey questionnaire was prepared to comprehensively assess the scope and nature of pain being experienced by Veterans in WNY, along with the kinds and satisfaction with pain treatment received by
the target group. After institutional review board approval was obtained, a random sample was selected and survey questionnaires were mailed using the Dillman’s Total Design Method (Dillman, 1979). Each Veteran sampled was sent the questionnaire with a cover letter and return envelope, and a follow-up reminder/thank you postcard 1 week later. Questionnaires were coded for confidentiality of response. Sample The study population was the 10,057 Veterans who were registered at the two primary care clinics at the VA WNY HS. A sample of 150 Veterans were randomly selected using a table of random numbers. Sample size of 150 was recommended by an expert epidemiologist as an adequate number for descriptive purposes. This target sample represented Veterans in WNY who were receiving ambulatory health services ranging from wellness and health promotion to treatment of acute episodes and chronic disease management for specific conditions or complex concerns. Although random sampling allowed for the span of ages and diagnoses representative of this VA primary care population, gender distribution was limited because of the predominance of males in the system. Instrument Development A data-collection tool was developed, called “The Veterans’ Pain Survey.” Three commonly used public domain pain measurement tools were reviewed. These were (1) the short form of the McGill Pain Questionnaire (Melzack, 1986), (2) the Brief Pain Inventory: Short Form (Cleeland, 1994), and (3) the American Pain Society Questionnaire (American Pain Society, 1995). The American Pain Society Questionnaire contained items needed to determine the effect of generalized pain on short-term quality of life issues (within past 24 hours) and satisfaction with prescribed painmanagement therapy. It also included items to assess personal and institutional barriers to seeking adequate pain relief. The Brief Pain Inventory: Short Form provided items to describe the location and nature of pain and to assess the level of pain relief. The McGill Pain Questionnaire listed precise pain characteristics to describe the quality of pain. The final instrument, The Veterans’ Pain Survey, included the pain descriptors used by McGill, 13 items (some modified) from the American Pain Society, six items from the Brief Pain Inventory, and some researcher-developed items. Researcher-developed items included a comprehensive listing of parts of the body from head to toe for the respondent to indicate the location of pain and its respective severity, frequency, and duration. Also included were a general well-being item, items specific
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Veterans’ Pain Experience
TABLE 1. Instrument items, Source (ⴱModified), Response set: Veterans Pain Survey Item(s) 1 2–5
6–16 17 18 19–25
26 27–33
34–40
41–49 50–55
Source of Item(s)
Content of Item(s)
Response Set
American Pain Society* Cleeland’s Brief Pain Inventory; American Pain Society Researcher developed Researcher developed McGill*
Pain in past 2 months
Yes/no
Extent of pain
Likert 0 ⫽ none to 10 ⫽ worst
Comments Yes¡go on No¡go to end Now; at worst; usual; at least
Body parts listedPain- yes/no How severe? Head to toe describe pain How frequent? How long? Extent of pain relief/ interventions 10 pain descriptors ✓all that apply Symptoms physical, visceral, or listed neurogenic Cleeland’s Brief Pain Interference with life Likert 0 ⫽ none to 10 ⫽ Subscale- internal consistencyInventory; activities completely alpha ⫽ 0.92; items to total ⫽ American Pain Subscale 0.66 to 1.89 Society Researcher General well-being Likert 1 ⫽ very sad to 6 ⫽ Global item developed very happy American Pain Aspects of treatment: Satisfy: 1 ⫽ very dissatisfied, Treatment Society* satisfaction, to 6 ⫽ very satisfied; Provider response occurrence, occurred ⫽ yes/no timely: Medication timeliness 1 ⱕa minute to 6 ⱖ24 h Medical management American Pain Respondent’s attitude Likert 0 ⫽ not agree to 5 ⫽ Subscale Society* regarding pain agree very much Internal consistency- alpha ⫽ management 0.71 subscale American Pain Pain-management Likert 1 ⫽ none given, to 6 Clarity of patient education Society* instructions ⫽ absolutely clear Researcher Kinds of treatment, Satisfaction Outside VA developed traditional, Within VA complementary
VA, Veterans Administration.
to VA WNY HS pain-related treatment, and a checklist of other non-VA pain treatment sought. Demographic and health information were included. Face validity was obtained by sending the draft instrument to 10 Veterans, with 100% response and feedback that was incorporated into a revised edition. In addition, two experts in instrument design reviewed the revised draft, and their recommendations were used to refine the instrument further. Next, two experts in pain treatment critiqued the instrument for content validity, and their recommendations guided instrument revision. The final version of the Veteran Pain Survey was presented in booklet form and consisted of 15 pages with 62 items, most having closed response options. The content, source, and response set of items are summarized in Table 1. Data Analysis Data were entered into SPSS version 10.0 (SPSS Inc., Chicago, IL) for analysis. Frequency and percentages
were calculated for nominal and ordinal data. Mean and standard deviations (SD) were calculated for interval and ratio data. Items that measured a single theoretic construct (subscale), such as interference of pain on life’s activities (items 19 –25) and attitude toward pain management (items 34-40), were summed to obtain subscale scores, which were presented as mean and SD. Co-relational and linear regression analyses were performed to assess relationships among certain variables.
RESULTS Demographics Questionnaires were returned from 114 people, for a 76% response rate. The average age of the respondents was 65 years old, with a range of 24 to 90 years. Almost all of the respondents were male (98%). Many of the Veterans were retired (47%); some were disabled (19%), employed (13%), or unemployed (4%).
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TABLE 2. Severity of Pain in Past Month (n ⴝ 87) Pain Intensity Pain History
Mean (SD)
% Mild (1–3)
Moderate (4–7)
% Severe (8–10)
Right now Worst, past month Average, past month Least, past month
4.4 (2.86) 6.7 (2.78) 5.0 (2.26) 3.1 (2.47)
35% 16% 30% 62%
51% 33% 58% 33%
14% 62% 12% 5%
SD, Standard deviation.
Most of the Veterans were married (48%), and fewer were widowed (18%), single (18%), or divorced (16%). One respondent was a World War I Veteran, 47 (41%) were World War II Veterans; 24 (21%) were Korean War Veterans, 21 (20%) were Viet Nam Veterans; and 3 (3%) were Gulf War Veterans. The general health status of this sample was assessed by requesting the respondents to complete a 20-item checklist to identify their current and chronic health problems. A wide range of medical conditions was indicated. The mean number of health problems checked was 3.6 (SD ⫾ 2.67) per person, with a range of 0 (9 Veterans) to 12. Seventeen respondents (15%) had seven or more health problems. The most frequently reported conditions were arthritis (51.8%), circulation problems (34.2%), heart disease (33.3%), back problems (33.3%), diabetes (26.3%), dental problems (26.3%), depression (23.7%), lung problems (20.1%), stomach (19.3%), anxiety (11.4%), posttraumatic stress disorder (10.5%), migraine (6.1%), and kidney disease (5.3%). So although this was a primary care sample, health status was somewhat compromised. Survey Findings Rate of Western New York Veterans experiencing pain. Among the 114 responding Veterans, 81 (71%) reported experiencing pain within the last 2 months, 27 (24%) reported they had not experienced pain, and 6 (5%) did not answer this question, but did complete the pain survey, suggesting the presence of pain. This rate was higher than the 56.6% of Veterans who reported pain in the quality improvement survey conducted earlier at the VA WNY HS. Characteristics of the pain. On a scale of 0 (no pain) to 10 (worst possible pain), the mean score for the pain intensity experienced on the day of completing the survey was moderate at 4.4 (SD ⫾ 2.86). Of the 81 Veterans reporting pain on the survey day, 12 (14.8%) were experiencing severe pain (rating 8 –10),
and an additional 23 (26%) were experiencing moderately severe pain (rating 6 –7). Twenty-one (25.9%) indicated moderate pain (ratings 4 and 5), and 15 (18.5%) recorded mild pain (ratings 1 and 2). Average pain, worst pain, and least pain in the past month were also elicited in the survey using the 0 (no pain) to 10 (worst possible pain) rating, to provide a more descriptive appreciation of one’s usual pain experience. Eighty-seven respondents described their usual, worst, and least pain in the past month. The range in all categories was from mild to severe, but the proportions differed. Mean scores for “right now,” “worst pain,” and “average pain” were all in the moderate pain range; “least pain” mean score was in the mild range. The responses are summarized in Table 2, associated with age groups in Table 3 and demographic characteristics in Table 4. Pain was further described in terms of its location(s) and respective frequency, duration, and sitespecific intensity. Of the 87 Veterans who described their pain, sites most commonly mentioned were the back (64%) and lower legs (60%). Shoulders (51%), upper legs (45%), and feet (40%) were also frequently mentioned. The average number of body parts in which pain was experienced was 4.4 of the 11 possible sites, and 40% of the respondents experienced pain in five or more sites. For each of the 11 locations of the body, the severity of pain was indicated as mild (1), moderate (2), or severe (3). The median pain intensity recorded for all 11 body locations was moderate. For 9 of the 11 locations, the most frequent response was moderate. The head and abdomen had “mild” scored as the most frequent intensity of pain. Forty (46%) of the 87 respondents had severe pain for at least one site, and 28 reported severe pain at two or more sites. The frequency of the pain was indicated by the 87 Veterans with pain on a four-point scale with the descriptors “rarely,” “sometimes,” “often,” or “always.” Eight of the 11 locations had the median value
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Veterans’ Pain Experience
TABLE 3. Pain Intensity by Age Pain Intensity Age Group
Average, Last Month
⬍49 (n ⫽ 14)
Median 6 Mean (SDs) Median 6 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs)
50–59 (n ⫽ 18) 60–69 (n ⫽ 13) 70–79 (n ⫽ 28) ⬎79 (n ⫽ 9) Total
Least, Last Month
Worst, Past Month
4 3.4 (⫾2.6) 4 3.6 (⫾2.5) 3 2.6 (⫾2.8) 3 3.3 (⫾2.5) 2 2.9 (⫾1.6) 3 3.2 (⫾2.5)
9 7.9 (⫾2.6) 8 7.7 (⫾1.5) 7 6.4 (⫾2.6) 7 6.8 (⫾2.6) 7 5.8 (⫾3.2) 8 7.0 (⫾2.5)
5.2 (⫾2.5) 5.6 (⫾2.0) 4.9 (⫾2.5) 5.2 (⫾2.0) 4.6 (⫾2.0) 5.1 (⫾2.2)
SD, Standard deviation.
TABLE 4. Pain Characteristics Associated with Demographics Demographics
Pain within last 2 months Reported pain:
Age
Mean Standard deviation
Gender
Male Female
Marital status
Single Married Divorced Widowed Divorced and widowed
Employment status
Employed Unemployed Retired Disabled Retired and disabled Employed, retired, and disabled
War experience
World War 1 World War 2 Korea Vietnam Gulf No war
Not reported
Not reported
Not reported
Not reported
No (n ⴝ 27)
Yes (n ⴝ 87)
72.6 65.4 12.9 16.7 Column % for each demographic category 88.9% 90.8% 2.3% 11.1% 6.9% 15.4% 17.2% 57.7% 42.5% 7.7% 14.9% 11.5% 19.5% 1.1% 7.7% 4.6% 11.1% 14.9% 3.7% 3.4% 63.0% 43.7% 7.4% 21.8% 7.4% 9.2% 1.1% 7.4% 5.7% 3.7% 1.1% 37.0% 42.5% 37.0% 16.1% 11.1% 20.7% 3.4% 11.1% 13.8% 3.7% 5.7%
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of “often,” and three locations (chest, abdomen, buttocks) had the median value of “sometimes.” Some of the Veterans reported their pain as always present for all locations except the head. Thirty Veterans (35%) reported “always” having pain at least one site, and 20 of these had constant pain in two or more sites. Of the 30 Veterans with constant pain, 19 had severe and constant pain in at least one site and 17 had severe and constant pain in two or more sites. The last response on the site-specific pain information indicated duration of the pain. The duration of pain was classified on a five-point scale with the descriptors “days,” “weeks,” “1 to 5 months,” “6 to 11 months,” or “years.” Across 10 of the 11 sites, both the median duration and the most frequent duration were “years.” For chest pain, the median duration was “6 to 11 months,” but the most frequent response was “years.” Seventy-one (82%) of the 87 Veterans reported having pain for “years,” with 51 having pain for years at two or more sites. Of the 19 Veterans with severe and constant pain, 16 had severe and constant pain for years, and 9 of these had severe and constant pain for years at more than one site. These nine Veterans are 10% of the 87 reporting pain and 8% of the 114 in this study. These characteristics suggest that a substantial portion of the WNY Veterans are experiencing longterm, complex chronic pain, which has implications for the kinds of pain-management services that are needed for the population represented. By using Pearson’s correlational analyses, the data were examined to look for relationships among the pain sites. Mild-to-moderate correlations were found between many of the sites, such as the head with the neck, neck with the shoulder, neck with the back, and ankle with the foot. Some unexpected correlations were found to be statistically significant, such as shoulder and foot pain, head and abdominal pain, and buttock and ankle pain (Table 5). Although the relationships are not explained, they support the complexity or perhaps generalized experience of pain, indicating that, for some Veterans, pain-treatment needs may involve multiple body parts and be complex. The 87 respondents with pain further defined their pain from a listing of nine descriptors, choosing as many as applicable or “none of these.” Fifty-two (60%) described their pain as throbbing. Thirty-four (39%) indicated their pain was sharp, whereas 25 (29%) noted their pain as dull. Twenty-five (29%) reported cramping, 17 (20%) reported tingling, 13 (15%) reported burning, 13 (15%) reported shocking, and 13 (15%) reported shooting pain. Pain and quality of life. By using the past 30 days as their reference, Veterans rated the impact of pain on their life. The “Interference with life” subscale (from
TABLE 5. Correlations Among Pain Sites Body Part/Pain Head pain with
Neck pain with Shoulder pain with Abdominal pain with Back pain with Buttock pain with Lower leg pain with Upper leg pain with Ankle pain with Foot pain with
Correlation Neck pain Abdominal pain Back pain Head pain Shoulder pain Back pain Neck pain Foot pain Head pain Head pain Neck pain Lower leg pain Ankle pain Buttock pain Ankle pain Foot pain Buttock pain Lower leg pain Foot pain Shoulder pain Upper leg pain Ankle pain
Pearson’s r 0.32 0.34 0.35 0.32 0.42 0.40 0.42 0.36 0.35 0.35 0.40 0.33 0.34 0.33 0.33 0.33 0.39 0.33 0.39 0.36 0.36 0.39
the Brief Pain Inventory: Short Form and the American Pain Society Questionnaire) was used for this measure. The response option was 0 (does not interfere) to 10 (completely interferes) for each of seven items, for a potential subscale range of 0 to 70. First, the reliability of this subscale with the Veteran sample was tested, with an internal consistency of ␣ ⫽ 0.92. The actual mean score was 34.8 (SD ⫾ 19.6), which was midway for this 70-point scale and indicated that the pain, overall, moderately interfered with the Veterans’ lives. Pain had a mild interference on one’s relationships with others (median ⫽ 3), but 68% reported at least some interference with this area. Pain had the strongest impact on walking (median value ⫽ 6.5 on 0 –10 scale), with 88% indicating at least some interference and 44% reporting great interference. Correlations were performed on “Interference with Life” subscale scores and degree of pain experienced. Statistically significant correlations (Pearson’s, p ⱕ .05) suggested a moderately strong relationship between the degree of pain and the extent that pain interfered with one’s life. The “interference” score correlated with 30-day average level of pain (r ⫽ 0.63), the worst pain experienced in 30 days (r ⫽ 0.70), and the pain experienced right now (r ⫽ 0.67). The 114 Veterans also assessed their overall general well-being in a single item. The most frequent
Veterans’ Pain Experience
state of general well-being was “slightly happy,” scored by 34% of respondents. Twenty-seven percent of the Veterans were slightly sad to very sad. Relationships were explored between well-being and extent of pain experienced. Statistically significant mild-to-moderate inverse correlations (Spearman’s, p ⱕ .05) were found with general well-being and 30-day average pain (r ⫽ ⫺0.39), worst pain in 30 days (r ⫽ ⫺0.41), and the amount of pain experienced “right now” (r ⫽ ⫺0.49). Perceptions about pain treatment. Veterans commented about various aspects of their pain-treatment experiences. Included were responsiveness of providers, satisfaction with treatment, attitudes toward treatment, self-management capabilities, and kinds of treatments used. Seventy-six percent of the 87 Veterans with pain received pain treatment at a VA facility. Of these, 44 (51%) recalled that their doctor or nurse expressed that pain treatment was important and encouraged them to report it. Eighty-three percent indicated they had reported their pain to a doctor, 77% to a physician assistant, 51% to a nurse, 3% to a pharmacist, and 6% to someone other than these providers. Twenty-four percent had received pain treatment services at non-VA facilities. Of these, 56% recalled they had been told the importance of pain treatment and reporting it. At non-VA facilities, 53% reported their pain to a doctor, 16% to a physician assistant, 10% to a nurse, 5% to a pharmacist, and 25% did not report it to anyone. Relief experienced. The 77 Veterans who had received pain treatment within the previous month commented on the degree of relief they felt as a result of treatment efforts. Complete relief was felt by 8%, and great relief was felt by 10%. The majority, 49%, had some relief. However, 16% had little relief and 17% indicated they had no relief. So for 33% of the Veterans treated, pain relief was not successful. This rate is fairly consistent with reported rates, such as American Pain Foundation (2005) findings that 4 of every 10 people with moderate-to-severe pain had yet to experience relief. Attitude. Barriers to pain relief were also of interest. A subscale imbedded in the pain survey instrument, called the “Attitude Toward Pain Management,” focused on one’s perception toward pain management. The potential range of scores for this subscale was 0 to 35. A low score suggested a positive attitude toward managing pain, whereas a high score was indicative of a negative attitude. For example, item 34, “Pain medication cannot really control your pain,” could be scored 0 (totally not agree) to 5 (agree strongly). Internal consistency obtained with the Veteran sample was calculated at ␣ ⫽ 0.71. The actual mean score was
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14.3 (SD ⫾ 7.49), on the positive side of the scale midpoint, with 50% of respondents’ scores ranging from 9 to 18. The mean score indicates that the Veteran respondents had a moderately positive attitude toward pain management. However, examination of individual items on the “Attitude Toward Pain Management” scale identified some specific negative beliefs about pain-management behaviors. For example, more than 33% expressed concern over the addictive capability of pain medication. More than 20% held one or more of these negative attitudes: disbelief that pain medication can control pain, feeling that “talking about pain is bad,” “may distract the physician,” “pain is better than side effects of medication,” “pain medication should be saved for later,” and “having pain means one’s illness is worse.” Preparation for self management. Eighty-seven percent of the 87 Veterans with pain thought they were prepared to manage their pain at home. Less than 8% thought instructions for taking pain medication were not given or were not clear. However, 24% did not know what to do if the pain medication did not relieve their pain or if they experienced side effects. Twenty-six percent did not know whom to call if they had questions . On the other hand, 10% had contacted their doctor or nurse about changes in pain medication in the previous 30 days. Satisfaction with care. Overall, 81% were satisfied with their VA pain treatment. Specifically, 78% were satisfied with their VA physician’s response to their report of pain and 81% were satisfied with their nurse’s response. When receiving treatment in non-VA settings, 76% of the Veterans reported satisfaction with their physician’s response to reports of pain and 57% were satisfied with their nurse’s response. Factors such as time to call back by provider and responsiveness of provider to changing medication when prescribed an ineffective one were implicated with satisfaction. A regression analysis was performed to explore the primary factors that influenced the Veteran’s level of satisfaction with pain-management services received at a VA facility. The level of satisfaction score was the dependent variable and pain characteristics (number of sites with pain, average severity of pain), Veteran characteristics (overall health status, extent pain interferes with life), and Veteran’s general attitude toward pain management were the dependent variables. The regression explained 32% of the variance (R2 ⫽ 0.32). When all variables were entered, only the “Interferes with Life” score was significant (p ⱕ .05) and the standardized beta was ⫺0.62. When the regression was re-run with only the “Interferes with Life” score as the dependent variable, 28% of the
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variance was explained (R2 ⫽ 0.28), and the standardized beta for “Interferes with Life was” ⫺0.54. To further understand which factors affect the Veteran’s satisfaction with pain management, all of the items in the “Interferes with Life” subscale were entered as dependent variables in a stepwise regression analysis. Two items were significant (p ⱕ .05), and 33% of the variance was explained (R2 ⫽ 0.33). The standardized beta for pain’s interference with the Veteran’s “enjoyment with life” was ⫺0.32, and the standardized beta for pain’s interference with “relationships with others” was ⫺0.31. Pain treatments used. Pain medication was the predominant approach used for pain management, with 68% of the Veterans reporting this method. More than half of the respondents indicated taking pain medication daily. The use of medication was considered to be ineffective by 48% of the Veterans. Forty-four percent had contacted their health care provider to ask for something different; 39% of these received a response within the hour, 64% received a response within 8 hours, and 34% received a response after more than 2 days. Forty-seven percent of the Veterans with unrelieved pain would have liked something stronger for their pain, but 28% did not want something stronger and expressed fear of addiction.
DISCUSSION AND CONCLUSION The WNY VA Pain Survey provided an effective method to obtain information regarding the pain being experienced by a sample of Veterans registered in primary care in WNY. Random selection of the sample and high response rate allow generalizability to the WNY VA’s primary care population, yet small sample size imposes caution. The results of this survey indicated that pain was a widespread phenomenon among Veterans in WNY. Pain, as reflected in the survey, was typically moderate in intensity, multisite in location, and “years” in duration. Further, the association of pain with other aspects of the life of the Veteran supported the notion that pain was in fact complex. The statistically significant direct correlation between extent of pain experienced and interference with life and indirect relationship between pain experienced and quality of life have clinical significance. As pain increased, quality of life decreased and interference with life’s activities increased. Both of these indicators suggested that the experience of pain was pervasive beyond the pure physical symptom. Pain seemed to be a serious problem in the Veteran sample represented. Pain treatment, predominantly use of medication, was not always effective. It could be improved by building in a feedback loop to ensure that providers
routinely assessed the effectiveness of prescriptions given in a timely fashion. The definition of whose role and responsibility it is among providers to assess pain relief could be helpful. The overall attitude toward pain-management therapies was positive, yet some respondents had misconceptions about the use of pain medication that could be a barrier to its effectiveness. Education to minimize misconceptions could be offered. The nature of pain experienced by these Veterans also has implications for guiding the kinds of services needed. Veterans reported pain of long duration, in many sites, limiting their life activities. The complexity of the pain requires a multidimensional approach to provide effective treatment. There is a need to differentiate among an episode of acute pain, an episode of chronic pain, and a continuous pain condition, which requires pain-treatment expertise. Access to a pain specialist or perhaps a pain-treatment team seems indicated. Pain specialists could enhance the skills of primary care providers, offer guidance regarding most effective and current strategies to treat pain, and provide direct services to those with difficult pain. Reliance on pharmacologic management of pain alone may not be sufficient. Recent interest and study of complementary therapies has some relevance to pain management and is a fertile area for future research. Matteliano (2003) has discussed the evolution of complementary therapies in relation to nursing care for pain management. Because more than the physical aspects of one’s life are influenced by pain, the spectrum of interventions and health care specialties beyond pharmacology needs further exploration with a population of Veterans. Social needs and resources could be explored and considered. A more holistic approach to pain management may address the complexity of the Veteran’s experience more effectively. A multidisciplinary team of providers may experience more positive outcomes. Pain treatment has specific implications for nurses. “The assessment and management of pain is an important domain of nursing practice” (White, 1999). Nursing skills for pain assessment, effectiveness evaluation, and documentation require attention, as observed by O’Connor (2003). The results of this survey have implications for the role of the generalist nurse in pain-management services given to Veterans, including the following: identification of persons experiencing pain, particularly in a primary care setting when pain is not a presenting symptom; education of Veterans about the appropriate uses, action, and benefit of pain medication; assessment and follow-up regarding effectiveness of pain treatments prescribed; availability as contact
Veterans’ Pain Experience
person when questions or concerns arise; liaison with physician or nurse practitioner; recognition of the pervasive nature of pain, providing support; referral when pain is interfering with life; and leadership in continuous quality management to improve services to Veterans for pain management. The role of the advanced practice nurse whose expertise in pain management is more clearly defined. In addition to providing direct services for pain management to patients, consultation with other nurses, families, and other providers is inherent. Education of patient populations as a whole regarding pain and its appropriate treatment is important. The conduct of research regarding the role and effectiveness of complementary and alternative therapies for holistic pain management also falls within the nurse specialist’s role. Pain management continues to be a current challenging issue that is central to the caring mis-
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sion of nursing. This survey supports its relevance, specifically when the population of interest is the Veteran. Future studies are indicated that compare and contrast treatment effectiveness in terms of patient outcomes and cost-effectiveness/resource use among the following options, compared with current usual care: (1) implementing a regional pain center, (2) hiring a pain specialist and specially educated pain-treatment team, (3) using a specially educated interdisciplinary treatment team of existing staff, (4) initiating routine patient education regarding pain treatment in primary care settings, and (5) tracking current patient and provider actions using quality management approaches. “Customized evidence-based treatment regimens should be implemented that fit the circumstances, increase patient participation in the treatment plan, and use pain management quality measures effectively” (Gordon, et al., 2005, p. 1575).
REFERENCES Acello, B. (2000). Meeting JCAHO standard for pain control. Nursing 2000, 20(3), 52-53. American Pain Foundation. (2005). Pain facts: An overview of American pain surveys. Chronic Pain in America: Roadblocks to Relief (1999 survey). Retrieved January 23, 2006, from http://www.painfoundation.org. American Pain Society. (1999). Press Release: New survey of people with chronic pain reveals out-of-control symptoms impaired daily lives. American Pain Society. (1998). Chronic pain in America. Roadblock to relief. Archives in Internal Medicine, 158, 62-53. American Pain Society. (1995). Guidelines for treatment of pain. Journal of the American Medical Association, 274(23), 1874-1880. Arnstein, P., Cadill, M., Mandle, C., Norris, A., Beasley, R. (1999). Self-efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain, 80, 483-491. Bond, M., Breivik, H. (2004). Why pain control matters in a world full of killer diseases. Pain Clinical Updates: International Association for the Study of Pain, 12(4), 1-4. Brennan, F., Cousins, M. (2004). Pain relief as a human right. Pain Clinical Updates: International Association for the Study of Pains, 12(5), 1-4. Cleeland, C. (1994). Brief pain inventory, short form. Pain Research Group, University of Wisconsin at Madison, In McCaffery, M., Passer O. Pain: clinical manual (p. 61). St. Louis: CV Mosby, Inc. Department of Veteran Affairs, Veterans Health Administration (2003). Pain Management. VHA Directive 2003-021. Washington, DC. Retrieved January 23, 2006, from http:// va.gov/vhapublications. Dillman, D. (1987). Mail and telephone surveys: the total design method. New York: John Wiley and Sons. Escalante, A. & Fischback, M. (1998). Musculoskeletal manifestation of pain and quality of life in Persian Gulf
War Veterans referred for rheumatology evaluation. Journal of Rheumatology, 25, 2059-2061. Foley, K. (1999). Summary of pain management— overview. Veterans Health System Journal, 4, 21-28. Gordon, D, Dahl, J., Miaskowski, C., McCarberg, B., Todd, K., Paice, J., et al. (2005). American Pain Society Recommendations for improving the quality of acute and cancer pain management. Archives of Internal Medicine, 165, 1574-1580. Gureje, O., Vonkorff, S., Simon, G. (1998). Persistent pain and well being: a WHO study in primary care. Journal of the American Medical Association, 280, 147-151. Harstall, C., Ospina, M. (2003). How prevalent is chronic pain? Pain Clinical Updates, 11(2), 1-4. International Association for the Study of Pain. Task Force on Taxonomy (1994). Classification of Chronic Pain. In H. Mersky & N. Bogduk (eds), Classification of Chronic Pain: Description of Chronic Pain Syndromes and Definition of Pain Terms (2nd edition) (pp 209-214). Seattle: IASP Press. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1999). Joint Commission focuses on pain management. (Press release, August 3, 1999). Oakbrook Terrace, IL. Kazis, L., Ren, X., Kee, A., Skinner, K., Rogers, W., Clark., J., et al. (1999). Health status in VA patients: results from the Veterans health study. The American Journal of Medical Quality, 14(1), 28-38. Kazis, L., Miller, D., Clark, J., Skinner, K., Lee, A., Rogers, W., et al. (1998). Health related quality of life inpatients served by the Department of Veteran Affairs. Archives of Internal Medicine, 158(6), 626-632. Leland, J. (1999). Chronic pain, primary care treatment of the older patient. Geriatrics, 54(1), 23-37. Loeb, J. (1999). Pain management in long tern care. American Journal of Nursing, 99(2), 48-52.
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Matteliano, D. (2003). Holistic nursing management of pain and suffering: a historical view with contemporary application. Journal of the New York State Nurses Association, 34(1), 4-8. Matteson, J. (2002). The language of pain. Reflections on Nursing Leadership (4th qtr.), 10-14. McCaffery, M., Pasero, C. (1999). Pain: Clinical Manual, New York: Mosby. Melzak, R. (1986). The short form: McGill Pain Questionnaire: major properties and scoring methods. Pain, 30(1), 191-197. Montrey, J. (1999). Quality forum on pain management. Veterans Health System Journal, 4, 21-28.
Navas, M., Sommer, C. (1999). Providing effective pain control. Federal Practitioner, 37-40, 43, 44. O’Connor, M. (2003). JHQ 124-pain management: improving documentation of assessment and intensity. Journal for Healthcare Quality, 15(1), 1-10. Serlin, R., Mendoa, T., Nakamura, Y., Edwards, K., Cleeland, C. (1995). When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain, 3(61), 277-284. Strevy, S. 1998. Myths and facts about pain. RN, 2, 42-45. White, C. (1999). Changing pain management practices and supporting patient outcomes. Clinical Nurse Specialist, 13(4), 166-172.
From the *Niagara University Department of Nursing, Niagara University, New York; †Veterans Health Administration, Buffalo, New York; and ‡Clemson University, Clemson, South Carolina. Address correspondence and reprint requests to Frances E. Crosby, EdD, RN, Niagara University Department of Nursing, Dunleavy Hall, PO Box 2026, Niagara University, NY 14109. E-mail: [email protected] This research was supported by the Veterans Administration Western New York Healthcare System, Health Services Research and Development Special Project. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. 1524-9042/$32.00 © 2006 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2005.12.001
ABSTRACT: Recent emphasis on pain and its impact on the health and well-being of individuals evoked the interest of health care providers about services needed for effective and efficient pain management. This study was undertaken to examine the feasibility of using a mailed survey to determine the prevalence, nature, and extent of pain being experienced by Western New York Veterans. The specific aims were to (1) determine the feasibility of using a mailed survey to obtain information about pain in a population of Veterans; (2) estimate the extent of pain in the sample; and (3) describe the nature and impact of the pain experienced by the respondents. A comprehensive survey was prepared by modifying preexisting, widely used pain-assessment tools to describe a Veteran group’s pain experience. It was mailed to a randomly selected sample of 150 Veterans registered at a primary care clinic at the Western New York Veterans Administration Health System. A 76% response rate (n ⴝ 114) was obtained. Respondents declared a wide variety of health problems, and 71% reported having pain. The average number of body parts affected was 4.4 of a possible 11. The average intensity of pain was moderate; 35% reported constant pain, and 85% reported the pain to be occurring for years. Seventy-nine respondents described their pain to be interfering with their life and well-being. Medication was the primary treatment approach and was reported as ineffective by 48%. Veterans’ satisfaction with specific aspects of pain treatment was mixed. © 2006 by the American Society for Pain Management Nursing
Pain has received increasing attention in health care, especially in relationship to patient well-being and quality of life. In 1997, the World Health Organization published as its sixth priority, “the alleviation of pain, the reduction of suffering and the provision of palliative care for those who cannot be cured” (Montrey, 1999). Concurrently, the Veterans Administration (VA) advocated pain as the fifth vital sign, encouraging its assessment for all clients. The VA recognized the need to address pain within its services to promote the health and well-being of its clients. In 1998, a national VA task force charged with examining the role of pain in the care of the Veteran patient concluded that pain and its management were significant issues and that more information about Veterans’ pain was needed (Department of Veteran Affairs, Veterans Pain Management Nursing, Vol 7, No 1 (March), 2006: pp 12-22
Veterans’ Pain Experience
Health Administration, 2003). They noted that Veterans had some unique issues that influence pain, such as increased homelessness, posttraumatic stress disorder, war injuries, and substance abuse (VA Strategic Healthcare Group Report, 1998). At the local level, the question of what kind of services to offer emerged. It became apparent that the resources needed for managing pain in a given population could best be determined by assessing the nature of pain in that respective population. An effective method to ascertain the quality and scope of pain was needed. Acello (2000) noted that pain-assessment tools are important and need to be appropriate to age, condition, and culture, recognizing that patients’ beliefs regarding pain modify their behavior and response. Although individual assessment was recognized as key to treating a person’s pain, group assessment was sought to guide program planning.
STATEMENT OF THE PROBLEM Before extensive planning and implementation of costly services for pain treatment were undertaken by the Veterans Administration Western New York Healthcare System (VA WNY HS), a more specific description of the extent and kind(s) of pain that groups of Veterans were experiencing was needed so that services could be planned responsively. Some questions that arose were as follows: What percentage of a given group of Veterans served by the medical center was experiencing pain? Was the pain predominantly acute, chronic, or mixed? Was chronic pain simple or complex, and what portion might be considered chronic pain syndrome? The purpose of this study was to provide greater understanding of Veterans’ pain as a group to guide the planning and implementation of pain-management services that would be tailored to the population’s needs.
BACKGROUND The International Association for the Study of Pain (1994) defined pain as the unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. It reduces quality of life and impairs functional status (Serlin, 1995). Pain crosses all ages, socioeconomic strata, and diagnostic categories; it is a concern in all health care settings. It is not a single dimension phenomenon. Pain can be a direct symptom of acute sources, such as a surgical procedure or a chronic condition such as cancer and arthritis. Pain can also result from a combination of conditions with a complex origin (Navas, et al., 1999). Pain can be a perva-
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sive experience that interferes with daily life, referred to as chronic pain syndrome or “nonmalignant” pain (McCaffey & Pasero, 1999). Matteson (2002) asserted that, of the hundreds of words used to describe painful experiences, consensus emerged on three best descriptors: pain (high intensity), ache (less intensity), and hurt (low intensity). Relief from pain is advocated as a human right (Brennan & Cousins, 2004). Yet, pain management is a major health care challenge that impacts patients’ health status, treatment decisions, service use, resource allocation, and costs of health care. In developed countries chronic pain afflicts approximately 20% of the adult population (Bond, 2004), and severe chronic pain prevalence was found to be approximately 11.8% (Harstall & Ospina, 2003). Acute pain in the United States is estimated to affect 23 to 25 million people annually (Foley, 1999). Pain is attributed to various sources such as backache (16 million people), trauma (4 million), burns (2 million), and herpes zoster (400,000 people) (Foley, 1999). Approximately 9% of the U.S. population is reported to have moderate to severe non– cancer-related chronic pain, often longer than 5 years in duration, and its prevalence increases with age (American Pain Society, 1998). It is predicted that 80% to 85% of persons aged more than 65 years will experience a serious health problem predisposing them to pain (Leland, 1999). Loeb (1999) reported that up to 80% of residents of long-term care facilities have significant pain. Pain is thought to be underreported, underdetected, and undertreated (Loeb, 1999; Montrey, 1999; Strevy, 1998). Untreated pain is a costly burden to society. It is estimated that the cost of disability associated with pain nationally is approximately $80 billion (VA Strategic Healthcare Group Report, 1998). Pain is a concern of the VA Healthcare System. Kazis et al. (1999; 1998) reported that Veterans’ pain, as measured on a quality of life instrument, was impaired and significantly worse than the pain of the general public. Approximately 700,000 Veterans reported chronic pain and approximately 500,000 Veterans experienced acute pain annually (VA Strategic Healthcare Group Report, 1998). A higher incidence of pain in Veterans was anticipated compared with the general public because of the greater exposure to trauma and psychologic stress (Arnstein et al., 1999), both of which increase pain and confound therapy. Escalante and Fishback (1998) reported that joint pain was widespread in Gulf War Veterans, and that their health-related quality of life was poor. At the VA WNY HS, a quality improvement chart review of 1334 Veterans who visited a primary care clinic at a specific time point revealed that approxi-
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mately 56.6% were experiencing pain. In fact, pain was the predominant concern identified, compared with weight, sleep, sexual functioning, finances, exercise, and general health. In addition, a snapshot record review of 132 acute care inpatients determined that 53% were experiencing pain. In contrast, others have reported that 22% of primary care patients reported persistent pain (Gureje et al., 1998). Pain and its management are of relevance to nursing practice. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) set standards for pain management as accreditation criteria (Acello, 2000). Nurses play a key role in meeting these standards and are often the caregivers responsible for assessing and documenting a patient’s pain (O’Connor, 2003). The JCAHO criteria include the following (JCAHO, 1999): ● ● ● ● ● ●
Patients have the right to appropriate pain assessment, treatment, or referral; Patients’ pain should be regularly assessed and reassessed; Patients should be taught the importance of effective pain management as part of care; Patients should be involved in decisions; Routine and prn analgesics should be administered as needed; Discharge planning should include pain management plans.
Because treatment strategies can be guided by better understanding of the nature of pain (American Pain Society, 1998), and more effective services with better use of resources could result from describing Western New York (WNY) Veterans’ pain, this study was undertaken.
RESEARCH QUESTIONS Five specific research questions were explored in this study to examine Veterans’ pain: What percentage of Veterans in WNY are experiencing pain? What are the characteristics of their pain? How does pain impact on Veterans’ quality of life? What kinds of treatment did WNY Veterans seek/receive for pain? How do Veterans perceive the effectiveness of pain treatment they received?
STUDY METHODS Procedure A written survey questionnaire was prepared to comprehensively assess the scope and nature of pain being experienced by Veterans in WNY, along with the kinds and satisfaction with pain treatment received by
the target group. After institutional review board approval was obtained, a random sample was selected and survey questionnaires were mailed using the Dillman’s Total Design Method (Dillman, 1979). Each Veteran sampled was sent the questionnaire with a cover letter and return envelope, and a follow-up reminder/thank you postcard 1 week later. Questionnaires were coded for confidentiality of response. Sample The study population was the 10,057 Veterans who were registered at the two primary care clinics at the VA WNY HS. A sample of 150 Veterans were randomly selected using a table of random numbers. Sample size of 150 was recommended by an expert epidemiologist as an adequate number for descriptive purposes. This target sample represented Veterans in WNY who were receiving ambulatory health services ranging from wellness and health promotion to treatment of acute episodes and chronic disease management for specific conditions or complex concerns. Although random sampling allowed for the span of ages and diagnoses representative of this VA primary care population, gender distribution was limited because of the predominance of males in the system. Instrument Development A data-collection tool was developed, called “The Veterans’ Pain Survey.” Three commonly used public domain pain measurement tools were reviewed. These were (1) the short form of the McGill Pain Questionnaire (Melzack, 1986), (2) the Brief Pain Inventory: Short Form (Cleeland, 1994), and (3) the American Pain Society Questionnaire (American Pain Society, 1995). The American Pain Society Questionnaire contained items needed to determine the effect of generalized pain on short-term quality of life issues (within past 24 hours) and satisfaction with prescribed painmanagement therapy. It also included items to assess personal and institutional barriers to seeking adequate pain relief. The Brief Pain Inventory: Short Form provided items to describe the location and nature of pain and to assess the level of pain relief. The McGill Pain Questionnaire listed precise pain characteristics to describe the quality of pain. The final instrument, The Veterans’ Pain Survey, included the pain descriptors used by McGill, 13 items (some modified) from the American Pain Society, six items from the Brief Pain Inventory, and some researcher-developed items. Researcher-developed items included a comprehensive listing of parts of the body from head to toe for the respondent to indicate the location of pain and its respective severity, frequency, and duration. Also included were a general well-being item, items specific
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Veterans’ Pain Experience
TABLE 1. Instrument items, Source (ⴱModified), Response set: Veterans Pain Survey Item(s) 1 2–5
6–16 17 18 19–25
26 27–33
34–40
41–49 50–55
Source of Item(s)
Content of Item(s)
Response Set
American Pain Society* Cleeland’s Brief Pain Inventory; American Pain Society Researcher developed Researcher developed McGill*
Pain in past 2 months
Yes/no
Extent of pain
Likert 0 ⫽ none to 10 ⫽ worst
Comments Yes¡go on No¡go to end Now; at worst; usual; at least
Body parts listedPain- yes/no How severe? Head to toe describe pain How frequent? How long? Extent of pain relief/ interventions 10 pain descriptors ✓all that apply Symptoms physical, visceral, or listed neurogenic Cleeland’s Brief Pain Interference with life Likert 0 ⫽ none to 10 ⫽ Subscale- internal consistencyInventory; activities completely alpha ⫽ 0.92; items to total ⫽ American Pain Subscale 0.66 to 1.89 Society Researcher General well-being Likert 1 ⫽ very sad to 6 ⫽ Global item developed very happy American Pain Aspects of treatment: Satisfy: 1 ⫽ very dissatisfied, Treatment Society* satisfaction, to 6 ⫽ very satisfied; Provider response occurrence, occurred ⫽ yes/no timely: Medication timeliness 1 ⱕa minute to 6 ⱖ24 h Medical management American Pain Respondent’s attitude Likert 0 ⫽ not agree to 5 ⫽ Subscale Society* regarding pain agree very much Internal consistency- alpha ⫽ management 0.71 subscale American Pain Pain-management Likert 1 ⫽ none given, to 6 Clarity of patient education Society* instructions ⫽ absolutely clear Researcher Kinds of treatment, Satisfaction Outside VA developed traditional, Within VA complementary
VA, Veterans Administration.
to VA WNY HS pain-related treatment, and a checklist of other non-VA pain treatment sought. Demographic and health information were included. Face validity was obtained by sending the draft instrument to 10 Veterans, with 100% response and feedback that was incorporated into a revised edition. In addition, two experts in instrument design reviewed the revised draft, and their recommendations were used to refine the instrument further. Next, two experts in pain treatment critiqued the instrument for content validity, and their recommendations guided instrument revision. The final version of the Veteran Pain Survey was presented in booklet form and consisted of 15 pages with 62 items, most having closed response options. The content, source, and response set of items are summarized in Table 1. Data Analysis Data were entered into SPSS version 10.0 (SPSS Inc., Chicago, IL) for analysis. Frequency and percentages
were calculated for nominal and ordinal data. Mean and standard deviations (SD) were calculated for interval and ratio data. Items that measured a single theoretic construct (subscale), such as interference of pain on life’s activities (items 19 –25) and attitude toward pain management (items 34-40), were summed to obtain subscale scores, which were presented as mean and SD. Co-relational and linear regression analyses were performed to assess relationships among certain variables.
RESULTS Demographics Questionnaires were returned from 114 people, for a 76% response rate. The average age of the respondents was 65 years old, with a range of 24 to 90 years. Almost all of the respondents were male (98%). Many of the Veterans were retired (47%); some were disabled (19%), employed (13%), or unemployed (4%).
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TABLE 2. Severity of Pain in Past Month (n ⴝ 87) Pain Intensity Pain History
Mean (SD)
% Mild (1–3)
Moderate (4–7)
% Severe (8–10)
Right now Worst, past month Average, past month Least, past month
4.4 (2.86) 6.7 (2.78) 5.0 (2.26) 3.1 (2.47)
35% 16% 30% 62%
51% 33% 58% 33%
14% 62% 12% 5%
SD, Standard deviation.
Most of the Veterans were married (48%), and fewer were widowed (18%), single (18%), or divorced (16%). One respondent was a World War I Veteran, 47 (41%) were World War II Veterans; 24 (21%) were Korean War Veterans, 21 (20%) were Viet Nam Veterans; and 3 (3%) were Gulf War Veterans. The general health status of this sample was assessed by requesting the respondents to complete a 20-item checklist to identify their current and chronic health problems. A wide range of medical conditions was indicated. The mean number of health problems checked was 3.6 (SD ⫾ 2.67) per person, with a range of 0 (9 Veterans) to 12. Seventeen respondents (15%) had seven or more health problems. The most frequently reported conditions were arthritis (51.8%), circulation problems (34.2%), heart disease (33.3%), back problems (33.3%), diabetes (26.3%), dental problems (26.3%), depression (23.7%), lung problems (20.1%), stomach (19.3%), anxiety (11.4%), posttraumatic stress disorder (10.5%), migraine (6.1%), and kidney disease (5.3%). So although this was a primary care sample, health status was somewhat compromised. Survey Findings Rate of Western New York Veterans experiencing pain. Among the 114 responding Veterans, 81 (71%) reported experiencing pain within the last 2 months, 27 (24%) reported they had not experienced pain, and 6 (5%) did not answer this question, but did complete the pain survey, suggesting the presence of pain. This rate was higher than the 56.6% of Veterans who reported pain in the quality improvement survey conducted earlier at the VA WNY HS. Characteristics of the pain. On a scale of 0 (no pain) to 10 (worst possible pain), the mean score for the pain intensity experienced on the day of completing the survey was moderate at 4.4 (SD ⫾ 2.86). Of the 81 Veterans reporting pain on the survey day, 12 (14.8%) were experiencing severe pain (rating 8 –10),
and an additional 23 (26%) were experiencing moderately severe pain (rating 6 –7). Twenty-one (25.9%) indicated moderate pain (ratings 4 and 5), and 15 (18.5%) recorded mild pain (ratings 1 and 2). Average pain, worst pain, and least pain in the past month were also elicited in the survey using the 0 (no pain) to 10 (worst possible pain) rating, to provide a more descriptive appreciation of one’s usual pain experience. Eighty-seven respondents described their usual, worst, and least pain in the past month. The range in all categories was from mild to severe, but the proportions differed. Mean scores for “right now,” “worst pain,” and “average pain” were all in the moderate pain range; “least pain” mean score was in the mild range. The responses are summarized in Table 2, associated with age groups in Table 3 and demographic characteristics in Table 4. Pain was further described in terms of its location(s) and respective frequency, duration, and sitespecific intensity. Of the 87 Veterans who described their pain, sites most commonly mentioned were the back (64%) and lower legs (60%). Shoulders (51%), upper legs (45%), and feet (40%) were also frequently mentioned. The average number of body parts in which pain was experienced was 4.4 of the 11 possible sites, and 40% of the respondents experienced pain in five or more sites. For each of the 11 locations of the body, the severity of pain was indicated as mild (1), moderate (2), or severe (3). The median pain intensity recorded for all 11 body locations was moderate. For 9 of the 11 locations, the most frequent response was moderate. The head and abdomen had “mild” scored as the most frequent intensity of pain. Forty (46%) of the 87 respondents had severe pain for at least one site, and 28 reported severe pain at two or more sites. The frequency of the pain was indicated by the 87 Veterans with pain on a four-point scale with the descriptors “rarely,” “sometimes,” “often,” or “always.” Eight of the 11 locations had the median value
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TABLE 3. Pain Intensity by Age Pain Intensity Age Group
Average, Last Month
⬍49 (n ⫽ 14)
Median 6 Mean (SDs) Median 6 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs) Median 5 Mean (SDs)
50–59 (n ⫽ 18) 60–69 (n ⫽ 13) 70–79 (n ⫽ 28) ⬎79 (n ⫽ 9) Total
Least, Last Month
Worst, Past Month
4 3.4 (⫾2.6) 4 3.6 (⫾2.5) 3 2.6 (⫾2.8) 3 3.3 (⫾2.5) 2 2.9 (⫾1.6) 3 3.2 (⫾2.5)
9 7.9 (⫾2.6) 8 7.7 (⫾1.5) 7 6.4 (⫾2.6) 7 6.8 (⫾2.6) 7 5.8 (⫾3.2) 8 7.0 (⫾2.5)
5.2 (⫾2.5) 5.6 (⫾2.0) 4.9 (⫾2.5) 5.2 (⫾2.0) 4.6 (⫾2.0) 5.1 (⫾2.2)
SD, Standard deviation.
TABLE 4. Pain Characteristics Associated with Demographics Demographics
Pain within last 2 months Reported pain:
Age
Mean Standard deviation
Gender
Male Female
Marital status
Single Married Divorced Widowed Divorced and widowed
Employment status
Employed Unemployed Retired Disabled Retired and disabled Employed, retired, and disabled
War experience
World War 1 World War 2 Korea Vietnam Gulf No war
Not reported
Not reported
Not reported
Not reported
No (n ⴝ 27)
Yes (n ⴝ 87)
72.6 65.4 12.9 16.7 Column % for each demographic category 88.9% 90.8% 2.3% 11.1% 6.9% 15.4% 17.2% 57.7% 42.5% 7.7% 14.9% 11.5% 19.5% 1.1% 7.7% 4.6% 11.1% 14.9% 3.7% 3.4% 63.0% 43.7% 7.4% 21.8% 7.4% 9.2% 1.1% 7.4% 5.7% 3.7% 1.1% 37.0% 42.5% 37.0% 16.1% 11.1% 20.7% 3.4% 11.1% 13.8% 3.7% 5.7%
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of “often,” and three locations (chest, abdomen, buttocks) had the median value of “sometimes.” Some of the Veterans reported their pain as always present for all locations except the head. Thirty Veterans (35%) reported “always” having pain at least one site, and 20 of these had constant pain in two or more sites. Of the 30 Veterans with constant pain, 19 had severe and constant pain in at least one site and 17 had severe and constant pain in two or more sites. The last response on the site-specific pain information indicated duration of the pain. The duration of pain was classified on a five-point scale with the descriptors “days,” “weeks,” “1 to 5 months,” “6 to 11 months,” or “years.” Across 10 of the 11 sites, both the median duration and the most frequent duration were “years.” For chest pain, the median duration was “6 to 11 months,” but the most frequent response was “years.” Seventy-one (82%) of the 87 Veterans reported having pain for “years,” with 51 having pain for years at two or more sites. Of the 19 Veterans with severe and constant pain, 16 had severe and constant pain for years, and 9 of these had severe and constant pain for years at more than one site. These nine Veterans are 10% of the 87 reporting pain and 8% of the 114 in this study. These characteristics suggest that a substantial portion of the WNY Veterans are experiencing longterm, complex chronic pain, which has implications for the kinds of pain-management services that are needed for the population represented. By using Pearson’s correlational analyses, the data were examined to look for relationships among the pain sites. Mild-to-moderate correlations were found between many of the sites, such as the head with the neck, neck with the shoulder, neck with the back, and ankle with the foot. Some unexpected correlations were found to be statistically significant, such as shoulder and foot pain, head and abdominal pain, and buttock and ankle pain (Table 5). Although the relationships are not explained, they support the complexity or perhaps generalized experience of pain, indicating that, for some Veterans, pain-treatment needs may involve multiple body parts and be complex. The 87 respondents with pain further defined their pain from a listing of nine descriptors, choosing as many as applicable or “none of these.” Fifty-two (60%) described their pain as throbbing. Thirty-four (39%) indicated their pain was sharp, whereas 25 (29%) noted their pain as dull. Twenty-five (29%) reported cramping, 17 (20%) reported tingling, 13 (15%) reported burning, 13 (15%) reported shocking, and 13 (15%) reported shooting pain. Pain and quality of life. By using the past 30 days as their reference, Veterans rated the impact of pain on their life. The “Interference with life” subscale (from
TABLE 5. Correlations Among Pain Sites Body Part/Pain Head pain with
Neck pain with Shoulder pain with Abdominal pain with Back pain with Buttock pain with Lower leg pain with Upper leg pain with Ankle pain with Foot pain with
Correlation Neck pain Abdominal pain Back pain Head pain Shoulder pain Back pain Neck pain Foot pain Head pain Head pain Neck pain Lower leg pain Ankle pain Buttock pain Ankle pain Foot pain Buttock pain Lower leg pain Foot pain Shoulder pain Upper leg pain Ankle pain
Pearson’s r 0.32 0.34 0.35 0.32 0.42 0.40 0.42 0.36 0.35 0.35 0.40 0.33 0.34 0.33 0.33 0.33 0.39 0.33 0.39 0.36 0.36 0.39
the Brief Pain Inventory: Short Form and the American Pain Society Questionnaire) was used for this measure. The response option was 0 (does not interfere) to 10 (completely interferes) for each of seven items, for a potential subscale range of 0 to 70. First, the reliability of this subscale with the Veteran sample was tested, with an internal consistency of ␣ ⫽ 0.92. The actual mean score was 34.8 (SD ⫾ 19.6), which was midway for this 70-point scale and indicated that the pain, overall, moderately interfered with the Veterans’ lives. Pain had a mild interference on one’s relationships with others (median ⫽ 3), but 68% reported at least some interference with this area. Pain had the strongest impact on walking (median value ⫽ 6.5 on 0 –10 scale), with 88% indicating at least some interference and 44% reporting great interference. Correlations were performed on “Interference with Life” subscale scores and degree of pain experienced. Statistically significant correlations (Pearson’s, p ⱕ .05) suggested a moderately strong relationship between the degree of pain and the extent that pain interfered with one’s life. The “interference” score correlated with 30-day average level of pain (r ⫽ 0.63), the worst pain experienced in 30 days (r ⫽ 0.70), and the pain experienced right now (r ⫽ 0.67). The 114 Veterans also assessed their overall general well-being in a single item. The most frequent
Veterans’ Pain Experience
state of general well-being was “slightly happy,” scored by 34% of respondents. Twenty-seven percent of the Veterans were slightly sad to very sad. Relationships were explored between well-being and extent of pain experienced. Statistically significant mild-to-moderate inverse correlations (Spearman’s, p ⱕ .05) were found with general well-being and 30-day average pain (r ⫽ ⫺0.39), worst pain in 30 days (r ⫽ ⫺0.41), and the amount of pain experienced “right now” (r ⫽ ⫺0.49). Perceptions about pain treatment. Veterans commented about various aspects of their pain-treatment experiences. Included were responsiveness of providers, satisfaction with treatment, attitudes toward treatment, self-management capabilities, and kinds of treatments used. Seventy-six percent of the 87 Veterans with pain received pain treatment at a VA facility. Of these, 44 (51%) recalled that their doctor or nurse expressed that pain treatment was important and encouraged them to report it. Eighty-three percent indicated they had reported their pain to a doctor, 77% to a physician assistant, 51% to a nurse, 3% to a pharmacist, and 6% to someone other than these providers. Twenty-four percent had received pain treatment services at non-VA facilities. Of these, 56% recalled they had been told the importance of pain treatment and reporting it. At non-VA facilities, 53% reported their pain to a doctor, 16% to a physician assistant, 10% to a nurse, 5% to a pharmacist, and 25% did not report it to anyone. Relief experienced. The 77 Veterans who had received pain treatment within the previous month commented on the degree of relief they felt as a result of treatment efforts. Complete relief was felt by 8%, and great relief was felt by 10%. The majority, 49%, had some relief. However, 16% had little relief and 17% indicated they had no relief. So for 33% of the Veterans treated, pain relief was not successful. This rate is fairly consistent with reported rates, such as American Pain Foundation (2005) findings that 4 of every 10 people with moderate-to-severe pain had yet to experience relief. Attitude. Barriers to pain relief were also of interest. A subscale imbedded in the pain survey instrument, called the “Attitude Toward Pain Management,” focused on one’s perception toward pain management. The potential range of scores for this subscale was 0 to 35. A low score suggested a positive attitude toward managing pain, whereas a high score was indicative of a negative attitude. For example, item 34, “Pain medication cannot really control your pain,” could be scored 0 (totally not agree) to 5 (agree strongly). Internal consistency obtained with the Veteran sample was calculated at ␣ ⫽ 0.71. The actual mean score was
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14.3 (SD ⫾ 7.49), on the positive side of the scale midpoint, with 50% of respondents’ scores ranging from 9 to 18. The mean score indicates that the Veteran respondents had a moderately positive attitude toward pain management. However, examination of individual items on the “Attitude Toward Pain Management” scale identified some specific negative beliefs about pain-management behaviors. For example, more than 33% expressed concern over the addictive capability of pain medication. More than 20% held one or more of these negative attitudes: disbelief that pain medication can control pain, feeling that “talking about pain is bad,” “may distract the physician,” “pain is better than side effects of medication,” “pain medication should be saved for later,” and “having pain means one’s illness is worse.” Preparation for self management. Eighty-seven percent of the 87 Veterans with pain thought they were prepared to manage their pain at home. Less than 8% thought instructions for taking pain medication were not given or were not clear. However, 24% did not know what to do if the pain medication did not relieve their pain or if they experienced side effects. Twenty-six percent did not know whom to call if they had questions . On the other hand, 10% had contacted their doctor or nurse about changes in pain medication in the previous 30 days. Satisfaction with care. Overall, 81% were satisfied with their VA pain treatment. Specifically, 78% were satisfied with their VA physician’s response to their report of pain and 81% were satisfied with their nurse’s response. When receiving treatment in non-VA settings, 76% of the Veterans reported satisfaction with their physician’s response to reports of pain and 57% were satisfied with their nurse’s response. Factors such as time to call back by provider and responsiveness of provider to changing medication when prescribed an ineffective one were implicated with satisfaction. A regression analysis was performed to explore the primary factors that influenced the Veteran’s level of satisfaction with pain-management services received at a VA facility. The level of satisfaction score was the dependent variable and pain characteristics (number of sites with pain, average severity of pain), Veteran characteristics (overall health status, extent pain interferes with life), and Veteran’s general attitude toward pain management were the dependent variables. The regression explained 32% of the variance (R2 ⫽ 0.32). When all variables were entered, only the “Interferes with Life” score was significant (p ⱕ .05) and the standardized beta was ⫺0.62. When the regression was re-run with only the “Interferes with Life” score as the dependent variable, 28% of the
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variance was explained (R2 ⫽ 0.28), and the standardized beta for “Interferes with Life was” ⫺0.54. To further understand which factors affect the Veteran’s satisfaction with pain management, all of the items in the “Interferes with Life” subscale were entered as dependent variables in a stepwise regression analysis. Two items were significant (p ⱕ .05), and 33% of the variance was explained (R2 ⫽ 0.33). The standardized beta for pain’s interference with the Veteran’s “enjoyment with life” was ⫺0.32, and the standardized beta for pain’s interference with “relationships with others” was ⫺0.31. Pain treatments used. Pain medication was the predominant approach used for pain management, with 68% of the Veterans reporting this method. More than half of the respondents indicated taking pain medication daily. The use of medication was considered to be ineffective by 48% of the Veterans. Forty-four percent had contacted their health care provider to ask for something different; 39% of these received a response within the hour, 64% received a response within 8 hours, and 34% received a response after more than 2 days. Forty-seven percent of the Veterans with unrelieved pain would have liked something stronger for their pain, but 28% did not want something stronger and expressed fear of addiction.
DISCUSSION AND CONCLUSION The WNY VA Pain Survey provided an effective method to obtain information regarding the pain being experienced by a sample of Veterans registered in primary care in WNY. Random selection of the sample and high response rate allow generalizability to the WNY VA’s primary care population, yet small sample size imposes caution. The results of this survey indicated that pain was a widespread phenomenon among Veterans in WNY. Pain, as reflected in the survey, was typically moderate in intensity, multisite in location, and “years” in duration. Further, the association of pain with other aspects of the life of the Veteran supported the notion that pain was in fact complex. The statistically significant direct correlation between extent of pain experienced and interference with life and indirect relationship between pain experienced and quality of life have clinical significance. As pain increased, quality of life decreased and interference with life’s activities increased. Both of these indicators suggested that the experience of pain was pervasive beyond the pure physical symptom. Pain seemed to be a serious problem in the Veteran sample represented. Pain treatment, predominantly use of medication, was not always effective. It could be improved by building in a feedback loop to ensure that providers
routinely assessed the effectiveness of prescriptions given in a timely fashion. The definition of whose role and responsibility it is among providers to assess pain relief could be helpful. The overall attitude toward pain-management therapies was positive, yet some respondents had misconceptions about the use of pain medication that could be a barrier to its effectiveness. Education to minimize misconceptions could be offered. The nature of pain experienced by these Veterans also has implications for guiding the kinds of services needed. Veterans reported pain of long duration, in many sites, limiting their life activities. The complexity of the pain requires a multidimensional approach to provide effective treatment. There is a need to differentiate among an episode of acute pain, an episode of chronic pain, and a continuous pain condition, which requires pain-treatment expertise. Access to a pain specialist or perhaps a pain-treatment team seems indicated. Pain specialists could enhance the skills of primary care providers, offer guidance regarding most effective and current strategies to treat pain, and provide direct services to those with difficult pain. Reliance on pharmacologic management of pain alone may not be sufficient. Recent interest and study of complementary therapies has some relevance to pain management and is a fertile area for future research. Matteliano (2003) has discussed the evolution of complementary therapies in relation to nursing care for pain management. Because more than the physical aspects of one’s life are influenced by pain, the spectrum of interventions and health care specialties beyond pharmacology needs further exploration with a population of Veterans. Social needs and resources could be explored and considered. A more holistic approach to pain management may address the complexity of the Veteran’s experience more effectively. A multidisciplinary team of providers may experience more positive outcomes. Pain treatment has specific implications for nurses. “The assessment and management of pain is an important domain of nursing practice” (White, 1999). Nursing skills for pain assessment, effectiveness evaluation, and documentation require attention, as observed by O’Connor (2003). The results of this survey have implications for the role of the generalist nurse in pain-management services given to Veterans, including the following: identification of persons experiencing pain, particularly in a primary care setting when pain is not a presenting symptom; education of Veterans about the appropriate uses, action, and benefit of pain medication; assessment and follow-up regarding effectiveness of pain treatments prescribed; availability as contact
Veterans’ Pain Experience
person when questions or concerns arise; liaison with physician or nurse practitioner; recognition of the pervasive nature of pain, providing support; referral when pain is interfering with life; and leadership in continuous quality management to improve services to Veterans for pain management. The role of the advanced practice nurse whose expertise in pain management is more clearly defined. In addition to providing direct services for pain management to patients, consultation with other nurses, families, and other providers is inherent. Education of patient populations as a whole regarding pain and its appropriate treatment is important. The conduct of research regarding the role and effectiveness of complementary and alternative therapies for holistic pain management also falls within the nurse specialist’s role. Pain management continues to be a current challenging issue that is central to the caring mis-
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sion of nursing. This survey supports its relevance, specifically when the population of interest is the Veteran. Future studies are indicated that compare and contrast treatment effectiveness in terms of patient outcomes and cost-effectiveness/resource use among the following options, compared with current usual care: (1) implementing a regional pain center, (2) hiring a pain specialist and specially educated pain-treatment team, (3) using a specially educated interdisciplinary treatment team of existing staff, (4) initiating routine patient education regarding pain treatment in primary care settings, and (5) tracking current patient and provider actions using quality management approaches. “Customized evidence-based treatment regimens should be implemented that fit the circumstances, increase patient participation in the treatment plan, and use pain management quality measures effectively” (Gordon, et al., 2005, p. 1575).
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