15
Pain, 42 (1990) 15-22 Elsevier
PAIN 01630
Review A rticle
Clinical judgments in pain management Janice Lander 3-103 Clinical Sciences, University of Alberta, Edmonton, Alberta T6G 2G3 (Canada) (Received
2 June 1989, accepted
2 March
1990)
From research reports published over the last 20 years, it appears that moderate to severe uncontrolled pain may be the norm for hospitalized patients despite recent advances in the management of pain. Research on the extent of under-management of pain and the factors associated with it is examined and summarized in this paper. Methodological imperfections of the research are identified. Several explanations for pain under-management have been proposed and these are reported. A clinical decision making model is also reviewed and it is suggested that this model could be applied to pain management problems. Further, it is suggested that this model may be very useful in developing educational interventions to improve health practitioners’ clinical skills in pain management.
SummarY
Key words:
Pain management;
Pain under-management;
Clinical judgment
Introduction Although the study of pain mechanisms and management can be traced back through many centuries, it is during this century that many advances have occurred. Increased knowledge about and increased availability of resources for pain management could be expected to reduce incidents of uncontrolled pain. Instead, the evidence indicates that moderate to severe uncontrolled pain continues to be the norm for hospitalized patients. From scattered research reports over the last 20 years, it appears that the problem is not so much in finding new strategies for managing pain (although the search for these must continue), but in having health care professionals utilize available scientific knowledge in their daily practices. Research findings implicate physicians and nurses as
Correspondence to: Dr. J. Lander, Ph.D., 3-103 Clinical Sciences, University of Alberta, Edmonton, Alberta T6G 2G3, Canada.
0304-3959/90/%03.50
0 1990 Elsevier Science. Publishers
having primary responsibility for the existence of unnecessary pain in patients, pain which is all too common a side effect of hospitalization and illness.
Extent of uncontrolled pain Research on pain management practices and attitudes has been conducted in a variety of settings. Much of it has been completed in general hospitals and involves convenience samples obtained from settings where diverse problems are treated. Further, no report could be found in the literature of an exhaustive study about pain management practices and attitudes which exist across settings or types of pain or even within particular settings or types of pain. Despite these limitations, the findings of the research are remarkably similar. It has been said that about three-quarters of patients experience moderate to severe pain distress while in hospital [7,27,48].
B.V. (Biomedical
Division)
Pain is generally considered to be under-managed for acute, chronic and cancer pain in adults [1,7,27,48] and pain in children [28,37]. There is even evidence from community surveys that pain is a frequent complaint among non-hospitalized people [9,45].
Effects of uncontrolled pain There are many reasons for not permitting people to suffer from pain which could be controlled or reduced. Uncontrolled pain can adversely affect pulmonary, gastrointestinal and circulatory systems [5]. Pain also compromises psychological functioning. Short-term pain evokes the protective withdrawal mechanism but if the pain continues (although still considered to be acute in nature) it results in perceptions that the pain is ‘unbearable and uncontrollable’ and produces anxiety. When pain becomes chronic, it often results in becoming ‘depressed, fearful, irritable, somatically preoccupied and erratic in the search for relief’ [S]. Similar psychological consequences have been observed in patients with acute pain [27]. An added dimension to uncontrolled and repetitive instances of pain is that this type of pain has the capacity to provoke conditioned avoidance responses [ 191. This may be the origin of dysfunctional behavior in which individuals avoid dental and/or health care. When the feared stimulus cannot be avoided, the individual suffers both psychologically and physically. The full economic and social effects of uncontrolled pain are unknown. One study on the costeffectiveness of a pain management program indicated a savings of over U.S. $200,000.00 from hospital beds not being occupied by 47 patients [20]. There was a 74% reduction in number of days hospitalized 1 year after the patients finished the program. Clearly, these findings illustrate only a part of the costs of uncontrolled pain.
Factors influencing pain management While patient and practitioner and beliefs interact in a complex
traits, behaviors way to influence
decisions examined
about pain management, separately in this review.
they
will be
Role of the putient Very little research has been undertaken to explore the patient’s contribution to pain management. Indeed, many of the factors that have been studied deal indirectly with the patient for typically researchers have been interested in how patient factors influence practitioners’ judgments. It seems as if the patient is generally regarded as a passive recipient of care. However, patients likely take on active roles in pain management. Their beliefs about pain and pain management could influence not only their expression of pain but their desire for relief. For example, about one-third of the patients questioned in one survey believed that pain builds character [48]. Having this belief may influence pain behavior. While the practitioner is usually implicated in poor pain management, the patient may also share responsibility. Several isolated findings support this notion. For one, patients may not always report pain accurately. It is not known how frequently patients minimize their pain in order to avoid receiving drugs, either out of fears about injections or aversions to anticipated side effects of analgesics. In one study, nurses thought that about 17% of patients minimize their pain [24]. Indirect evidence for minimization of pain comes from studies which have found under-management of pain in about three-quarters of patients [7,48]. Notwithstanding the researchers’ conclusions, most patients in those studies reported that pain management was satisfactory. This may indicate a tendency to minimize pain or it may suggest other conclusions. One of these is that the questionnaire item used in the studies was poorly designed and could cause response bias. Other researchers would suggest that the socio-political environment of the hospital and the lack of power of the patient would make them likely to deny that care was unsatisfactory regardless of whether it was unsatisfactory [13]. As mentioned, some patients may avoid taking analgesics. It is not clear whether or not avoidance of analgesics can be attributed to fear of addiction. In one study, patients were found to be less
17
fearful of addition than practitioners usually are [7]. In fact, patients seemed less concerned about becoming addicted than they were about having access to needed analgesics. Roles ofphysicians and nurses Research about pain management practices and beliefs mainly pertains to physicians and nurses while excluding other health practitioners (such as dentists and physiotherapists). Furthermore, much of the available literature considers only nurses. This is particularly true for the influence of patient traits on the practitioner, where the literature almost entirely relates to nurses. (a) Patient influences on clinical judgment. A number of patient traits have been investigated for their influence on: (a) practitioners’ inferences regarding the amount of pain the patient is experiencing or (b) clinical decisions about pain management. It should be noted as well that convenience samples of practitioners from select regions have been utilized in these studies. Moreover, the study of patient traits has not been thorough and has not yielded an orderly and practical body of knowledge. Among the traits studied are the paralingual expressions of pain which can influence the practitioner’s perception of pain [44]. Different groups of individuals learn to express pain in ways which are particular to their cultural group [49]. Therefore, ethnic background of the patient may influence both inferences about and management of pain. The impact of ethnic background on pain management probably ensues from practitioner’s beliefs about ethnic differences in amount of pain experienced or from ethnic differences in the expression of pain. In this latter instance, the expression of pain would influence the practitioner’s inference about pain. In one American study, whites and residents with ancestral ties to the region in which the study was conducted received significantly more analgesia after surgery [42]. Further, nurses inferred greater pain for hypothetical Jewish and Spanish patients presented in case studies compared to Black, Mediterranean, Oriental and white patients [lo]. Several other patient traits have also been related to nurses’ inferences. These include patient
socioeconomic status and gender. Nurses inferred greater pain to hypothetical patients described as having a low socioeconomic status compared to moderate or high status [lo]. Nurses in the same study believed that females suffered more pain than males. An apparent contradiction to that view is the observation in another study that nurses believed that females should have smaller amounts of narcotics compared to males with the same problem [7]. Regardless, male and female patients indeed are given similar amounts of analgesia following surgery [l&25]. Although gender is not related to amounts of analgesia given, age of the patient is [14,39]. In general, younger children [39] and older adults are prescribed and/or administered fewer analgesics [14,18,37]. On the other hand, patient age was not found to influence beliefs about amount of pain suffered [10,12]. Time since surgery [18] has been negatively related to amount of analgesia given. Also duration of pain influences inferences about amount of pain. Patients with chronic pain have been viewed by nurses as having less pain than patients with acute pain [10,43]. With regard to diagnosis, nurses were found to hold the opinion that patients with cardiovascular disease and severe trauma experience more pain than patients with any other condition [lo]. When asked what criteria were used to decide on amount of analgesia to be given, nurses mentioned the size of the patient and the type of surgery most often [7]. (b) Knowledge and attitudes. Poor pain management is often thought to arise from basic flaws in knowledge and from negative attitudes. Considering that nurses and physicians have an interactive effect on pain management, knowledge and attitudes of both professionals are important for effective pain management. Lack of understanding about addiction liability of narcotics has commanded much of the attention of researchers. It has been said that physicians under-prescribe analgesia and nurses compound the problem by under-administering the drugs [28]. Both nurses and physicians have been reported to overestimate the probability of addiction to prolonged use of narcotics (nurses overestimate more than physicians) [48]. At least a
third of nurses thought that greater than 5% of hospital patients actually do become addicted [7] (although a liberal estimate is about l/100% [38]). Several investigators have asked physicians or nurses about perceived risk of addition when 100 mg meperidine is given to a hospitalized patient every 4 h for 10 days [7,27,47,48]. Most nurses and physicians think the probability is less than 0.15 that a patient would become addicted under those circumstances. One would think that a perceived risk of addiction as low as 0.15 would not influence clinical judgments and lead to constraints on amounts of narcotics given to patients. One recent study suggests that earlier research has underestimated the extent of fear about addiction owing to poorly designed questions which provide cues to respondents about the correct risk of addition [24]. With a revised question, almost all nurses in the study were shown to be incorrect in estimating the risk of addiction. Further, most considered the risk to be substantially greater than it actually is. In contrast, another recent study found that overestimation of addiction risk is not universal [26]. Every nurse and physician working on a bum unit stated that there was a zero probability that any of their patients would become addicted in spite of prolonged narcotic administration. Their explanation for the low risk was that their patients could not become addicted because they had ‘real’ pain. Other misconceptions have also been noted. For example, most nurses erroneously attributed analgesia to be the cause of respiratory changes on the day after surgery rather than uncontrolled pain as the correct cause [7]. Both physicians and nurses have inaccurate knowledge about correct doses and duration of action of analgesics [27,47]. Fox [16] and Noyes [33] found knowledge about cancer pain management among nurses and physicians lacking and the cause of the under-treatment of cancer pain. Another example of inadequate knowledge is that far too many nurses and physicians falsely believe that a placebo response is a sign that the patient’s pain was not ‘real pain’ [24,48]. Misconceptions such as these have been considered to be at the root of the problem of poor pain management.
Poor knowledge alone does not explain the performance of health professionals in the management of pain. They seem to have some underlying attitudes or beliefs which could lead to poor pain management. One of these beliefs is overconfidence in their clinical skills. They tend to possess a strong belief in the accuracy of their judgments about pain intensity and rely on their assessments more than the patient’s statements [24]. As well, they tend to believe that pain management is better than it is [24,48]. This belief may arise from their goals for pain management. Unlike patients, nurses stated that they do not hope to achieve complete relief with analgesics [7] although many specialists in pain management believe complete relief to be the appropriate goal
[481. Some studies suggest a callous disregard for the plight of the patient. For example, there is the study which found that some nurses would give placebos or low drug dosages for unremitting pain in patients who are terminally ill with cancer [7]. Case reports have been presented by Fagerhaugh and Strauss [13] describing hardened attitudes among some practitioners who are dealing with patients’ pain. Some nurses assume that patients who are described as having negative behaviors also possess other negative attributes. When told that a patient’s pain was not supported by observable pathology, nurses used negative adjectives to describe the patient [43]. It has also been suggested that patients with difficult or negative behaviors are likely to be labeled as not having real pain or as being addicted to analgesics [24]. (c) Practitioner traits. Few practitioner traits have been studied to see if they are related to adequacy of pain management. Inferences about patient pain have been reported to be positively correlated with nurse’s reported intensity of own pain and to be related to ethnic background of the nurse [lo]. Traits which do not seem to affect pain management are type of education, age and job satisfaction [12]. Several investigators have found that more experienced nurses and physicians underestimate patient pain [19,37] whereas others have found no relationship between amount of experience and
19
judgments about pain [12,24]. Nurses’ beliefs about patients’ pain change over the course of their nursing education according to Davitz and Davitz [lo]. Toward the end of their educational program, nurses believe that patients suffer less pain than what they believed during the early stages of their education. Davitz and Davitz [lo] assume that this change in belief can be attributed to an ‘acculturation process.’ As mentioned, there are large gaps in our understanding about the factors which influence pain management skills of practitioners. In particular, there is no clear evidence that data gathered about factors influencing skills of one group of practitioners would necessarily generalize to other health practitioners.
Explanations for poor pain management Socio-political
There are several views about the causes of poor pain management. One explanation that has been espoused is that the socio-political environment of a hospital leads to poor pain management [ 131. In particular, practitioners have expectations about the amount of pain patients should have and how they can be expected to behave. Fagerhaugh and Strauss [13] refer to these normative expectations as trajectories. Patients are subtly and sometimes blatantly encouraged to conform with practitioner expectations. Since patients have very little power, they often do conform. Those who do not conform risk being branded as deviants and having further pressure applied to conform. To date, research does not seem to have been undertaken to test this view nor to develop strategies for improving pain management. It may be possible to engineer improved pain management through manipulation of beliefs about pain trajectories. Knowledge
One popular and uncomplicated view is that practitioners manage pain poorly because they have inadequate knowledge about pain management. The solution that is advocated is that educa-
tors must improve basic and continuing education programs for the health professions. Many programs for health professionals are regarded as having minimal content about pain and pain management and this content is dispersed throughout a program rather than being presented in cohesive blocks that would improve learning opportunities. At least as early as 1973, educators were being encouraged to shoulder the responsibility for improving knowledge about pain among health professionals. Notwithstanding, recent research confirms that no significant improvement has been noticed in pain management. This suggests that either educators have not responded to the challenge or have failed to alter the misconceptions that practitioners possess. Recently, one researcher has admitted that his belief in the idea that enhancing practitioners’ knowledge will improve pain management has wavered owing to the failure of an educational program [36]. Before abandoning the view that knowledge and through it, pain management, can be improved, it will be important to develop effective education programs. Moreover, evaluation of effectiveness of any educational intervention will be mandatory. Faculty clinical judgment
Another view is that the clinical judgment process may be faulty, resulting in needless suffering. Although not specifically applied to pain management, a clinical decision making model could be utilized. Research on clinical decision making has in many ways taken a parallel path to research on pain management problems. There have been, for example, studies on the effects of social class, ethnicity and gender on clinical decisions [3,40] and studies on the influence of physical traits of the patient on clinical decisions [23,34]. Researchers have also assessed covariations between quality of clinical decisions and increased education or experience of practitioners [6,29,46]. According to one clinical decision making model, the failure to manage pain appropriately would be seen as an inferential error arising from a failure to use the principles and tools of scientific inquiry and arising from the application of simple inferential strategies to problems requiring
20
more complex strategies [32]. Knowledge structures and judgmental heuristics are central to this model. Information is processed very quickly through the knowledge structure. It is in this structure that objects and events are defined and expectations and responses determined. There are several judgmental strategies which are used to turn complex inferential tasks into simple judgmental steps. These include the representativeness heuristic and the availability heuristic. These cognitive strategies can be useful in simple decision making or can lead to inferential biases or errors of judgment when misapplied in complex decision making. Kahneman and Tversky [22] believe that people can make errors of comprehension (failing to understand the inferential rule) or errors of application (failing to apply an inferential rule which they do understand). According to Kahneman et al. [21], the representativeness heuristic is used if, during cognition, an event or object is matched to the essential features of a schema (a cognitive structure that represents a stimulus domain). Errors are likely to occur when the frequency of the event in the population is not considered; this is termed the base rate of the event. Errors are also likely to occur when the potential for sampling bias is not considered. People have been shown to ignore base rate information (information which was essential to a correct solution of the problem) in favor of information about the case (called indicant information) [2,4,30,50]. It is not that people are unaware of base rate information, for when no indicant information is available, they can correctly use the base rate information. Therefore, their errors are errors of application. Several views have been expressed about the reason for ignoring base rate information. These include the views that indicant information may be seen to be more relevant than base rate information [4], and that base rate information is usually pallid whereas indicant information is vivid [30] (this is the difference between pallid group statistics and a vivid case report). Practitioners dealing with pain management problems may ignore the base rates of drug abusers in the population and of addiction occurring dur-
ing medically supervised administration of drugs. They may favor more vivid case information about the patient (such as behavior or traits) leading to a faulty judgment about likelihood of the patient becoming addicted. While proponents of the poor knowledge view about under-management of pain have demonstrated that practitioners lack knowledge about base rates, the clinical decision view would suggest that practitioners also must be taught how to use base rates. A second judgmental strategy, the availability heuristic, is used when people view an object or event as more probable or more frequent if it is easily retrieved from memory (that is, how accessible or available it is). Hence. memory is thought to mediate judgment. Some studies suggest that memory does not mediate judgment but that some features of the decision making task influence judgment directly [41]. One task feature is vividness: vivid material biases judgments [30,41]. Another biasing factor is the perception of an illusory correlation, that is perceived co-occurrences of events where in reality no correlation exists. It has been suggested that the pairing of two salient events is capable of producing an illusory correlation [17]. The tendency of nurses to correlate negative attributes of patients with other negative events, as described earlier in this paper, may be evidence of an illusory correlation. Training and experience tend to enhance the use of representativeness and availability heuristics in decision making [46]. This means that experience does not protect the practitioner from faulty clinical decisions but rather makes him more vulnerable. As the amount of information that people have increases, their confidence in their decisions increases [35]. Further, confidence is negatively related to accuracy in judgment (that is, the more confident the judge, the less likely he is to be accurate) [32]. This is called overconfidence and, paradoxically, people are more likely to exhibit overconfidence with difficult tasks than with simple ones [40]. This model would seem to be applicable to the pain management setting. Further, the model suggests specific strategies for improving decision making in pain management. The main strategies
21
recommended for reducing judgmental biases are education about decision making strategies and manipulation of information that is provided to decision makers [15,31]. Varying the vividness of information may also be a useful strategy.
Conclusions As a general criticism, research on pain management suffers from serious methodological weaknesses. The samples of subjects that have been studied are often very small and are not representative of the population of practitioners or patients. Data analyses are often poor. Virtually all of the research has been atheoretical, making it superficial in its approach to the problem. The superficiality of the research means that it has very little to offer in the way of guidance toward understanding the causes of poor pain management or guidance toward developing solutions to the problem. Further, much of the research has concentrated on patient or practitioner traits as correlates of poor pain management. It should be noted that many of the patient or practitioner traits which have been studied are not amenable to manipulation or intervention. Therefore, this research is not contributing to our ability to better manage pain. Attention needs to be paid to factors that are suitable for intervention. It is also imperative that researchers give more consideration to the patient’s role in pain management. Over the past 20 years, researchers have commented about poor pain management in health care institutions. These conclusions have been quite consistent and one of the reasons is that a number of the studies [7,27,47,48] have used much the same survey instrument or many of the same questionnaire items. This would not be a problem if the instrument were a good one, but a review of the items used by researchers suggest that many are poorly phrased questions that can bias respondents’ answers. One suggestion made in this paper is that researchers give attention to the development of a valid and reliable tool for assessing knowledge and judgments about pain management.
Attention should be paid to identifying the underlying reasons for the apparent inability of educators to improve the knowledge and clinical pain management skills of practitioners over the past 15 years. This is important because education is probably the single most important tool for improving pain management. Future research should also be designed with a view to developing and assessing interventions which increase knowledge and which reduce faulty judgments about pain management. These should be interventions which can be used by those who are responsible for education of health professionals. A clinical decision model developed by Kahneman and Tversky is recommended as a stepping off point.
References 1 Ahles, T., Ruckdeschel, J. and Blanchard, E., Cancer-related pain: prevalence in an outpatient setting as a function of stage of disease and type of cancer, J. Psychosom. Res., 28 (1984) 115-119. 2 Arkes, H. and Rothbart, M., Memory, retrieval and contingency judgements, J. Pers. Sot. Psychol., 49 (1985) 59% 606. 3 Bamgbose, O., Edwards, D. and Johnson, S., The effects of race and social class on clinical judgment, J. Clin. Psychol., 36 (1980) 605-609. 4 Bar-Hillel, M., The base-rate fallacy in probability judgments, Acta Psychol. (Amst.), 44 (1980) 211-233. 5 Benedetti, C., Bonica, J. and Bellucci, G., Pathophysiology and therapy of postoperative pain. In: C. Benedetti, R. Chapman and G. Moricca (Eds.), Recent Advances in the Management of Pain, Raven Press, New York, 1984. 6 Brenner, D. and Howard, K., Clinical judgment as a function of experience and information, J. Clin. Psychol., 32 (1976) 721-728. 7 Cohen, F., Post-surgical pain relief: patients’ status and nurses’ medication choice, Pam, 9 (1980) 265-274. 8 Craig, K., Emotional aspects of pain. In: R. Melzack and P.D. Wall (Eds.), The Textbook of Pain, Churchill Livingstone, London, 1984. 9 Crook, J., Rideout, E. and Browne, G., The prevalence of pain complaints in a general population, Pain, 18 (1984) 299-314. 10 Davitz, J. and Davitz, L., Inferences of Patients’ Pain and Psychological Distress: Studies of Nursing Behaviors, Springer, New York, 1981. 11 Domjan, M. and Burkhard, B., Principles of Learning and Behavior. Brooks-Cole, Monterey, CA, 1986. 12 Dudley, S. and Holrn, K., Assessment of the pain experience in relation to selected nurse characteristics, Pain, 18 (1984) 1799186.
22 13 Fagerhaugh, S. and Strauss, A.. Politics of Pain Management: Staff Patient Interaction. Addison-Wesley, Menlo Park, CA. 1977. 14 Faherty, B. and Grier, M., Analgesic medication for elderly people post surgery, Nurs. Res., 33 (1984) 369-372. 15 Fischhoff, B. and Bar-Hillel, M., Focusing techniques: a short-cut to improving probability judgments, Org. Behav. Hum. Perform., 34 (1984) 1755194. 16 Fox, L., Pain management in the terminally ill cancer patient: an investigation of nurses’ attitudes, knowledge. and clinical practice, Milit. Med., 147 (1982) 455-460. 17 Hamilton, D. and Gifford, R.. 111usory correlation in interpersonal perception, J. Exp. Sot. Psychol., 12 (1976) 392407. 18 Hargreaves, S.A., Implementing TENS to control postoperative pain, Unpublished Master’s Thesis, University of AIberta. Edmonton, Alberta, 1987. 19 Iafrati, N., Pain on the bum unit: patient vs nurse perceptions. J. Bum Care Rehab., 7 (1986) 413-416. 20 Jacobs, D.. Cost-effectiveness of specialized psychological programs for reducing hospital stays and outpatient visits, J. Clin. Psycho]., 43 (1987) 729-735. 21 Kahneman, D., Slavic, P. and Tversky, A., Judgment Under Uncertainty: Heuristics and Biases, Cambridge Univ. Press, Cambridge, 1982. 22 Kahneman, D. and Tversky, A., On the study of statistical intuitions, Cognition, 11 (1982) 123-141. 23 Klein, D., Najman, J., Kohrman, A. and Munro, C., Patient characteristics that elicit negative responses from family physicians, J. Fam. Pratt., 14 (1982) 881-888. 24 Lander, J., Fallacies and phobias about addiction and pain. Br. J. Addict.. (1990) in press. S. and Hargreaves, A.. Gender 25 Lander. J.. Fowler-Kerry, effects in pain perception. Percept. Motor Skills. 68 (1989) 1089-1090. 26 Lander, J. and Oberle, K.. Perceptions about pain and pain management, Unpublished study, University of Alberta, Edmonton, 1988. of medical inpa27 Marks, R. and Sachar, E., Undertreatment tients with narcotic analgesics, Ann. Intern. Med.. 78 (1973) 1733181. 28 Mather, L. and Mackie, J., The incidence of postoperative pain in children, Pain, 15 (1981) 271-282. A., Moss, J., Belville, R. and Smith, H., ln29 Meyerson, fluence of experience on major clinical decisions: training implications, Arch. Gen. Psychiat., 36 (1979) 423-427. 30 Nisbett, R., Borgida, E., Crandall, R. and Reed, H., Popular induction: information is not necessarily informative. In: D. Kahneman, P. Slavic and A. Tversky (Eds.), Judgment under Uncertainty: Heuristics and Biases, Cambridge Univ. Press, Cambridge, 1982. 31 Nisbett, R., Krantz, D., Jepson, C. and Fang, G., lmproving inductive inference. In: D. Kahneman, P. Slavic and A.
Tversky (Eds.), Judgment under Uncertainty: Heuristics and Biases. Cambridge Univ. Press, Cambridge, 1982. 32 Nisbett, R. and Ross, L.. Human Inference: Strategies and Shortcomings, Prentice-Hall, Englewood Cliffs, NJ, 1980. 33 Noyes, R., Treatment of cancer pain, Psychosom. Med.. 43 (1981) 57-70. 34 O’Leary, M.. Donovan, D.. Chaney, E. and O’Leary, D., Interpersonal attractiveness and clinical decisions m alcoholism treatment, Am. J. Psychiat., 136 (1979) 618-622. 35 Oskamp, S.. Overconfidence in case-study judgments. .I. Consult. Clin. Psychol., 29 (1965) 261-265. 36 Perry, S.. Undermedication for pain on a burn unit. Gen. Hosp. Psychiat., 6 (1984) 308-316. 37 Perry. S. and Heidrich, G., Management of pain during debridement: a survey of U.S. bum units, Pain. 13 (1982) 267-280. 38 Porter. J. and Jick, H., Addiction rare in patients treated with narcotics, New Engl. J. Med., 302 (1980) 123. 39 Schnurrer. J., Marvin, J. and Heimbach, D., Evaluation of pediatric pain medications, J. Bum Care Rehab., 6 (1985) 105-107. 40 Settin. J. and Bramel, D., Interaction of client class and gender in biasing clinical judgment, Am. J. Orthopsychiat.. 51 (1981) 510-520. 41 Shedler, J. and Manis. M., Can the availability heuristic explain vividness effects?, J. Pers. Sot. Psycho]., 51 (1986) 26-36. 42 Streltzer, J. and Wade. T., The influence of cultural group on the undertreatment of postoperative pain, Psychosom. Med., 43 (1981) 397-403. 43 Taylor. A.. Skelton J. and Butcher, J.. Duration of pain condition and physical pathology as determinants of nurses’ assessments of patients in pain, Nurs. Res., 33 (1984) 4-8. 44 Von Baeyer, C., Johnson, M. and McMillan, M.. Consequences of nonverbal expression of pain: patient distress and observer concern, Sot. Sci. Med., 19, (1984) 1319-1324. 45 Von Korff. M., Dworkin, S.. Le Resche, L. and Kruger. A., An epidemiologic comparison of pain complaints, Pain. 32 (1988) 173-184. 4h Watts, F.. Clinical judgement and clinical training, Br. J. Med. Psychol., 53 (1980) 955108. 47 Watt-Watson, J.. Nurses’ knowledge of pain issues: a survey. J. Pain Symptom Managem., 2 (1987) 207-211. 48 Weiss, D., Sriwatanakul, K.. Alloza, J., Weintrauh, M. and Lasagna, L., Attitudes of patients, house staff and nurses toward postoperative analgesic care, Anesth. Analg., 62 (1983) 70-74. 49 Zborowski, M., Cultural components in responses to pain. J. Sot. Issues, 8 (1952) 16-30. 50 Zukier, H. and Pepitone, A., Social roles and strategies in prediction: some determinants of the use of base-rate information, J. Pers. Sot. Psychol., 47 (1984) 349-360.
Pain, 42 (1990) 15-22 Elsevier
PAIN 01630
Review A rticle
Clinical judgments in pain management Janice Lander 3-103 Clinical Sciences, University of Alberta, Edmonton, Alberta T6G 2G3 (Canada) (Received
2 June 1989, accepted
2 March
1990)
From research reports published over the last 20 years, it appears that moderate to severe uncontrolled pain may be the norm for hospitalized patients despite recent advances in the management of pain. Research on the extent of under-management of pain and the factors associated with it is examined and summarized in this paper. Methodological imperfections of the research are identified. Several explanations for pain under-management have been proposed and these are reported. A clinical decision making model is also reviewed and it is suggested that this model could be applied to pain management problems. Further, it is suggested that this model may be very useful in developing educational interventions to improve health practitioners’ clinical skills in pain management.
SummarY
Key words:
Pain management;
Pain under-management;
Clinical judgment
Introduction Although the study of pain mechanisms and management can be traced back through many centuries, it is during this century that many advances have occurred. Increased knowledge about and increased availability of resources for pain management could be expected to reduce incidents of uncontrolled pain. Instead, the evidence indicates that moderate to severe uncontrolled pain continues to be the norm for hospitalized patients. From scattered research reports over the last 20 years, it appears that the problem is not so much in finding new strategies for managing pain (although the search for these must continue), but in having health care professionals utilize available scientific knowledge in their daily practices. Research findings implicate physicians and nurses as
Correspondence to: Dr. J. Lander, Ph.D., 3-103 Clinical Sciences, University of Alberta, Edmonton, Alberta T6G 2G3, Canada.
0304-3959/90/%03.50
0 1990 Elsevier Science. Publishers
having primary responsibility for the existence of unnecessary pain in patients, pain which is all too common a side effect of hospitalization and illness.
Extent of uncontrolled pain Research on pain management practices and attitudes has been conducted in a variety of settings. Much of it has been completed in general hospitals and involves convenience samples obtained from settings where diverse problems are treated. Further, no report could be found in the literature of an exhaustive study about pain management practices and attitudes which exist across settings or types of pain or even within particular settings or types of pain. Despite these limitations, the findings of the research are remarkably similar. It has been said that about three-quarters of patients experience moderate to severe pain distress while in hospital [7,27,48].
B.V. (Biomedical
Division)
Pain is generally considered to be under-managed for acute, chronic and cancer pain in adults [1,7,27,48] and pain in children [28,37]. There is even evidence from community surveys that pain is a frequent complaint among non-hospitalized people [9,45].
Effects of uncontrolled pain There are many reasons for not permitting people to suffer from pain which could be controlled or reduced. Uncontrolled pain can adversely affect pulmonary, gastrointestinal and circulatory systems [5]. Pain also compromises psychological functioning. Short-term pain evokes the protective withdrawal mechanism but if the pain continues (although still considered to be acute in nature) it results in perceptions that the pain is ‘unbearable and uncontrollable’ and produces anxiety. When pain becomes chronic, it often results in becoming ‘depressed, fearful, irritable, somatically preoccupied and erratic in the search for relief’ [S]. Similar psychological consequences have been observed in patients with acute pain [27]. An added dimension to uncontrolled and repetitive instances of pain is that this type of pain has the capacity to provoke conditioned avoidance responses [ 191. This may be the origin of dysfunctional behavior in which individuals avoid dental and/or health care. When the feared stimulus cannot be avoided, the individual suffers both psychologically and physically. The full economic and social effects of uncontrolled pain are unknown. One study on the costeffectiveness of a pain management program indicated a savings of over U.S. $200,000.00 from hospital beds not being occupied by 47 patients [20]. There was a 74% reduction in number of days hospitalized 1 year after the patients finished the program. Clearly, these findings illustrate only a part of the costs of uncontrolled pain.
Factors influencing pain management While patient and practitioner and beliefs interact in a complex
traits, behaviors way to influence
decisions examined
about pain management, separately in this review.
they
will be
Role of the putient Very little research has been undertaken to explore the patient’s contribution to pain management. Indeed, many of the factors that have been studied deal indirectly with the patient for typically researchers have been interested in how patient factors influence practitioners’ judgments. It seems as if the patient is generally regarded as a passive recipient of care. However, patients likely take on active roles in pain management. Their beliefs about pain and pain management could influence not only their expression of pain but their desire for relief. For example, about one-third of the patients questioned in one survey believed that pain builds character [48]. Having this belief may influence pain behavior. While the practitioner is usually implicated in poor pain management, the patient may also share responsibility. Several isolated findings support this notion. For one, patients may not always report pain accurately. It is not known how frequently patients minimize their pain in order to avoid receiving drugs, either out of fears about injections or aversions to anticipated side effects of analgesics. In one study, nurses thought that about 17% of patients minimize their pain [24]. Indirect evidence for minimization of pain comes from studies which have found under-management of pain in about three-quarters of patients [7,48]. Notwithstanding the researchers’ conclusions, most patients in those studies reported that pain management was satisfactory. This may indicate a tendency to minimize pain or it may suggest other conclusions. One of these is that the questionnaire item used in the studies was poorly designed and could cause response bias. Other researchers would suggest that the socio-political environment of the hospital and the lack of power of the patient would make them likely to deny that care was unsatisfactory regardless of whether it was unsatisfactory [13]. As mentioned, some patients may avoid taking analgesics. It is not clear whether or not avoidance of analgesics can be attributed to fear of addiction. In one study, patients were found to be less
17
fearful of addition than practitioners usually are [7]. In fact, patients seemed less concerned about becoming addicted than they were about having access to needed analgesics. Roles ofphysicians and nurses Research about pain management practices and beliefs mainly pertains to physicians and nurses while excluding other health practitioners (such as dentists and physiotherapists). Furthermore, much of the available literature considers only nurses. This is particularly true for the influence of patient traits on the practitioner, where the literature almost entirely relates to nurses. (a) Patient influences on clinical judgment. A number of patient traits have been investigated for their influence on: (a) practitioners’ inferences regarding the amount of pain the patient is experiencing or (b) clinical decisions about pain management. It should be noted as well that convenience samples of practitioners from select regions have been utilized in these studies. Moreover, the study of patient traits has not been thorough and has not yielded an orderly and practical body of knowledge. Among the traits studied are the paralingual expressions of pain which can influence the practitioner’s perception of pain [44]. Different groups of individuals learn to express pain in ways which are particular to their cultural group [49]. Therefore, ethnic background of the patient may influence both inferences about and management of pain. The impact of ethnic background on pain management probably ensues from practitioner’s beliefs about ethnic differences in amount of pain experienced or from ethnic differences in the expression of pain. In this latter instance, the expression of pain would influence the practitioner’s inference about pain. In one American study, whites and residents with ancestral ties to the region in which the study was conducted received significantly more analgesia after surgery [42]. Further, nurses inferred greater pain for hypothetical Jewish and Spanish patients presented in case studies compared to Black, Mediterranean, Oriental and white patients [lo]. Several other patient traits have also been related to nurses’ inferences. These include patient
socioeconomic status and gender. Nurses inferred greater pain to hypothetical patients described as having a low socioeconomic status compared to moderate or high status [lo]. Nurses in the same study believed that females suffered more pain than males. An apparent contradiction to that view is the observation in another study that nurses believed that females should have smaller amounts of narcotics compared to males with the same problem [7]. Regardless, male and female patients indeed are given similar amounts of analgesia following surgery [l&25]. Although gender is not related to amounts of analgesia given, age of the patient is [14,39]. In general, younger children [39] and older adults are prescribed and/or administered fewer analgesics [14,18,37]. On the other hand, patient age was not found to influence beliefs about amount of pain suffered [10,12]. Time since surgery [18] has been negatively related to amount of analgesia given. Also duration of pain influences inferences about amount of pain. Patients with chronic pain have been viewed by nurses as having less pain than patients with acute pain [10,43]. With regard to diagnosis, nurses were found to hold the opinion that patients with cardiovascular disease and severe trauma experience more pain than patients with any other condition [lo]. When asked what criteria were used to decide on amount of analgesia to be given, nurses mentioned the size of the patient and the type of surgery most often [7]. (b) Knowledge and attitudes. Poor pain management is often thought to arise from basic flaws in knowledge and from negative attitudes. Considering that nurses and physicians have an interactive effect on pain management, knowledge and attitudes of both professionals are important for effective pain management. Lack of understanding about addiction liability of narcotics has commanded much of the attention of researchers. It has been said that physicians under-prescribe analgesia and nurses compound the problem by under-administering the drugs [28]. Both nurses and physicians have been reported to overestimate the probability of addiction to prolonged use of narcotics (nurses overestimate more than physicians) [48]. At least a
third of nurses thought that greater than 5% of hospital patients actually do become addicted [7] (although a liberal estimate is about l/100% [38]). Several investigators have asked physicians or nurses about perceived risk of addition when 100 mg meperidine is given to a hospitalized patient every 4 h for 10 days [7,27,47,48]. Most nurses and physicians think the probability is less than 0.15 that a patient would become addicted under those circumstances. One would think that a perceived risk of addiction as low as 0.15 would not influence clinical judgments and lead to constraints on amounts of narcotics given to patients. One recent study suggests that earlier research has underestimated the extent of fear about addiction owing to poorly designed questions which provide cues to respondents about the correct risk of addition [24]. With a revised question, almost all nurses in the study were shown to be incorrect in estimating the risk of addiction. Further, most considered the risk to be substantially greater than it actually is. In contrast, another recent study found that overestimation of addiction risk is not universal [26]. Every nurse and physician working on a bum unit stated that there was a zero probability that any of their patients would become addicted in spite of prolonged narcotic administration. Their explanation for the low risk was that their patients could not become addicted because they had ‘real’ pain. Other misconceptions have also been noted. For example, most nurses erroneously attributed analgesia to be the cause of respiratory changes on the day after surgery rather than uncontrolled pain as the correct cause [7]. Both physicians and nurses have inaccurate knowledge about correct doses and duration of action of analgesics [27,47]. Fox [16] and Noyes [33] found knowledge about cancer pain management among nurses and physicians lacking and the cause of the under-treatment of cancer pain. Another example of inadequate knowledge is that far too many nurses and physicians falsely believe that a placebo response is a sign that the patient’s pain was not ‘real pain’ [24,48]. Misconceptions such as these have been considered to be at the root of the problem of poor pain management.
Poor knowledge alone does not explain the performance of health professionals in the management of pain. They seem to have some underlying attitudes or beliefs which could lead to poor pain management. One of these beliefs is overconfidence in their clinical skills. They tend to possess a strong belief in the accuracy of their judgments about pain intensity and rely on their assessments more than the patient’s statements [24]. As well, they tend to believe that pain management is better than it is [24,48]. This belief may arise from their goals for pain management. Unlike patients, nurses stated that they do not hope to achieve complete relief with analgesics [7] although many specialists in pain management believe complete relief to be the appropriate goal
[481. Some studies suggest a callous disregard for the plight of the patient. For example, there is the study which found that some nurses would give placebos or low drug dosages for unremitting pain in patients who are terminally ill with cancer [7]. Case reports have been presented by Fagerhaugh and Strauss [13] describing hardened attitudes among some practitioners who are dealing with patients’ pain. Some nurses assume that patients who are described as having negative behaviors also possess other negative attributes. When told that a patient’s pain was not supported by observable pathology, nurses used negative adjectives to describe the patient [43]. It has also been suggested that patients with difficult or negative behaviors are likely to be labeled as not having real pain or as being addicted to analgesics [24]. (c) Practitioner traits. Few practitioner traits have been studied to see if they are related to adequacy of pain management. Inferences about patient pain have been reported to be positively correlated with nurse’s reported intensity of own pain and to be related to ethnic background of the nurse [lo]. Traits which do not seem to affect pain management are type of education, age and job satisfaction [12]. Several investigators have found that more experienced nurses and physicians underestimate patient pain [19,37] whereas others have found no relationship between amount of experience and
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judgments about pain [12,24]. Nurses’ beliefs about patients’ pain change over the course of their nursing education according to Davitz and Davitz [lo]. Toward the end of their educational program, nurses believe that patients suffer less pain than what they believed during the early stages of their education. Davitz and Davitz [lo] assume that this change in belief can be attributed to an ‘acculturation process.’ As mentioned, there are large gaps in our understanding about the factors which influence pain management skills of practitioners. In particular, there is no clear evidence that data gathered about factors influencing skills of one group of practitioners would necessarily generalize to other health practitioners.
Explanations for poor pain management Socio-political
There are several views about the causes of poor pain management. One explanation that has been espoused is that the socio-political environment of a hospital leads to poor pain management [ 131. In particular, practitioners have expectations about the amount of pain patients should have and how they can be expected to behave. Fagerhaugh and Strauss [13] refer to these normative expectations as trajectories. Patients are subtly and sometimes blatantly encouraged to conform with practitioner expectations. Since patients have very little power, they often do conform. Those who do not conform risk being branded as deviants and having further pressure applied to conform. To date, research does not seem to have been undertaken to test this view nor to develop strategies for improving pain management. It may be possible to engineer improved pain management through manipulation of beliefs about pain trajectories. Knowledge
One popular and uncomplicated view is that practitioners manage pain poorly because they have inadequate knowledge about pain management. The solution that is advocated is that educa-
tors must improve basic and continuing education programs for the health professions. Many programs for health professionals are regarded as having minimal content about pain and pain management and this content is dispersed throughout a program rather than being presented in cohesive blocks that would improve learning opportunities. At least as early as 1973, educators were being encouraged to shoulder the responsibility for improving knowledge about pain among health professionals. Notwithstanding, recent research confirms that no significant improvement has been noticed in pain management. This suggests that either educators have not responded to the challenge or have failed to alter the misconceptions that practitioners possess. Recently, one researcher has admitted that his belief in the idea that enhancing practitioners’ knowledge will improve pain management has wavered owing to the failure of an educational program [36]. Before abandoning the view that knowledge and through it, pain management, can be improved, it will be important to develop effective education programs. Moreover, evaluation of effectiveness of any educational intervention will be mandatory. Faculty clinical judgment
Another view is that the clinical judgment process may be faulty, resulting in needless suffering. Although not specifically applied to pain management, a clinical decision making model could be utilized. Research on clinical decision making has in many ways taken a parallel path to research on pain management problems. There have been, for example, studies on the effects of social class, ethnicity and gender on clinical decisions [3,40] and studies on the influence of physical traits of the patient on clinical decisions [23,34]. Researchers have also assessed covariations between quality of clinical decisions and increased education or experience of practitioners [6,29,46]. According to one clinical decision making model, the failure to manage pain appropriately would be seen as an inferential error arising from a failure to use the principles and tools of scientific inquiry and arising from the application of simple inferential strategies to problems requiring
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more complex strategies [32]. Knowledge structures and judgmental heuristics are central to this model. Information is processed very quickly through the knowledge structure. It is in this structure that objects and events are defined and expectations and responses determined. There are several judgmental strategies which are used to turn complex inferential tasks into simple judgmental steps. These include the representativeness heuristic and the availability heuristic. These cognitive strategies can be useful in simple decision making or can lead to inferential biases or errors of judgment when misapplied in complex decision making. Kahneman and Tversky [22] believe that people can make errors of comprehension (failing to understand the inferential rule) or errors of application (failing to apply an inferential rule which they do understand). According to Kahneman et al. [21], the representativeness heuristic is used if, during cognition, an event or object is matched to the essential features of a schema (a cognitive structure that represents a stimulus domain). Errors are likely to occur when the frequency of the event in the population is not considered; this is termed the base rate of the event. Errors are also likely to occur when the potential for sampling bias is not considered. People have been shown to ignore base rate information (information which was essential to a correct solution of the problem) in favor of information about the case (called indicant information) [2,4,30,50]. It is not that people are unaware of base rate information, for when no indicant information is available, they can correctly use the base rate information. Therefore, their errors are errors of application. Several views have been expressed about the reason for ignoring base rate information. These include the views that indicant information may be seen to be more relevant than base rate information [4], and that base rate information is usually pallid whereas indicant information is vivid [30] (this is the difference between pallid group statistics and a vivid case report). Practitioners dealing with pain management problems may ignore the base rates of drug abusers in the population and of addiction occurring dur-
ing medically supervised administration of drugs. They may favor more vivid case information about the patient (such as behavior or traits) leading to a faulty judgment about likelihood of the patient becoming addicted. While proponents of the poor knowledge view about under-management of pain have demonstrated that practitioners lack knowledge about base rates, the clinical decision view would suggest that practitioners also must be taught how to use base rates. A second judgmental strategy, the availability heuristic, is used when people view an object or event as more probable or more frequent if it is easily retrieved from memory (that is, how accessible or available it is). Hence. memory is thought to mediate judgment. Some studies suggest that memory does not mediate judgment but that some features of the decision making task influence judgment directly [41]. One task feature is vividness: vivid material biases judgments [30,41]. Another biasing factor is the perception of an illusory correlation, that is perceived co-occurrences of events where in reality no correlation exists. It has been suggested that the pairing of two salient events is capable of producing an illusory correlation [17]. The tendency of nurses to correlate negative attributes of patients with other negative events, as described earlier in this paper, may be evidence of an illusory correlation. Training and experience tend to enhance the use of representativeness and availability heuristics in decision making [46]. This means that experience does not protect the practitioner from faulty clinical decisions but rather makes him more vulnerable. As the amount of information that people have increases, their confidence in their decisions increases [35]. Further, confidence is negatively related to accuracy in judgment (that is, the more confident the judge, the less likely he is to be accurate) [32]. This is called overconfidence and, paradoxically, people are more likely to exhibit overconfidence with difficult tasks than with simple ones [40]. This model would seem to be applicable to the pain management setting. Further, the model suggests specific strategies for improving decision making in pain management. The main strategies
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recommended for reducing judgmental biases are education about decision making strategies and manipulation of information that is provided to decision makers [15,31]. Varying the vividness of information may also be a useful strategy.
Conclusions As a general criticism, research on pain management suffers from serious methodological weaknesses. The samples of subjects that have been studied are often very small and are not representative of the population of practitioners or patients. Data analyses are often poor. Virtually all of the research has been atheoretical, making it superficial in its approach to the problem. The superficiality of the research means that it has very little to offer in the way of guidance toward understanding the causes of poor pain management or guidance toward developing solutions to the problem. Further, much of the research has concentrated on patient or practitioner traits as correlates of poor pain management. It should be noted that many of the patient or practitioner traits which have been studied are not amenable to manipulation or intervention. Therefore, this research is not contributing to our ability to better manage pain. Attention needs to be paid to factors that are suitable for intervention. It is also imperative that researchers give more consideration to the patient’s role in pain management. Over the past 20 years, researchers have commented about poor pain management in health care institutions. These conclusions have been quite consistent and one of the reasons is that a number of the studies [7,27,47,48] have used much the same survey instrument or many of the same questionnaire items. This would not be a problem if the instrument were a good one, but a review of the items used by researchers suggest that many are poorly phrased questions that can bias respondents’ answers. One suggestion made in this paper is that researchers give attention to the development of a valid and reliable tool for assessing knowledge and judgments about pain management.
Attention should be paid to identifying the underlying reasons for the apparent inability of educators to improve the knowledge and clinical pain management skills of practitioners over the past 15 years. This is important because education is probably the single most important tool for improving pain management. Future research should also be designed with a view to developing and assessing interventions which increase knowledge and which reduce faulty judgments about pain management. These should be interventions which can be used by those who are responsible for education of health professionals. A clinical decision model developed by Kahneman and Tversky is recommended as a stepping off point.
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