2. Professional related factors
2.2 Professionals’ technical knowledge regarding pain management
Ehrenberg, 2002; Briggs & Dean, 1998). Briggs & Dean (1998) reviewed patients’ records and applied content analysis to nursing documentations. They found that nurses’ assessments of pain were poorly documented. While only 34% of patients’ records reported that patients had pain, about 91% of interviewed patients, whose records were reviewed, said that they had experienced pain.
Dalton et al. (2001) supported these findings and reported, upon reviewing patients’ profiles, that the minimal documented data in patients’ charts reflected the minimal pain assessment and management activities.
The majority of studies reported inadequate pain assessment, reassessment, and documentation practices by nurses. However, insufficient explanation was provided for the prevalence of such inadequate practices.
2.2 Professionals’ technical knowledge regarding pain
management
This is another factor investigated for its potential effect on pain management practices. Many studies reported professionals’ lack of knowledge, in particular regarding the pharmacological aspects of pain management. These findings were consistent for many countries around the world and have been observed over a considerable period of time.
Both Hamilton & Edgar (1992), and Van Niekerk & Martin (2001) reported that inadequate knowledge regarding painkillers and their side effects, such as addiction, ceiling effect, and respiratory depression was dominant among nurses in acute care hospitals in Canada and Australia.
Other studies, such as Lui, So, & Fong (2008) in Hong Kong, Salvado- Hernandez et al. (2009) in Spain, and Kaki et al. (2009) in Saudi Arabia, presented a picture which was no better, and reported a lack of knowledge among nurses regarding the pharmacological aspects of medical and acute surgical pain management.
Inadequate knowledge, as well as beliefs about opioid induced addiction and respiratory depression has also been reported among physicians (Messeri, Abeti, Guidi, & Simonetti, 2008; Zanolinet al., 2007; Visentin, Trentin, De Marco, & Zanolin, 2001). However, when comparing the knowledge of groups of nurses and doctors, there was a significant statistical difference in the knowledge scores, with nurses scoring much lower than doctors.
Reasons for the reported lack of knowledge among professionals varied between several research studies. Some studies found hospitals to be providing inadequate information to staff (Van Niekerk & Martin, 2001). Akbas and Oztunc (2008) reported that 88% (n=198, mean of 12 years experience) of nurses had not received education about pain outside nursing school and did not read about pain in journals. Other researchers, such as Horbury et al. (2005), found that organizations provided education in this area but that nurses show poor attendance at such in-service sessions.
Another group of researchers identified inadequacies in university education and syllabuses as potential reasons for a lack of knowledge and understanding of pain management (Rahimi-Madiseh, Tavakol, & Dennick, 2010; Goodrich, 2006; Plaisance & Logan, 2006; Chiu, Trinca, Lim, & Tuazon, 2003; Ferrell, McGuire, & Donovan, 1993).
For these studies to be properly considered however, it is necessary to evaluate whether professionals’ knowledge actually influences their practical approach to pain management.
Wolfert et al. (2010) found that 23% of 216 physicians thought that addiction is defined purely by physiological characteristics, such as physical dependence or withdrawal symptoms and tolerance, and only 19% correctly defined addiction as a compulsive use of harm. Interestingly, doctors who prescribed opioids frequently were those who defined addiction correctly in terms of behavioural characteristics. This suggests that lack of knowledge regarding painkiller addiction might impact on the physicians’ opioid prescription practices. This finding echoes Marks and Sachar (1973), who reported that 73% of patients who reported pain were under-treated because of physicians’ concerns about opioids induced addiction.
The above findings of the study by Wolfert et al. (2010) do not seem to support findings of a study conducted earlier by Watt-Watson et al.(2001). While Watt-Watsonet al.(2001) found that there are many misbeliefs and a knowledge deficit about pain management among all participating nurses (n=94), and that only 47% of patients were given their recommended doses of painkillers. Their research also reported that nurses’ knowledge scores
were not significantly related to their patients’ pain ratings or the analgesics administered. This suggests that even if nurses’ knowledge scores are high, this alone is insufficient to improve pain management.
This in part seems to support the findings of other studies which examined the effect of nurses’ educational level on their practices. For example, Hamers et al. (1997) found that the higher education level of nursing staff did not influence their pain management practices, but that practical experience did have an influence. Latimeret al. (2009) showed that nurses’ level of pain knowledge, education level, or access to education had no effect on their pain management practices.
The above review shows that there has been an effort to study the influence of inadequate knowledge on professionals’ pain management practices. It was frequently concluded that health professionals are responsible for inadequate pain management because of lack of knowledge and that an improvement of knowledge regarding pain management might decrease patients’ ratings of pain. There is however some limited, but important, evidence that even when nurses have good knowledge, pain scores do not necessarily improve (Watt-Watsonet al., 2001).
There is a notable gap in the reviewed literature regarding the effect of professionals’ background knowledge on their pain management practices. Most of the studies examine the influence of technical or ‘foreground knowledge’ (May, 1992: 473), on nurses’ pain management practices, while researchers ignored the ‘background knowledge’ (May, 1992: 473), or ‘social background’ knowledge (Fagerhaugh & Strauss, 1977: 23)
professionals had of their patients. The professionals’ foreground knowledge can be considered to be that “which establishes the clinical definition of the body” (May, 1992: 473), and therefore considers the patient as a case more than as a human with experience. However, the professional’s background knowledge “establishes the patient as an idiosyncratic and private subject, and opens this up as an appropriate focus of nurses’ work” (May, 1992: 473).
Nurses and other health professionals may have a limited knowledge of aspects of a patients’ social background, and biographical data, and thus, such considerations are often not a focus of professionals’ concern in their work with patients (Fagerhaugh & Strauss, 1977). The importance of having this knowledge is that a patients’ background might influence their beliefs, practices, and interactions with staff in the hospital, (Fagerhaugh & Strauss, 1977).
In addition, in the literature, much attention is focused on tools to examine professionals’ technical knowledge and attitudes to pain management (Akbas & Oztunc, 2008; Ferrell & McCaffery, 2008; Visentin et al., 2001; Watt-Watson et al., 2001; Tanabe, Buschmann, Forest, & Forest, 2000; McCaffery & Ferrell, 1997; Hamilton & Edgar, 1992; Watt-Watson, 1987), but there is little focus on attempts to assess staff knowledge regarding their patients’ backgrounds and variables relevant to pain and its management.
A third gap found in this area of the literature is that all of the studies, without exception, examined either the quantity or the quality of nurses’ knowledge, or both, but did not consider the ‘type’ of taught knowledge.
May (1995: 170) argues that the ‘type’, not the quantity or the quality of nurses’ knowledge influences their position in the power relations with doctors and therefore the extent to which they can apply alternative forms of legitimate knowledge and interventions (Chapter One; Section Two; Subsection 1). May argues that the type of knowledge that doctors acquire through their training enables them to observe, analyze and evaluate a patient’s problem and upon that, to decide what is most suitable for that particular patient. Further discussion on this gap is introduced in Section Two of this chapter.