Research ArticlePainful Discrimination in the Emergency Department: Risk Factors for Underassessment of Patients’ Pain by Nurses
Section snippets
Study design and setting
This study is part of a prospective follow-up study; the “PROgnostic factors for the Transition from Acute to Chronic pain in Trauma patients” (PROTACT). The PROTACT study includes adult patients with isolated musculoskeletal extremity injury who attended the emergency department of Medisch Spectrum Twente in Enschede, The Netherlands. This 24/7 emergency service is accessible for 264,000 persons in the Twente region and treats approximately 27,000 patients annually. This study was approved by
Patients’ characteristics
Between September 2011 and July 2013, a total of 803 adult patients with isolated musculoskeletal extremity injury provided written informed consent. Data for 541 patients who filled in both the ED and follow-up questionnaire were used for analyses. For 2 patients, the nurse’s pain score was not registered and therefore those patients were excluded from analyses. The median age of the 539 patients was 45.9 years (interquartile range 33.9-59.2), and 57.9% were women (Table 1). Pain prevalence at
Discussion
Assessment of pain is difficult because pain is a highly subjective and personal experience, which is hardly clinically measurable with objective criteria. In the PROTACT study, nurses significantly underassessed patient’s pain with a mean difference of 2.4 on an 11-points NRS. More important than a statistical significant difference between both assessments is the issue of clinical relevant difference. Earlier findings have demonstrated that a difference of 33% in acute pain scores is
Implications for Emergency Nurses
Knowing which factors can increase risk for discrepancies in pain assessment is a necessary first step toward optimizing pain management and pain relief. Nurses should be aware in which patients they usually underassess the pain. Underestimation of patients’ pain can have negative effects if appropriate treatment is withheld, not only in terms of patient suffering, but unrelieved pain may also lead to adverse physiological effects such as cardiovascular side effects and negative effects on
Acknowledgments
We gratefully acknowledge the nurses and staff, especially A. Christenhusz and M. Poessé- Vennevertloo, in the emergency department of Medisch Spectrum Twente, for their assistance, and we thank patients for participating in the PROTACT-study. Furthermore, we acknowledge the contribution of Ambulance Oost, especially J. Legebeke and F. van Eenennaam, for providing data from the ambulance emergency medical services.
Jorien G.J. Pierik is Researcher, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands, and Policy Advisor, Regional Network for Emergency Care, Acute Zorg Euregio, Enschede, the Netherlands.
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2019, Social Science and MedicineCitation Excerpt :However, nurses did not adhere to these guidelines; instead of combining the two ratings, they relied almost solely on the ‘objective’ NRS, asking patients to self-report their pain score only when the ‘objective’ NRS was considered ambiguous or inconclusive. Such deviations from guidelines are of course not uncommon (cf. Timmermans and Epstein, 2010), but this particular practice seemed puzzling, as self-report is widely seen as ‘the gold standard’ for pain assessment (cf. Pierik et al., 2017). Indeed, one influential definition states that pain is “whatever the experiencing person says it is, existing whenever the experiencing person says it does” (cited in Woodrow, 2002, p. 62).
Jorien G.J. Pierik is Researcher, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands, and Policy Advisor, Regional Network for Emergency Care, Acute Zorg Euregio, Enschede, the Netherlands.
Maarten J. IJzerman is Professor, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.
Menno I. Gaakeer is ED Physician, Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, the Netherlands.
Miriam M. R. Vollenbroek-Hutten is Professor, Biomedical Signals and Systems, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.
Carine J.M. Doggen is Associate Professor, Health Technology & Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University Twente, Enschede, The Netherlands.