Pain – believe, evidence, act, escalate!

How many times have you heard someone say “pain is what the patient says it is”? I have heard this a lot of late, so much so that I am beginning to question it’s credibility. It was in 1968, over 50 years ago, that McCaffrey defined pain as “it’s whatever the experiencing person says it is, existing whenever and wherever the person says it does” and whilst I agree wholeheartedly with this I wonder if it’s time to change the messaging on pain? I hear nurses quoting McCaffrey often when talking about pain, yet I am not sure that this really changes the experiences of the people we care for and it won’t until we not only talk about pain being what the person says it is but also take action.  

Let me share 2 situations with you …. The first is a person who is being cared for in hospital following an operation, they suddenly become dizzy and the first thing the nurse caring for them does is take their blood pressure, pulse, respirations, oxygen saturations and temperature.  The person is found to be hypotensive and immediately action is taken and a doctor is called.  The second situation is very similar in that a person is being cared for in hospital following an operation but this time they start to experience increasing amounts of pain.  This time the nurse checks the last time the person had analgesia, they check when they were last seen by the pain team and they then decide that the person has had all the analgesia they can have and they explain this to the person.  In the first situation there is a sense of urgency, the nurse found something tangible and real and was able to easily justify further action.  In the second situation however there is less urgency, the person’s pain is only what the patient says, there is nothing tangible or real other than what the person is saying, so the nurse feels the only course of action is to explain to the person that they have had their quota of analgesia.  

I admit these two scenarios are over simplistic, but they illustrate an important point, because although we, as nurses, recite McCaffrey’s “the pain is what the patient says it is” the action we take does not reflect this mantra. It seems that we say it, but do we really believe it? And furthermore do we believe it every time? Is it hard to justify clinical action based on what the patient says? Are clinical settings systems, policies and processes set up[ in such a way that we can escalate concerns based on what the patient says? There is so much at play here – yes pain is what the patient says it it but I want to challenge that thinking ….. saying “pain is what the patient says it is” is not enough, we need to believe this, we need to evidence it, we need to act on it and we need to escalate it. 

In order for this to happen changes need to be made, and although they may seem obvious and simplistic at first glance we need to understand that in order to embed this into nursing culture we need to think about large scale behaviour and even system change.  

• People should be asked their pain levels as often as observations are taken, so that evidence can be gathered as to their general levels of pain and any escalation can be evidenced. 
• People should be asked their pain levels following analgesia / intervention to assess the efficacy of the analgesia / intervention. 
• Documentation, systems and processes need to be designed with the above in mind. 
• When a person reports that they are in pain they should be asked what their pain levels are and their verbal and non verbal signs of pain should be recorded. 
• Increasing levels of pain should be treated as an urgent problem and acted on and escalated, and nurses should be supported and encouraged to do this. 
• A person in pain being advised that they have had all of the analgesia they have been prescribed should be a never event. 

I realise that some clinical settings get pain right and I realise that there are many nurses that act on pain every time, and that is fantastic, however there are many that don’t and this is the biggest change that needs to happen.  Every nurse and every clinical setting should get pain right, with no exceptions, and at the heart of this should be that when a person is in pain it’s not enough to say ‘pain is what the patient says it is’ we need to believe them, we need to evidence it, then act on it and if necessary escalate it. 

McCaffery, M. (1968) Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions. Los Angeles: University of California at LA Students Store.