Knowledge of health professionals about pain and analgesia*

BACKGROUND AND OBJECTIVES: Pain relief is a basic human right and an ethical issue involving all health professionals. This study aimed at describing what professionals of a multidisciplinary hospital team know about pain and analgesia. METHODS: This is a descriptive, cross-sectional study with quantitative approach, carried out at the Teaching Hospital of the Federal University of Sergipe. Sample was made up of 33 physicians, 26 nurses, 10 physiotherapists, 8 pharmacists and 5 psychologists. Data collection tool was a self-applied questionnaire encompassing knowledge about definitions and types of pain, evaluation and measurement, pharmacological and non-pharmacological management, and professional qualification in pain. Data were analyzed by simple descriptive statistics and are presented as tables. RESULTS: Participants of the study were predominantly females (72.0%), young adults (40.2%), with residence as maximum qualification (53.7%). Pain was considered discomfort/ unpleasant sensation (46.3%) and chronic pain was defined as a symptom 48.8%). Only one professional reported using multimodal treatment for pain relief. Most professionals stated having acquired knowledge about pain and analgesia after graduation (79.3%) and that they feel the need for specific qualification (70.7%). CONCLUSION: This study has provided a situational diagnosis of the knowledge of the multiprofessional team of the hospital, showing that there is inconsistency between participants’ theoretical basis and their role in handling pain and humanizing assistance.


INTRODUCTION
Pain is an unpleasant sensory and emotional experience related to real or potential tissue injury, or described in such terms 1 .It may also be defined as the fifth vital sign to stress the importance of its systematic measurement, similar to other vital signs 2,3 .A recent study points that there are still few analgesic protocols and that some professionals are not skilled in measuring and evaluating pain 4 .So, effective pain control is health pro-fessionals' duty, a right of patients and a critical step for the effective humanization and quality of health services 5 .Effective pain evaluation allows the identification of its nature and clinical correlations as a function of patients emotional, motivational, cognitive and personality characteristics.Pain relief is considered a basic human right and as such it is not limited to clinical issues but it is rather an ethical issue involving all health professionals.Additionally, untreated pain may adversely affect patients' wellbeing or evolve to a stage of persistent pain generating financial and social burden 6 .The health team must know its responsibility with regard to painful patients so that they may identify adequate interventions for its relief, thus contributing to better clinical outcomes and humanized assistance.And the question is: what does a multidisciplinary team of a teaching hospital know about pain measurement, evaluation and management methods?This study is justified by the need to understand the theoretical basis of a multidisciplinary team when handling pain, since cultural and practical issues based on previous personal experiences may negatively influence pain evaluation and management 6 .The interest of the authors for the theme, associated to the desire of a humanized practice based on scientific principles for pain management have leveraged the development of this research, which aimed at describing multidisciplinary team members knowledge about pain and analgesia.

METHODS
This is a descriptive, cross-sectional study with quantitative approach, carried out in the Teaching Hospital of the Federal University of Sergipe (HU-UFS).Although being a teaching hospital, field of graduation disciplines practice of several health area courses and of medical and multiprofessional residency, it lacks a systematic pain evaluation method.Sample was non-probabilistic, intentional and by convenience, made up of health professionals of the following categories: physicians, nurses, physiotherapists, pharmacists and psychologists.Inclusion criteria were acting in the institution, having college graduation, and accepting to participate in the research after information supplied by investigators.A self-applicable questionnaire developed by the authors was used.This questionnaire had questions about socio-demographic, academic and professional data; basic concepts of pain; pain evaluation and measurement; pharmacological and non--pharmacological approaches for pain relief; acquisition of knowledge about pain and analgesia.Data collection tool was filled by respondents under supervision of investigators.Data were collected in the working place of participants from October to November 2013.
With regard to pain management (Table 3) there is poor knowledge about using opioids for its pharmacological management, because just 20.7% of professionals have stated knowing the use of non-steroid anti-inflammatory drugs (NSAIDs) and 42.7%, 12.2% reported use them for assistance.It should be stressed that one professional has referred using multimodal treatment for pharmacological pain management.In addition, it was observed lack of knowledge about non-pharmacological pain relief methods being acupuncture the most commonly mentioned method (34.1%).
As to the origin and acquisition of knowledge about pain and analgesia (Table 4), 65.8% of participants have referred having attended disciplines addressing the subject during graduation, being most frequently mentioned: Pharmacology (35.2%),Anesthesiology (18.5%), and Physiology (14.8%).
Most respondents have stated having acquired knowledge about pain and analgesia after graduation (79.3%) and that they feel the need for specific qualification (70.7%).Finally, when asked about types of pain they believed were the most frequent in the Brazilian population, most prevalent answer was headache (40.2%), followed by low back pain (20.7%).

DISCUSSION
Results have shown that less than 50% of all studied categories have concepts compatible with the statement of the International Association for the Study of Pain (IASP).Pain is always subjective and each individual learns how to use this word through his/her experiences 1 .In addition, respondents had wrong concepts about chronic pain, since this is not just a symptom 7 .This pain impairs quality of life of individuals and their daily activities 7 .Data show that poor knowledge of professionals about pain-related concepts may have direct implications on its management.Pain evaluation, measurement and systematic recording, added to adequate knowledge about pain and analgesia, prevent physical and mental suffering of hospitalized patients.Evaluation and measurement are words constantly used in the context of pain measurement.However, it was noticed that participants have wrong concepts about this issue, since a large number of professionals have stated "evaluating" pain by means of one-dimension scales.Measurement refers to quantification of pain severity or intensity in a simple, fast, non--invasive and valid way, such as one-dimension scales 8 .On the other hand, pain evaluation is a more complex process since it considers other pain aspects, being necessary the use of multidimensional tools to get information about pain, its meaning and its effects on patients 9 .Adequate pain evaluation and measurement contribute to shorter hospitalization time, prevent associated comorbidities and improve patients and relatives' satisfaction.So it is critical that health professionals have this knowledge aiming at subsidizing their actions and support clinical practice.Simple analgesics were most commonly mentioned by professionals when asked about pharmacological strategies and methods for pain relief.A recent study states that in some cases, by fear of adverse effects such as tolerance and dependence (uncommon when used to treat acute pain) and respiratory depression (dose-dependent phenomenon)), health profes-sionals are still cautious with the administration of potent opioids 2 .This is against the recommendation of the World Health Organization (WHO) about the analgesic ladder, which determines that pain should be treated according to its intensity 10 .Simple analgesics and NSAIDs have antipyretic and anti-inflammatory characteristics which control mild to moderate pain 3 .It has to be emphasized that pain management method of choice is the multimodal combined therapy characterized by the use of different drugs with different action mechanisms associated to non-pharmacological pain management methods 11 .The combination of different classes of drugs is critical for the management of different pain intensities, considering that all available resources should be used for effective pain control.
We have observed little knowledge of professionals about non-pharmacological treatment.According to their reports, the team still uses, in a very discreet and poorly evidenced manner, low cost therapies such as compresses, distraction, respiratory exercises and massage.Since non-pharmacological management is today a means to empower other professional categories, such as nursing, physiotherapy and psychology, there was a positive expectation with regard to diversity of knowledge and applicability at work.We have noticed that there is the need for multiprofessional qualification with regard to these pain management methods.With regard to professional qualification and acquisition of knowledge about pain and analgesia, most health professionals had, during graduation, some discipline involving the subject; however there is a deficit in this knowledge even after professional practice.So, it is necessary that health graduation courses address pain in a more specific way, giving higher importance to the subject for the qualification of professionals 12 and allowing them to effectively manage pain.The development of the subject pain in an isolated and independent way, without the necessary links with clinical understanding, impairs knowledge and results in qualification of professio- nals without an integrated view of this phenomenon 12 .So, there is the need for teaching proposals giving attention to pain in its multidimensional aspects, as IASP recommendation of targeted teaching since graduation 13 .
Headache was mentioned as one of the most frequent types of pain in the Brazilian population.It is supposed that this pain is more frequent in the hospital, thus being more frequently managed by professionals.A research aimed at determining the incidence of headache and its interference with daily activities (DA) in adolescents has concluded that the prevalence of headache was 87.7% 14 , in addition to the negative impact on DA 15 .So, headache is considered the most prevalent complaint, being few the individuals able to state that have never had during life one episode of this type of pain 16 .Headache brings many losses to patients, including decreased productivity, changes in interpersonal relationships and mood, in addition to increasing anxiety.So, early headache prevention and management are critical to decrease such disorders and, as a consequence, to provide patients with better quality of life.

CONCLUSION
This study has provided a situational diagnosis about the knowledge of the HU-UFS multiprofessional team, showing that there is inconsistency between participants' theoretical basis and their role in managing pain and humanizing assistance.Additionally, although professionals state having acquired information about pain evaluation and measurement during graduation, many consider that professional experience has further increased such knowledge.This factor may be negative for assistance since just experience-based practices, without support of sound scientific evidences, may perpetuate misunderstandings about the subject.Although being a teaching hospital, the institution lacks a committee specialized in pain.We suggest the need for institutional protocols for systematically evaluate pain and analgesia, associated to ongoing education of the team, as well as the strengthening of the insertion of the subject pain throughout the whole academic qualification cycle of health professionals.

Table 1 .
Sample characterization of socio-demographic data, academic graduation and professional action.Aracaju (SE),Brazil, 2013With regard to basic knowledge about pain, 35.4% have defined it as discomfort or unpleasant sensation; 46.3 and 33.0% have attributed different concepts to acute and chronic pain, respectively.When asked whether chronic pain was a symptom or a disease, almost half the sample has stated being a symptom (48.8%).With regard to pain evaluation and measurement, respondents did not know the difference, since 57.3% stated that evaluation is carried out by means of scales (numeric, analog and verbal descriptors) and 63.4% have answered that measurement is carried out by the same methods.It is worth stressing that 72.7% of physicians have a wrong understanding about methods used for pain evaluation (Table

Table 3 .
Distribution of professionals with regard to pharmacological and non-pharmacological pain management.Aracaju (SE), Brazil, 2013 AF = absolute frequency; RF = relative frequency.

Table 4 .
Distribution of professionals with regard to origin of knowledge about pain analgesia.Aracaju (SE), Brazil, 2013 Continues...

Table 4 .
Distribution of professionals with regard to origin of knowledge about pain analgesia.Aracaju (SE), Brazil, 2013 -continuation AF = absolute frequency; RF = relative frequency.