Pain management : evaluation of practices adopted by health professionals of a secondary public hospital

BACKGROUND AND OBJECTIVES: Pain is the primary reason for looking for healthcare services. So, this study aimed at knowing healthcare professionals practices with regard to managing pain in a secondary public hospital of the Northern region of Paraná. METHODS: This is a descriptive and exploratory study with quantitative approach, carried out from March to May 2015 by means of a semi-structured questionnaire. Participated in the study 112 healthcare professionals (nurses, physicians, physiotherapists and nursing technicians). Data were analyzed by basic descriptive statistics. RESULTS: Pain was a vital sign for 88.4% of professionals; however only 18.8% have reported having some pain evaluation scale as working material. Pain is always recorded on medical charts by 49.1% of professionals. Difficulties to evaluate pain were reported by 46.4%. With regard to drug administration, 27 (24.2%) professionals have reported having some difficulty to administer drugs to patients. For 48.2%, patients must have moderate pain to receive analgesics. Half professionals have never participated in specific pain training courses and 73.2% have answered that patients lie when reporting pain presence and intensity. CONCLUSION: Deficiencies which may impair adequate pain management were observed. The lack of specific qualification regarding pain may lead professionals to ineffective approaches, often prolonging patients’ distress.


INTRODUCTION
Considered a major reason for looking for healthcare services, pain is defined by the International Association for the Study of Pain (IASP) as "disagreeable sensory and emotional experience, associated to real or potential tissue injury, or described in terms of such injuries" 1 .Pain is a subjective, individual and complex symptom, made up of previous painful experiences and multidimensional phenomena, such as sociocultural and emotional aspects [2][3][4][5]  Every patient has the right for adequate pain management, in addition to being considered a quality assistance criterion.When untreated, pain negatively influences patients' clinical evolution, leading to cardiovascular, immune, thrombolytic, psychological and social changes, sleep disorders or even to pain chronicity 6 .
As from the year 2000, American associations recommend that pain should be evaluated in a standardized way, together with other vital signs; so, pain was defined as the fifth vital sign 7 .Managers should encourage and follow-up health teams with regard to effective implementation of pain as the fifth vital sign, aiming at a humanized care when minimizing a distress which is often controllable 8 .Four basic tools are used to evaluate and measure pain manifestations and expressions, among them numeric, nominal, analogical and illustrated scales 3,9 .Self-report is the golden standard for pain evaluation.In this sense, it is critical that the health team appreciates pain complaints to trigger actions to control it 2,10,11 .However, difficulty to understand patients' pain extension is a critical point for pain control.Limited knowledge with regard to pain identification and measurement, associated to poor adhesion of health institution managers to pain evaluation as the fifth vital sign, perpetuate unnecessary distress and decreased quality of life (QL) of acute and chronic pain patients 4 .This contributes for pain underreporting and inadequate management in spite of existing classification systems and measurement tools.Some reasons impairing pain management are related to inadequacy of evaluation models in health institutions, to deficiencies related to health professionals academic qualification with regard to pain management and to negligence with painful patients, leading to analgesic choices not validated by the literature and insufficient to control pain 12,13 .This research is part of the activities of the Pain Management Committee instituted in the studied hospital.This committee is made up of a multiprofessional team and aims at discussing subjects related to pain evaluation, measurement and management.The first initiative of the committee was to identify pain management actions adopted by health professionals.
This study aimed at understanding pain management practices of health professionals of a secondary public hospital of Northern Paraná.

METHODS
This is a descriptive and exploratory research with quantitative approach.ties are shown in table 1.We have also asked which is the initial intensity patients have to express to receive analgesics, being that 54 (48.2%) professionals have reported moderate intensity (Figure 1).When asked whether patients omit pain presence and intensity, 82 (73.2%) professionals have answered yes.Table 2 shows the frequency in which professionals observe that patients lie when evaluating pain.Suggestions of actions to be carried out by the to improve practices related to pain management are shown in table 3.

DISCUSSION
Adequate pain management is made up of patients' evaluation, measurement, management and revaluation.This is critical when it is understood that pain is one vital sign.This way, a humanized and effective care of painful patients is assured 14 .This study has shown that most of the times, professionals use behavioral aspects, such as face expression, tone of voice, weeping and way of acting to evaluate pain, seldom mentioning pain measurement scales.In this aspect, authors state that for adequate pain evaluation and quantification, it is necessary to choose an adequate method considering type of pain and patients' clinical condition.Several tools may be used to measure pain intensity and their advantages and limitations should be taken into consideration 15 .
Health professionals have used specific intensity scales or verbal descriptors scales to measure pain.This was compatible with a different study where 82.4% of interviewed professionals would describe pain intensity by means of verbal descriptors (mild, moderate or severe) 8 .As to recording pain, our study has shown that pain site was the most common record, followed by intensity and interventions.Some studies show that nurses are limited to re-cording numeric intensity evolution, location and analgesia used, however records should encompass not only site and intensity but also variables such as worsening and improvement, pain-related losses, pain description and satisfaction with analgesia 16 .Detailed recording of pain and its characteristics in medical charts is critical for its adequate management.These data allow the team to evaluate the efficacy of analgesic strategies and also pain evolution.Even lack of pain should be recorded.
In the analysis of 60 medical charts, pain was recorded in 46.6% and 53.4% had no record whatsoever 16 .Among difficulties to evaluate pain, knowing whether the report is true or false was the most quoted among professionals.This is often due to lack of training and information received since graduation.A study evaluating knowledge on pain received during graduation with 60 students from the last year has shown that just 56% reported having received information about the subject "pain" and that 95% of students have never participated in events about pain during graduation.This contributes to perpetuation of distress and decreased QL of painful patients 17 .Pain, for being a subjective symptom, needs special attention from professionals when observing, listening to and interacting with patients.So, it is up to the nursing team to evaluate real patients' needs, thus appreciating their pain complaint 18 .Another difficulty found by professionals and specifically related to analgesic administration involves medical prescription deficiency, in addition to administrative difficulties.These results are in line with the literature which describes difficulties related to physicians (lack of analgesic prescription, insufficient analgesic prescription and lack of pain evaluation) and administrative difficulties (lack of the drug in the institution, lack of controlled prescription form for opioids and non-delivery of drugs to sectors when they are prescribed "if needed") 8,17 .The choice of analgesics, dose and interval between doses, in addition to rarely used new drugs are also pointed as difficulties.Combined administration of analgesics, according to the Analgesic Ladder of the World Health Organization, is a recommended practice; however, studies show that nursing professionals still do not recognize this practice, and have even difficulties in validating morphine as the analgesic of choice when other pharmacological therapies are ineffective 18,19 .With regard to drug administration, some professionals were in doubt, being that most of them administer analgesics when patients refer moderate pain.This might be due to little knowledge of recently graduated professionals about acute pain, to lack of ongoing education, to lack of experience with pain management protocols and routines and to lack of guidance about the choice of analgesic methods.So, further care with professional education and formation of multidisciplinary teams may contribute to improve the quality of care, to decrease pain-related complications and to decrease patients' distress 20 .With regard to patients' evaluation after analgesic administration, professionals have stated that most of the times, or always, they evaluate patients, confirming literature data where 85% of professionals have reported evaluating pain after analgesia.On the other hand, no record was found about pain improvement after analgesic administration in a medical charts audit study 8,16 .

CONCLUSION
Our study has observed that health professionals evaluate and measure pain in a non-standardized way and very often with inadequate With regard to analgesia, patients had to refer moderate pain to receive analgesics.This practice contradicts pain management-related evidences, because it shows lack of knowledge and perpetuation of patients' distress.
It was evident the need for ongoing education, together with sensitization of hospital managers to discuss ways to adequately manage pain.

Table 1 .
addition to aspects related to the truth of information referred by patients during pain evaluation.Participated in the study 112 health professionals, among them nurses, physicians, physiotherapists and nursing technicians working in different sectors of the institution.Inclusion criteria by simple sampling were being active during data collection period, participate in assistance activities and agree in participating in the study.Exclusion criteria were employees members of the Pain Management Committee of the institution, since this committee had already been qualified with regard to pain management.Basic descriptive statistics were used for data analysis, being data transcribed and tabulated by means of double data entry and presented in tables and figure.Statistical Package for the Social Sciences (SPSS) version 21.0 was the software used.This study was approved by the Research Ethics Committee, Universidade Estadual de Londrina (CAAE: 39596814.3.0000.5231),opinion 921.128 of 2014, as recommended by Resolution 466/2012 of the National Health Council.Data were collected after participants having signed the Free and Informed Consent Term (FICT).Considerations reported by professionals with regard to painful patients' evaluation, measuring, recording and managing, Northern The study was carried out in a secondary public hospital of a city in the Northern Paraná.Studied institution has 117 beds for clinical and surgical hospitalization, with monthly mean of 560 hospitalization and 5800 admissions to the first-aid unit.Data were collected from March to May 2015, by means of a semi-structured tool.Addressed issues were related to evaluation, measurement, recording and handling of painful pa-tients, in ing it, 40 (35.7%)most of the times, 16 (14.3%)sometimes and 01 (9%) seldom records it.With regard to pain management qualification, half the professionals have never received specific training on pain and 47 (42%) were trained in other institutions where they worked.About drug administration, 27 (24.2%)professionals had some difficulty in administering analgesics.Reported difficul-

Table 2 .
Frequency in which patients omit pain presence and intensity, Northern Paraná, 2015

Table 3 .
Measures institution should adopt to improve pain management efficacy, Northern Paraná, 2015