Teaching of Nursing interventions as non-pharmacological strategy for pain relief

BACKGROUND AND OBJECTIVES: This study is justified by the relevance of highlighting strategies which may be used by the nursing team to contribute to pain management, considering the importance of pain as the fifth vital sign. This study aimed at describing Nursing interventions to be taught as strategies for pain relief, according to Nursing professors’ perception. METHODS: This is a descriptive, exploratory and qualitative study. The scenario was a Nursing Graduation Course and participants were Nursing professors teaching Nursing disciplines. All participants have signed the Free and Informed Consent Term. Data collected by means of semi-structured interviews recorded in audio were afterward organized in categories. RESULTS: From data analysis, the category “Nursing care as non-pharmacological intervention to manage pain” has emerged. Specific Nursing action strategies taught during the course were additional care, such as effective communication, patients’ positioning and mobilization and support with artifacts, added to family monitoring. CONCLUSION: Nursing interventions adopted as non-pharmacological therapies to manage pain were the strategies used by professors during the teaching process.


INTRODUCTION
The International Association for the Study of Pain (IASP) defines pain as "unpleasant sensory and emotional experience associated to real or potential tissue injury, or described in terms of such injuries.People learn how to use this term through their previous traumatic experiences…" 1 .According to the Brazilian Association for the Study of Pain (SBED) 2,3 , population longevity associated to increased survival with regard to trauma and chronic diseases favors, in general, the appearance of painful sequelae, fact which requires the development of strategies directing health professional actions to its correct and adequate control.This means that human resources duly graduated and qualified to lead management processes and attention to evaluate and treat pain are critical and, for such, nurses play an important role considering their responsibilities related to sectoral management, planning of assistance of the team coordinated by them, in addition to generalist and holistic qualification which should involve their graduation.Nurses have preponderant role on accurate pain evaluation and on promotion, maintenance and recovery of painful patients' comfort, through the organization of assistance given by them or by the Nursing team to patients with pain 4 .Nursing care may promote pain relief, which justifies the need for efforts that reproduce assistance patterns specifically aimed at different pain manifestations and perceptions, by using scales and other tools to translate pain intensity and quality, in addition to the use of Nursing care strategies or non-pharmacological interventions to decrease physiological reactions and promote comfort 5,6 .This statement shows the imminent need to prepare Nursing professionals, since their qualification, for the development of such competence 7 .
The reference of Nursing care as additional strategy for pain relief is based on the use of techniques such as music, guided imagery, environmental noise control, touch, massage, physical therapies, in addition to communication itself, as resources to decrease distress secondary to pain, which should be discussed with professionals along their formal and ongoing education process 8,9 .
This justifies this study based on the relevance of strategies which may be used by the Nursing team to contribute to pain management, considering the importance of pain as the fifth vital sign.
This study aimed at describing Nursing interventions to be taught as strategies for pain relief, according to the perception of nursing professors.

METHODS
This is a descriptive and exploratory research with qualitative focus of the theme content analysis-type.

RESULTS
With regard to characterization, a total of 5 professors participated in this study, being called "A", "B", "C", "D" and "E".From these, 4 were females aged between 31 and 40 years; with regard to graduation time, 4 were graduated in Nursing for more than 10 years and 4 acted as professors for 10 to 15 years.Table 1 shows selected statements, registry units, understanding core and category.

DISCUSSION
From the category "Nursing care as non-pharmacological intervention for pain management", mentions to available treatments for pain management have emerged.In this perspective, professors reported acknowledging that Nursing interventions per se represent non-pharmacological actions for comfort and to improve pain: "Changing position, dressing, patient in bed for a long time, one could keep him sitting until hygiene which brings comfort, and this "feeling good" ends up helping resistance to pain" (A)."Emotional care is with non-pharmacological interventions, such as replacing the mattress, touch, changing position and encouraging mobility" (D).Pain management based on the association of Nursing actions and therapeutic techniques decreases costs, in addition to avoiding the presence of potential adverse effects related to the use of drugs and invasive interventions; this is the importance of Nursing for the management of the fifth vital sign 2 .
It is important to supply Nursing students with tools to identify specific assistance needs for each patient with pain, based on recommendations of Nursing class entities regarding the study of human responses to biological, emotional and social distress that pain may induce 10 .
In the Children's Health Nursing area, professor's perception has converged to non-pharmacological techniques as the first pain management choice, focused on the child and on the family, as follows: "Family has to be oriented to value what the child feels, the speech… once pain is diagnosed, we teach to try first to intervene with non-pharmacological measures, such changing position, or even a toy… I try to orient students… that we cannot eliminate pain, but rather minimize it" (B).Conventional pharmacological approaches for pediatric pain have been effectively associated to additional techniques; pediatric patients' imagery stimulation is the primary element of assistance 11 .With regard to Nursing assistance for painful children and teenagers, especially during hospital stay, one has to consider the importance of emotional care, flexibility, playfulness motivation, use of imagination and establishing communication with them and with the support system to understand the perception of each element about pain, and from then be able to establish strategies for its control 12 .
Communication was referred as a tool for mental health care in light of painful experience specificity for painful patients: "I approached a patient with a student ... he spontaneously told us that he was apart from the family, that he could not pick his niece in lap, that the physician was decreasing drug doses" (C).Pain in the context of mental disease is considered differentiated in the evaluation of these patients, and the management of the fifth vital sign is inserted in the recommendation for health and Nursing assistance of those "needing special care" 2 .Communication as pain management tool favors pain evalua-tion, allowing the expression of discomfort intensity and quality.In addition, it involves the relief strategy, be it by guidance, by guided imagery or by the possibility of verbalization 13 .Pain management was considered within this category, in its non-pharmacological version, as care interventions of the Nursing team.When teaching this approach, communication, physical movement, support, use of devices and follow-up of the family support system are specific Nursing strategies.

CONCLUSION
Teaching pain as the fifth vital sign reinforces the need for efforts contributing to the development of pain management strategies.In this sense, Nursing is an important element of this process, by applying specific care science interventions.So, Nursing interventions represented by positioning, by communication, by applying dressings, by adopting elements favoring creativity may be adopted as non-pharmacological therapies for pain management, according to the perception of nursing professors.
5935/1806-0013.20140057Teaching of Nursing interventions as nonpharmacological strategy for pain relief Rev Dor.São Paulo, 2014 oct-dec;15(4):264-6 structured interview was carried out and recorded in audio, as from the guiding question: "According to your perception, which are the Nursing interventions to be taught as strategies for pain relief?"Then,recordedinterviews were transcribed and after their accurate and thorough reading, they were classified as shown in table1, being established Registry Units from which Understanding Cores resulted having as reference landmark the Pedagogic Module of the Brazilian Society for the Study of Pain.After analysis, a new regrouping and classification was performed, resulting in Categories.Reflexive and relational analysis of contents was based on theoretical referential, aiming at understanding the meaning of the phenomenon about Nursing graduation professors perception.This study was approved by the Research Ethics Committee (Process CEP UMC 137/2010, CAAE 0131.0.237.237-2010).
The study was carried out in a Nursing graduation course of a university located in Mogi das Cruzes.Participated in the study all nurses who have taught, during 2011, Nursing disciplines.Participants have signed the Free and Informed Consent Term (FICT).Data were collected to characterize participants, such as gender, age, graduation time and nursing teaching time, and then a semi-

Table 1 .
Categorization process, São Paulo, 2014 "I approached a patient with a student ... he spontaneously told us that he was apart from the family, that he could not pick his niece in lap, that the physician was decreasing drug doses… it is magic, these are details of our profession, talking to patients is a non-pharmacological therapeutic and behavioral technique" (C)."Emotional care is with non-pharmacological interventions, such as replacing the mattress, touch, changing position and encouraging mobility" (D)."To observe the patient is nothing, one has to encourage him to talk" (E).