This section explores the nurse’s role in effective pain care in a plural society. The nurse’s specialist role and multidisciplinary team role in pain management are also examined. Ethical considerations around the delivery and management of pain are reviewed in the light of documents such as the Human Rights Act, 1998/2000 and Human Rights Act, 1998/2000 and the Children Act 1989/2004.

In this section you will bring together the issues covered by the previous three sections as well as your existing knowledge and experiences to explore the care of four individuals related to the specialist branches of nursing. It is also relevant to consider your personal gain in relation to your knowledge base and evidence of learning.

On pages 265–267 there are four case studies, each one relating to one of the branches of nursing. You may find it helpful to read one of them before you start the chapter and use it as a focus for your reflections while reading.

This section explores the physiology of pain. Theories of pain transmission are discussed and you are encouraged to apply these to your own experiences.

Pain fibres or nociceptors (noxious sensation receptors) are specialized neurones located throughout the body, particularly in the skin (Fig. 11.1). These specialized nerve endings recognize tissue damage. Pain results when the impulses from these nerves reach consciousness. The nerve endings can be stimulated by chemical, mechanical or thermal inputs. When the peripheral nerve fibres carrying impulses generated by the painful stimuli enter the spinal cord, they enter the dorsal horn of the spinal grey matter, passing through the dorsal root of the spinal nerve. When a nerve fibre ends it is involved in a synapse where the nerve message is chemically transmitted to the next nerve cell and its fibre. Many different chemicals are involved in transmission at different synapses and no one transmitter substance is confined to a single functional system. The primary actions and functions of some of these neurotransmitters are listed in Table 11.2. A useful introduction to pain perception/transmission can be found in Wood (2002).

One of the most widely accepted theories of pain, first suggested in 1965, is the gate theory, which proposed that pain is determined by interactions between three spinal cord systems (Melzack & Wall 1996). Simply it suggests that the ‘transmission of pain from the periferal nerve through the spinal cord was subject to modulation by both intrinsic neurones and controls emanating from the brain’ (Dickenson 2002: 755). It proposes that pain impulses arrive at a gate, thought to be the substantia gelatinosa (one of the most dense neuronal areas of the central nervous system). When open the impulses easily pass through; if partially open only some pain impulses can pass through; and if closed none can pass through. It further suggests that the gate position depends on the degree of small or large fibre firing. Accordingly, when large fibre firing predominates (non-noxious sensations), the gate closes, and when small fibre firing predominates (pain fibres) the pain message is transmitted (Fig. 11.2). For more detailed information see Wood (2002). It is now evident that the actuality is more complex than this explanation. Dubner in 1997 found that the nervous system has the ability to change its sensitivity following tissue injury or nerve injury, termed plasticity. Gate theory also did not take into account the long-term changes that occur due to noxious stimuli or other external factors and also that there is not a single pain centre (Jones 2001).

There are differences between acute and chronic pain and these impact upon the individual experiencing pain, since the physiological responses, psychological and social consequences differ. Acute pain is associated with a well-defined cause. There is an expectation that it is timebound and will disappear when healing has occurred. Chronic pain continues long after an injury has healed. It is a situation for the person experiencing it rather than an event (Munafò & Trim 2000).

Chronic pain can be further subdivided as either malignant or non-malignant. Chronic non-malignant pain is persistent and has no end point. It has far-reaching effects and may cause problems with partners, family, friends and employers. Loeser (2005) argued that chronic pain should be considered a disease in its own right. Treatment philosophies centre around helping patients to take responsibility for their pain and helping them to cope with it using a variety of strategies, such as in the care of a person with arthritis. Such strategies might include psychological interventions that focus on the behavioural, cognitive and emotional aspects of the illness, for example dealing with anxiety and depression, educating them about their condition and increasing the individual’s control by teaching coping skills. In contrast, chronic malignant pain may have an end point; treatment approaches include sufficient analgesia to relieve pain and techniques such as relaxation. Such differences in definition reflect the multidimensional nature of the pain.

The International Association for the Study of Pain (IASP) has defined neuropathic pain as ‘pain initiated or caused by a primary lesion or dysfunction of the nervous system’ (Merskey & Bogduk 1994). However, this definition has more recently been criticized as being too vague. Because of the incidence of both malignant and non malignant diseases in an aging population and greater survival rates from cancer and its treatment, there is likely to be an increase in the occurrence of neuropathic pain (Dworkin 2002).

In this section, definitions and ideologies are explored along with misconceptions of the experience of pain for the individual.

Pain is a difficult concept to understand. The assumption that there is a simple and direct relationship between a noxious stimulus and subsequent pain has been disputed by the realization that many environmental and internal factors modify pain perception (Main & Spanswick 2000). As has been previously stated, nociception is not pain until it is interpreted and perceived as pain. This pain perception is influenced by a range of factors. There are numerous causes of pain and these are not only physical. Also the terms ‘pain threshold’ and ‘pain tolerance’ (the greatest intensity of pain an individual can endure) are sometimes used synonymously. This leads to confusion since there are differences between them. There is also thought to be a link between a person’s pain threshold and their risk of developing chronic pain and this may be because they have a mixture of genetic mutations that increase their sensitivity to pain (Couzin 2006).

This is further complicated by factors such as emotion, culture and previous experience, the end result being a unique experience for that individual. It is important then, that the nurse working with a person experiencing pain is able to accept that pain is both physical and psychological. Thus pain is both biologically and phenomenologically embodied. Moreover culture intercedes in the pain experience and therefore transcends the mind–body divide.

Some of the recognized behavioural responses to both acute and chronic pain are listed in Table 11.4. These may be used as cues by nurses in their quest to determine the pain experience of the patient.

Assessment is a process by which a conclusion is reached about the nature of a problem. Planning effective pain management is a crucial part of the nurse’s role. In order to achieve this it is necessary to assess the level of the individual’s discomfort in an attempt to identify a potential course of action. No single assessment strategy – e.g. interpretation of behaviours or estimates of pain by others – is sufficient by itself (Herr et al 2006). However, each element can be used in an endeavour to find a complete picture of the individual’s pain experience. The nurse needs to be able to draw conclusions about the individual’s pain to assess the level and intensity of the pain based on information from the patient. Once this has been achieved it is then possible to plan a course of action to alleviate the pain, implement this and evaluate the action. Although this is possible without the patient’s cooperation, it is better to involve the individual in the assessment of their pain. Otherwise nurses are simply applying their own beliefs and values to the situation and making assumptions about patients’ pain levels. Researchers suggest that the patient needs not only to be asked about their pain but also for their responses to be believed (Dahlman et al 1999). The nurse must be proactive and skilled in recognizing potentially painful situations, particularly in those instances where the patient may not be able to communicate verbally. To achieve this we need to ascertain whether pain assessment is an appropriate action, believe that the person has pain, and be committed to assessing the pain. This should lead to a clarification of the extent of pain and its treatment. In some circumstances this assessment will need to be not only accurate but also swift, for example when dealing with a patient suffering the pain of a myocardial infarction (heart attack), where the need for immediate and effective pain relief is a priority.

Although the nurse’s role in this area is paramount, the only individual who is truly able to assess the pain is the person who is suffering it. The patient’s spoken report of pain is the most reliable indication of pain (Cranford 2001). Wherever possible the patient should be assessing their pain rather than having it assessed by the nursing staff. In circumstances where the patient is unconscious, has a communication difficulty or is a baby, the nurse must make an informed decision based on the evidence presented by the patient, given that the family and other carers can be asked for further clarification.

The accurate assessment of an individual’s pain is an inherently difficult process. The nurse must be able to establish a trusting relationship with the patient and his or her family or carers. The nurse must also be aware of their own beliefs and prejudices about pain. Timing of pain assessment is very important and dependent upon many factors, not least of which is the desire of the patient to participate in the assessment, the severity of the pain and the potential pain treatment. Such assessment involves the skills of observation so that the non-verbal pain behaviours can be seen and recognized (Box 11.1). It must be remembered that these behaviours are influenced by the individual’s social and cultural norms. Your interpretation will also be influenced by these factors. Therefore it is not possible to make assumptions based on the absence of a recognized non-verbal pain behaviour since each pain experience for the individual is unique.

An initial assessment should include some information about the history of the pain as follows: