VoL 5 ~0. I t~b,~ 7 199o jen,,~o/e~,,on~sy,,q~n M~,~, ,~ tt
Pain Description by Nurses and Physicians Kristine Turner Norvell, RN, Fannie Gaston-Johansson, Dr Med So, and Lani Zimmerman, PhD College of Nursing, Uaiversit 3 of Nebraska Medical Center, Omaha, Nebraska
Abstma The purpose of this study was to determine ~'nurses and physiciaus selected similar words to describe painlike experiences and to determine how they rated terms commonly used to describe pain. Thirty.seven registered nurses and 21 physiciaus comprised the sample. The Visual Analogue Scale (VAS) was used to measure the terms ache, hurt, and pain. The McGill Pain Questionnaire (MPO~ provided a list of word descriptors from which the subjects selected words that best represented the terms ache, hurt, and pain. There was no s~gn~6cant d~erence between the nurses and physicians in the mean rating of any of the pain terms on the VAS. The nurses and physicians chose very similar word descriptors from the MPQ to discriminate one pain term from another. These findings ,u~fgest th~ nurses and physicians may have a common understandiag of the language used to d~cribe painlihe experiences. J Pain Symptom Manage 1990;5:11-17.
Pain language, semantics, pain intensity
lntroduct/on Accurate assessment of a patient's pain is the
basis for appropriate treatment. Also impor- tant is a common under.~,4nding of the mean- ing of various pain descriptors, if a patiem says he has an ache, the physicians and nurses car- ing for him should have a common understand- ing of what is meant by "ache" in order to inter- vene appropriately.
The purpose of this study was (a) to describe how health care p~fe~i,)nal~ (HCP~) r~e th~ intettsity of basic pain terms (i.e., pain, harg, and ache), (b) to identify which word descriptors are selected by HCPs to describe these pain terms,
Address reprint requests to: Fannie Oaston-Johaasson. Dr. Med. Sc., University of Nebraska Medical Center. College of Nursing, 42nd amd Dewey Aveaue. Omaha, NE 68105. Atypical f0r/ndd/cat/0n: March 29, 1989.
and (c) m determine if there is a commonality in description of pain among HCPs.
The International Association for the Study of Pain (IASP) t has defined pain as "an un- pleasant sensory and emotional experience as- sociated with actual or potential tissue dam- age." While many authors concur with this definkion, there is disagreement as to the words used to describe pain.
The words cbosey, :o describe pare usually re- flect both a sensory and an emotional (affective) coml~oec, t. &~jeedves used to describe both components of pain are often imt~rtam in the diagnosis of disease and are used by both pa- tients and HCPs to describe the pain experi- ence.
A variety of words have been identified as use[ul for describing pain~ Pain, ache, and hurt were words identified by Fabrege and Tyma* and Gaston-Johamson s as common terms used
@ U.S. Cancer Pain Relief Committee, 1990 Published by Elsevier, New York, New York 088~$~,1~0~S,S0
12 Norvdl et al. ]our~,l ~ Pain and SymJ~ora Mam~eraet~
to describe painlike experiences. These terms have been found to have different intensity values and different meanings in relation to quality, s-s
Typically, there is little thought given to the use and meaning of pain terms. However, they are freely used to describe pain by both those experiencing the pain, and by persons responsi- ble for assessing and treating a parson in pain. A common understanding of the use and meaning of pain terms is important in the as- sessment and treatment of pain.
Therefore, k seems essential to know if nurses and physicians are communicating when they confer with each other about a patient's pain.
The following questions were investigated in this study:
!. How did nurses and physicians rate the in- tentities of the terms ache, hurt, and pain?
2. Were there similarities in how nurses and physicians rated the intensity of these pain terms?
8. What word descriptors did nurses and physi- cians select to describe the tecots ache, hurt, pain with respect to their sensory and affec- five components?
4. Were there similarities in the description of the~e pain terms by nurses and physicians?
s,~eas The subjects for this study consisted of 58
conveniently selected nurses and physicians working at a teach!r,g hospital in a midwestern city. Thirty-seven licensed registered nurses and 21 physicians comprised the sample. Per- mission to conduct the study was granted by the lnstimtinnal Review Board of the study hospi- tal.
Insmmm~ T~vo established instruments were used in the
stnd~, d~e Visual Analogue Scale (VAS)' and the blcGill Pain Questionnaire (MPQ), r
VA& The VAS consists of a 10-cm line with anchors on each end that represent no pain and pain as bad at it can be. The VAS is commonly used for rating pain intensity and is generally reported as valid and reliable, s-H However, it
provides only a unidimensional rating of pain intensity and has been shown to be difficult for some parsons to understand, s.n The VAS was used in this study to obtain intensity ratings of the three pain terms.
MPQ. The MPQ consists of 78 word descrip- tor's that represent sensory, affective, evaluative, and miscellaneous components of pain. The word descriptors were used in this study for subject selection of words that describe pain terms.
Several authors have completed reliability and validity testing of the MPQ. Both Melzack r and Graham and colleagues 's found high inter- correlations among several measures on the MPQ. Kremer and Atkinson Is found support for the construct validity of the affective dimen- sion of the MPQ. Byrne and coUeagues 14 and Prieto and colleagues m subjected the MPQ to factor analysis, each resulting in four factors that were highly simUar, with significant corre- lations occurring across studies in throe o! the four f~ctors (r ~ ,74 to .g3),
Dm,wgrap~ D~a. Demographic data were collected using a questionnaire developed by the investigators. Data obtained included age, sex, educational level, length of employment, and specialty area.
Informed consent was ,~btained. and each subject was given a VAS with the three pain terms pain. ache. and hurt alphabetized and printed horizontally across the top of the page. The words were presented this way in an at- tempt to avoid ranking the intensities of the words. The subjects were then asked to mark on the VAS where they perceived the intensities of pain, ache, and hurt to be represented. A list of the word descriptors was then given to the subjects. The descriptors from the MPQ were placed randomly on the data collection sheet in an effort to eliminate any bias that might have occurred by presenting the words according m classifications. The su~ects were asked to iden- tify which of the descriptors were associated with the terms pain. ache, or hurt. A separate list was used for each term, and the terms were presented in a random manner.
Vol. 5 No. 1 Fd~ 1990 Pain Descripgon by Nurses mul P ~ 13
An analysis of variance (ANOVA) for repeat- ed measures was used to calculate differences in VAS ratings of the pain terms. Posthoc Tukey tests were conducted to determine where the pairwise differences were located. A Student's t test was used to determip.e differences in VAS ratings by nurses and physicians.
Frequencies and percentages were computed for each word descriptor. A discriminative power index (DP1) wa~. calculated as a ratio of each of the 78 word descriptors with each pain term. Once words with DPIs above 0.50 were identified for each pain term, they were divided into two categories: sensory and affective.
Rendts The mean age of both nurses and physicians
was 35 yr. The nurses had practiced a mean of 12.9 yr, while the physicians had practiced a mean of 7.7 yr.
The majority (07%) of the nurses were fe- male, as compared to 26% of the physicians. A variety of educational levels were represented in the nurse sample, with the BSN being most common (45%). Among physicians, 36% were surgeons or pathologists; 33% of the nurses practiced in medical/surgical areas.
There were no significant differences in the mean ratings of the terms pain, ache, and hurt on the VAS by nurses and physicians (Figure 1). Therefore, the groups were combined, and an ANOVA for repeated measures was used to determine differences between the ratings of the pain terms. A statistically significant differ- ence occurred between the mean ratings of ache, hurt, and pain [F(53, 105) = 8.81, p < 0.0001], with ache having the lowest mean in- tensity (P~3.92) on the VAS followed by hurt (45.21), and pain having the highest value (74.96) (Figure 2). Posthoc Tukey tests indicat- ed significant differences between all pairwise comparisons ~e < 0.01).
se~ o/Word ~. fo r Pm 8mm~ Wera~. Nurses and physicians chose similar sensory words (n = IS) to discriminate the word pain from the words hurt and ache (Table 1). The nurses chose four words with
Worst poss ib le pa in
Pain x - 74.96 + 16.59
-- Hurt ~t - 43.21 +_ 12.40
- - Ache x - 23 .92 + 1~.55
0 ~ m
l~o pain Fig. 1, The mcin raenss of pain terms by health care pro- fessional~ (nurses and physicians) on the Visual Analogue Scale (VAS).
DPls of at least .64 that the physician~ did not choose ~ound/ng, spread/ng, squee~g, and bmt- /ng). The physicians, in turn, chose three words with a DPI of at least 0.73 that were not chosen by the nurses (quive~ng, ra.vping, andflash/ng).
A Ie~ Words. The nurses chose the same af- fective words (n ffi 15) as the physicians (except for the word v/r/eas) to discriminate the word pain from the words hurt ~ad ache. Additional affective words chosen by physicians were ~.//nd- /ng, o-uel, and dreadful (Table 1).
endAd~ Hurt. The sensory words jumping, hurting, sore, and tender were chosen by all subjects to repre- sent die term hurt. The physicians chose no additional words; however, the nurses selected six more word descriptors to represent hurt (Table 2)~
No affective words were identified to repre- sent the word hurt by either group of subjects.
Adw. The sensory word descriptor~ ~k/ng and numb were chosen by both nurse~- and physi- cians to represent the word ache. In addition, nurses also chose the word du//, whereas physl- clans chose the word /~h/ng. The affective
Pro fe l l s io f t
. / i
ACHE HURT PAIN POIn Terrnn
FiB. ~. l)iffetences in mean valacs of ache, hurt and pain between nurses and phyJicia~
words nagg/ng and ~ were chosen by both 8roups of subjecO. The nurses also chose the word aeno~g (Table 2).
D/smss/on The subjects in this study were ,dl convenient-
ly chmen and may not be representative of HCPs working in the midwestern United State,. The sample size was small and was limit- ed to practitioners from one institution. While there was a wide range of educational levels and specialties inclnded, caution must be taken in interpredng the results because of the small number of participants.
z,,tms~ sae~cs No signffic, m differences occurred between
the intensity rating of the three pain terms be- tween the nurses and physicians. Significant differences did occur, however, in the place- mere of the terms on the VAS. These findings indicate a consenms among the subjects in this study m to the relative intensity values of these terms. "l~tls llndinll my be important when HCPs are d~cusdn~ appropriate treatment o1~ dons, sa they should have a common under- standing u to the intensity of a particular term.
~ of Pro Tr,~ As was expected, the term pai~ had the high-
est intensity value, The DPrs of the words se- lected to describe pain were also higher than those selected for ache or hurt. Additionally, a greater number of sensory and affect/ve w~rds were chosen to describe pain than either of the other two terms.
Several subjects indicated difficulty in chore- ing descriptors tl'mt defined a particular pain term. For example, several subjects comment- ed that they could have beth a nagging ache and a nagging hurt. Subjects seemed m have the most difficulty describing the term hurt and could find no affective words m describe it. This was not true with the term pain, which tended m have well-defined descriptors at- tached m it, such as ~ and crushing.
One possible explanation for this finding is that HCPs often associate pain intensities wim diagnose~ and procedures. Several authors have found that new surgical patients, burn pa- tients, and trauma patients consisuendy are as- sessed as having higher levels of pain than other types of patients, m-re
Many of the words chosen to describe pain were also analogous with the use of certain medical instrumentS, and correspond with a
Vd. ~ No. i Feb ,~ l~90 P, en ~ ~ N~ ~ Pk~ns 1~
Tabie l Semory and Affecfive Words Clumm by the Subje~ as Discrlmimedve fro- the Term pc/8
De,criptor DPI Des~ptor DPi
See~.. piercing 0.89 tearing 0.89 crushing 0.89 lancina~g 0.87 tearing 0.86 " "
0 .83 0.83 shooO.,g 0.8~'
lacerating 0.8S crushing 0.8O shooting 0.83 w~ncinn 8 0.78 stabbing 0.79 stabbing 057 w~nchin 8 0.76 p~g 0.77 splitting 054 drilling 0.75 pounding 0,72 squeezing 0.71 0.73 beating 0.70 ramping 0.73 radiating 0.70 radiating 0.08 penetrating 0.68 cutting 0.67 ~ndnatin g 0.67 sharp 0.65 spreading 0.64 penetrating 0.65 cutting 0.03
g 1.00 blinding 1.00 suffocating 1.00 fearful 1.00 tortudnmg 0.88 terrif~ng 0.9'2 unstable 0.8~t cruel 0.91 terrifying 0.83 suffocating 0.89 ago~ng 0.70 unbe-amhle 0.85 w~e~,d 0.70 grueling 0.85 intense 0.77 punb,~'ng 0.85
0,77 agomzmg 0.82 fearful 0.75 killing 0.81 frightful 0.71 ~ghff.l 0.78 punishing 0.71 wretched 0.78 grueling 0.68 nameatin 8 0.75 nameatin 8 0,68 dreadful 0.75 sickening 0.61 torturing 0.72 exhamdng 0,60 interne 0.72
~ickening 0.67 exhausting 0,61
classification of pain terminology developed by Gaston-Johansson and Allwood. s Perhaps the familiarity of dealing with patients who have more intense ~Pain allowed these subjects to de- scribe more adequately that level of pain.
The majority of word~ chceen by this group of nurses and physicians to describe pain terms were the same, with a few discrete differences occurring between the groups. It appears, then, that not only do these HCPs have a com- mon understanding of the intensity of these pain terms, they also describe them in a similar manner. By having a shared understanding of these terms, the auassmant and communication
of a patient's pain should be more consistent be- tween the two groups.
C ~ The sample size in this study was small and
fimited to one institution, and, therefore, it may be difficult to generalize the results to other groups or settings. Nonetheless, the findings of this study suggest that HCPs have a common understanding of the level of intensity that is meant by the terms ache, hurt, or pain. In ad- clifton to rating the intensity values of pain terms simila...