Download A Survey of Perceptions with Pain Management in Spanish Inpatients

Vol. 32 No. 4 October 2006
Journal of Pain and Symptom Management
361
Original Article
A Survey of Perceptions with Pain
Management in Spanish Inpatients
Jorge Malouf, MD, Oscar Andión, BPsych, Rafael Torrubia, PhD,
Montserrat Cañellas, MD, PhD, and Josep-E. Baños, MD, PhD
Department of Experimental and Health Sciences (J.M., J.-E.B.), School of Health and Life Sciences,
Universitat Pompeu Fabra, Barcelona; Department of Psychiatry and Health Legislation (O.A., R.T.),
School of Medicine, Universitat Autònoma de Barcelona, Barcelona; and Department of Anesthesiology
(M.C.), Hospital de Sabadell, Sabadell, Spain
Abstract
The aim of this study was to document the satisfaction with pain management in a Spanish
inpatient population and its relationship with pain ratings. Two hundred fifty inpatients of
four departments were interviewed: Surgery, Orthopedics, Gynecology, and Internal
Medicine. A 32-item questionnaire was used, and the main variables evaluated were pain
severity, dissatisfaction with pain management and caregivers, and patient expectations
regarding pain relief. Relationships among the variables were analyzed by means of
Spearman’s correlation between item scores and regression analysis. Median satisfaction
scores were consistent with ‘‘very satisfied.’’ Mean (SD) worst pain during the past 24 hours
was 68.8 (27.5) on a 100 mm visual analogue scale. ‘‘Dissatisfaction with Pain
Management’’ correlated positively with ‘‘Dissatisfaction with Medical Staff’’ (0.42), and
inversely with ‘‘Pain Now’’ (0.41) and ‘‘Expected Pain Relief’’ (0.38). Regression
analysis showed that ‘‘Dissatisfaction with Pain Management’’ was dependent on ‘‘Pain
Now,’’ ‘‘Least Pain,’’ and ‘‘Dissatisfaction with Medical Staff,’’ with statistically significant
beta weight values of 0.277, 0.197, and 0.280, respectively. The study shows that patients
were highly satisfied with pain management, even when they were in pain. Moreover, it
establishes that patient dissatisfaction with treatment was highly related to the satisfaction
with caregivers and pain intensity. J Pain Symptom Manage 2006;32:361e371.
Ó 2006 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Key Words
Pain management, satisfaction with treatment, patient perceptions with analgesic treatment
Introduction
Address reprint requests to: Josep-E. Baños, MD, PhD,
Department of Experimental and Health Sciences,
Universitat Pompeu Fabra, Doctor Aiguader 80,
08003 Barcelona, Spain. E-mail: josepeladi.banos@
upf.edu
Accepted for publication: May 10, 2006.
Ó 2006 U.S. Cancer Pain Relief Committee
Published by Elsevier Inc. All rights reserved.
In spite of many decades of effort, undertreatment of acute and chronic pain in hospitalized patients is a common situation in
many countries.1e6 This evidence is difficult
to understand since enough effective therapies
for treating pain are available to adequately
deal with it.7 At least in part, this failure to
achieve adequate treatment is a consequence
0885-3924/06/$esee front matter
doi:10.1016/j.jpainsymman.2006.05.006
362
Malouf et al.
of the medical habit of underprescribing
pain medications, and nurses compound the
problem by failing to administer the analgesics
prescribed on a regular basis.8e11 Several strategies developed to overcome this situation
have included professional education,12 patient education,13 and the development of
guidelines for the management of pain.14,15
In the opinion of many experts, all of these initiatives would not make a significant change in
optimal pain management unless analgesic
care is institutionalized.16,17 It is generally accepted that quality assurance and quality improvement programs may be used to achieve
this goal.14,16e18
To change this situation, a questionnaire was
developed by the Committee on Quality Assurance Standards of the American Pain Society
(APS) in the early 1990s to assure that pain
was communicated and that treatment was rapidly adjusted to provide adequate pain relief.19
This questionnaire, known as APS Quality Assurance Standards (APS-QAS), has been used
in the last decade to evaluate if analgesic treatment was adequate in hospitals. It has also
been successfully used to improve cancer
pain management.20
The APS-QAS considers the satisfaction of
patients with treatment as a valid measure of
the adequacy of analgesic treatment and has
been extensively used to assess this aspect of
medical care.19 The APS-QAS has been used
in several studies. Miaskowski et al.21 performed a patient satisfaction survey in San
Francisco in 1994 with a modification of the
survey instrument recommended by the APS.
They analyzed a small sample of 72 patients
from acute care hospitals. Ward and Gordon22
examined patient satisfaction with pain management in a sample of 217 adults and 31 children in a university hospital. Both studies
found that even when some patients experienced moderate to severe pain and had to
wait relatively long periods of time for pain
medications, most of them were satisfied with
their pain management. Also, most patients reported that they had received communication
from physicians or nurses that their pain and
pain management was considered a therapeutic priority. Similar results were found by studies performed later.17
The reason for this apparent paradox has
been a matter of discussion. For instance,
Vol. 32 No. 4 October 2006
Ward and Gordon suggested that patients
have low expectations about pain relief. In this
regard, Kuhn et al.22,23 reported that only 36%
of postoperative patients expected complete
pain relief. Donovan8 asked postoperative patients why they were satisfied even when they
had pain and almost 40% of them answered
that they expected pain after a surgical procedure. However, other authors have suggested
other explanations, such as the pattern hypothesis, which explains the satisfaction of patients
with pain treatment considering that the analgesic effectiveness meets their expectations
rather than with full pain relief.17 As a consequence, Miaskowski et al. and Ward and Gordon
indicated that the APS-QAS should be modified
to gain more information about this severe
pain-high satisfaction paradox, and the consequence was the American Pain Society Patient
Outcome Questionnaire (APS-POQ), which includes several questions to clarify these issues
and a numerical method to score satisfaction.17,21,22 Using the APS-POQ, McNeill
et al.24 have published a replication of the previous studies using the APS-QAS.
Recently, a Chinese and an Italian version
have been developed and have shown, in essence, the same usefulness to evaluate pain satisfaction as the original version of the APS
questionnaire.25,26 Patient satisfaction questionnaires may help to make pain undertreatment easier to detect, and then to proceed
accordingly. Besides the positive effect of this
provision on patient quality of life and suffering, it is also important for hospital policies,
since adequate analgesic therapy is now recognized as one important aspect of quality care.27
Unfortunately, several studies have also
shown that pain is a common experience
among Spanish inpatient populations.11,28,29
Nevertheless, no specific study has been performed to investigate if the findings reported
in American and Chinese patients are present
in the Spanish population. Furthermore, no
study that we know of has analyzed whether
Spanish inpatients are satisfied with the pain
treatment they receive in our hospitals. There
is a need for studies like these to be aware of
patient perceptions with pain management.
Given this background, in this study we have
assessed patients’ satisfaction with pain management and the relationships among pain
ratings, satisfaction, and some demographic
Vol. 32 No. 4 October 2006
Perceptions with Pain Management
characteristics (age, gender, and educational
level). For this purpose, we use an instrument
adapted from the APS questionnaire, given differences in culture and beliefs, for the Spanish
population.
Methods
Setting and Patients
The study was conducted in the Hospital of
Sabadell, a 600-bed medical center located in
Catalonia, a region of northeast Spain. This
hospital provides full health services for inpatients and outpatients in a wide area comprising 300,000 people. The study was performed
on patients coming from the Departments of
General Surgery, Orthopedic Surgery, Obstetrics and Gynecology, and Internal Medicine.
No separate Oncology Department is available
at this center, and cancer patients are admitted
to the wards of the Departments of Internal
Medicine and Surgery (if awaiting a surgical
procedure).
The local Institutional Review Board approved the study protocol, and patients gave
their consent.
Inclusion criteria to participate in the study
are as follows: 18 years or older; surgical patient having undergone surgery during the
prior 24 hours; medical patient reporting
pain during the prior 24 hours; and able to understand the meaning of the scales and to answer them accordingly.
Instrument
A questionnaire, which we have called
Patient Perception with Pain Management
363
(PPPM) (Appendix), was created by adapting
the questions included in the APS-POQ22,27
and the Inpatient Pain Management Survey
(IPMS).17 The IPMS is a variation of the APSPOQ, which includes the same items as the former, except the first question about the need
for treating pain at any time during the care
of the patient and the question about suggestions to improve pain management. Furthermore, the IPMS includes three new questions
about the level of pain relief that the patients
thought it should have been possible to receive, the level of pain relief they wanted to receive, and the reasons for the dissatisfaction
with the analgesic treatment they received.
Items of the two questionnaires were considered reliable to analyze patient perceptions
of pain management, as they explored dissatisfaction with pain treatment and medical staff,
pain intensity, patient expectations of pain relief, and interest of medical staff in pain treatment. All of these items have been studied and
their importance in patient satisfaction analyzed.30 The PPPM questionnaire had 12
closed questions (multiple choice or dichotomous yes/no answers) and one open question.
A visual analogue scale (VAS) of 100 mm was
used (0 ¼ no pain, 100 ¼ the most severe pain
imaginable) to evaluate the intensity of pain
(Table 1). Items on both questionnaires were
translated to Spanish and then back-translated.
The adequacy was evaluated by three experts
on pain treatment who were fluent in both languages. Some additional questions, which were
considered as pertinent by these specialists,
were also added to the final list.
Table 1
Characteristics of the Survey Patients
Department
General Surgery
Orthopedics
Obstetrics and Gynecology
Internal Medicine
Age
n
(%)
Mean (SD)
84
79
57
30
33.6
31.6
22.8
12
e
e
e
e
250
e
53.8 (18.20)
Gender
Female
Male
157
93
62.8
37.2
e
e
Education (yrs)
Less than 8
Between 8 and 12
12
More than 12
172
14
57
7
68.8
15.6
22.8
2.8
e
e
e
e
Type of pain
Postoperative
Acute medical
Cancer
210
21
19
84.0
8.4
7.6
e
e
e
e
364
Malouf et al.
The first three questions referred to the presence of pain and were answered with yes or no.
They specifically asked the following questions:
1) if the patient, since arrival at the hospital, had
been in pain or not; 2) if he/she had been in
pain for the last 24 hours (this question, although very similar to the previous one, was important since it was an inclusion criterion for
the nonsurgical patients); and 3) if he/she
had needed any additional treatment for pain,
besides the original analgesic schedule.
In the next three questions, patients were
asked to rate their pain intensity using the
VAS for three different situations: 1) Pain
Now (at the moment of the interview); 2)
Least Pain (the least pain felt since admission);
and 3) Worst Pain (the worst pain felt since
admission).
In the seventh question, patients were also
asked about their perception of the time
elapsed from their request for an analgesic to
its administration. The answers were placed
into one of six different categories: 1) I did
not ask for any analgesic, 2) delay of 0e15 minutes, 3) delay of 16e30 minutes, 4) delay of
31e60 minutes, 5) delay of more than 60 minutes, and 6) asked for but never administered.
This variable was referred to as ‘‘Time
Elapsed.’’
The eighth and ninth questions asked about
patient dissatisfaction with pain management
and with the medical and paramedical staff.
They were evaluated using a Likert scale of
seven categories: 1) highly satisfied, 2) very satisfied, 3) satisfied, 4) neither satisfied nor dissatisfied, 5) dissatisfied, 6) very dissatisfied,
and 7) highly dissatisfied. These variables will
be referred to as ‘‘Dissatisfaction with Staff’’
and ‘‘Dissatisfaction with Treatment’’ throughout this document.
In the tenth question, patients were asked if
their physicians and nurses had told them
about the importance they gave to pain treatment. This variable was referred to as ‘‘Comment on Pain Importance.’’ For the eleventh
question, patients were asked if physicians or
nurses had told them to notify them when
they were in pain; this variable was referred
to as ‘‘Notify when in Pain.’’ The possible answers to these questions included Nurse, Physician, Both, or Neither one.
The last question asked about patient expectation of pain relief according to the actual
Vol. 32 No. 4 October 2006
pain relief they experienced, and was recorded
using the same type of scale with seven categories: 1) much more than I expected, 2)
more than I expected, 3) slightly more than I
expected, 4) what I expected, 5) slightly less
than I expected, 6) less than I expected, and
7) much less than I expected. This variable
was referred to as ‘‘Expected Pain Relief.’’
Procedure
Once the patients were chosen and inclusion
criteria were met, they were approached individually by one of the investigators (JM), who
identified himself as a researcher independent
of the hospital staff, informed them of the characteristics of the study, and asked them to participate by signing a written consent. Strong
emphasis was made that the information would
be considered anonymous and strictly confidential, and that the medical staff would not have
access to the answers. They were also advised
that their care would not be compromised at
all if they refused to participate.
Sample Size
The sample size was calculated assuming an
expected prevalence of pain of 50%, which is
a common finding in inpatients in the medical
literature.26,31,32 A confidence interval was set
at 99%. Using the sample size utility of the
Epi Info program, the sample was established
in 250 patients was calculated.
We assumed that a sample of 250 patients
would be enough to reach adequate conclusions. A similar sample size had been used successfully in previous surveys.17,33 A total of 397
patients were originally approached, 312 accepted and were interviewed, and 250 interviews were eligible to be analyzed. The main
reasons for excluding the interviews were inability to understand the VAS and incoherence
in the patient’s answers.
To have an adequate sample of all patients
of the hospital, the number of patients of
each department who were interviewed was
calculated considering the number of beds of
each department. The organization of the hospital included four large departments: Internal
Medicine, General Surgery, Obstetrics and Gynecology, and Orthopedic Surgery.
Vol. 32 No. 4 October 2006
Perceptions with Pain Management
Analysis
Demographic information regarding age,
gender, race, completed years of education,
and type of pain was recorded. Descriptive statistics were conducted to analyze these variables. The Student’s t-test was used to evaluate
differences by gender in dissatisfaction scores
and for the ‘‘Comments on Pain Importance’’
and ‘‘Notify when in Pain’’ items.
Spearman correlation analyses were performed to establish the existence of any relationship among variables. A multiple regression
analysis was carried out to evaluate to what
extent variables included in the PPPM would
predict the result of ‘‘Dissatisfaction with
Staff,’’ ‘‘Dissatisfaction with Treatment,’’ and
‘‘Expected Pain Relief.’’ The independent
variables used were ‘‘Pain Now,’’ ‘‘Least Pain,’’
‘‘Worst Pain,’’ the difference between ‘‘Worst
Pain’’ and ‘‘Least Pain,’’ ‘‘Time Elapsed,’’ ‘‘Comments on Pain Importance,’’ ‘‘Dissatisfaction
with Treatment,’’ ‘‘Dissatisfaction with Staff,’’
and ‘‘Expected Pain Relief.’’
Multiple collinearity analyses were performed
taking into account the criteria established by
Tabachnick and Fidell.34 (One criterion, the
Tolerance Index, is included in Table 6.) Following these criteria (including the Tolerance
Index), a lack of collinearity can be seen.
Results
Sociodemographic Description of the Sample
The characteristics of the sample are shown
in Table 1. A total of 250 patients were interviewed, including 84 (33.6%) from General
Surgery, 79 (31.6%) from Orthopedics, 57
(22.8%) from Obstetrics and Gynecology, and
30 (12%) from the Internal Medicine departments. Most of the patients of the Departments
365
of Obstetrics and Gynecology, and Orthopedics
were postoperative patients. The age of the entire group ranged from 18 to 99 years, with
a mean (SD) of 53.8 (18.2), and females
(62.8%) predominated. In terms of education,
four categories were established according to
the number of years of education. Most patients
(68.8%) had fewer than 8 years of education.
The majority had postoperative pain (84%).
Descriptive Statistics
Every patient reported pain in the previous 24
hours, but just 118 patients (47.2%) sought
medical staff intervention. The patients’ answers
on pain severity showed a mean (SD) of 27.2
(25.3) for ‘‘Pain Now,’’ 68.8 (27.5) for ‘‘Worst
Pain,’’ and 12.8 (18.0) for ‘‘Least Pain.’’ In addition, a fourth value, indicating the difference
between ‘‘Worst Pain’’ and ‘‘Least Pain’’ was
calculated showing a mean (SD) of 56.0 (25.3).
Regarding the question ‘‘Time Elapsed,’’ 119
patients did not ask for medication (47.6%).
Of those who did, 125 (50%) had to wait just
15 minutes for its administration; one patient
(0.4%) waited 16e30 minutes; four patients
(1.6%) waited 31e60 minutes; and only one
patient (0.4%) waited longer than one hour.
For ‘‘Dissatisfaction with Treatment’’ the median was 2, which means that most of the patients were satisfied. For ‘‘Dissatisfaction with
Staff’’ the median was 1, which corresponds to
‘‘very satisfied.’’ Detailed results are reported
in Table 2.
Results on the questions ‘‘Comment on Pain
Importance’’ and ‘‘Notify when in Pain’’ are
summarized in Table 3. Most patients reported
that no one had told them that pain was important for health professionals. However,
nurses insisted more than physicians on the
importance of notifying pain.
Table 2
Dissatisfaction with Treatment, and with Nurses and Physicians
Dissatisfaction with
Nurses and Physicians
Dissatisfaction with Treatment
Highly satisfied
Satisfied
Slightly satisfied
Neither satisfied
nor dissatisfied
Slightly dissatisfied
Dissatisfied
Highly dissatisfied
n
%
n
%
112
117
10
5
44.8
46.8
4.0
2.0
172
74
3
1
68.8
29.6
1.2
0.4
2
2
2
0.8
0.8
0.8
0
0
0
0.0
0.0
0.0
366
Malouf et al.
Vol. 32 No. 4 October 2006
Table 3
Comments on Importance of Pain and Pain Notification
Notify when
in Pain
Comment on Importance of Pain
Physician
Nurse
Both
None
n
%
n
%
7
14
4
225
2.8
5.6
1.6
90.0
11
168
24
47
4.4
67.2
9.6
18.8
low coefficient values. The highest values of
correlation coefficients obtained when comparing PPPM variables are summarized below.
‘‘Dissatisfaction with Staff’’ was related to
‘‘Dissatisfaction with Treatment’’ (r ¼ 0.423).
‘‘Dissatisfaction with Treatment’’ was related
to ‘‘Pain Now’’ (r ¼ 0.405), ‘‘Least Pain’’
(r ¼ 0.342), and ‘‘Expected Pain Relief’’
(r ¼ 0.383). ‘‘Pain Now’’ was positively related
to ‘‘Worst Pain’’ (r ¼ 0.453) and ‘‘Least Pain’’
(r ¼ 0.622). ‘‘Worst Pain’’ was related to ‘‘Least
Pain’’ (r ¼ 0.446), ‘‘Worst Pain Least Pain’’
(r ¼ 0.720), and ‘‘Time Elapsed’’ (r ¼ 0.364).
Regarding the answers to the questions
‘‘Comment on Pain Importance,’’ ‘‘Notify
when in Pain,’’ and for the different genders,
a Student’s t-test was used to evaluate the level
of dissatisfaction with the staff, the treatment,
and the pain expectation in these groups.
The results showed no difference regarding
On the subject of ‘‘Expected Pain Relief,’’ the
median was 4, ‘‘what I expected,’’ which means
that most of the patients expected the pain they
suffered (57.6%). Forty-one (16.4%) patients
answered that they had less relief than they
expected from the analgesic treatment, of
whom just 9 (3.6%) patients had much less
relief. The remaining 65 (26%) patients got
more alleviation than they expected.
Relationships Among Variables
Spearman correlations between the most
important variables were performed (Table
4), and the correlation coefficients were statistically significant in half of the comparisons. A strong and significant negative
correlation was seen between educational
level and age (r ¼ 0.597), but the other significant correlations between age and educational level, and variables of the PPPM had
Table 4
Spearman Correlation Between the Different Questions of the PPPM and the Sociodemographic Variables
Dissatisfaction with
Treatment
Dissatisfaction with R
staff
P
Dissatisfaction with R
treatment
P
0.423
<0.001
Pain
Now
Worst Least Expected Pain Worst Pain Pain
Relief
Least Pain
Age
Educational Time
Level
Elapsed
0.101
0.111
L0.144
<0.05
L0.144
<0.05
0.114
0.072
0.014
0.825
0.060
0.342
0.405 0.293 0.342
<0.001 <0.001 <0.001
L0.383
<0.001
0.063
0.325
0.126
<0.05
0.082
0.195
0.138
<0.05
0.073 0.089
0.251 0.161
Pain now
R
P
0.453 0.662
<0.001 <0.001
L0.264
<0.001
0.007
0.918
0.240
<0.001
0.098
0.123
0.222
<0.001
Worst pain
R
P
0.446
<0.001
L0.217
<0.001
0.720
<0.001
0.075
0.234
0.011
0.861
0.364
<0.001
Least pain
R
P
L0.298
<0.001
L0.216
<0.001
L0.201
<0.001
0.095
0.133
0.208
<0.001
0.035
0.586
0.118
0.062
L0.147
<0.05
L0.125
<0.05
0.014
0.826
0.014
0.824
0.269
<0.001
L0.597
<0.001
0.067
0.291
Expected pain relief R
P
Worst least pain
R
P
Age
R
P
Educational level
R
P
R ¼ correlation coefficient; P ¼ level of significance.
Bold numbers indicate significant correlation coefficients.
0.040
0.526
Vol. 32 No. 4 October 2006
Perceptions with Pain Management
any question. No difference was seen between
genders for the ‘‘Dissatisfaction with Staff’’ or
‘‘Expected Pain Relief.’’ Male patients were
more dissatisfied with treatment than female
patients (Table 5).
Patients of four different departments participated in this study, but since the distribution among the departments was not normal,
a Kruskal-Wallis test was carried out to seek
the existence of differences depending on the
department. No differences were found in the
different variables, such as ‘‘Pain Now’’ (c2
¼ 2.357; df ¼ 3; P ¼ 0.50), ‘‘Worst Pain’’
(c2 ¼ 4.027; df ¼ 3; P ¼ 0.26), ‘‘Least Pain’’
(c2 ¼ 6.827; df ¼ 3; P ¼ 0.78), ‘‘Dissatisfaction
with Staff’’ (c2 ¼ 2.603; df ¼ 3; P ¼ 0.46), and
‘‘Dissatisfaction with Treatment’’ (c2 ¼ 7.393;
df ¼ 3; P ¼ 0.60).
The educational level of the participants was
not homogenous, and some of the categories
had a small number of subjects. Therefore,
some of the four original categories were collapsed to ‘‘less than 8 years of education’’
and ‘‘more than 8 years of education.’’ After
statistical comparisons using the Mann-Whitney U test were carried out, no significant differences among them were found in ‘‘Pain
Now’’ (P ¼ 0.13), ‘‘Worst Pain’’ (P ¼ 0.82),
‘‘Least Pain’’ (P ¼ 0.06), ‘‘Dissatisfaction with
treatment’’ (P ¼ 0.22), and ‘‘Dissatisfaction
with Staff’’ (P ¼ 0.55).
Prediction of Dissatisfaction
with Pain Management
A multiple regression analysis was performed to evaluate to what extent the
367
dissatisfaction of the patients with the staff
and their expectation of pain relief would predict the different results of pain perception
and general satisfaction. Three different analyses were performed, considering ‘‘Dissatisfaction with Staff,’’ ‘‘Dissatisfaction with
Treatment,’’ and ‘‘Expected Pain Relief’’ as dependent variables. The predictors entered into
the analysis were ‘‘Pain Now,’’ ‘‘Least Pain,’’
‘‘Worst Pain,’’ the difference between ‘‘Worst
Pain’’ and ‘‘Least Pain,’’ ‘‘Time Elapsed,’’
‘‘Age,’’ ‘‘Dissatisfaction with Staff,’’ ‘‘Dissatisfaction with Treatment,’’ and ‘‘Expected Pain
Relief.’’
As can be seen in Table 6, the predictors
‘‘Pain Now,’’ ‘‘Least Pain,’’ ‘‘Dissatisfaction
with Staff,’’ and ‘‘Expected Pain Relief’’ have
a predictive value for the variable ‘‘Dissatisfaction with Treatment’’ (beta values: 0.277,
0.197, 0.280, and 0.148, respectively). Also,
for the variable ‘‘Expected Pain Relief,’’ the
only variable with a significant predictive value
was ‘‘Dissatisfaction with Treatment’’ (beta
value: 0.332). Finally, for ‘‘Dissatisfaction
with Staff,’’ the variable with a significant predictive value was ‘‘Dissatisfaction with Treatment,’’ with a beta value of 0.357.
Discussion
Perhaps the most intriguing finding from
this patient perception survey is that many patients were very satisfied with the analgesic
treatment given during their hospitalization,
and with the medical staff, although they
were still in pain at the moment of the interview and had experienced severe pain during
Table 5
Student’s t-Test for Dissatisfaction with Treatment, Dissatisfaction
with Staff, and Expected Pain Relief by Gender
Female (n ¼ 157)
Dissatisfaction
with staffa
Dissatisfaction
with treatmenta
Expected pain
reliefb
Male (n ¼ 93)
Mean
SD
Mean
SD
t
P
1.31
0.49
1.38
0.57
1.037
0.301
1.62
0.74
1.90
1.22
2.269
0.024c
4.33
1.42
4.13
1.27
1.131
0.259
df ¼ 248.
a
Dissatisfaction with staff and dissatisfaction with treatment (Likert scale): 1) highly satisfied; 2) very satisfied; 3) satisfied; 4) neither satisfied nor
dissatisfied; 5) dissatisfied; 6) very dissatisfied; and 7) highly dissatisfied.
b
Expected pain relief (Likert scale): 1) much more than I expected; 2) more than I expected; 3) slightly more than I expected; 4) what I expected;
5) slightly less than I expected; 6) less than I expected; and 7) much less than I expected.
c
P < 0.05.
368
Malouf et al.
Vol. 32 No. 4 October 2006
Table 6
Multiple Regression Analysis of the Main Variables of the PPPM Questionnaire
Dependent Variables
Dissatisfaction
with Treatment
Predictor
Pain now
Least pain
Worst least pain
Time elapsed
Age
Dissatisfaction
with staff
Dissatisfaction
with treatment
Expected pain relief
Overall F (df)
R2
Expected Pain
Relief
Dissatisfaction
with Staff
Beta
Weight
Tolerance
Index
Beta
Weight
Tolerance
Index
Beta
Weight
Tolerance
Index
0.277a
0.197b
0.006
0.027
0.015
0.280a
0.507
0.488
0.819
0.876
0.925
0.960
0.125
0.101
0.066
0.020
0.072
0.029
0.484
0.477
0.822
0.876
0.930
0.865
0.101
0.003
0.096
0.118
0.098
e
0.827
0.474
0.821
0.888
0.935
e
e
e
0.332a
0.876
0.148b
16.365
(7.242)
0.321
0.892
e
1.739
(7.242)
0.048
e
0.357a
0.953
0.026
5.449
(7.242)
0.136
0.789
e
n ¼ 250.
a
P < 0.001.
b
P < 0.05.
their hospital stay. These findings are not unexpected and are consistent with those reported in previous studies on the topic, such
as those of Ward and Gordon,22 Miaskowski
et al.,21 Bookbinder et al.,20 and Lin.25 These
authors also found that patients were satisfied
with their analgesic treatment even when
they had or had had severe pain. In our opinion, this could mean that many Spanish patients still think, in some way, that to feel
pain is normal after a surgical procedure or
during the evolution of a disease. The APS
Quality of Care Committee has provided a similar explanation.27 They proposed that the paradox of high satisfaction despite high pain
scores could have two possible explanations.
First, that a high score in pain intensity
(VAS) has a poor clinical correlation with perceived pain and, second, that the patient satisfaction scores are a reflection of their
satisfaction with the medical staff and not
with the analgesic treatment. Hirsh et al.,35 investigating satisfaction with treatment for
chronic pain, recorded these findings separately. They analyzed two different variables:
satisfaction with care and satisfaction with
improvement. The results showed that satisfaction with care was significantly higher than satisfaction with improvement.35 There is no full
and proven explanation for this paradox, and
studies are underway in our country to prove
or refute such hypotheses.36 However, some
assumptions based on the correlation and
the multiple regression analyses carried out
in this survey will now be discussed.
The Spearman correlation analysis shows
a positive relationship between ‘‘Dissatisfaction
with Staff’’ and ‘‘Dissatisfaction with Treatment.’’ This finding suggests that those patients satisfied with pain treatment were also
those who were satisfied with the medical staff,
and confirms the strong link between both
items. On the one hand, this can be considered as positive, because it is logical that one
factor can be influenced by the other and,
on the other hand, it brings out a limitation
of the instrument because it cannot differentiate between whether the patient is genuinely
satisfied with the analgesic treatment or if it
is just a reflection of his/her satisfaction with
the medical staff. The positive relation between ‘‘Dissatisfaction with Treatment’’ and
‘‘Pain Now,’’ ‘‘Worst Pain,’’ ‘‘Least Pain,’’ and
‘‘Expected Pain Relief’’ is also reasonable. Factors such as pain intensity and the time elapsed
from when a patient asks for an analgesic until
it is administered can influence the opinion of
any patient, even if he/she expects to feel
a specific amount of pain.
‘‘Pain Now’’ was negatively related to ‘‘Age,’’
meaning that older people were the ones who
stated feeling less pain at the time of the interview. These results conflict with the results of
similar studies made with patients of different
Vol. 32 No. 4 October 2006
Perceptions with Pain Management
cultures,37 where older patients tend to express a higher intensity of pain than younger
ones. It has to be taken into consideration
that a large number of the older patients had
a surgical cause of pain, since surgical patients
tend to have a higher score in pain intensity
than nonsurgical ones. Several studies have
demonstrated an increased prevalence of
pain with increasing age,38,39 but these studies
were done with ordinary ambulatory persons,
and there are just a few studies that address
age-related prevalence of pain in hospitalized
patients.40 Melotti et al.32 also found the highest prevalence in young patients (19e30 years
old). Additionally, a factor that was not considered in our study was the length of hospital
stay of patients from Internal Medicine. However, most patients were from surgical wards
with a short hospital stay, so then, the contribution of this factor to our results might be negligible. A specific survey that addressed this
hypothesis merits further exploration.
The study shows us that pain is still a problem at our hospital, as many patients described
having severe pain. This does not mean that
analgesic treatment is not, at least partially, effective to relieve pain. For instance, the mean
difference between ‘‘Worst Pain’’ and ‘‘Least
Pain’’ was 56, which corresponds to a great reduction in pain. It can be inferred from these
results that analgesic treatment is effective,
though some therapeutic details have to be reviewed to be able to reach a goal of lesser pain
perception during hospitalization.
Another interesting finding is that almost
half of the studied population did not ask for
an analgesic; this does not mean they were
not in pain, but rather that they did not ask
for any medication even though they were in
pain. So, there were many patients who felt severe pain, did not ask for an analgesic, and
were satisfied with the analgesic treatment as
well as with the medical staff. This finding is
very peculiar in some places where the patients’ beliefs about pain lead them to expect
pain after surgery or during a disease. This assertion is justified by another finding of our
study. Fifty-eight percent of the patients felt
the quantity of pain they expected, and more
than 30% expected more, meaning that a great
many patients expected to suffer pain during
their hospitalization. These data counsel for
better education on pain issues to erase
369
patients’ misbeliefs and avoid this unnecessary
and silent suffering.
Ninety percent of all patients answered that
they were not told that pain treatment was important to the medical staff. This finding not
only manifests the lack of importance given to
the treatment of pain or to the perception of
pain during the course of an illness, but also
suggests that the attitudes of the medical staff toward pain and its importance are not adequate
and should be investigated. Additionally, 10%
of the positive answers to the item regarding
the importance given by the medical staff to
pain treatment differ greatly with the results of
previous studies made with subjects of different
cultures, such as Miaskowski et al.,21 who reported 67%, Ward and Gordon,22 who recorded
84%, or McNeill et al.,24 who gave a figure of
67%. Although there are no comparative studies analyzing attitudes of Spanish medical staff
on pain treatment, the prevalence rates of postoperative pain in recent studies seem to indicate
that this is not a high priority of care.10,11
Data from multiple regression analysis
makes a significant contribution to understanding how dissatisfaction with treatment is
influenced by characteristics of pain treatment
and peculiarities of medical care. In this way, it
suggests that ‘‘Pain Now,’’ ‘‘Least Pain,’’ ‘‘Dissatisfaction with Staff,’’ and ‘‘Expected Pain Relief’’ may predict ‘‘Dissatisfaction with
Treatment.’’ This shows the considerable impact that the medical staff and the perception
of pain can have on patient satisfaction. Since
pain is a subjective experience, patient satisfaction has to be interpreted as the sum of a great
variety of factors, which will also depend on
the cultural beliefs of the studied population.
Our efforts should be directed to changing
the patient’s belief that feeling pain is a normal
and expected sensation that will be experienced after any surgery or medical condition.
This assumption is also justified by the observation that ‘‘Dissatisfaction with Treatment’’ is
strongly related to ‘‘Expected Pain Relief’’:
more ‘‘Expected Pain Relief’’ and less ‘‘Dissatisfaction with Treatment.’’ As shown by this analysis, age did not contribute to explain such
differences.
In summary, our study shows that perceptions of Spanish patients with pain management are in some agreement with studies
performed in other countries and confirm
370
Malouf et al.
the severe pain-high satisfaction paradox.
Additionally, a relationship among different
variables, such as expected pain relief, dissatisfaction with medical care, and pain intensities,
has been identified. All three contribute independently to the dissatisfaction of patients with
pain management. This raises the hypothesis
that analgesic treatment may improve if patients change their beliefs on pain issues and
ask their physicians for better treatment. Further studies should refine this statement and
test whether there is any relationship with sociodemographic variables, such as gender and
age.
Acknowledgments
The authors would like to thank Dr. Jeanette
A. McNeill for sharing with them several articles that have enriched this survey’s discussion.
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Appendix
Patient Perception with Pain Management Questionnaire (PPPM)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
En algún momento desde que su ingreso en el hospital, ¿ha tenido dolor? Si , No ,
En las últimas 24 h, ¿ha tenido dolor en algún momento? Si , No ,
¿Ha necesitado pedir analgésicos para tratar su dolor? Si , No ,
En una escala de 0 a 10 representando 0 ‘‘no dolor o ausencia de dolor’ y 10 ‘‘el peor dolor que pueda imaginar’
¿qué dolor tiene actualmente?
En esta escala, ¿cuál es el dolor más leve que ha tenido desde el ingreso?
En esta escala, ¿cuál es el peor dolor que ha tenido desde el ingreso?
En las últimas 24 h, cuando pidió analgésicos/calmantes, ¿cuál fue el mayor tiempo que tuvo que esperar
hasta su administración?
, No pidió analgésicos , 0-15 min , 16-30 min , 31-60 min , más de 60 min , No se administró
¿Qué opinión le merece la mejorı́a del alivio del dolor con los analgésicos/calmantes?
, Estoy muy satisfecho , Estoy satisfecho , Algo satisfecho , Ni satisfecho ni insatisfecho , Algo
insatisfecho , Insatisfecho , Muy insatisfecho
¿Qué opinión le merece la atención de los médicos/las enfermeras al explicarles que tenı́a dolor?
, Estoy muy satisfecho , Estoy satisfecho , Algo satisfecho , Ni satisfecho ni insatisfecho , Algo
insatisfecho , Insatisfecho , Muy insatisfecho
¿Le comentaron sus médicos y/o enfermeras que el tratamiento del dolor era importante para ellos?
, Sólo los médicos , Sólo las enfermeras , Ambos , Ninguno
¿Le insistieron sus médicos y/o enfermeras que les avisara si tenı́a dolor?
, Sólo los médicos , Sólo las enfermeras , Ambos , Ninguno
¿Qué grado de alivio le ha proporcionado el tratamiento del dolor que se le ha administrado?
, Mucho menos de lo que esperaba , Bastante menos de lo que esperaba , Algo menos de lo que
esperaba , Lo que esperaba , Algo más de lo que esperaba , Lo que esperaba , Algo más de lo
que esperaba , Bastante más de lo que esperaba , Mucho más de lo que esperaba