This month’s important CE article, Identifying Pain and Effects on Quality of Life from Chronic Wounds Secondary to Lower-Extremity Vascular Disease: An Integrative Review, underscores the need for highly organized and active listening skills on the part of the practitioner when taking and documenting a pain history from individuals with chronic wounds. The pain history is interdependent on the assessment of the “whole person” as promulgated by Siebens1; this holistic concept pulls us back from our professional purviews (specialties), reminding us to perform as an interprofessional team centering the patient. The Siebens Domain Model1 expands beyond the evaluation of a single wound, to encompass (1) medical/surgical issues, (2) mental status/emotions/coping, (3) physical function, and (4) living environment.1
For lower-extremity vascular disease, the Siebens Domain Model may add a multidimensional aspect to the patient evaluation.1 Venous ulcers (VUs) are a relevant public health issue, with high cost, excess morbidity, and reduced quality of life.2 The natural history of VUs exemplifies issues of chronicity, the complexity of care, and recurrence. Moreover, patients with this disease are susceptible to impairment.2–4 In a systematic review related to the quality of life of people with VU, the most frequently patient-reported symptom is pain, giving the patient a constant awareness of the disease.2 From this perspective, it is clear that providers must evaluate self-efficacy and augment it through teaching and learning strategies.2–6
Self-efficacy describes a set of beliefs about oneself, specifically about one’s ability to perform specific behaviors within a particular environment.5,6 Self-efficacy in those suffering from pain involves feelings about one’s ability to control the pain, the nihilistic emotions associated with exacerbations of pain while preforming activities of daily living, communicating their needs to health providers, and implementing advice about their pain. There is some evidence that higher self-efficacy brings more favorable outcomes, higher return-to-work rates, better treatment adherence, more effective pain control, and a better prognosis.5,6
Although many commonly used pain scales have been found to be reliable and valid, most rely on subjective patient communication, which may skew clinicians’ patient perception and pain interpretation.7 Currently, there exists no valid and reliable method of objectively quantifying an individual’s experience of pain.8 Kleinman9 uses an explanatory model to reconstruct the patient’s “illness narrative.” This ethnographic approach involves a series of questions to understand the meaning of illness or the pain based on the patient’s learned experiences. The following is a list of qualitative interrogatives clinicians can use to discover the patient’s lived experience, while expanding knowledge about the patient and the illness9:
- What do you call this problem?
- What do you believe is the cause of this problem?
- What course do you expect it to take? How serious is it?
- Why do you think it started when it did?
- What do you think this problem does inside your body?
- How does it affect your body and your mind?
- What do you most fear about this condition?
- What do you most fear about the treatment?
Getting an accurate pain history involves active listening skills, a “whole person” approach, promoting self-efficacy, and a combination of qualitative communication methods. With careful attention, providers can help patients effectively self-report pain.
1. Siebens H. Applying the domain management model in treating patients with chronic diseases. Jt Comm J Qual Improv 2001;27(6):302–14.
2. Oliveira RA, de Oliviera e Araujo R, Gomes da Costa V, et al. Self-efficacy, self-esteem and adherence to treatment in people with venous ulcer in primary health care. Bioscience J 2017;33(6).
3. Green J, Jester R. Health-related quality of life and chronic venous leg ulceration: part 1. Br J Community Nurs 2009;14(12):S12, S14, S16–7.
4. Green J, Jester R. Health-related quality of life and chronic venous leg ulceration: part 2. Br J Community Nurs 2010;15(3):S4–6, S8, S10.
5. Miles CL, Pincus T, Carnes D, Taylor SJ, Underwood M. Measuring pain self-efficacy. Clin J Pain 2011;27(5):461–70.
6. Baldwin KM, Baldwin JR, Ewald T. The relationship among shame, guilt, and self-efficacy. Am J Psychother 2006;60(1):1–21.
7. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs 2005;14(7):798–804.
8. Younger J, McCue R, Mackey S. Pain outcomes: a brief review of instruments and techniques. Curr Pain Headache Rep 2009;13(1):39–43.
9. Kleinman A. Supplementary Module 1: Explanatory Model. DSM-5 Handbook on the Cultural Formulation Interview. Arlington, VA: American Psychiatric Association; 2015.