Purpose. To assess the overall awareness and use of nonpharmacologic interventions among clinical nurses as well as the efficacy of pain management in one tertiary medical center.
Methods. This descriptive study used quantitative methods and cross-sectional data collection involving a convenience sample of nurses. Triangulation involving three distinct methods of data collection was used to strengthen the rigor (see Defining terms).
Results. All participants used one or more nonpharmacologic interventions. Interventions used most frequently were positioning and repositioning (97%), application of heat or cold (95.6%), and distraction (92.7%). Interventions used least often were spiritual practices (20.6%), transcutaneous electrical nerve stimulation (10.3%), and superficial massage (32.4%).
Conclusion. This study provided an initial glimpse into the use of nonpharmacologic interventions by clinical nurses and identified opportunities for future research and for education of nursing students and practicing nurses. Because nurses believe that they have not been sufficiently educated about nonpharmacologic methods of pain management, further education should be given to nurses regarding assessing and understanding pain holistically, along with the use of nonpharmacologic interventions.1
In the US, over 15,000 people died from an overdose of prescription opioids in 2015.2 According to the CDC, opioid prescriptions and overdose deaths have quadrupled since 1999.2 In 2012 alone, healthcare providers (HCPs) wrote a quarter of a billion opioid prescriptions. Two times more opioids were prescribed per person in the US than were prescribed in Canada.3 Not surprisingly, prescription opioids are now recognized as a driving force in what the CDC is calling an opioid overdose epidemic, and HCPs and hospitals are scrambling to understand and address the problem.4,5 With this recent focus on the overprescribing of opioids for pain control, nurses need to be aware of nonpharmacologic interventions to manage pain.
Pain has been defined as the perceived and unpleasant response to actual or potential tissue damage.6 Pain is also categorized as mild, moderate, or severe. Mild pain is characterized as annoying and nagging; it does not typically impact activities of daily living. Moderate pain is irritating and can impair the person's ability to perform activities of daily living. Severe pain dominates one's senses, preventing performance of activities of daily living.7
In healthcare settings, pain intensity is frequently rated on a scale of 0 (no pain) to 10; the greater the pain, the higher the score.8
Beyond numeric pain ratings, pain can also be classified by source or location or by duration.
Using opioid analgesics to treat pain is widely accepted for patients experiencing acute pain, cancer-related pain, or terminal illness.9 However, the CDC recommends nonopioid and nonpharmacologic interventions as first-line approaches for the treatment of chronic pain not related to cancer or end-of-life care.10 If opioids are needed for chronic pain, they should be used in conjunction with nonopioid medications and nonpharmacologic interventions.4
Nonpharmacologic interventions, which include physical and psychological strategies to reduce pain, can be used as a first-line measure and as an adjunct in multimodality management. Nonpharmacologic interventions include distraction, relaxation, or imagery; superficial massage; breathing techniques; music therapy; spiritual practices; environmental modification (such as reducing lighting and noise); positioning and repositioning; heat or cold application; and transcutaneous electrical nerve stimulation (TENS).8 Among these nonpharmacologic interventions, only the application of TENS requires an HCP prescription.
Because effective pain management is such an important concern in healthcare, The Joint Commission mandates that hospitals have a system in place to address patients' reports of pain. However, The Joint Commission guidelines do not require a pain intensity level goal of 0 in managing pain. Rather, they require a patient-centered approach with consideration of the risks and benefits of the strategies used to manage pain as well as the potential for dependence and abuse.11
The Joint Commission also supports a multimodal approach using both pharmacologic and nonpharmacologic strategies to effectively manage pain.11 A multimodal approach to manage pain is the use of two or more medications with different mechanisms of action and nonpharmacologic interventions.6 This patient-centered approach is individualized to effectively meet the patient's pain needs and often involves lower doses of analgesia and fewer adverse reactions.12 The purpose of this study was to assess the overall awareness and use of nonpharmacologic interventions among clinical nurses in one tertiary medical center as well as the efficacy of pain management.
This study was guided by Watson's Theory of Human Caring for the conceptual framework. Watson's Theory portrays the practice of nursing with many parts in a relationship between caring, holism, and the scientific method.13 It supports the acceptance by nurses of patients' assessment of their pain, the significance of comfort in each patient's life, and an individualized response to patients. This descriptive study used quantitative methods and cross-sectional data collection involving a convenience sample of nurses. Triangulation involving three distinct methods of data collection was used to strengthen the rigor.
Setting and sample
The setting for this study was one large tertiary medical center in the Midwest. While the medical center has 31 inpatient nursing units, the study was limited to two nursing units: surgical and orthopedic. These two units were chosen based on similar size and pain management needs of the patient population. Nurse participation was voluntary and no names or personal identifying information was recorded.
Following institutional review board approval, an online survey was sent to 104 RNs on the two nursing units. Before the survey was sent, content validity for the survey tool was established through the review, revision, and consensus of two educators, four clinical nurses, and the medical center's nursing research committee.
The survey tool was comprised of 15 items. Of these, 3 demographic items addressed age, gender, and length of time as a nurse; 2 items asked whether the nurse believed he or she understands nonpharmacologic pain interventions and if the nurse had used a mix of pharmacologic and nonpharmacologic interventions in his or her nursing care; and 10 items addressed the use or nonuse of the nonpharmacologic interventions.
Data from patient interviews and the review of data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey addressed efficacy of pain management and use of nonpharmacologic interventions and enabled a triangulation of data. For the patient interviews, the principal investigator (PI) asked the charge nurse of each unit to suggest patients who were not confused but who had reports of pain. The PI then approached the suggested patients (eight patients on each unit) and posed the following five questions:
- Do you feel that your pain has been managed appropriately by your nurse(s)?
- Have you noticed that techniques other than pharmacologic (medication) have been used to assist in your pain management?
- If so, what? Heat or cold therapy, music, positioning/repositioning, relaxation and imagery, spiritual practices, superficial massage.
- Do you feel that the nonpharmacologic interventions helped?
- Has more than one nurse offered a nonpharmacologic pain intervention for you during this stay?
As per hospital protocol, HCAHPS surveys mailed to patients following hospital discharge include several items addressing patient care and patient satisfaction. For this study, HCAHPS analysis was limited to the patient's response of one survey item: “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”
The online survey was sent to clinical nurses and was open for 25 days. Of the 104 nurses invited to participate, 68 nurses responded to the survey for a response rate of 65.4%. Most respondents (n = 65) were female. The largest proportion of respondents were ages 18 to 30 (n = 28, 41.2%) and had worked as a nurse for 0 to 5 years (n = 36, 53%). All the nurses reported understanding what constitutes nonpharmacologic interventions and indicated that they had used both pharmacologic and nonpharmacologic interventions in managing patients' reports of pain.
All participants used one or more nonpharmacologic interventions. As shown in the chart above, interventions used most frequently were positioning and repositioning (66, 97%), application of heat or cold (65, 95.6%), and distraction (63, 92.7%). Interventions used least often were superficial massage (22, 32.4%), spiritual practices (14, 20.6%), and TENS (7, 10.3%).
All statistical analyses were performed using the open-source statistical program R, version 3.3.2, against a two-sided alternative hypothesis with a 95% confidence level. Counts and proportions of nurses that reported using each nonpharmacologic pain intervention divided by age categories (18 to 30, 31 to 43, 44 to 56, and 57 to 70) showed no significant difference (P < .05). However, a chi-square test (χ2) did reveal that the proportion of nurses who have used music as a pain intervention is distributed differently across length of time as nurse categories, χ2 (2, N = 68) = 7.93, P = .02. Approximately 76.5% of the group with 11 or more years of experience reported using music as a pain intervention, while only 40% of the nurses with 6 to 10 years of experience and 36.1% of the nurses with 0 to 5 years of experience reported using it. No other significant differences were found between the proportions of nurses using nonpharmacologic interventions across length of time as nurse categories.
Patient reports gathered during interviews were varied but were overall favorable regarding pain control with nonpharmacologic interventions. Of the 16 patients interviewed, 15 reported that their pain had been effectively managed during their hospitalization. When provided with examples, all patients reported that at least one of the nursing staff had utilized a nonpharmacologic pain intervention along with pain medication to assist in pain relief during their hospitalization.
In response to the HCAHPS item, a quarterly report of 431 HCAHPS scores from each unit was examined. Findings were similar, with 85% and 83% of patients indicating that the staff did everything they could to help with pain management. While these scores were deemed favorable, they did not meet the target threshold of 88% for this item, meaning there is still room for improvement in terms of the patient perspective.
Discussion and implications
It was encouraging that all nurses reported an understanding of nonpharmacologic interventions and had reported using both pharmacologic and nonpharmacologic interventions in their nursing practice. However, the limited use of some of the nonpharmacologic interventions, such as superficial massage, relaxation and imagery, and spiritual practices, indicate that more staff education concerning these interventions is needed to better promote adoption of these strategies. Additionally, the use of TENS as a nonpharmacologic intervention was rare. Only seven nurses (10.3%) indicated use of this intervention. The application of TENS requires an HCP prescription at this facility. Considering that systematic review of six studies involving TENS demonstrated evidence of pain reduction, TENS use represents a potential area of growth.14 Therefore, education regarding this strategy and its benefits may prompt nurses to request this intervention when escalating a patient's pain report.
Patient interviews were used, and all interviews were conducted by the PI. However, the PI did not perform medical record reviews, so it was unclear what the cause or location of the pain was, or if the patient's pain was acute or chronic. Also, asking patients if their pain has been appropriately managed may need rewording to something more precise, such as “Please describe what attempts nurses have made to control your pain.” Based on the response to this open-ended item, the PI could then list pharmacologic and nonpharmacologic interventions and ask which specific interventions were used.
While the findings did reveal three instances of significance related to length of time as a nurse and select nonpharmacologic interventions, the limitations of this study must be considered. Among these limitations are the one cross-sectional instance of data collection using a convenience sample of nurses at one tertiary care medical center, a relatively small number of patient interviews. Still, the findings provide a foundation on this important and timely topic and offer opportunity for future investigation. Continued study could better reveal current practice, changing trends in nonpharmacologic intervention use, and the influence of nurses' age and length of time as a nurse on the use of nonpharmacologic interventions.
This study provides an initial glimpse into the use of nonpharmacologic interventions by clinical nurses and identifies opportunities for future research and for education of nursing students and practicing nurses. At a time when opioid use is under close scrutiny, the need for innovative strategies to address pain management is a timely topic. Because nurses believe that they have not been sufficiently educated about nonpharmacologic methods of pain management, further education should be given to nurses regarding assessing and understanding pain holistically, along with the use of nonpharmacologic interventions.1 Nurses should integrate best practice initiatives and consider the danger and long-term consequences for patients taking opioids to effectively manage their reports of pain.11
1. Stewart M, Cox-Davenport RA. Comparative analysis of registered nurses' and nursing students' attitudes and use of nonpharmacologic methods of pain management. Pain Manag Nurs
2. Centers for Disease Control and Prevention. Prescription opioid overdose data. 2016. http://www.cdc.gov/drugoverdose/data/overdose.html
3. Centers for Disease Control and Prevention. Opioid painkiller prescribing. 2014. http://www.cdc.gov/vitalsigns/opioid-prescribing
4. Centers for Disease Control and Prevention. Increases in drug and opioid overdose deaths—United States, 2000-2014. MMWR Morb Mortal Wkly Rep
6. International Association for the Study of Pain. IASP Taxonomy
. 2014. http://www.iasp-pain.org/Taxonomy
7. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses
. Rockville, MD: Agency for Healthcare Research and Quality; 2008:474–502.
8. Potter P, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing
. 9th ed. St. Louis, MO: Elsevier; 2017.
9. Thomson L, Rait K, Miller L. Opioids in the management of persistent non-cancer pain. Anaesth Intensive Care Med
10. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report: CDC guideline for prescribing opioids for chronic pain—United States, 2016. http://www.cdc.gov/mmwr/
11. The Joint Commission. Joint Commission statement on pain management. 2016. http://www.jointcommission.org/joint_commission_statement_on_pain_management
12. Pasero C, Potenoy RK. Neurophysiology of pain and analgesia and the pathophysiology of neuropathic pain. In: Pasero C, McCaffery M, eds. Pain Assessment and Pharmacologic Management
. St Louis, MO: Mosby Elsevier; 2011.
13. Schreiber JA, Cantrell D, Moe KA, et al Improving knowledge, assessment, and attitudes related to pain management: evaluation of an intervention. Pain Manag Nurs
14. Igwea SE, Tabansi-Ochuogu CS, Abaraogu UO. TENS and heat therapy for pain relief and quality of life improvement in individuals with primary dysmenorrhea: a systematic review. Complement Ther Clin Pract
15. Kim M, Mallary C. Statistics for Evidence-Based Practice in Nursing
. 2nd ed. Burlington, MA: Jones & Bartlett Learning; 2016.
16. Salkind NJ. Encyclopedia of Measurement and Statistics
. Thousand Oaks, CA: Sage Publications; 2007.
17. Polit D, Tatano Beck C. Nursing Research: Generating and Assessing Evidence for Nursing Practice
. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.
18. Dawson B, Trapp RG. Basic and Clinical Biostatistics
. New York, NY: McGraw-Hill Medical; 2004.
19. Dumont C, Meisinger S, Whitacre MJ, Corbin G. Horizontal violence survey report. Nursing
20. Heale R, Forbes D. Understanding triangulation in research. Evid Based Nurs
21. Pagano M, Gauvreau K. Principles of Biostatistics
. 2nd ed. Boston, MA: Cengage Learning; 2000.