The purpose of this project was to survey nurses' knowledge of pain management for patients with combat-related traumatic brain injuries (TBI).
The purpose of this project was to survey nurses' knowledge of pain management for patients with combat-related traumatic brain injuries (TBI).
A survey was used to collect data regarding nurses' knowledge of pain assessment and management for patients with combat-related TBI. Nurses were invited to participate in the study via email and provided with a link to the electronic survey.
Twenty-five surveys were returned (52% response rate). A total of 76% of nurse respondents perceived that TBI patients over report pain intensity. Only 40% of nurses were able to correctly identify the appropriate medication to treat migraine-type headache pain in TBI patients.
This study identified gaps in knowledge regarding pain management for patients with combat related TBIs.
Nurses need additional education regarding common pain syndromes, available treatments, and a better understanding of addiction in order to provide optimal care to these patients.
Approximately 273,859 service members and veterans acquired a traumatic brain injury (TBI) between 2000 and February of 2013 (Defense and Veterans Brain Injury Center [DVBIC], 2013). These numbers include deployed and nondeployed service members as well as veterans in the United States Armed Forces with a medical diagnosis of TBI. The severity of TBI is ranked in the Armed Forces Health Surveillance Center as penetrating, mild, moderate, severe, or not classifiable (DVBIC, 2013). Penetrating TBI encompassed 4,275 cases from 2000 to 2013. Mild TBI represents the majority of cases with a total of 225,718 injuries. Moderate TBIs were diagnosed in 22,404 cases, severe TBI in 2,799, and 18,663 of TBIs were not classifiable (DVBIC, 2013). The prevalence of these TBI within the military/veteran population has increased since 2000, and this may be attributed to increasing blast exposure (Adamson & Metscher, 2008; Tan et al., 2009). Since people with TBI frequently lack external signs of trauma, they are considered “invisible injuries” and often go unrecognized, under diagnosed, and untreated (Schell & Marshall, 2008; Tan et al., 2009).
The incidence of TBI is of increasing concern because one of the most frequent complications of combat-related TBI is chronic pain, most commonly experienced as headache (Nampiaparampil, 2008; Tan et al., 2009; Theeler, Lucas, Reichers & Ruff, 2013). Service members and veterans with combat related TBI experience significantly less pain relief compared to those with other combat injuries and are more likely to experience loss of auditory and/or visual sensation from extensive tissue damage (Walker, Clark & Sanders, 2010). These impairments are detrimental to patient's cognitive functioning and can interfere with their ability to communicate symptoms (Lew, Garvert et al., 2009; Lew, Otis et al., 2009). Thus, these deficits frequently make pain assessment and management more challenging.
Service members and veterans with combat-related TBIs are at higher risk for chronic pain, depression, and posttraumatic stress disorder (PTSD; Adamson & Metscher, 2008; Tan et al., 2009). Development of PTSD can create overlapping symptoms with TBI and chronic pain, making pain assessment during rehabilitation more complex and difficult (Tan et al., 2009). TBI-related pain is involved and problematic to evaluate and manage without an understanding of the relationships among these issues. For example, poor concentration and depressed mood can occur with PTSD, chronic pain, and TBI (Lew, Garvert et al., 2009; Lew, Otis et al., 2009). Inadequate pain management will continue to be a problem in this population because TBI guidelines currently lack an approach to assess and manage combat-related TBI pain (Bazarian, McClung, Cheng, Flesher & Schneider, 2005; United States Department of Veterans Affairs, 2010). The current management of combat-related TBI utilizes clinical practice guidelines for primary headache and/or opioid therapy that are not necessarily specific to TBI (DVBIC, 2011; United States Department of Veterans Affairs, 2010; Waung & Abrams, 2012). Without additional guidance, care providers, including rehabilitation nurses, may be unaware of or inconsistent in their use of best practices regarding pain assessment and management of patients with a combat-related TBI. The purpose of this project was to survey rehabilitation nurses' knowledge of pain assessment and management for people with combat-related TBI.
Combat-related injuries are complex and present with unique characteristics that require intensive, early rehabilitation care. In examining the unique aspects of combat-related injuries, Sayer et al. (2008) reviewed veteran cases (n = 188) and noted the most common impairments observed included impairment of cognition (88%) and pain (83%). Additionally, concurrent psychiatric symptoms were observed in 57% of cases, with PTSD observed in 42% of cases. These results are consistent with findings from a retrospective study by Lew, Garvert et al. (2009), Lew, Otis et al. (2009) that reported the presence of chronic pain in 81.5% of veterans with combat-related TBI, postconcussive symptoms in 66.8%, and PTSD in 68.2%. Postconcussive symptoms refer to physical, cognitive, and/or behavioral difficulties lasting longer than 3 months following a TBI. Further analysis demonstrated that 42% of injured veterans simultaneously experienced all three of these conditions (Lew, Garvert et al., 2009; Lew, Otis et al., 2009). The interactions between chronic pain, postconcussive symptoms, and PTSD are poorly understood and require further investigation as inadequate knowledge of the interaction of these problems makes pain assessment and diagnosis challenging in patients with combat related TBI.
Those headaches associated with combat-related TBI can be complex to assess and treat. Patil et al. (2011) investigated characteristics of acute headache pain associated in service members with combat-related TBIs. Headache pain was reported by 74% of the sample, and 64% of those surveyed reported at least one blast exposure. The types of headaches most frequently observed in the study included migraine headache (44.6%) and chronic daily headache (19.6%). Headaches were primarily managed by patients treating themselves with medication, namely acetaminophen (50%) or ibuprofen (29%). Neurologists, on the other hand, treated subjects with triptans or anticonvulsants for prevention of headaches. The effectiveness of medication regimens started by neurologists for people in the study was unknown due to poor compliance with follow-up appointments. Currently, patients returning with combat related TBI and headache pain are being managed using United States Department of Veterans Affairs (2010) clinical practice guideline algorithms for primary headache management and/or opioid therapy. According to this algorithm, headaches are classified as either episodic or chronic (DVBIC, 2011). Within these guidelines, episodic headaches are treated with acute abortive treatments including the use of triptans, nonsteroidal anti-inflammatory drugs, combination medications (e.g., acetaminophen/butalbital/caffeine [Fioricet®, Watson Pharmaceuticals, Parsippany, NJ] or acetaminophen/dichloralphenazone/isometheptene [Midrin®, Caraco Pharmaceutical Laboratories Ltd., Detroit, MI]), or alternative agents such as metoclopramide. Chronic headaches, defined as those that occur greater than 15 days per month, are treated with antidepressants, antiepileptics, and beta-blockers per available guidelines (DVBIC, 2011). While it is current standard of practice to treat combat-related TBI using a primary headache and/or opioid algorithm, these do not yet have supporting evidence for their effectiveness in this specific population and further study is warranted.
Nurses and patients are dissatisfied with the effectiveness and use of current pain measurement tools. A series of qualitative studies have revealed problems with clinical pain assessment tools identified both by patients and nurses. In one such qualitative study of 23 adults with a chronic disabling condition (e.g., spinal cord injury [SCI], multiple sclerosis) performed to examine patient's experiences of pain (Yorkston, Johnson, Boesflug, Skala & Amtmann, 2010), the major themes identified included the uniqueness of their pain experiences, patients' dissatisfaction with the Likert-type numerical pain rating scale, and patients' poor communication with providers. However, the majority of participants were white women, so study findings may not be applicable to the entire disabled population experiencing pain, particularly male veterans. Nurses also report dissatisfaction with current pain assessment tools used in critically ill patients (Subramanian, Allcock, James & Lathlean, 2011). The majority of nurses felt pain assessment tools are inconsistently used and more guidance in their use is needed. Overall, nurses in this study felt inadequately prepared to evaluate and treat pain despite the majority having 5 years or more of critical care nursing experience (Subramanian et al., 2011). It is possible that a relationship exists between years of nursing experience and knowledge levels in pain management. Although the critical care setting is very different from the rehabilitation setting, it is likely that similar gaps in pain assessment and management knowledge exist across settings where nurses encounter patients.
In summary, patients with combat-related TBI frequently experience concurrent headache pain, cognitive and psychiatric impairments. These complex factors make pain assessment and management difficult in this population. Additionally, pain assessment tools used in practice are problematic, particularly in people with chronic disabling conditions, such as combat-related TBI. Developing an understanding of nurses' knowledge of pain management practices in people with TBI is therefore important, given the complex pain management needs and treatment decisions required to ensure optimal care. The goal of this study was to describe nurses' knowledge levels of pain assessment and management of TBI on rehabilitation units. As a secondary goal of the study, we wanted to explore if level of education or years of experience were associated with knowledge of pain.
A nonexperimental cross sectional survey design was used to describe nurses' knowledge of pain assessment and management for patients with combat-related TBI. The study received Institutional Review Board approval.
A convenience sample of nurses working on two rehabilitation units in the Pacific Northwest (General Rehabilitation and SCI) was used. Rehabilitation nurses were invited to participate in the study via e-mail. Although SCI is frequently a specialty unit, nurses on the study unit provide rehabilitation care to patients with other injuries including mild to severe TBI. This is relevant outside of this particular setting as it has been estimated that 25–70% of patients with SCI have concomitant brain injuries (Bradbury et al., 2008; Tolonen, Turkka, Salonen, Ahoniemi & Alaranta, 2007). Participants had to meet the following inclusion criteria: Nurse (RN or LPN) working on a participating rehabilitation unit who has cared for patients with combat-related TBI in the past year. Nurses needed more recent experience with the TBI population to identify if an association exists between years of experience and knowledge of pain.
A validated survey to evaluate cancer pain, McCaffery and Ferrell's Brief Pain Survey (Ferrell & McCaffery, 1999) was used for this study. The initial instrument has a test-retest reliability of r > .80 and an internal consistency reliability of alpha r > .70 (Ferrell & McCaffery, 1999). The original survey was used to assess nurses' knowledge of cancer pain. To assess nurses' knowledge of TBI pain, approximately 10 questions were amended. A panel of three PhD prepared nurses was established to assess the content validity of the survey. The specific expertise of the panel is as follows: the first panelist has over 25 years of experience as a rehabilitation nurse practitioner and care of TBI patients and is certified in rehabilitation nursing (CRRN); the second panelist is trained as both a neuroscience clinical nurse specialist and nurse practitioner and is certified in neuroscience nursing (CNRN) and is a nationally recognized expert in TBI; the third panelist is a nationally recognized pain expert. A pilot test to ensure clarity of the newly amended items was subsequently conducted among nurses with rehabilitation experience who did not participate in the study sample (n = 2). The survey consisted of five demographic items, eight knowledge questions, and six questions regarding adequacy of pain knowledge and tools. Questions were divided into two categories: (1) adequacy of current assessment tools and (2) knowledge in TBI pain assessment and management.
During shift report, potential participants were invited to complete the survey and notified that participation was voluntary. Eligible participants received information about the study and were provided with an electronic link to complete the anonymous survey (WebQ, Catalyst Tools, University of Washington, Seattle, WA) via e-mail. Participants had 2 weeks to complete the survey and a reminder was sent out 1 week following the initial invitation to encourage survey completion. Return of the survey was deemed consent to participate.
Survey data were collected and downloaded into both SPSS 16.0 (IBM, Armonk, NY) and Excel (Office 2010, Microsoft, Redmond, WA). SPSS software was used to perform statistical analyses including simple descriptive statistics (number, percentage) and Chi-squared testing. Chi-squared testing was performed to explore the relationship between knowledge of pain and level of education or years of experience. Values were considered statistically significant if p < .05. An Excel spreadsheet was used to organize data from the open-ended responses to questions. The spreadsheet was then used for coding and organization into thematic areas.
Twenty-five nurses completed the survey (52% response rate). The majority of participants were female (52%), white/non-Hispanic (44%) and had greater than 10 years of experience (52%; Table 1).
|Sex||Female 13 (52)|
|American Indian||1 (4)|
|African American||3 (12)|
|White, non-Hispanic||11 (44)|
|Decline to respond||3 (12)|
|Years of experience|
When participants were investigated if TBI patients over-report the amount of pain they have, 76% of respondents reported that >40% of patients over-report pain. However, when nurses were investigated “Who is the most accurate judge of pain intensity?” 96% reported the patient as the best judge. When comparing differences in TBI pain management across educational preparation, the only statistically significant difference (p < .05) identified involved the perception that patients over-report pain. Licensed Practical Nurses were more likely than those with ADN, BSN or advanced nursing degrees to think TBI patients over-report the amount of pain they have.
In a case scenario question of a patient with inadequate pain relief with orders to give “morphine 1–3 mg IV q1 h as needed (prn) for pain relief,” only 33% of nurses were willing to give the maximal allowed dose despite inadequate pain relief with a prior dose of 2 mg and no contraindications to administering the higher dose. In another case scenario question, a TBI patient complained of a persistent, sharp unilateral headache rated 9/10. Survey responses indicated nurses were just as likely to choose to give Tylenol® ([McNeil Consumer Healthcare, Fort Washington, PA] (acetaminophen; 40%) as Maxalt® ([Merck and Co., Whitehouse Station, NJ] rizatriptan benzoate; 40%) from a list of ordered as-needed medications as the first medication for headache treatment. However, 64% of nurses were able to identify the appropriate complementary therapies (e.g., biofeedback) for headache in a separate case scenario.
Nurse respondents were also investigated as to how well they felt they and other practitioners were doing in providing treatments for (or managing) TBI-related pain. The majority of nurses felt they and practitioners are doing a “good job” at providing treatments for TBI-associated pain (Table 2). Most nurses reported, being “somewhat confident” in managing TBI-associated pain. (Table 3).
|Rating of Ability to Treat TBI-Associated Pain||Physicians (or Other Prescribing Practitioners, %)||Nurses (%)|
At the end of the survey, nurses were given the opportunity in an open-ended question to describe what they believe are “the biggest gaps in pain management” for people with TBI. Themes reported included lack of understanding of TBI-related pain as well as addiction. Additional themes involved a need for more TBI education and a formal pain assessment and management protocol as exemplified by the following examples:
The biggest gap that I can think about is my lack of understanding and knowledge on how to relate to a [patient] with TBI. More in-services should be done to ensure that nurses will have the knowledge to interact and care for TBI patients.
It's differentiating [between] subjective and objective data. I was taught that “pain is always what the patient states”; however, there have been instances where “drug seeking” and patients learning how to work the system have been a problem. If the patient is able to function [does] ADLs and shows no apparent symptoms (i.e., facial grimacing, covering painful areas), but reports 8/10 pain I would def[initely] re-check orders/med[ication] parameters and monitor signs of medication abuse. Neuro checks and good judgment.
When investigated about what should be done to improve TBI pain management practice, 83% of nurses responded with algorithms, pain scales, and tools. The preferred methods to receive TBI education based on survey responses were via in-service (68%) and an online module (24%).
Open-ended responses from nurse participants echo the survey findings that there is a lack of knowledge and a need for further education for rehabilitation nurses in pain management for patients with combat-related TBI.
In summary, a survey was used to measure nurses' knowledge of pain management for patients with combat-related TBI on rehabilitation units and the following issues for continued education were identified: (1) migraine-type headache management, (2) misconceptions about who is the best judge of pain, and (3) patients over-reporting pain levels. Another aim of this study involved making comparisons between level of education and years of experience and knowledge of combat-related TBI pain management. The only significant finding (p < .05) identified between RN and LPNs was misconceptions regarding patients over-reporting pain levels. Based on these study findings, it is possible that nurses in general lack understanding of the complexity of TBI pain. TBI-related pain is complicated because it can overlap with components of PTSD, chronic pain, and cognitive impairments (Lew, Garvert et al., 2009; Lew, Otis et al., 2009; Sayer et al., 2008). Additional education is needed in overlapping mental health conditions to improve pain assessment and management. While a full discussion of TBI pain and its management within the context of a mental health disorder is beyond the scope of this study, those interested in understanding more are pointed to existing reviews on the topic (e.g., Dobscha et al., 2009; Maguen, Lau, Madden & Seal, 2012; Theeler et al., 2013; Vanderploeg et al., 2012; Wilk, Herrell, Wynn, Riviere & Hoge, 2012).
Other studies have explored nurses' knowledge about pain management for specialized populations (e.g., oncology, geriatric, and pediatric). Our study findings are similar to those of Patiraki et al. (2006) who reported over 50% of oncology nurses incorrectly answered pretest pain assessment questions. The highest percentage of incorrect answers were for the following concepts: analgesic properties of pain medications, nursing actions for reporting severe pain in the absence of altered vital signs, and nursing actions for patients reporting severe pain in the absence of behavioral changes. Incorrect responses were given for analgesic properties of headache medications, nursing actions for treating patients with inadequate pain relief in the absence of behavioral changes, and nurses reporting of patients' pain experiences. In this trial, knowledge levels significantly increased after a 1-day educational intervention involving videotape viewing and a case scenario discussion.
It is critical to consider the format of in which education is delivered to successfully translate content to the practice setting. The effectiveness of a 30-minute in-person nurse education program on pain assessment and management was evaluated using a quasi-experimental approach (Micheals, Hubbartt, Carroll & Hudson-Barr, 2007). Nurses from medical/surgical, geriatric, and pediatric units participated in this study. No differences were noted after the intervention. Thus, while 68% of nurses in our study preferred to receive TBI education as an in-service, careful consideration must be made to the cost-effectiveness of such a format. These brief unit-based in-services require one or more individuals to deliver content to multiple shifts, and frequently do not reach all staff. Although these short briefings may be preferred, they may not be the most successful means of translating evidence to practice as per the Micheals, Hubbartt, Carroll and Hudson-Barr (2007) study. In contrast, Salinas and Abdolrasulnia (2011) conducted a quasi-experimental study evaluating pain-related decision making using multimedia case vignettes. The educational intervention used in this study involved 10 regional meetings and one satellite symposium over the course of 6 months. Participants were nurses from hospitals and pain clinics. Case vignettes revealed that intervention participants were significantly (51%) more likely to assess pain more frequently than control group participants (36%). Overall, intervention participants were 52% more likely to later make evidence-based pain care decisions. This study demonstrates that multimedia pain education programs can be an effective intervention for not only pain education delivery but also to support evidence-based practice decisions. As participants in our study indicated that online learning module was an acceptable method of pain education delivery, and this method has demonstrated success in pain education, it is recommended for future development due to other benefits such as ability to reach all staff on all shifts once developed.
Pain impacts at least 116 million American adults. It is costing the nation up to $635 billion each year in lost productivity and medical treatment (IOM, 2011). Reliable data are lacking especially in military service members and veterans. Improving pain management education should allow rehabilitation nurses to better understand TBI and PTSD. Increasing understanding of invisible injuries, TBI and PTSD, of the Iraq and Afghanistan war is a Joining Forces Initiative (Joining Forces, 2012).
This study identified nurses' knowledge about TBI pain management on rehabilitation units. It is important to measure the extent of knowledge among nurses because they play a key role in the recovery of service members and veterans. Nurses are expected to assess and document pain intensity, select appropriate treatments, and document outcomes. Efforts need to be made to gain a better understanding of pain and overlapping mental health conditions to bridge knowledge gaps. Bridging knowledge gaps and increasing understanding of TBI pain for service members and veterans has the potential to improve care delivery.
There are limitations of this study that ought to be noted. The sample size was small and involved nurses from only two rehabilitation units in one medical facility and thus, findings may not be applicable to all nurses in a variety of clinical settings. It is also possible potential selection bias may have influenced findings.
In this study, a survey was used to identify nurses' knowledge regarding pain management for patients with combat-related TBI on rehabilitation units. Knowledge gaps were identified to gain an understanding of nurses' knowledge as a basis for planning future educational programs. This study differs from others because it is the first published study that we are aware of to examine pain management knowledge of nurses caring for service members and veterans with combat-related TBI on rehabilitation units. Validation of these findings in other samples of nurses is needed. Further work to improve pain management curricula and impact of overlapping mental health conditions for all nurses caring for TBI patients is warranted, and should be included in national efforts such as the NIH Centers of Excellence in Pain Education and ARN Clinical Practice Guidelines. Once developed, these curricula need to be evaluated for their ability to change not only knowledge levels, but translate to evidence-based practice decisions. Redesigning pain management education may be a useful approach for reduced symptom burden, enhanced quality of life, and improved healthcare delivery for service members and veterans with TBI.
This study was made possible by the Nurse Practitioner Healthcare Foundation/Purdue Pharma L.P. Pain Management Grant and National League of Nursing Jonas Scholar Award. Special thanks to the rehabilitation nurses on the SCI unit for their support with this project.
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Directions: Please select one answer for each question
Years of experience as health professional
Which unit do you work in?
Highest level of education
Patient A: Andrew is 25 years old and he has a combat-related traumatic brain injury (TBI). As you enter the room, he smiles and continues talking and joking with his visitor. Your assessment reveals the following information: BP = 120/80; HR = 80; R = 18; on scale of 0–10 (0 = no pain/discomfort, 10 = worst pain/discomfort) he rates his pain as 8.
Patient B: Robert is 25 years old and has a combat-related TBI. He complains of a persistent sharp 9/10 unilateral headache. The medications available per request as needed (PRN) for headache pain include Tylenol, Oxycontin, and Maxalt. What medication therapy would you select to provide the most pain relief for his headache?
Questions 1–5 were developed by Ferrell and McCaffery (1996) Pain Assessment Behavior Survey.
Questions 6–10 were developed by Ferrell and McCaffery and Ferrell (1996) Brief Cancer Pain Information Survey.