Pain and suffering: responsiveness, progress and perserverence


30th Anniversary Invited Editorial reflecting on: Copp L.A. (1993) An ethical responsibility for pain management. Journal of Advanced Nursing 18, 1–3

Professional standards, public policy, the law and community conscience require pain assessment and pain management with sufferers seeking care and relief. The funding, reputation, accreditation and licensure of staff in hospitals, clinics, hospices and agencies offering home care depend on it. Thus, pain assessment and diverse modalities of intervention have gradually improved and evolved, replacing apathy, denial and inattention to pain and suffering.

In my 1993 Guest Editorial for Journal of Advanced Nursing (Copp 1993), I highlighted pain management as a fundamental ‘ethical responsibility’ of professional conduct. The introduction of pain assessment as a requirement may have seemed sudden to some nurses. To others, it seemed long overdue. There were those who said ‘but don't we already do that?’ These mixed perceptions indicate the wide disparity in pain practices not only among care facilities, but between care givers in the same setting.

Pain assessment

The nurse inquires of the patient: ‘On a pain scale of one to ten (one indicating the least pain and 10 the most) can you rate the pain you are having?’ The patient opens his eyes and replies, ‘About eight, nurse.’ The number hangs in the air. And then what?

The response of the nurse and subsequent therapeutic or non-therapeutic actions and interactions will depend on, and be the result of, several dimensions of needed skills and insights. These aspects represent pain work and outcomes on which nurse researchers, educators, and practising nurses have made steady progress in care of those in pain. They also signify large areas of crucial skills and insights necessary for continual development.

Skills and insights

Improved pain management and therapeutic practices require skills and insights which include:

  • • Ability to make skilled and astute choices regarding the effectiveness and appropriateness of pain assessment tools and techniques.
  • • Commitment to therapeutic and ethical pain practices.
  • • Participation in developing innovative pain management practices which includes identifying, testing and evaluating new approaches being considered for relevancy, appropriateness and efficacy.
  • • Communication skills with the pain sufferers who may or may not be able to express their pain experience, including those who may be verbal (with various levels of word choices and descriptive expression), preverbal (babies and infants) or postverbal (those who no longer speak due to mental conditions, cardio- vascular accidents, injury or brain change) as well as those unable or unwilling to speak of their pain due to language barriers, fear, anger, values, beliefs and superstitions.
  • • Awareness of the pain needs of special and vulnerable populations.
  • • Evidence of knowledge and understanding of current pain research and the implications for nursing practice.
  • • Ability to acknowledge our common humanity (nurse to patient, family, friends or partners; nurse to nurse; nurse to other professional colleagues).

Positive pain management legacies

How have the benefits of progress in pain management come to us? It is through such means as:

  • • Multidisciplinary approaches to pain and an integrated approach to pain management.
  • • Insistence and persistence of professional collaboration.
  • • The forming of pain teams, coalitions, forums, colloquia, symposia and consensus conferences.
  • • Focused multidisciplinary organizations and groups, the International Association for the Study of Pain being a stellar example.
  • • Pain publications and sharing of pain advances through sophisticated technology.
  • • Self-reports and insights of pain survivors by which the patient instructs the pain team from first hand data.
  • • Pro-active community leaders, volunteers and patient advocates dedicated to the improvement of the quality of life by the effective management of pain.
  • • Policy formulators, legislators and leaders in the health sciences.
  • • Funding of pain initiatives at local, national and international levels.
  • • Philanthropy, sponsorships and scholarships related to pain practice improvement.

Pain taboos

In the past, the word and concept of suffering was taboo and its use highly discouraged in pain settings and scientific publications, perhaps because it might suggest neglect or reflect poor pain practices. Multidisciplinary approaches desensitized this avoidance, bringing to bear a convergence of rich philosophical, historical and spiritual threads of pain inquiry.

Today, it would appear that the word and concept of torture continues to be taboo. Perhaps, there is political worry it connotes social injustice or flaunting of international law. The suggestion of intentional use of pain as a tool is anathema. Nevertheless, the pain needs of this population worldwide are overwhelming.

Under-addressed pain needs

To maintain progress and momentum, it is important to recognize overlooked or neglected areas where, to varying degrees, there are unaddressed pain needs, including:

  • • Special populations such as the incarcerated, hostages and prisoners of war.
  • • The mentally ill who may not be able to recognize their physical jeopardy.
  • • Victims of natural disasters or man-caused pain.
  • • The addicted of all ages, including those in utero.
  • • The disenfranchised due to the absence or unaffordability of health care.
  • • The elderly with special attention to those with hearing and vision loss, partial or complete.
  • • The homeless, a virtually invisible special population, often manifesting multiple pain problems, including refugees made homeless and nomadic.

In my 1993 Guest Editorial in JAN, I ended with the assertion that ‘our colleagues in hospices have made the moral judgement to relieve their patient's pain unconditionally’, and I asked: ‘Can we accept the challenges in hospitals, nursing homes, outpatient clinics and in the home to manage pain as an ethical and professional imperative?’ That challenge certainly now seems to be widely accepted in all nursing settings and around the world, but pain and suffering still persist. Perseverance is the key.