Addressing the Pain: An International Perspective on Wound Pain and Trauma
This article is excerpted from Moffat CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. European Wound Management Association Position Document. Pain at Wound Dressing Changes. Medical Education Partnership Ltd.;2002. Used with permission.
Several articles on the pain and trauma associated with dressing change have cited the results of a recent international study. A previous study in the UK that sought to identify practitioners' views on pain and trauma and their relationship with wound care products involved a large sample of nurses from two national wound care organizations. Findings from this research prompted a broader investigation into the similarities and differences among related wound care practices in Europe and North America. The goal of the international study was the development of an international perspective that may be valuable in highlighting the differences that wound care delivery systems have on practitioner performance, patient experience, and access to wound care products. The results of the international effort represent a first attempt to stimulate further research and discussion in this area and to bring together the international wound care community to address issues that once were considered beyond the scope of evidence-based care. The following discussion focuses on the results of the international study that pertain to wound dressing change-related pain.
Eleven countries participated in the international survey (in order of highest to lowest number of respondents: France, Canada, Finland, UK, US, Switzerland, Sweden, Spain, Austria, Denmark, and Germany). Out of a total of 14,657 questionnaires distributed, 3,918 people responded (27%). The questionnaire was adapted from the one originally used in the UK.1 It aimed to identify practitioners' primary considerations in their approach to pain and tissue trauma at dressing changes and the strategies used in the treatment and selection of products for their patients. The questionnaire comprised structured questions with multiple choice answers. Although designed to ask comparable questions of all nationalities, some variations occurred, particularly regarding types of products available. A question pertaining to practitioners' views on the importance of wound dressing characteristics and performance was added. The questionnaires were translated into the appropriate languages for each country. A variety of distribution methods was used, from mailing to members of wound care societies to circulation among wound conference attendees. Hence, the samples may not be representative of the nursing population within each country. Some respondents gave more than one answer to a question even though only one was requested; to overcome this, results were ranked according to the frequency of the response to each question, rather than to the absolute percentages. Thus, the most important or highest ranked response for each country was 1 (first), with larger values indicating lower importance (second, third, etc.). This allowed for all countries to have equal rating for their responses, irrespective of the response frequency.
Results: Questionnaire Responses
Main considerations. Preventing trauma was the most important factor to consider when changing a dressing as ranked by participants from seven of the 11 countries. Pain prevention was the next highly ranked. Only one country ranked infection prevention as the top priority; among the other countries, infection prevention was ranked third. Preventing skin damage and "other" were fourth and fifth ranked, respectively.
Patient pain experience. Practitioners consistently rated dressing removal as the time of greatest pain, closely followed by wound cleansing. This raises issues regarding the methods used to cleanse wounds. A range of contributory factors includes the use of antiseptics and other more aggressive mechanical methods of cleansing. This may indicate definite differences in wound care practices in different countries.
Pain assessment. In eight of the 11 countries, talking to the patient was the most important factor in identifying pain. France ranked talking third, stating facial expression was most important. In the US, facial and body language were the most important factors, while Finland said body language alone was most important. These variations may reflect cultural differences among countries, with some populations more vocal than others. Little importance seemed to be placed on pain assessment before and after dressing changes, suggesting a more global assessment of pain rather than one relating to procedure. Also, little evidence came to light supporting practitioner use of previous experience treating similar patients when rating the significance of wound pain.2
Factors contributing to pain. Practitioners indicated that dried-out dressings and products that adhered to the wound were the most important factors leading to wound pain at dressing changes. However, the use of gauze packing was rated very low after adhesive dressings, cleansing, previous experience, and fear of hurting, respectively. These results are surprising, given that gauze is likely to be the most adherent product in wound care and its use is no longer recommended as best practice.3 These results may be further confounded by the fact that in some countries, practitioners rarely use gauze.
Strategies to manage pain. The most common pain management strategies were to soak old dressings, select non-traumatic dressings, and to choose dressings that offer pain-free removal. Given that soaking dry dressings in not recommended nor based on the principles of moist wound management, these results also are surprising. Only two countries rated giving analgesia before dressing changes as the most important strategy. Involving patients in strategies to avoid pain was not considered a priority, despite evidence that using adhesive wound care products leads to skin stripping and potential skin trauma and pain.4,5
Importance of dressing characteristics. Pain-free removal was the most highly desired dressing characteristic; five countries said it was the most important factor. Nonadherence to the wound was the second most important priority. Two countries (Canada and the US) considered promotion of speedy granulation the most important dressing characteristic, and while comfort was rated second in Canada, it was ranked eleventh in Germany. The relevance of research documentation appeared to be of little importance to the clinicians who participated, regardless of country.
Dressings that cause pain. Complete agreement was expressed that gauze was the product that most often caused pain at dressing changes. This was followed by knitted viscose, film dressings, paraffin tulle, and low-adherence dressings. Foam dressings and hydrocolloids were ranked equally. Hydrogels, hydrofibers, alginates, and soft silicones were deemed products least likely to cause pain at dressing changes.
Discussion
The last decade has seen a marked increase in practitioner appreciation of the role of pain in the life experience of patients with wounds. Research in the context of quality of life6,7 has established that patients with wounds such as leg ulcers experience significantly greater bodily pain than the normal population - not merely as a consequence of aging but as a feature of the wound and underlying abnormal pain mechanisms.8,9 Health-related quality-of-life studies consistently have shown that pain improves significantly with effective treatment that promotes healing.10,11 Despite this data, practitioners are often complacent or unwilling to accept the degree of suffering in patients with wound-related pain.12 Patients may remember procedural pain over decades, often developing elaborate coping strategies to prevent practitioners from inflicting further pain during a dressing procedure.13
The international survey results underscore the fact that while many practitioners are aware of issues relating to wound trauma and pain, numerous international variations exist in practice. This area requires a coordinated approach to standardize recommendations for good practice based on best available evidence. The survey has stimulated many research questions. A key component in improving practice is access to appropriate products. Wound associations and industry must seek to develop markets in countries where pain and trauma-relieving products are as yet unavailable. Two confounding factors will need to be addressed especially: the lack of consensus on the correct assessment of pain and the scant evidence to guide decision making in wound pain and trauma.
Conclusion
Although the international survey has a number of limitations (different sampling frames in different countries, varying levels of expertise, possibly non-representation of practitioner views within countries, no correlation of findings to actual patient experience, and no validation under strict research conditions), it is groundbreaking in its attempt to examine wound pain and trauma from an international perspective. If for the sheer sake of awakening clinicians to the importance of considering the relevance of pain to the wound experience, this effort deserves the acknowledgments it has garnered in the literature and the subsequent research it has spawned.
Addressing the Pain is made possible through the support of Molnlycke Health Care, Newtown, Pa.
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