Content of this journal is licensed under a Abstract
Aim
This descriptive and cross-sectional study investigated the individual factors that affect procedural pain and discomfort in individuals who had nasopharyngeal swabs by nurses.
Methods
A total of 193 participants in two COVID-19 test centers located in a city in Southeastern Türkiye between April and May 2022 were included in this study. Personal information form was used to collect data. The visual analog scale was used to assess the pain and discomfort. Risk factors related to pain and discomfort were investigated through a logistic regression model.
Results
During the nasopharyngeal swabbing, it was determined that pain was stronger in women and those who considered nasopharyngeal swabbing as a painful procedure (p < .05). Also, discomfort was stronger in women and those who considered nasopharyngeal swabbing as an uncomfortable procedure (p < .05). It was determined that the participants’ discomfort scores were higher than their pain scores.
Conclusion
Women and individuals with negative opinions about the procedure experienced more pain and discomfort during the nasopharyngeal swabbing. Most of the participants complained more about discomfort than pain. It is recommended to apply alternate test methods and conduct nurse-led information studies to reduce the anticipation of procedural pain/discomfort.
Keywords: COVID-19, discomfort, nasopharynx, nurse, pain
Introduction
Some viral respiratory system diseases can spread rapidly and become a social threat after they appear. The spread of diseases in society may be prevented if these viruses are detected early and the appropriate precautions are implemented. One of the most prominent and effective diagnostic methods for identifying these diseases is the real-time reverse transcriptase polymerase chain reaction (rRT-PCR) method (Marty et al., 2020; Temel et al., 2021). In earlier influenza and coronavirus outbreaks, the rRT-PCR method has been safely used to diagnose patients (de la Tabla et al., 2010). The quality of the samples collected in the rRT-PCR method is crucial for the test to produce reliable results. Samples can be collected through various techniques, such as nasal wash, nasal aspirate, oropharyngeal swab, and nasopharyngeal swab. One of these techniques, nasopharyngeal swabbing, is frequently preferred by patients and practitioners (doctors or nurses) since it is a reliable, simple, and quick technique (Irving et al., 2012).
Nasopharyngeal swabbing is one of the most often used diagnostic tests in the diagnosis and contact screening of the coronavirus infectious disease (COVID-19) causing the pandemic as of December 2019 (Bayır et al., 2020; Cheng et al., 2020). It is estimated that approximately one million tests have been performed each day in the United States alone during the pandemic (Hakimi et al., 2022). According to the legislation in Türkiye, this procedure can be done by nurses (Turkish Ministry of Health, General Directorate of Public Health, 2020). Although the nasopharyngeal swabbing procedure used to diagnose COVID-19 is simple and reliable, it does pose some risks for the patients. During nasopharyngeal swabbing, some individuals may have complications such as gagging, coughing, sneezing, vomiting, and nasal mucosa injury (Bayır et al., 2020; Fidancı & Atmış, 2020). Pain and discomfort are also experienced by individuals as a result of the nasal mucosa injury that occurs during nasopharyngeal swabbing (Ekemen Keleş & Yılmaz Çiftdoğan, 2020; Gupta et al., 2021). Studies on pain have indicated that the primary requirement for pain management is the ability to assess pain (Mannion et al., 2007; Shafshak & Elnemr, 2021). However, it is not always feasible to easily assess abstract concepts, such as pain and discomfort (Shafshak & Elnemr, 2021). Pain associated with nasopharyngeal swabbing reduces patients’ compliance with the procedure. All of these unpleasant situations experienced by individuals have resulted in insufficient or poor-quality samples, delays in the delivery of the sample to the laboratory, and incorrect test results (Ekemen Keleş & Yılmaz Çiftdoğan, 2020). Because incorrect results cause tests to be repeated, it may increase the workload of nurses and laboratory staff. Decreased compliance with the procedure not only results in incorrect test findings but also in various injuries and complications. There are case reports stating that the swab stick broke and remained in the nasal cavity as a result of non-compliance developing in the patient during nasopharyngeal swabbing (Suresh, 2021). All these situations require a detailed examination of the pain and discomfort Experienced by individuals during a nasopharyngeal swab. However, the factors that affect procedural pain and discomfort in individuals due to nasopharyngeal swabbing during the COVID-19 pandemic have not been sufficiently examined. In a study conducted on the subject, the effect of conventional swab and self-swab procedures on pain and discomfort was examined. However, individual variables affecting pain and discomfort were not adequately examined in this study (Moisset et al., 2021). The aim of this study is to investigate the individual factors that affect pain and discomfort experienced during nasopharyngeal swabbing by nurses.
Methods
Research Questions
1. Do the individual characteristics of the participants affect the pain during the procedure?
2. Do the individual characteristics of the participants affect the feeling of discomfort during the procedure?
Study Design
A descriptive cross-sectional design was used in this study.
Sample
This study was conducted at the COVID-19 test centers in the State Hospital and Community Health Centre in Gaziantep between April and May 2022. The inclusion criteria were as follows; being asymptomatic for COVID-19, being willing to participate in the study, being under 18 years old or over, and having no communication and comprehension problems. The exclusion criteria were as follows; being symptomatic for COVID-19, don’t being voluntary to participate in the study, being under 18 years old, and having communication and comprehension problems. In Türkiye, COVID-19 tests are mandatory for asymptomatic people in many cases (to obtain travel permission, to enter some public spaces, to perform medical interventional procedures, etc.). Since the number of people who had symptoms during the study period decreased significantly, only those who were asymptomatic were included in the study. It was intended to avoid bias by excluding people with symptoms. When the results of previous studies were analyzed, the rate of feeling pain during the nasopharyngeal swabbing was found to be 28.4% (Moisset et al., 2021). Based on this information, the minimum sample size was determined to be 159 participants (margin of error = 0.07, confidence level = 0.95). A total of 193 people participated in the study. The “Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist” was used to ensure suitable data reporting.
Data Collection Tools
Personal Information Form
It was prepared by the researcher upon review of the relevant literature (Moisset et al., 2021; Shafshak & Elnemr, 2021; Temel et al., 2021). The participants’ age, sex, smoking, alcohol use, use of analgesics, previous nasopharyngeal swabbing, and views on the nasopharyngeal swabbing were examined as independent variables.
Visual Analog Scale
The visual analog scale (VAS) was used to assess the pain and discomfort of the participants. Self-reporting is regarded as the gold standard in the assessment of pain and discomfort (Kawade et al., 2021). The VAS, one of the self-reporting methods, may be used to digitize some data that cannot be analyzed objectively. It is well known that the use of VAS is reliable in the subjective assessment of pain and discomfort. During the VAS assessment, two extreme definitions of the parameter to be analyzed are typed at both ends of a 10-cm line. The respondent is asked to mark where his/her condition falls on this line (Wewers & Lowe, 1990). In this study, “no pain” was written at one end (0 points) and “worst pain” (10 points) at the other end. The participants were asked to mark the pain they felt during the nasopharyngeal swabbing. For discomfort, the same procedure was followed. The gagging, sneezing, and withdrawing behaviors of the participants during the nasopharyngeal swabbing procedure were effective in determining the discomfort scores. Pain and discomfort were analyzed as continuous variables but also as ordinal variables categorized according to the literature, that is, a score ≥4/10 corresponding to significant pain or discomfort (Moisset et al., 2021).
Nasopharyngeal Swabbing Procedure
After the researchers filled out the relevant sections of the individual information form, the nurses of the institution collected a nasopharyngeal swab. During data collection, researchers wore personal protective equipment (mask, goggles, overalls, and bonnet). For all procedures performed during the nasopharyngeal swabbing, the guideline published by the Ministry of Health was followed (Turkish Ministry of Health, General Directorate of Public Health, 2020). Before the procedure, the participants entered the testing booth by putting on masks. The nasopharyngeal swab was collected outside the testing booth by a nurse wearing personal protective equipment (mask, goggles, overalls, and bonnet). After taking off their masks, the participants waited for the nasopharyngeal swab to be collected, either standing or sitting, with their heads in a neutral posture and facing the nurse running the test. Before the procedure, the participants were asked to determine the nostril through which they breathe better. A sterile Dacron swab with a plastic handle was inserted into this nostril and moved forward parallel to the palate. The participant’s head was tilted back 70°, and they were asked to look up toward the ceiling. The swab was pushed through the nostril to the outer aperture of the ear parallel to the palate, or until it came into contact with the posterior pharyngeal wall (tears appearing in the eye on that side are an indication of proper distance). In the event that the swab came across resistance while it was being advanced, the direction taken by the stick was altered in an effort to go around the blockage. After the tip of the swab was moistened with the secretion, it was gently removed by rotating the swab around itself. Before leaving the testing booth, the participants were reminded to put their masks back on. After the procedure, pain and discomfort scores as expressed by the participant were recorded in the relevant sections of the individual information form.
Statistical Analysis
The Statistical Package for Social Sciences version 24.0 software (IBM Corp.; Armonk, NY, USA) was used to analyze the data. Frequency, percentage, mean, and standard deviation were used as descriptive statistics. For independent group comparisons of categorical variables, the chi-square test was used.
Variables with a significant difference between the participants’ pain and discomfort in the univariate analysis were entered into the logistic regression model. Odds ratio (OR) and the 95% CI were used to evaluate the independent contribution of significant factors.
Ethical Considerations
For the study, approval from the Clinical Trials Ethics Committee of a Gaziantep University (Approval no: 2022/83, Date: February 23, 2022), permission from the Ministry of Health (Approval no: 2021-03-17T10_59_52), permission from the institutions where the study was held (Approval no: E-83362127-604.02.02), and written consent from the participants were obtained.
Results
Pain and Discomfort experienced by Individuals During Nasopharyngeal Swabbing
The majority of the participants were aged 26 and over (61.7%), male (78.8%), non-smokers (51.3%), non-alcoholics (90.2%), used analgesics once or less than once per month (82.9%), used no analgesics in the last 24 hours (87%), had previously undergone a nasopharyngeal swab (53.4%), and did not find the procedure painful (56%) but uncomfortable (58%) (Table 1).
Table 1.
Individual Characteristics of the Participants (n = 107)
| n (%) | |
|---|---|
| Age (year) | |
| 18-25 | 74 (38.3) |
| 26 years and above | 119 (61.7) |
| Gender | |
| Male | 152 (78.8) |
| Female | 41 (21.2) |
| Smoking | |
| Yes | 94 (48.7) |
| No | 99 (51.3) |
| Alcohol consumption | |
| Yes | 19 (9.8) |
| No | 174 (90.2) |
| Frequency of analgesic use | |
| Once or less per month | 160 (82.9) |
| Several times a week | 33 (17.1) |
| Use of analgesics in the last 24 hours | |
| I used | 25 (13) |
| I did not use | 168 (87) |
| Previous swabbing | |
| Yes | 103 (53.4) |
| No | 90 (46.6) |
| The swabbing is painful | |
| Yes | 85 (44) |
| No | 108 (56) |
| The swabbing is uncomfortable | |
| Yes | 112 (58) |
| No | 81 (42) |
A VAS score of ≥4/10 of the participants in this study indicated the presence of pain and discomfort. When the pain experiences during the nasopharyngeal swabbing were examined, it was observed that procedural pain was higher in women and those who considered nasopharyngeal swabbing as painful and uncomfortable (p < .05). When the discomfort experiences of the participants during the procedure were examined, it was determined that women, those who used analgesics several times a week, used analgesics in the last 24 hours, and thought that the nasopharyngeal swabbing was uncomfortable had more procedural discomfort (p < .05). Also, most of the participants complained more about discomfort than pain (Table 2).
Table 2.
The Pain and Discomfort in the Participants (n = 107)
| Pain Experience | p | Discomfort Experience | p | |||
|---|---|---|---|---|---|---|
| <4/10 | ≥4/10 | <4/10 | ≥4/10 | |||
| n (%) | n (%) | n (%) | n (%) | |||
| Age (year) | ||||||
| 18–25 | 39 (52.7) | 35 (47.3) | .546 | 31 (41.9) | 43 (58.1) | .805 |
| 26 years and above | 68 (57.1) | 51 (42.9) | 52 (43.7) | 67 (56.3) | ||
| Gender | ||||||
| Male | 90 (59.2) | 62 (40.8) | .042* | 78 (51.3) | 74 (48.7) | .001* |
| Female | 17 (41.5) | 24 (58.5) | 5 (12.2) | 36 (87.8) | ||
| Smoking | ||||||
| Yes | 52 (55.3) | 42 (44.7) | 0.974 | 41 (43.6) | 53 (56.4) | 0.867 |
| No | 55 (55.6) | 44 (44.4) | 42 (42.4) | 57 (57.6) | ||
| Alcohol consumption | ||||||
| Yes | 11 (57.9) | 8 (42.1) | .821 | 12 (63.2) | 7 (36.8) | .062 |
| No | 96 (55.2) | 78 (44.8) | 71 (40.8) | 103 (59.2) | ||
| Frequency of analgesic use | ||||||
| Once or less per month | 92 (57.5) | 68 (42.5) | .205 | 74 (46.3) | 86 (53.8) | .045* |
| Several times a week | 15 (45.5) | 18 (54.5) | 9 (27.3) | 24 (72.7) | ||
| Use of analgesics in the last 24 hours | ||||||
| I used | 13 (52) | 12 (48) | .711 | 6 (24) | 19 (76) | .040* |
| I did not use | 94 (56) | 74 (44) | 77 (45.8) | 91 (54.2) | ||
| Previous swabbing | ||||||
| Yes | 54 (52.4) | 49 (47.6) | .368 | 44 (42.7) | 59 (57.3) | .931 |
| No | 53 (58.9) | 37 (41.1) | 39 (43.3) | 51 (56.7) | ||
| The swabbing is painful | ||||||
| Yes | 37 (43.5) | 48 (56.5) | .003* | 33 (38.8) | 52 (61.2) | .298 |
| No | 70 (64.8) | 38 (35.2) | 50 (46.3) | 58 (53.7) | ||
| The swabbing is uncomfortable | ||||||
| Yes | 54 (48.2) | 58 (51.8) | .018* | 38 (33.9) | 74 (66.1) | .003* |
| No | 53 (65.4) | 28 (34.6) | 45 (55.6) | 36 (44.4) | ||
*Significant at .05.
Factors Affecting Pain and Discomfort During Nasopharyngeal Swabbing
As a result of the logistic regression analysis, it was determined that pain was higher in women (OR: 2.049, 95% CI: 1.017–4.129) and those who considered nasopharyngeal swabbing a painful procedure (OR: 2.390, 95% CI: 1.334–4.281) (p < .05) (Table 3). Also, discomfort was higher in women (OR: 6.772, 95% CI: 2.482–18.478) and those who considered nasopharyngeal swabbing an uncomfortable procedure (OR: 2.158, 95% CI: 1.149–4.054) (p < .05) (Table 4).
Table 3.
Factors Affecting Pain During Nasopharyngeal Swabbing
| Risk Factor | Odds Ratio | 95% Cl | p |
|---|---|---|---|
| Gender | |||
| Male (ref.) | 1.00 | ||
| Female | 2.049 | 1.017–4.129 | .046* |
| The swabbing is painful | |||
| Yes | 2.390 | 1.334–4.281 | .014* |
| No (ref.) | 1.00 | ||
| The swabbing is uncomfortable | |||
| Yes | 0.925 | 0.383–2.234 | .862 |
| No (ref.) | 1.00 |
*Significant at .05.
Table 4.
Factors Affecting Discomfort During Nasopharyngeal Swabbing
| Risk Factor | Odds Ratio | 95% Cl | p |
|---|---|---|---|
| Gender | |||
| Male (ref.) | 1.00 | ||
| Female | 6.772 | 2.482–18.478 | .001* |
| Frequency of analgesic use | |||
| Once or less per month (ref.) | 1.00 | ||
| Several times a week | 1.331 | 0.516–3.433 | .555 |
| Use of analgesics in the last 24 hours | |||
| I used | 1.973 | 0.662–5.875 | .222 |
| I did not use (ref.) | 1.00 | ||
| The swabbing is uncomfortable | |||
| Yes | 2.158 | 1.149–4.054 | .017* |
| No (ref.) | 1.00 |
*Significant at .05.
Discussion
For many years, nasopharyngeal swabbing has been used to diagnose many respiratory system diseases. It is frequently preferred as an effective and safe way to diagnose COVID-19, which has affected the whole world (Marty et al., 2020). However, procedural pain and discomfort reduce the patient’s compliance with the procedure. This non-compliance affects the proper execution of the procedure. Incompletely or incorrectly collected samples cause false test results (Ekemen Keleş & Yılmaz Çiftdoğan, 2020). The present study examined various individual factors that affect pain and discomfort during nasopharyngeal swabbing.
Acute pain may develop based on various medical procedures. The assessment of acute pain is mostly done by nurses (Deldar et al., 2018). However, since pain is a subjective concept, not everyone expresses it with the same intensity. Acute pain is known to be affected by many sociocultural, psychological, and biological factors (Wiesenfeld-Hallin, 2005). Female participants in the present study were found to be more likely than male participants to report pain and discomfort. It has been known that women are more sensitive to a variety of painful experiences compared to men (Sorge & Totsch, 2017). Pain developing during nasopharyngeal swabbing may reduce women’s compliance and result in false test findings. Although numerous theories have attempted to explain why women have higher pain sensitivity than males, high pain sensitivity in women is not a condition that can be altered. Therefore, instead of focusing on the physiology of pain, the use of alternative diagnostic methods (e.g., rapid antigen test on saliva) could be considered as an option in order to alleviate discomfort during the nasopharyngeal swab collection method. It is well known that relieving pain may diminish discomfort, particularly when self-administered alternative diagnostic methods are used (De Marinis et al., 2021). In addition, previous nursing studies show that aromatic oils such as orange, chamomile, and lavender oil inhaled prior to painful procedures can reduce pain (Ilter et al., 2019). In future studies, it may be recommended to investigate the effect of aromatic oil inhalation to reduce pain before the nasopharyngeal swab procedure in individuals whose sense of smell is not damaged.
In the present study, individuals who were about to have a nasopharyngeal swab were asked whether or not the procedure was painful or uncomfortable. It was determined that individuals who had negative views about the procedure experienced increased pain and discomfort throughout the nasopharyngeal swabbing. Fear of pain is a term used in the literature for this circumstance, which is described as the expectation that a medical intervention would be painful. Fear of pain might emerge as a result of previous negative experiences or discourses (from relatives, media, etc.). In a study conducted with patients undergoing thoracic surgery, it was determined that patients with high fear of pain expressed more post-operative pain (Luo et al., 2022). In the present study, however, no difference was found between pain and discomfort scores of individuals who had previously undergone a nasopharyngeal swab collection and those who had not. In addition, most of the participants complained more about discomfort than pain. This suggests that the participants’ fear of pain may have emerged not as a result of previous experiences but rather as a result of negative discourses. It would be useful to conduct informative studies in order to alter the negative views of individuals who will have a nasopharyngeal swab collected on pain and discomfort. It is known that information and awareness studies conducted by nurses are effective in changing the negative attitudes and thoughts of individuals (Azami et al., 2018; Ghatwal et al., 2021). Individuals should be informed about the importance of following the instructions of healthcare professionals in future information studies in order to collect suitable samples. Thus, the negative views about the nasopharyngeal swabbing will be diminished while the compliance with the procedure will be increased.
The risk of incorrect results can also be reduced by increasing process compliance. Incorrect test results cause unnecessary repetition of the process. Repeating the process causes an increase in the workload of nurses. It is known that the increase in the workload of nurses is associated with medical error, interpersonal relations, and job satisfaction (Aydın Sayılan & Mert Boğa, 2018). Therefore, increasing the compliance with the procedure will reduce the workload of the nurses. Thus, the risk of nurses making medical errors can be reduced. It may be useful to investigate this issue in future studies.
Study Limitations
The self-reporting method (e.g., VAS) was used in this study to assess pain and discomfort experienced during the nasopharyngeal swabbing. This caused the collected data to be subjective. Also, since the number of individuals with COVID-19 symptoms was very low at the time of the study, the participants consisted of asymptomatic healthy individuals. These limitations are considered to prevent the generalizability of the study results.
Conclusion and Recommendations
It was determined that women and individuals with negative opinions about the procedure experienced more pain and discomfort during the nasopharyngeal swabbing. Most of the participants complained more about discomfort than pain. The widespread use of alternative diagnostic methods (e.g., rapid antigen test on saliva) could be considered as an option to alleviate pain and discomfort during the nasopharyngeal swabbing. It would be useful to conduct informative studies led of nurses in order to alter the negative views of individuals who will have a nasopharyngeal swab collected on pain and discomfort. Thus, the negative views and fear about the nasopharyngeal swabbing would be reduced, and the compliance with the procedure would be increased. We predict that the risk of incorrect results will be reduced by increasing compliance with the procedure. In this way, the workload of nurses due to repeated tests will be reduced. In future studies, it may be recommended to investigate the effect of non-pharmacological methods such as aromatic oil inhalation to reduce pain before the nasopharyngeal swab procedure. Furthermore, given the limitations of the study, we recommend planning studies that include individuals with symptoms and use objective assessment methods.
Funding Statement
The authors declared that this study has received no financial support.
Footnotes
Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Gaziantep University (Approval no: 2022/83; Date: February 23, 2022).
Informed Consent: Written informed consent was obtained from people who participated in this study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept - U.D.; Design - UD., G.K., S.M.İ.; Supervision - U.D.; Resources - U.D., G.K.; Materials - U.D., G.K.; Data Collection and/or Processing - U.D., G.K.; Analysis and/or Interpretation - U.D.; Literature Search - U.D., G.K., S.M.İ.; Writing Manuscript - U.D., G.K., S.M.İ.; Critical Review - U.D.
Declaration of Interests: The authors have no conflict of interest to declare.
Availability of Data and Materials
The data that support the findings of this study are available on request from the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author.