Assessment of pain in chronic wounds: A survey of Australian health care practitioners

Abstract

Pain associated with chronic wounds can delay wound healing, affects quality of life, and has a major impact on physical, emotional, and cognitive function. However, wound‐related pain is often under‐assessed and may therefore be suboptimally managed. The aim of this study was to describe the assessment practices used to assess chronic wound pain by health practitioners in Australia. A structured self‐administered questionnaire was posted to members of an Australian national wound care organisation, whose membership represents various health practitioners involved in wound management. A total of 1190 (53%) members completed the survey. Overall, wound pain assessment was most commonly conducted at every consultation or wound dressing change (n = 718/1173, 61%). Nurses were more likely to assess wound‐related pain before, during, and after the wound dressing procedures compared with other health care practitioners. In contrast, podiatrists assessed wound pain only when the patient complained about the pain. The most common assessment method was simply talking to the patient (n = 1005/1180, 85%). Two‐thirds of practitioners used a validated pain assessment tool. The most commonly used tool was the numerical analogue scale (n = 524/1175, 46%). In summary, these findings suggest that there is no consistent method for the assessment of wound‐related pain, and there are substantial variations in how and when wound‐related pain is assessed between different professions.

1. INTRODUCTION

The experience of living with chronic wounds has a significant impact on the patient's quality of life, with wound pain being a major contributor to the patient's distress.1

Chronic wound‐related pain has a high prevalence, with up to 80% of patients experiencing persistent pain between dressing changes.2, 3 Wound pain adversely affects quality of life by having a negative impact on psychological well‐being, with depression, anxiety, and decreased socialisation often rendering these patients immobile or unable to carry out their daily activities.1, 4

Wound‐related pain is complex, incorporating both acute and chronic pain experiences. Krasner's conceptual model of wound‐related pain integrates cyclic and non‐cyclic acute pain and chronic wound pain that occurs in the absence of any handling and is usually associated with the underlying aetiology of the wound.5 The presence of pain associated with tissue injury is a clinically important symptom,6 indicating a warning sign of significant deterioration in wound healing.7 An increase in pain can indicate the presence of infection, poor immune response, or other forms of wound irritation such as intolerance to wound dressing materials.6

If a wound does not heal, persistent pain with nociceptive and neuropathic properties may develop, becoming a chronic pain condition affecting the patient's health and sleep.8 If wound pain is not addressed, recalcitrant pain develops, which is associated with impaired mobility, insomnia, depression, and suicidal ideation.9, 10, 11 Impaired mobility can decrease effective vascular circulation by prohibiting the function, endurance, and power of the calf muscle pump. In turn, this may hinder tissue perfusion, thus depleting the wound of vital oxygen and nutrients necessary for wound healing.12

There is growing evidence that the reporting of persistent wound‐related pain by patients is either dismissed by health practitioners or not assessed appropriately.13, 14, 15 Health practitioners often give wound pain a low priority as they focus predominantly on the healing processes rather than the patients’ total pain experience. The greatest concern for health practitioners is the presence of pain during dressing removal and cleansing of the wound.16, 17, 18, 19

Possible rationales for this behaviour include the difficulty in conducting comprehensive pain assessments or a lack of confidence in managing this type of pain.20 In addition, some patients may perceive wound pain as an inevitable consequence of their condition that must be tolerated.11, 21 Many patients, particularly older patients, are reticent about reporting their wound pain for fear of being seen as difficult or annoying22 or distracting the clinician from treating the wound.13, 23 Pain may also be under‐recognised, particularly in those with cognitive impairment or communication difficulties.24 Furthermore, patients describe not having their pain acknowledged or managed appropriately. Barriers to pain management result in the pain experienced not being reported and, consequently, being poorly managed or patients being left to self‐manage their pain experience.24

While there has been a focus in the literature on reducing pain during dressing changes6, 16, 25, 26 persistent wound‐related pain that can be continuous or intermittent is under‐recognised and under‐treated27, 28 and has been stated as “one of the failures of modern medicine”.29 The extent to which wound pain assessment and treatment are part of everyday practice remains understudied.

Therefore, to determine current practices in wound pain assessment, a postal survey of health care practitioners involved in wound care was conducted. The primary aim of this study was to determine how practitioners assess wound‐related pain, including the types of assessment tools used and frequency of assessment.

2. METHODS

2.1. Study design

This was a descriptive study that used convenience sampling to recruit participants involved in wound management. The study data were collected using a structured self‐administered questionnaire to determine how health practitioners assess persistent wound‐related pain. The study was approved by the Faculty of Health Sciences Human Ethics Committee La Trobe University. FHEC No: 10/121.

2.2. Participants

Surveys were posted to 2350 health practitioners who were members of Wounds Australia, the national wound care organisation. A Reply Paid envelope was supplied to encourage participation. No follow‐up reminder was provided.

2.3. Survey tool

A new survey tool was developed based on wound pain‐related literature and available literature on the efficient design for self‐administered questionnaires.30 The self‐administered questionnaire asked practitioners to identify wound pain assessment and pain management strategies used. It consisted of structured questions with pre‐coded responses, and some provided an open option for comments. There were 3 sections in the survey: (1) general characteristics, (2) wound pain assessment, and (3) wound pain management (see Supporting Information). This study will focus on wound pain assessment strategies.

The questions on general characteristics required participants to identify their profession, primary place of work, and the type of wounds they treated. The wound pain assessment section included questions on if, when, and how pain was assessed and the frequency of wound pain assessment. The multi‐choice question on “what validated pain assessment tool do you use?” listed the 4 most common validated pain assessment tools, the verbal rating scale, visual analogue scale, the faces scale, and the numerical analogue scale. These tools were selected based on Nementh et al's appraisal of pain assessment tools for leg ulcers, which indicated that these 4 tools were the most common tools used in wound care.31 Included in the question was the option of “other” where non‐listed tools could be provided.

A pilot study was conducted using 4 participants for input regarding content, clarity, and ease of completion. Following minor amendments, it was distributed to 5 wound practitioners who generally represented the type of practitioners in wound care to test for content validity, and amendments were made based on their feedback.

2.4. Statistical analysis

All statistical tests were conducted using IBM SPSS version 24 for Windows (IBM Corp, New York). Descriptive analysis was conducted using absolute (n) and relative (%) values for categorical data. Differences between health professionals' approach to when and how wound pain was assessed were explored using χ ² statistics.

3. RESULTS

Responses were received from 1298 participants. Of these, 108 were removed as the respondent indicated that he or she did not meet the inclusion criteria, resulting in an eligible response rate of 53% (1190/2242).

3.1. Participant characteristics

The majority of participants were nurses (n = 1064, 89%), followed by podiatrists (n = 85, 7%) and others (n = 40, 3%), which included pharmacists, medical practitioners, dieticians, scientists, and sales representatives. Participant characteristics are detailed in Table 1, including the type of work place setting of where the different professions practice. Most worked predominantly in a hospital (n = 510, 43%) or local community health setting (n = 362, 30%). Just under a third of all the participants (n = 327, 28%) worked in a specialty wound clinic.

Table 1.

Participant characteristics

Professionb
Nurse	1064 (89)
Podiatrist	85 (7)
Othera	40 (3)
Place of workb
Hospital	510 (43)
Community health	362 (30)
Aged care facility	136 (11)
Private practice	113 (9)
Othera	66 (6)
Working in specialty wound clinics
Nurse	277 (26)
Podiatrist	39 (46)
Othera	11 (28)

Values are n (%).

^aIncludes pharmacists, medical practitioners, dieticians, and scientists.

^bPercentages do not add up to 100 because of missing data (profession: 1 missing case, place of work 3 missing cases).

3.2. Wound pain assessment

The majority of health practitioners (n = 1166, 99%) asked patients if they were experiencing wound pain. This was a consistent trend across all professional backgrounds: 99% of nurses (n = 1048), 98% of podiatrists (n = 83) and 88% of other (n = 35). Respondents who did not ask about wound pain (n = 17) were not required to complete the remainder of the questionnaire.

The most common frequencies of wound‐related pain assessment reported by participants are outlined in Table 2. Overall, wound pain assessment was most frequently conducted once during the dressing changes at an unspecified time “every consultation and or wound dressing change” (n = 718, 61%), followed by 3 times during the dressing change (“before, during and after wound dressing changes”) (n = 498, 43%).

Table 2.

When pain assessment was conducted by the different health professionals

	Nurse (n = 1049)	Podiatrist (n = 84)	Other (n = 40)	Total (n = 1173)	P a
Initial assessment	104 (10)	13 (16)	7 (18)	124 (11)	.263
Only when patient complains	51 (5)	15 (18)	2 (5)	68 (6)	.001
Every consult/wound dressing change	638 (61)	58 (69)	22 (55)	718 (61)	.321
Before, during, and after dressing change	481 (46)	11 (13)	6 (15)	498 (43)	<.001
Other	103 (10)	4 (5)	6 (15)	113 (10)	.299
Combinations
Initial assessment + every consult	53 (5)	4 (5)	2 (5)	59 (5)	.954
Every consult + before, during, and after	104 (10)	13 (16)	7 (18)	124 (11)	.263
Initial assessment + every consult + before, during, and after	51 (5)	15 (18)	2 (5)	68 (6)	.001

Values are n (%).

^aSignificance of chi‐square analysis comparing frequency of responses across the 3 health professional groups.

Statistical differences were found when comparisons were made between professions in relation to when the assessments were conducted. Podiatrists were more likely to assess wound pain only in response to a patient's complaints (χ ² = 24.0, df = 2, P < .001), while nurses were more likely to assess wound pain before, during, and after the dressing procedure (χ ² = 34.2, df = 2, P < .001). Although there was a significant difference between professions (χ ² = 7.5, df = 2, P = .024) for the combined approach of every consultation and before, during, and after dressing change, the overall numbers selecting this option were very low.

3.3. Assessment methods of wound pain identification

Various methods of assessment were used to identify wound pain, including talking to the patient, observing the patient's facial expressions, examining their body language, or using a validated pain assessment tool. Most participants used a combination of these methods (Table 3). Overall, the most common method of wound pain assessment was by talking to the patient (n = 1005, 85%).

Table 3.

Wound pain assessment methods

	Nurse (n = 1049)	Podiatrist (n = 84)	Other (n = 40)	Total (n = 1173)	P a
Talking	897 (85)	78 (92)	30 (75)	1005 (85)	.233
Facial expression	712 (68)	46 (54)	20 (50)	778 (66)	.039
Body language	692 (66)	48 (57)	20 (50)	760 (64)	.223
Validated tool	686 (65)	36 (42)	16 (40)	738 (63)	<.001
Combinations
Talking + facial expression + body language	667 (63)	45 (53)	19 (48)	731 (62)	.159
Talking + facial expression + body language + validated tool	444 (42)	19 (22)	11 (28)	474 (40)	.002

Values are n (%).

^aSignificance of chi‐square analysis comparing frequency of responses across the 3 health professional groups.

When comparing the methods of assessment between the professions, nurses were more likely to use a validated assessment tool (P < .001); facial expression (P = .039); and a combination of talking, observing facial and body language, and the use of a validated tool (P = .002) compared with the other professions.

3.4. Pain assessment tools

A total of 63% (n = 738) of practitioners indicated that they used a validated pain assessment tool. The most common validated pain assessment tool used by all 3 categories of professions was the numerical analogue scale (n = 524, 46%), followed by the verbal rating scale (n = 328, 28%). When comparing the use of validated tools between the professions, nurses were more likely to use the visual analogue scale (χ ² = 7.82, df = 2, P = .020), faces scale (χ ² = 7.99, df = 2, P = .018), and numerical analogue scale (χ ² = 12.46, df = 2, P = .002) compared with the other professions (Table 4). The most frequently reported “other” tool was the Abbey scale32 for cognitively impaired patients (n = 50).

Table 4.

Use of validated wound pain assessment tools

	Nurse (n = 1049)	Podiatrist (n = 84)	Other (n = 40)	Total (n = 1173)	P a
Verbal rating scale	298 (28)	21 (25)	9 (23)	328 (28)	.735
Visual analogue scale	249 (24)	9 (11)	8 (20)	266 (23)	.020
Faces scale	151 (14)	3 (4)	4 (10)	158 (13)	.018
Numerical analogue scale	491 (47)	23 (27)	10 (25)	524 (46)	.002
Abbey scale	48 (5)	1 (1)	1 (3)	50 (4)	.320
Other	26 (3)	1 (1)	3 (8)	30 (3)	.721

Values are n (%). Multiple responses allowed for this question.

^aSignificance of chi‐square analysis comparing frequency of responses across the 3 health professional groups.

4. DISCUSSION

The aim of this study was to determine how and when health practitioners assess wound pain. Contrary to the literature that wound pain is ignored or is often considered low priority,16 the findings of this survey confirm that almost all participating wound health practitioners asked their patients about the pain they were experiencing with their wound. A variety of assessment methods were used to gather information about the patients' pain, and the process used to identify pain was not uniform among practitioners.

It has been recommended that wound pain assessment be performed at every wound intervention and should be an ongoing process so that any changes in pain can be identified.16, 33 However, the findings of this study indicate that only 38% of clinicians assess wound pain at every wound consultation or wound dressing change. This may be attributed to local institutional protocols for wound assessment and management or because of a lack of time and available resources. Assessment of persistent pain may require a lengthy examination to determine the cause and multiple factors influencing the pain experience. This can take time and patience to enable the patient to express the pain and to ensure an understanding of the assessment tools used, which can be challenging for the health practitioner to conduct and document in a busy and time‐poor environment.

Another explanation for not assessing wound pain at every wound dressing change is that many practitioners may not know what to do with the pain score or apply it to patient management and, therefore, do not assess the pain. This reflects the simplifying of tasks as described by von Baeyer and Pasero when protocols are difficult to achieve.34 This saves time and side‐steps rules and policies, particularly when practitioners do not understand them or believe they are unnecessary.

Despite there being well‐established guidelines for best practice in wound assessment and management, only 11% of practitioners assessed wound pain at the initial patient assessment. Although pain is considered the fifth vital sign, the literature suggests that there is poor compliance with local pain assessment protocols.35 There is much uncertainty in wound care, which means decision making can be difficult, contributing to ineffective treatment and patient harm.36 Uncertainty can affect any health care decision, such as assessment, diagnosis, and management. Results of numerous studies37 over the past decades provide evidence that many nurses caring for patients in pain lack adequate information about pain management, which can also be applied to other health professionals involved in wound care. This suggests a need for good‐quality research on wound pain assessment and management relevant to patients and health care professionals that will assist in tackling uncertainties in clinical decision making and improve adherence to clinical guidelines.

The World Union of Wound Healing Society consensus document on minimising wound pain at wound dressing changes recommends that wound‐related pain should be assessed and rated before, during, and after wound dressing processes.26 The survey results indicate that nurses undertook this strategy for pain assessment significantly more often than other health practitioners. This difference could be attributed either to the types of wounds usually treated by different professions or the role the health practitioner has in wound management. Podiatrists predominantly treat diabetic foot ulcers, which are more likely to be neuropathic in nature, so podiatrists may be more likely to assume that the patient does not experience pain and therefore undertake no pain assessment. Physiotherapists, occupational therapists, and pharmacists may focus on other aspects of wound management that does not involve wound dressing procedures, while medical practitioners may focus on managing the progress of wound healing and do not necessarily undertake wound dressing procedures.

The most common approach in identifying and assessing pain by all categories of health professionals was talking to the patient and asking the patient to give a self‐report rating of their pain. This supports the findings of Ferrell et al, who found that the most frequent method of assessing pain and the most influential factor in determining pain intensity was to ask the patient.38 Generally, in clinical practice, much of the pain communication occurs as part of the everyday dialogue between patients and nurses.39, 40 Verbal communication can provide rich descriptive words, including an array of metaphors;24 however, the information obtained by this method is highly variable and may not be a valid indicator of pain. Pain perception is highly individual, and the quality of pain can be difficult to describe and is open to interpretation. This is further complicated by differing expressions of pain influenced by factors such as social, cultural, beliefs, or tolerance.11, 24 In some cases, the patient may be unable to accurately recall their pain experiences over a defined period of time,24, 41 and others may not report their pain for fear of being a burden or nuisance.22

Practitioners' beliefs and attitudes towards wound pain may also create barriers to pain assessment and wound pain management. Practitioners often bring preconceived perceptions about a patient's pain based on assumptions related to aetiology of the wound or size of the wound, for example, arterial ulcers are more painful than venous ulcers, or small ulcers are less painful than large ulcers.42 Furthermore, the practitioners' perception of the pain experience may differ from that of the patient.43 It has also been suggested that nurses may view pain as a good sign as it is thought to represent healing.8

A significant number of nurses (n = 686; 65%) reported the use of a validated pain assessment tool, in comparison with other health professionals who more frequently used observational assessments of body language and facial expressions. This is consistent with Ferrell et al38 who found that 59% of nurses used a pain‐rating scale to measure pain. This may be influenced by the regulated system of documentation to ensure effective reporting and handover between multiple clinicians.

There are a number of pain scales or tools that are useful for the assessment of a patient's level of wound pain.44 The World Union of Wound Healing Society recommends the use of simple pain scales, such as a visual, numerical, or verbal scale, or pain diaries.26 An appraisal of pain assessment tools identified 3 methods most frequently used in assessing pain related to chronic leg wounds: the visual analogue scale, verbal rating scale, and the short‐form McGill Questionnaire. However, there is insufficient evidence to recommend any 1 pain assessment tool over another.31 The most common pain tools used by practitioners in this study were those recommended by the World Union of Wound Healing Society: the numerical analogue scale, verbal rating scale, and the visual analogue scale. Nurses used the numerical analogue scale and verbal rating scale more frequently than the other health practitioners. These unidimensional pain assessment tools are simple and quick to use and are considered to be accurate measures of pain intensity. The advantage of using the verbal rating scale is ease of administration, particularly with older patients and those with some degree of cognitive impairment. The numerical analogue scale is often used because of its simplicity, lack of ambiguity, and ease of cross‐linguistic pain measurement in a great diversity of patients.31 In addition to these common tools, the Abbey scale32 for cognitively impaired patients was a common tool listed in the qualitative responses; however, in the wound pain assessment literature, the Abbey scale is not widely considered.

The findings of this study need to be viewed in the context of several limitations. First, the study used convenience sampling of practitioners who were members of a wound association. The advantage of this targeted approach is that the participants represented experts in the area of wound management; however, this may have excluded health practitioners who were involved in wound management but were not members of the wound association. An important limitation was that the dissemination of the survey was restricted to a one‐off mail out, and no follow‐up reminders were sent. In order to increase the response rate, a brief advertisement was placed in the wound association's newsletter before and after the survey mail out.

Although the questionnaire was piloted with a study sample, the reliability and validity of the questionnaire was untested. The structure of the questionnaire predominantly consisted of closed questions, with only a few questions offering the option of “other” to include qualitative responses. Closed‐ended questions enable researchers to produce aggregated data, but the range of possible answers is predetermined by the researchers and not by the respondents, which limits the depth of potential responses. Closed‐ended questions may cause frustration for respondents, usually because researchers have not considered or offered all potential responses.30 Another limitation of using self‐administered questionnaires is the perceived expectation of professional behaviour, whereby what the participants say they do may not be the same as what they actually do, especially when they think their practice is being judged by others.30

5. CONCLUSION

The assessment, diagnosis, and treatment of wound‐related pain requires a systematic and standardised approach to ensure accurate assessment and documentation This study shows that the majority of wound practitioners ask about wound pain; however, there is significant variability in relation to when and how wound pain is assessed. Although clinical guidelines recommend that pain should be assessed regularly using the same standardised validated tool, this study suggests that health care practitioners use various methods of identifying or assessing wound pain. Practitioners should be vigilant with wound pain assessment given that there is a high prevalence of pain in wound patients, which impacts wound healing and their quality of life. Further research is required to develop universal guidelines to achieve a standardised approach to wound pain and management to be used by all health practitioners in wound care.

Supporting information

Appendix S1. Health practitioner survey on wound pain assessment

Frescos N. Assessment of pain in chronic wounds: A survey of Australian health care practitioners. Int Wound J. 2018;15:943–949. 10.1111/iwj.12951