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ADVANCE Perspective: Nurses

Pain Bias Toward Patients

Published March 25, 2011 2:46 PM by Guest Blogger

By Diane M. Goodman, APRN, BC, CCRN, CNRN

Most of our healthcare providers believe they deliver professional, deliberate and unbiased care to patients no matter the ethnicity or socioeconomic status of the patient.

This may be true. When the patient has had experience with pain, though, and/or is known to be a "frequent flyer," eyebrows begin to raise and assumptions are made, often before the patient can begin to be assessed.

Woe to the patient who has the audacity to show up in our healthcare system(s), asking for hydromorphone, diphenhydramine or morphine sulfate by name. They must be drug-seekers, for how else would they know what to ask for, especially the dose, frequency and method by which the drug(s) should be delivered? These patients are usually labeled as "challenging" right out of the gate, often before a history has been taken or the patient has been asked to undress.

What happens to our compassion when these instances occur? Is it a lack of overall education related to pain, or has the "territory" of nurse/patient geography been breached? Why is it so difficult for nurses to comprehend the concept of chronicity, particularly for the patient who may have lived months or even years with unrelenting pain?

Patients with chronic pain may demonstrate behaviors consistent with pseudoaddiction, such as doctor shopping, drug hoarding frequent utilization of healthcare services and (gasp!) knowing the names of which medications work best for them during acute exacerbations of symptoms. Patients who are pseudoaddicted are typically undertreated for pain pharmacologically, which often translates into an improvement in behavior once pain is adequately treated.

Beware of demonstrating your pain biases the next time your patient seems to know a little more about pain numbers, pain assessment and pain medications than your comfort level can take. Take a deep breath and remember patients have a right to effective pain management. At no time should this be more important than to the patient whose pain has been present a long time, and who may be exposed to the type of bias where medications are withheld for fear of adding to an "addiction" problem that probably does not exist.

Be compassionate and talk to the patient about his pain needs. It is likely the patient will be very willing to share her symptoms and discuss the severity of her pain, as well as the frustration of being so easily misunderstood. They may also recognize you for the true professional you have become, someone who is willing to defer biases until all the facts are in.



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Shanon Hakanson, hi September 3, 2013 2:00 AM

As a patient with chronic pancreatitis, I deal with nurses, residents, and doctors frequently who have little knowledge and very little experience with my condition.  I try to advocate for myself in the midst of severe pain and try to steer the treatment away from previous mistakes that have been made.  For example, because of Sphincter of Oddi dysfunction, I cannot have morphine; it makes me worse.  I know what I can have and ask for a low dose because of nauseau.  Then if I ask for more, there are the typical frowns.  Also, since I am used to concealing my pain from family and the public, if I don't demonstrate that I am in a lot of pain, there are more frowns.  I would give an awful lot not to be in the shape I am in.  If anyone thinks that I enjoy this, they really have to be the ones whose rationality is in question.  No one would opt for this painful condition.

Patricia September 20, 2012 2:01 PM
San Francisco CA

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Aelicia Doore, Certification - CNA, Traning March 31, 2011 7:05 AM
New Jersey NJ

We see a lot of adolescents who have gone to significant lenghts to suicide.  A recent patient admitted to our facility came to us after being treated for a gun shot wound to the gut from a high powered weapon.  This young man did have a history of substance abuse and was diagnosed with Conduct Disorder.  When this young man stated he had pain and requested appropriate and ordered PRN medications it typically raised eyebrows and created quite a conversation amongst the treatment team.  Unfortunately we are not a medical psychiatric facility however we do have a terrific pediatrician who sent him across the street for testing.  He had developed a pretty large pocket of infection and was indeed experiencing real pain that went untreated for several hours due to the nurses and his psychiatrist's bias against him due to his history and diagnosis.  

Dawn Cheshire, Psychiatry - House Supervisor, UNM Children's Psychiatric Hospital March 27, 2011 11:44 AM
Albuquerque NM

I know a young man that has stated he will "no longer go to the hospital unless it is to be pronounced dead." He has been telling doctors for 2 years about his pain issues. When he moves you can hear his joints popping. Sometimes when he tries to walk you can tell his feet hurt and sometimes he has trouble even holding a cup in his had. He is 22 and knows the pain scale before it is explained. He can tell you if the pain is from bone, nerve or muscle. He knows words like neuropathy. When pain gets to what he will rank at a level of "20" he will go to the ER. He has been treated like a drug seeker so many times he is now refusing to go to the hospital. He had an order to get a chest X-Ray and his doctor sent the order to the local hospital. That is when he made the statement, "I will go to the hospital when they need to pronounce me dead." Oh, by the way, the young man has even asked for physical therapy for pain management. Does that sound like a drug seeker? He has yet to be treated for pain. I have tried to help but I myself am getting frustrated with the situation.    

Katherine Burke March 26, 2011 6:42 PM

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