Communication, Anxiety, and the Management of Postoperative Pain
Postoperative pain is a noxious experience for many patients, and pharmacological remedies are not totally effective in pain management. Anxiety is viewed as a major contributor to the perception of pain, and open communication between health care professional and patient appears to be a most appropriate strategy for intervening in the pain-anxiety cycle. Additional nonpharmacological approaches to pain management are reviewed. Implications and suggestions for future research are discussed.
Acute pain following surgery is a serious, widespread, and well-documented problem. Thirty percent of all postoperative patients in the United States experience moderate levels of pain, whereas 40% experience severe or very severe pain ( 1980). Severe anxiety often accompanies acute pain as the patient becomes frightened of the intensity or the meaning of the pain ( 1982). Moreover, physical complications may be associated with acute pain ( 1976; 1983 ). For example, patients who hurt may not relieve their respiratory systems of fluid by coughing. Elevated blood pressure associated with acute pain may threaten patients with heart and circulatory problems.
The advent of pharmacological remedies to postsurgical pain has been relatively recent. In fact, until the 18th century, the use of chemicals to relieve pain was shunned by doctors who believed that pain was good for body and spirit ( 1982). Today, narcotics are used to manage postoperative pain in most patients; however, narcotics are commonly given in inadequate doses (1980; 1979 ; 1976), and much pain remains unrelieved ( 1984). Of course, even in large doses, narcotics are not totally effective (1981; 1982). In summary, pain following surgery is a serious problem both quantitatively and qualitatively, and pharmacological intervention is an incomplete solution to management of acute pain. Consequently, cognitive and behavioral approaches to the management of pain have been suggested and tested ( 1979; 1984; 1982; 1983; , 1977). Because there is no extant review of the literature detailing the relationship between state anxiety, communication, and the experience of acute postoperative pain, the development of such a review is one original contribution of this article. Moreover, theoretical explanations for this relationship are advanced. The need for open communication and the value of communication skills are stressed in nonpharmacological approaches to pain management. Finally, this article contributes suggestions for future research and emphasizes the importance of communication skills development among health care providers.
ANXIETY AND PAIN
Pain is a subjective experience that cannot be directly observed by the health care professional (1988). Individuals and cultural groups differ widely in the degree to which the experience of pain is outwardly expressed (1983 ; 1977), and health care professionals may give greater attention to the needs of expressive patients, especially patients who express pain through behaviors like moans and grimaces (1980). Understanding the subjective component of pain is important if remedies are to be found for the psychological, as well as the physical, causes of pain and if discriminatory treatment of patients is to be avoided.
To say that pain is experienced subjectively, however, is not to deny its reality. Direct neuronal and neurophysiological links between psychological state and the perception of pain have been proposed and supported in the medical literature (1986). Essentially, these pain models suggest that, although anxiety does not increase the neural impulses from the periphery, physiological amplification of the pain signal occurring in the brain, attributable to anxiety, results in increased perception of pain. This means that anxiety has the potential not only for affecting patients’ reactions to pain but also their actual perceptions of pain.
The deleterious affects of anxiety cannot be overstated. In addition to a direct impact on the pain experience, prolonged anxiety may weaken patients’ immune response (1985). (1980) discussed harmful effects associated with both high and unrealistically low anxiety (results were mixed on low anxiety). Depression, hostility, and acute postoperative anxiety were among these negative consequences.
There are numerous causes of anxiety following surgery, not the least of which is uncertainty resulting from novelty. Much uncertainty surrounds the conduct of medical procedures; however, many patients also experience uncertainty about pain levels and their ability to cope with pain. ( 1986 ) stated:
Surgery is a new experience for many: hospital procedures constituted the unknown. Most patients ask, “How much will I hurt?” not, “Will I hurt?” They expect the pain. Patients also feared expected undignified situations (bedpans, catheters, bodily exposure) and losing control. This anticipatory anxiety, which can occur before surgery, could have adverse effects if allowed to continue. ()
( 1966 ) suggested that states of physiological arousal, such as pain, lead individuals to develop evaluative needs. Briefly, there is a human need to attribute intense feelings to some identifiable cause. When a known cause is available (e.g., “My doctor told me that this is a painful surgical procedure, but I will feel much better in a few days”), attributions of cause may provide reassurance and the reduction of state anxiety. In the absence of reassuring information, however, patients may believe that something is pathologically wrong, that narcotics have not been properly administered, or that some other dire cause is resulting in intense pain. Findings of ( 1977 ) strongly indicate a correlation between anxiety during recovery and postsurgical pain intensity. Moreover, as expected, they find that “patterns of anxiety response vary among patients who attribute different types of meaning to the surgical experience” (1977).
It is important to note that the relationship between pain and anxiety is reciprocal. Painful experiences may lead to anxiety (e.g., “Something must be wrong . . . Will this pain get worse? I won’t be able to stand this much longer”). Increased anxiety will lead to accentuated perception of pain, which further increases the anxiety level. Obviously, potentially traumatic experiences may result unless there is some intervention in this pain-anxiety cycle. Narcotics may be helpful, but psychological interventions are quite appropriate in this regard.
PAIN MANAGEMENT ALTERNATIVES
As suggested earlier, many nonpharmacological approaches to pain management have been recommended. ( 1986 ) developed a trimodal classification system for these alternative approaches. The first category, cognitive strategies, is self-initiated and involves thoughts and private events (e.g., imagery, self-statements, and attention diversion). The next category, behavioral manipulation, is public, externally manipulated, and involves actions or behaviors. Some of these strategies are high in external control (e.g., hypnosis, biofeedback, and modeling), whereas others are low (attribution and perceived controllability). Finally, a category of physical intervention is included (e.g., physical relaxation, pharmacological agents, transcutaneous electrical nerve stimulation).Several of these coping strategies emphasize communication skills. A lack of communication is a major problem in the relationship between patient and health care professional ( 1983) and may be one reason why pain patients are undertreated ( 1983).
Communicating With Patients in Pain
Although physicians believe that patients should be given important information about their condition (etiology, course, and prognosis) and therapy, most patients possess only fragmented and isolated facts (1983 ). Several explanations for this discrepancy have been suggested, including the inability to communicate to patients when using a highly specialized vocabulary, status differences, inability for patients to ask questions while they are in pain, and a perception on the part of some physicians that patients cannot comprehend medical information. ( 1978 ) detailed a variety of communication problems between physicians and patients and presented data suggesting that health care professionals often deny the existence of patient pain. ( 1983) concluded:
The fact that physicians avoided communicating with patients, viewed them as poorly informed, even dull, and unable to handle information and that patients performed at even a lower level than the physician estimated may be in part the physicians’ self-fulfilling prophecy.
This lack of communication extends to the nursing profession. ( 1987 ) found significant gaps in nurses’ knowledge of pain assessment and means of intervention. Sofaer ( 1983 ) outlined several conclusions backed by research:
1.
Nurses stereotype patients in surgical wards and subsequently treat them according to their prejudices.
2.
Differences exist between patients’ and nurses’ perceptions of the patients’ pain.
3.
Preoperative discussions with patients about pain relief are not usually practiced.
Any lack of communication is especially troubling because uncertainty about procedures and physical sensations may be a major source of pa- tients’ anxiety. This is consistent with the theoretical positions advanced by ( 1966 ) and, in the area of interpersonal outcomes, ( 1975 ) uncertainty reduction theory. In fact, several studies have demonstrated that increases in patients’ knowledge and understanding (resulting from preoperative instructions) serve to significantly reduce pain (1986). For example, a classic study by ( 1964 ) indicated that doctors who maintained contact and freely communicated with patients not only reduced perceived pain but also reduced the need for postsurgical narcotics and extended hospital stays. The procedure has also worked well in reducing the postsurgical pain of children (1986).
Reduction of pain accompanying increased communication appears to stem directly from the attenuation of state anxiety. ( 1977 ) stated: “Reducing the incongruency between expectations and experience is one way of reducing anxiety based on the fear of the unknown. The sensory component of pain remains the same, but the feeling of distress is changed” (). ( 1973 ) found that descriptive information regarding sensations to be experienced was more helpful in reducing pain than was information that only dealt with procedures to be used. ( 1979 ) developed similar findings regarding the efficacy of sensory information but also found that warnings about high levels of pain blocked the reduction of distress that otherwise occurred. Their interpretation of these findings was that sensory information elicited a cognitive, evaluative response, whereas pain information elicited an affective, emotional response.
Communicating with patients about possible coping strategies has also proven helpful in reducing postoperative pain ( 1978). ( 1983 ) used the term stress inoculation to identify the process whereby patients learn to cope with anxieties of surgery. To reduce stress, recommended that health care providers communicate with patients about three things: (a) realistic information, including details of inherent risks; (b) feelings of loss of personal control are counteracted by reminding patients of their personal resources and abilities to cope; and (c) asking the patient to develop a personal coping repertoire–strategies for dealing with pain and injury probably most efficient for the particular patient ( 1983 ). The “work of worrying” is also theorized as an essential ingredient in stress reduction and recovery (1983). The idea here is that patients require time to work through preoperative anxieties and to plan personal reactions. Obviously, patients given little preoperative information concerning procedures, sensations, prognosis, and so forth may not have completed the work of worrying and may experience greater postoperative pain and anxiety.
( 1978 ) concluded, from clinical observation, that the following interventions were most helpful in reducing pain: discussing pain with the patient, teaching the patient (and the patient’s support group) about pain, establishing an interpersonal relationship with the patient, remaining in the presence of the patient, and providing distraction. Obviously, to some extent, the health care professional is the cure. A demonstration of care and concern, a willingness to listen and empathize, and development of an interpersonal relationship may be as important as decreasing patient uncertainty in the management of pain. ( 1986 ) presented a more comprehensive listing of “interventions that could serve as a buffer between the patient and the pain-anxiety cycle” (). These include:
1.
Orientation to the environment
2.
Reduce environmental stimuli
3.
Touch/hand holding
4.
Audiovisuals
5.
Decrease anticipatory anxiety
6.
Ensure confidentiality
7.
Psychological support
8.
Introduce team members
9.
Explain procedures
10.
Explain relaxation techniques
11.
Discuss new sensations
12.
Honesty
13.
Discuss postoperative interventions
14.
Discuss hospital policy
15.
Discuss sequence of surgical events
16.
ICU visit
17.
Explain pain reduction adjuncts
18.
Encourage diversion (of attention)
19.
Include family during education
20.
Maintain privacy and dignity (p. 681)
These interventions span pre-, intra-, and postoperative time periods. Although direct clinical evidence of the effectiveness of many of Bray’s suggested interventions does not exist, most of them seem reasonably appropriate for the reduction of patients’ anxiety.
Other Approaches to Pain Management
The previous discussion of pain management has focused on the content of health professional-patient communication in reducing anxiety and uncertainty. Although other pain management alternatives may not have an equal emphasis on information, the ability of the health professional to communicate skillfully remains important to the conduct and success of the strategy.
One of these pain management alternatives is therapeutic touch. ( 1967 ) contended that physical contact, from as extensive as a back rub to as brief as a hand stroking the forehead, can potentially reduce patients’ fears and, ultimately, pain. The feeling, on the part of the patient, that “someone cares and is doing something for me” is at least a potentially powerful placebo. At most, tactile stimulation may tap a neurophysiological connection to the pain experience.
Encouraging relaxation has also been linked to reduction of pain ( 1976), although the primary benefit of relaxation seems to be psychological: It does not appear to affect physiological variables (1982). Methods for eliciting relaxation may range from hypnosis (1982) to relatively simple techniques where patients are taught to concentrate on pleasant memories ( 1974; 1989). One advantage of relaxation is that patients perceive an increased ability to control their pain ( 1974).
Related to relaxation is the coping strategy of distraction. Although inappropriate for moderate to severe levels of pain, distraction may be a preferred strategy for many patients (1982). Getting one’s mind off the pain is a simple approach that can be assisted by nursing staff, family, and friends of the patient. Although this approach sounds reasonable on the surface, recent evidence has challenged the primary role of distraction in reducing pain. For example, ( 1989 ) suggested that it is the production of affect, positive or negative, that occurs during communication with patients, rather than the consumption of attention (distraction) that leads to the reduction of pain.
Communication professionals are generally aware of the tremendous power of cognitive restructuring in reducing performance anxiety (1989). Similarly, cognitive approaches can be used quite effectively in the management of postoperative pain (1979). Examples include positive self-statements (e.g., “I’m in control,” “Relax and the pain won’t last long”), reinterpretation of painful stimuli (e.g., visualizing pain as a sensation of healing or as pleasant radiant heat), and stress inoculation.
The Role of Family and Friends
The possible effects of friends and family on the recovering patient have not been systematically studied. It is known that there is a significant relationship between anxiety, depression, and pain (1986) and that spousal and family support can mediate the relationship and positively impact the perception of pain (1984). It seems reasonable that the emotional support provided by family and friends is useful in motivation and encouragement of the patient. In addition, hospitals may be quite dull and boring, leaving the patient little to think about except painful sensations. The presence of a support group should provide distraction. The environment immediately following surgery–tubes and monitors, a lack of windows and sunlight, and the restriction against visit by family and friends–may be disorienting. Even brief contact with close family members at this point, followed later by liberal visiting privileges, barring medical exigencies, may establish orientation and reduce anxieties.
A potential problem exists when family and friends attend and respond only to pain behavior (moaning and crying), thereby reinforcing and encouraging the behavior (1984). Instead of reacting only to pain, family and friends should provide attention and concern at all times. It is important to remind family and friends not to belittle or minimize the patients’ postoperative pain. In fact, if the patient believes he or she is experiencing more pain than is normal, this could further anguish the patient and become yet another source of anxiety.
CONCLUSIONS AND IMPLICATIONS
Even a cursory examination of the literature base reveals that the great majority of published research dealing with communication and acute pain is located in journals characterized as allied health and clinical psychology. Of this available research, there is an overabundance of case studies and clinical observation and a lack of controlled experimentation. Many relevant questions remain unanswered and should be addressed by future research. For example, although it is generally accepted that preoperative instruction produces beneficial postoperative outcomes, specific characteristics of the preoperative instruction that produce the benefit are not well understood.
Physician-initiated communication may be characterized as having either an informational or an affective style (1985). Given the significant negative correlation between amount of physician-patient communication and the experience of postoperative pain, it would be worthwhile to know the extent to which the informational and affective components of communication contribute to pain reduction. In fact, ( 1982 ) generalized on this concept by suggesting a need to conduct component analyses of cognitive and cognitive-behavioral strategies in order to know which aspects are necessary and sufficient.
Research in pain management has focused on coping strategies developed and initiated by health care professionals. Although data support the effectiveness of many of these strategies, the value of others is a matter of conjecture (further investigation is warranted). For example, the list of clin- ical strategies developed by ( 1986 ), previously discussed, is based on clinical experience and needs to be extended through research. In addition the effectiveness of the strategies within a variety of populations and subgroups is not well understood. Groups differing in cultural, social, and religious backgrounds may differ widely in reactions to pain and approaches to dealing with pain. Although this fact has been widely documented (1977), its potential and unique effect on pain management alternatives warrant study.
Further descriptive research is needed to assess the extent to which patients are informed about pain and medical procedures. ( 1973 ) found that information concerning painful sensations was more valuable in reducing pain than information about procedures. Yet, it seems likely that health care professionals concentrate more on procedures than on painful feelings when communicating with patients. In fact, the presence of postoperative pain is not usually a part of informed consent preceding surgery. It would be helpful to know how much information patients typically possess about pain, where they get their information, and which cognitive and behavioral coping strategies are most commonly employed. Finally, in terms of descriptive research, further epidemiological studies of the incidence and prevalence of pain have been called for (1987).
A further area requiring research is the dissemination and implementation of new information about pain management, particularly in the areas of communication, psychological coping strategies, and behavior alternation techniques. Although much recent attention has been given to pain management, doctors are not yet making use of much of the information (1987).
Lack of knowledge about pain management among health care professionals highlights a final important conclusion: the need for education and training. ( 1980 ) found a lack of knowledge among nurses of nonpharmacological strategies of pain management. ( 1987 ) found that same lack of information regarding administration of narcotics as well as pain assessment. Typically, the nurses under- or overestimated the severity of pain and then overestimated the effectiveness of pain relief measures (1990; 1987).
Beyond a more general emphasis on the management of pain, improvement of communication skills should be strongly considered in the curriculum of medical and nursing schools. Communication skills coursework in medical and nursing schools is presently offered with unremarkable frequency. Premedical programs rarely mandate coursework in communication skills development, unless those courses are contained in broader, university core curriculums. A lack of time and pressures for expertise in other areas (biology, chemistry, etc.) is often cited as the reason for this oversight. This view generally assumes; however, that communication skills contribute more to health care style than to health care substance. The relationship between communication, anxiety, and postoperative pain argues against this viewpoint.
Few health care providers today subscribe to the old view that there is moral value in pain and suffering. The reduction of postoperative pain should be viewed as a very worthy and important goal. To facilitate its accomplishment, health care professionals should be competent and openminded listeners, persuasive speakers, and conversationalists willing to devote time to the reduction of patients’ uncertainties about procedures, painful sensations, therapeutic measures, and the like. In short, research should carefully investigate the relationship between communication competence and therapeutic effectiveness, and professional training should place an emphasis on skillful communication.
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