Background
Leg ulceration presents a significant health-care problem for patients and health-care services (Briggs and Closs, Reference Briggs and Closs2003; Graham et al., Reference Graham, Harrison, Nelson, Lorimer and Fisher2003). In studies investigating the prevalence of pain in this patient population, at least three quarters of the participants reported moderate to severe pain (Phillips et al., Reference Phillips, Stanton, Provan and Lew1994; Chase et al., Reference Chase, Whittemore, Crosby and Freney2000; Wissing and Unosson, Reference Wissing and Unosson2002; Nemeth et al., Reference Nemeth, Harrison, Graham and Burke2004; Hareendran et al., Reference Hareendran, Bradbury, Budd, Geroulakos, Kenkre and Symonds2005; Briggs et al., Reference Briggs, Bennett, Closs and Cocks2007; Heinen et al., Reference Heinen, Person, Van de Kerhof, Otero and Achterberg2007; Park et al., Reference Park, Ferreira and Santos2008; Price et al., Reference Price, Fagervik-Morton, Mudge, Beele-Ruiz, Nystrom, Lindholm, Maume, Melby-Ostergaard and Harding2008). Pain is associated with all types of leg ulcers: venous, arterial, as well as those with mixed aetiology (Ebbeskog et al., Reference Ebbeskog, Lindholm and Ohman1996; Briggs and Flemming, Reference Briggs and Flemming2007; Closs et al., Reference Closs, Nelson and Briggs2008). It is of no surprise that patients report pain associated with the tissue damage of their leg ulceration. Ulcers become chronic because they do not follow the normal healing trajectory associated with acute wounds (Snyder, Reference Snyder2005) and remain in the inflammatory stage.
To manage pain effectively, it is necessary first to assess pain accurately (Donaldson, Reference Donaldson2009). There was little evidence in the literature of this activity being undertaken for patients with leg ulceration. In a study of district nursing practice in relation to leg ulcer management, Roe et al. (Reference Roe, Luker, Cullum, Griffiths and Kenrick1993) observed that 55% (n = 80) of community nurses caring for patients with leg ulceration did not assess pain as part of their care. Hollinworth (Reference Hollinworth1995) found similar results, observing that community nurses often failed either to assess pain verbally or to use pain assessment tools. Lorimer et al. (Reference Lorimer, Harrison and Graham2003) reported that out of 66 nursing records taken from patients receiving home care only 15% contained any pain documentation. In another study investigating community nurses’ views about pain and trauma at dressing changes, 3300 questionnaires were sent to nurses from three European countries (Kammerlander and Eberlein, Reference Kammerlander and Eberlein2002). Just 16% (n = 79) of these used a standardised pain scale, although there was only a 15% response rate overall.
These studies suggest that pain is a significant problem for many patients with leg ulcers and that pain assessment is not a routine activity among community nurses. As it is predominantly nurses who care for this patient group, a detailed investigation of their knowledge of pain and associated assessment and management techniques for patients with leg ulceration was proposed.
Aim of the study
This study was designed to build on a related qualitative study of patients’ experiences of pain associated with leg ulceration. Findings suggested that both the assessment and the management of the pain were inadequate (Taverner, Reference Taverner2010). This study, therefore, aimed to increase our understanding of nursing practice, by exploring community nurses’ knowledge and beliefs about the pain associated with chronic leg ulceration. The study objectives were as follows:
i) To explore community nurses’ perceptions of the nature of the pain from chronic leg ulceration.
ii) To describe current strategies used by community nurses to manage pain in this patient group.
iii) To survey nurses’ attitudes in relation to providing pain management for this group.
Methodology
Ethics committee approval was obtained from the local research ethics committee and research governance procedures were adhered to.
This was a feasibility study of a sample of community nurses in the North of England, United Kingdom. All community nurses (including health-care assistants) from one community organisation were invited to participate (n = 354). Nurses were sent postal questionnaires individually and asked to complete them independently. Consent was implied if the nurse completed and sent back the questionnaire. Covering letters and study information leaflets were sent with questionnaires. Confidentiality of data was assured.
To be eligible, respondents were required to meet the following criteria:
Inclusion criteria: The study included qualified nurses and health-care assistants employed by the community organisation and caring for patients with chronic leg ulceration within their caseload.
Exclusion criteria: The study excluded nurses working within the organisation but not employed by the organisation (ie, student nurses and agency nurses), as well as nurses whom the organisation employed but who did not look after patients with chronic leg ulceration.
Research tools
Although there were a limited number of studies relating to pain associated with leg ulceration, these only asked questions relating to pain assessment. They did not ask about the nature of the pain or the management of the pain associated with leg ulceration (Roe et al., Reference Roe, Luker, Cullum, Griffiths and Kenrick1993; Kammerlander and Eberlein, Reference Kammerlander and Eberlein2002; Moffatt et al., Reference Moffatt, Franks and Hollinworth2002; Lorimer et al., Reference Lorimer, Harrison and Graham2003). Previous studies have used validated questionnaires to assess pain knowledge and attitudes (McCaffery and Ferrell, Reference McCaffery and Ferrell1992). However, there were no validated questionnaires available that had questions specifically related to pain associated with leg ulceration. Therefore, it was necessary to develop a new questionnaire based on the findings of the qualitative study (Taverner, Reference Taverner2010; Taverner et al., Reference Taverner, Briggs and Closs2006) together with other relevant literature, following thorough review.
This questionnaire addressed nurses’ pain knowledge, pain assessment, pain management practices and pain management beliefs. Data were also collected relating to pain management support within the individuals’ clinical areas of work.
Ethics committee approval was obtained from the local research ethics committee and research governance procedures were adhered to.
Analysis
The data were analysed using the Statistical Package for the Social Sciences version 13.0 (SPSS Inc., Chicago, USA). χ 2 or Fisher's exact tests, as appropriate, were used to probe for inter-group differences.
Validity and reliability
Content validity of the questionnaire was determined by expert opinion of the subject matter being investigated (Heffner, Reference Heffner2004). The content of the questionnaire was assessed and designed by the author, two other researchers with relevant expertise and tissue viability nurse specialists.
Face validity of the questionnaire was achieved by piloting the questionnaire with a group of community nurses. Face validity was also achieved by asking an expert in the topic of the questionnaire to provide feedback (Anastasi, Reference Anastasi1988).
To determine the reliability of the questionnaire, internal consistency of the responses was tested using the Cronbach α coefficient. A value of 0.5 or above can be considered acceptable (Bowling, Reference Bowling2005), and if a value of 0.7 or above is established then the questionnaire can be considered to have good reliability (Pallant, Reference Pallant2003). The Cronbach α coefficient score for this survey was 0.89, demonstrating good reliability.
Results
Participant profile
Out of the 354 questionnaires sent out, 115 completed questionnaires were returned, with a response rate of 32%. Four participants were excluded as they did not meet the study inclusion criteria. The characteristics of the study participants are presented in Table 1.
Study participant characteristics
The age range of respondents was similar to the breakdown of age among nurses registered with the nursing and midwifery council in the United Kingdom at the time of data collection (NMC, 2006). Job title distribution among the respondents represented a typical community nurse team working in the organisation studied. This was determined by obtaining information regarding the distribution of job titles within each team included in the survey.
Nature and consequences of pain associated with leg ulceration
A significant majority, that is, 90.1% (n = 100), of respondents indicated that they thought pain with leg ulceration could be acute and chronic. A high percentage indicated that patients with leg ulceration might have both neuropathic pain and nociceptive pain (77.5%, n = 86). Nurses who had formal pain management training were significantly more likely to indicate that leg ulcer pain may have both nociceptive and neuropathic properties (Fisher's exact = 4.93, df1, n = 109, P = 0.025).
Chronic pain may lead to depression, pain at night, insomnia, loss of mobility, suicidal ideation, social isolation and desire for amputation. Table 2 represents the data that suggest that a significant number of nurses were aware of these issues.
Percentage (n) of nurses who were aware that pain may lead to the following negative consequences
The majority of respondents thought that compression bandages might cause or worsen pain in some patients (94.6%, n = 105). Participants were also asked what they thought the reason for this was. The reasons are displayed in Figure 1. The most common reasons given were if the compression was too tight or applied to an ulcer of mixed aetiology.
Percentage (n) of respondents who identified each cause of pain associated with compression
Nurses’ responses to the pain
Respondents were asked whether pain was a good sign, indicating sensation, healing and infection. A significant number thought that pain was a good sign as it indicated sensation (38.7%, n = 43), a small number indicated that pain was a good sign as it indicated healing (6.3%, n = 7) and 46.8% (n = 52) of nurses thought that pain was a good sign as it indicated infection.
The questionnaire also explored nurses’ opinions on using patients’ report of pain severity and pain triggers (such as leg position) as an indicator of the type of leg ulcer. A significant number of respondents stated that they used pain severity as a tool to identify the type of leg ulcer, and 44.1% (n = 49) indicated that patients’ report of pain intensity helped them in identifying the type of leg ulcer. Eighty-seven per cent (n = 97) indicated that patients’ pain triggers helped them in identifying the type of leg ulcer. Respondents were significantly more likely to indicate that pain triggers such as elevating legs, standing and pain at night were an indication for the type of leg ulcer compared with respondents who indicated that they used pain intensity (Fisher's exact = 4.90, df1, n = 96, P = 0.029).
Assessment and management of pain associated with chronic leg ulceration
Just under half of the respondents stated that they assessed pain using both verbal report and a pain score (46.8%, n = 51), with 30.6% (n = 34) assessing pain using a pain score only. Nearly a quarter of the respondents (22.5%, n = 24) either left the question blank (7.2%, n = 8) or took a verbal report, but did not record a pain score (15.3%, n = 17). Participants were also asked when and how frequently they measured and documented pain. Just over half the participants measured and documented pain on every visit (55.9%, n = 62), 9.9% (n = 11) measured and documented pain only if the patient reported pain. Just 15.3% (n = 17) stated that they never measured and documented pain. To explore the relationships between nurse characteristics and whether they assessed patients’ pain using a pain score and verbal report χ 2 tests were undertaken; however, none were found to have statistical significance (see Table 3). A Bonferroni correction was applied to each variable because of multiple testing (Tabanick and Fidell, Reference Tabanick and Fidell1996).
Association between nurse characteristics and whether they undertook pain scoring and verbal report (χ 2 test)
In terms of managing the pain, most nurses indicated that they recommended paracetamol (acetaminophen; see Table 4), with 46.8% (n = 52) of respondents indicating that they ‘always’ recommended paracetamol and 35.1% (n = 39) recommending it ‘sometimes’. The next most frequently recommended analgesic was codeine. Fisher's exact determined that paracetamol was significantly more likely to be recommended than codeine (Fisher's exact = 6.56, df1, n = 69, P = 0.009).
Percentage (n) of nurses who indicated that they recommended the following analgesics to their patients
To manage neuropathic pain, the nurses indicated that they would recommend amitriptylene, with 46.8% (n = 52) of the community nurses stating that they recommended this drug ‘sometimes’. Nearly half of the respondents, that is, 45% (n = 50), stated that they recommended gabapentin sometimes. A very small number of respondents stated that they would recommend pregabalin (8.1%, n = 9). Gabapentin was significantly more likely to be recommended ‘sometimes’ than pregabalin (Fisher's exact = 8.04, df1, n = 56, P = 0.004).
Nurse prescribing is a relatively new practice within the nursing profession and 34.2% (n = 38) of the respondents stated that they were nurse prescribers. Nurses were asked if they were nurse prescribers did they routinely prescribe analgesics always, sometimes or never. Only 12.6% (n = 14) prescribed analgesics to this group of patients ‘sometimes’. The majority of nurses who could prescribe stated that they never prescribed analgesics (21%, n = 24). Comparisons between nurse prescribing and job title show that 92% (n = 23) of caseload holders were nurse prescribers, but only 28% (n = 7) of them prescribe analgesics sometimes. Five per cent (n = 2) of senior staff nurses could prescribe and only 3% (n = 1) of them prescribe analgesics sometimes. Only 6% (n = 2) of staff nurses were nurse prescribers and none of them stated that they prescribed analgesics.
Participants were asked what they used for pain at dressing changes. Most stated that they were using a gentle dressing technique (73.9%, n = 82). Provision of analgesics before and after dressing was frequently stated as being used to manage pain. In all, 39% (n = 43) reported that they always gave analgesics before dressing changes and 60.4% (n = 67) reported that they gave them sometimes. Extra analgesics after the dressing changes were stated as being given always by 2.7% (n = 3) of respondents and 61.3% (n = 68) reported giving them sometimes. Forty-three per cent (n = 47) of nurses who had received formal pain management training also recommended pre-emptive analgesia compared with 20% (n = 22) of nurses who had not had formal pain management training. Using χ 2 analysis, it was demonstrated that formal pain management training was associated with pre-emptive analgesics being given (χ 2 = 6.85, df2, n = 111, P = 0.033).
Professional attitudes
Half of the respondents indicated that healing was the primary goal (50.5%, n = 56). Participants were asked whether with repeated exposure some nurses might become desensitised to patients expressing pain during dressing changes. A significant number of the community nurses agreed with this statement (52.3%, n = 58). The majority of the community nurses agreed that patients with pain from leg ulcers have a right to expect pain relief (95.5%, n = 106). Only 35.1% (n = 39) indicated that they were confident about managing pain for this patient group and 82% (n = 91) stated that they would like more training with regard to managing pain associated with leg ulcer pain. χ 2 tests were used to determine whether there were significant relationships between nurses’ characteristics and confidence in pain management. A Bonferroni correction was applied because of multiple testing. This showed no associations between nurses’ characteristics and their confidence in managing pain for this patient group (see Table 5).
Association between nurses’ characteristics and confidence in managing pain (χ 2 test)
Discussion
This study was undertaken to explore community nurses’ knowledge and beliefs about the nature and management of pain associated with leg ulceration. The aims of the research were as follows:
i) To explore community nurses’ perceptions of the nature of the pain from chronic leg ulceration.
ii) To describe current strategies used by community nurses to manage pain in this patient group.
iii) To survey nurses’ attitudes in relation to providing pain management for this group.
The key areas of importance in the results were concerned with nurses’ knowledge about the nature and consequences of pain associated with leg ulceration; their response to this pain; their assessment and management of this pain; and their professional attitudes towards it. These are discussed below.
Nature of pain associated with leg ulceration
Neuropathic pain can be a possible component of chronic leg ulceration (Briggs et al., Reference Briggs, Bennett, Closs and Cocks2007) and the majority of respondents rightly identified that pain associated with chronic leg ulceration may have a neuropathic component. Insufficient knowledge and training in pain management have been reported as causing a barrier to providing effective pain management (Elliott and Elliot, Reference Elliott and Elliot1992; Fife et al., Reference Fife, Irick and Painter1993; Elliott et al., Reference Elliott, Muray, Elliott, Braun, Oken, Johnson, Post-White and Lichtblau1995; Oneschuk, et al., Reference Oneschuk, Fainsinger, Hanson and Bruera1997; Jastrab et al., Reference Jastrab, Fairbrother, Kerr and McInerney2003). Therefore, it was to be expected that the nurses in this sample, who had received formal pain management training, were significantly more likely to indicate that leg ulcer pain may involve both nociceptive and neuropathic pain mechanisms. The majority of nurses (91–97%) were aware that chronic pain may lead to insomnia, depression, loss of mobility, pain at night and social isolation. The literature supports this and it is reassuring that the results from the survey demonstrated that these comorbidities were acknowledged by the nurses caring for this group of patients (Krasner, Reference Krasner1998; Hyde et al., Reference Hyde, Ward, Horsfall and Winder1999; Ebbeskog and Ekman, Reference Ebbeskog and Ekman2001; Douglas, Reference Douglas2001; Husband, Reference Husband2001a; Rich and McLachlan, Reference Rich and McLachlan2003; Hopkins, Reference Hopkins2004; Hareendran et al., Reference Hareendran, Bradbury, Budd, Geroulakos, Kenkre and Symonds2005; Mudge et al., Reference Mudge, Holloway, Simmonds and Price2006; Turk et al., Reference Turk, Dworkin, Revicki, Harding, Burke, Cella, Cleeland, Cowan, Farrar, Hertz, Max and Rappaport2008). The interrelationship of depression and insomnia and pain is complex; many chronic pain patients are depressed and anxious; sleep deprivation can lead to anxiety; depression can be both the cause and the result of sleep disturbance (Nicholson and Verma, Reference Nicholson and Verma2004). Patients with leg ulceration require assessment of pain, as well as depression and sleep problems. Patients may benefit from a more holistic management model that would include focus and attention on sleep hygiene, depression and social circumstances. The leg ulcer management guidelines need to address the management of these patients using a more holistic approach, and currently the focus of these guidelines is predominantly concerned with healing the ulcer (Scottish Intercollegiate Guideline Network (SIGN), 1998; Registered Nurses of Ontario (RNAO), 2004; Royal College of Nursing (RCN), 2006).
This survey identified that the majority of the community nurses thought that compression bandaging caused or exacerbated pain. Reasons for the compression causing further pain were identified as predominantly being caused by compression being applied to an ulcer of mixed aetiology. Again the leg ulcer guidelines and literature recommend that an increase in pain may be a sign of arterial involvement (RCN, 1998; 2006; Scottish Intercollegiate Guideline Network, 1998; Phillips, Reference Phillips2004; RNAO, 2004; Dowsett, Reference Dowsett2005). It is understandable that the nurses cited that the pain caused by compression could be caused by the bandage being applied incorrectly and by the bandage slipping. There is a strong emphasis within the leg ulcer literature that suitably trained nurses must undertake application of compression to ensure that it is applied correctly (Moffatt, Reference Moffatt2004; RCN, 2006). Heinen et al. (Reference Heinen, Person, Van de Kerhof, Otero and Achterberg2007) found that patients could not tolerate compression because it was too tight, as did Briggs and Closs (Reference Briggs and Closs2006). It is not possible to ascertain whether these patients could not tolerate the compression because it felt too tight (but needed to be), or because the bandaging had in fact been applied incorrectly.
Ten per cent (n = 10) of the nurses indicated that the pain was psychological. This is a concern, but perhaps reflects the current leg ulceration literature, which suggests that compression is associated with a reduction of pain (Franks et al., Reference Franks, Moffatt and Connolly1994; RCN, 2006; Fogh et al., Reference Fogh, Glynn, Junger, Jorgensen, Krasner, Osterbrink, Price and Sibbald2008). Fogh et al. (Reference Fogh, Glynn, Junger, Jorgensen, Krasner, Osterbrink, Price and Sibbald2008) developed a wound pain management model, within which it was suggested that compression should be used to reduce pain. This may create confusion in the nurses applying the compression. Furthermore, some patients do not experience a reduction in pain with compression, regardless of correct and appropriate application (Phillips et al., Reference Phillips, Stanton, Provan and Lew1994; Chase et al., Reference Chase, Whittemore, Crosby and Freney2000; Wissing and Unosson, Reference Wissing and Unosson2002; Nemeth et al., Reference Nemeth, Harrison, Graham and Burke2004; Hareendran et al., Reference Hareendran, Bradbury, Budd, Geroulakos, Kenkre and Symonds2005; Briggs et al., Reference Briggs, Bennett, Closs and Cocks2007; Heinen et al., Reference Heinen, Person, Van de Kerhof, Otero and Achterberg2007; Park et al., Reference Park, Ferreira and Santos2008; Price et al., Reference Price, Fagervik-Morton, Mudge, Beele-Ruiz, Nystrom, Lindholm, Maume, Melby-Ostergaard and Harding2008). Allodynia is a likely characteristic of neuropathic pain (Wall, Reference Wall1991); therefore, applying a tight heavily layered bandage can be expected to cause further pain. Moreover, hyperalgesia is also a common feature of neuropathic pain (Wall, Reference Wall1991). Both hyperalgesia and allodynia, if present, would cause a significant amount of pain if a bandage were being applied to the area, regardless of correct or appropriate application. Most of the nurses in this survey indicated that leg ulceration can have both nociceptive and neuropathic pain components. However, the majority did not demonstrate an understanding of neuropathic pain because they did not suggest that neuropathic pain may be a cause of pain associated with compression. If the nurses had knowledge of neuropathic pain, they would understand hyperalgesia and allodynia, and therefore would understand the impact that compression may have on the pain.
In a systematic review carried out by Van Hecke et al. (Reference Van Hecke, Grypdonck, Beele, De Bacquer and Defloor2008), pain and discomfort were reported as being a main cause for non-adherence to compression. Others have also reported that patients take off their bandages to reduce discomfort (Edwards, Reference Edwards2003; Herber et al., Reference Herber, Schnepp and Rieger2007). By managing the neuropathic pain, patients may not only have a reduction in pain but their ability to adhere to treatment may also be enhanced.
Nurses response to the pain
A significant number of the respondents indicated that they thought pain could be a good sign as it may indicate infection or sensation. This may not be conducive to effective pain management. Previous studies have identified professionals preserving the pain when using it as a clinical indicator and have shown that this impacts negatively on the pain management ability of the clinician (Lebovits et al., Reference Lebovits, Florence and Bathina1997; Levin et al., Reference Levin, Berry and Leiter1998; Ponte and Johnson-Tribino, Reference Ponte and Johnson-Tribino2005). It has been shown that pain intensity and pain triggers such as elevating legs are unreliable indicators of leg ulcer aetiology and infection (Ebbeskog et al., Reference Ebbeskog, Lindholm and Ohman1996; Gardner et al., Reference Gardner, Frantz and Doebbeling2001; Cutting and White, Reference Cutting and White2005; Briggs et al., Reference Briggs, Bennett, Closs and Cocks2007; Closs et al., Reference Closs, Nelson and Briggs2008). However, the leg ulcer literature encourages the use of pain as an indicator of infection, sensation or arterial involvement. The clinical guidelines (RCN, 1998; 2006; SIGN, 1998; RNAO, 2004) suggest that infection can be detected by an increase in pain severity. The Scottish guidelines (SIGN, 1998) correctly comment that leg ulcers are painful. However, they go on to say, ‘particularly if they have an arterial component’. Reichenberg and Davis (Reference Reichenberg and Davis2005), in a review of management of venous leg ulceration, state that venous ulcers are associated with a minimum of pain. This study has shown that a significant number of the community nurses did use pain severity to aid diagnosis of the type of leg ulcer. Furthermore, the majority of the community nurses indicated that they used a report of pain triggers in aiding diagnosis of type of leg ulcer. The report of trigger of pain as an aid to diagnosis is again endorsed by the guidelines and within the literature on leg ulcer. It is reported that patients with arterial ulcers are more likely to have an increase in pain when their leg ulcers are elevated or after exertion (RCN, 1998b; 2006; SIGN, 1998; Phillips, Reference Phillips2004; RNAO, 2004). Moreover, it is suggested that only severe arterial disease will cause pain at rest (Phillips, Reference Phillips2004). The literature and current practice guidelines suggest that patients with venous ulcers are more likely to have pain with exercise and relief of pain can be gained by elevating their legs (SIGN, 1998; Phillips, Reference Phillips2004; RCN, 2006). This perhaps offers an explanation as to why the nurses use severity of pain and pain triggers as an indicator of the aetiology of a leg ulcer.
Assessment and management of pain associated with chronic leg ulceration
The key to effective pain management is thorough and appropriate assessment (Donaldson, Reference Donaldson2009). The nurses’ accurate assessment, prompt intervention and evaluation of pain relief measures are necessary for positive patient outcomes (Ersek et al., Reference Ersek, Turner, McCurry, Gibbons and Kraybill2003). Just under half of the respondents stated that they were assessing pain using verbal report and a pain score (46.8%). Therefore, over half of the respondents stated that they were not measuring and assessing pain appropriately. It is not possible to state why this was the case. However, inadequate pain management can be related to a number of factors, one of which is an absence of any formal pain management procedures (Pargeon and Hailey, Reference Pargeon and Hailey1999). The literature supports the recommendation that pain can only be assessed on an individual basis using self-report, careful pain histories and external indicators (McCaffery and Pasero, Reference McCaffery and Pasero1999; Brown, Reference Brown2004). Others have reported similar findings to suggest that pain assessment and documentation are not routinely carried out by community nurses (Walker et al., Reference Walker, Akinsanya, Davis and Marcer1990; Roe et al., Reference Roe, Luker, Cullum, Griffiths and Kenrick1993; Hollinworth, Reference Hollinworth1995; Kammerlander and Eberlein, Reference Kammerlander and Eberlein2002; Lorimer et al., Reference Lorimer, Harrison and Graham2003; Breivik et al., Reference Breivik, Collett, Ventrafridda, Cohen and Gallacher2006).
This study included a question about nurse prescribing activity among community nurses caring for patients with chronic leg ulceration. The data showed that 34.2% (n = 38) of the nurses indicated that they were nurse prescribers. However, only 12.6% (n = 14) stated that they were prescribing analgesics ‘sometimes’ and the majority (21%, n = 24) stated that they never prescribed analgesics. There could be various reasons for this. The literature identified certain issues preventing nurses from using their prescribing rights, which included not having confidence in prescribing analgesics (Luker et al., Reference Luker, Hogg, Austin, Ferguson and Smith1998; Baird, Reference Baird2001) One reason for this may be that they do not get the opportunity to consolidate their training (Ryan-Woolley et al., Reference Ryan-Woolley, McHugh and Luker2007). Another reason may be insufficient infrastructures and mentoring mechanisms available to support nurse prescribing (Luker et al., Reference Luker, Austin, Ferguson and Smith1997; Humphries and Green, Reference Humphries and Green2000; Sodha et al., Reference Sodha, McLaughlin, Williams and Dhillon2002). A significant number of respondents reported using pre-emptive analgesia always (39%) or sometimes (60.4%). The use of pre-emptive analgesics would be appropriate and if used could be beneficial to this patient group (Ong et al., Reference Ong, Lirk, Seymour and Jenkins2005). Pre-emptive analgesia, given before a painful intervention, is thought to decrease the post-intervention incidence of hyperalgesia and allodynia by decreasing the altered central sensory processing (Kissin, Reference Kissin2000).
The analgesic that the nurses were most likely to recommend for chronic leg ulceration was paracetamol, confirming findings from earlier studies (Ebbeskog et al., Reference Ebbeskog, Lindholm and Ohman1996; Husband, Reference Husband2001b; Guarnera et al., Reference Guarnera, Tinelli, Abeni, Di Pietro, Sampogna and Tabolli2007). The same literature suggests that the use of paracetamol alone does not offer adequate pain management for this group of patients. Fifty-five per cent of the respondents stated that they were recommending codeine sometimes. The literature reflects this finding and the use of codeine for management of pain associated with leg ulceration is apparent (Husband, Reference Husband2001b; Guarnera et al., Reference Guarnera, Tinelli, Abeni, Di Pietro, Sampogna and Tabolli2007). Forty-six per cent of nurses in this survey recommended amitriptylene ‘sometimes’ and 45% recommended gabapentin ‘sometimes’ for neuropathic pain. Nurses indicated that they would preferentially recommend amitriptylene for neuropathic pain, despite it not being licensed for this specific use (BNF, 2008). This practice is common throughout the medical profession (Maxwell, Reference Maxwell2000). However, amitriptylene is not suitable for use in older adults (Dworkin et al., Reference Dworkin, O'Connor, Backonja, JLoeser, Miaskowski, Nurmikko, Portenoy, Rice, Stacey, Treede, Turk and Wallace2007), and therefore may not be appropriate for the majority of patients with leg ulceration. Neuropathic pain management guidelines recommend gabapentin and pregabalin as first-line agents for managing neuropathic pain (Dworkin et al., Reference Dworkin, O'Connor, Backonja, JLoeser, Miaskowski, Nurmikko, Portenoy, Rice, Stacey, Treede, Turk and Wallace2007). Several pharmacokinetic properties of gabapentin and pregabalin are particularly suited for use in older adults (Dworkin et al., Reference Dworkin, O'Connor, Backonja, JLoeser, Miaskowski, Nurmikko, Portenoy, Rice, Stacey, Treede, Turk and Wallace2007) and these drugs also have a beneficial effect on sleep (Rice and Maton, Reference Rice and Maton2001). This may be particularly relevant for this patient group because of the associated pain at night and insomnia. Gabapentin was stated as being frequently recommended; the literature demonstrates the successful use of gabapentin with older adults who have neuropathic pain (McQuay, Reference McQuay2002). The fact that pregabalin was a relatively newly available drug at the time of data collection (Dworkin et al., Reference Dworkin, O'Connor, Backonja, JLoeser, Miaskowski, Nurmikko, Portenoy, Rice, Stacey, Treede, Turk and Wallace2007) may explain why the nurses were not recommending this drug.
Professional attitudes
A significant majority of nurses in this survey thought healing was the primary goal for all patients regardless of recurrence rates and history. This is in line with the leg ulceration literature where the emphasis is on the healing and not on symptom management. Such a focus on healing may distract attention from necessary symptom management. Healing outcomes are not realistic for some patients, particularly older adults (Phillips, Reference Phillips1999; Barwell et al., Reference Barwell, Deacon, Taylor, Wakley, Poskit and Whyman2001; Laible et al., Reference Laible, Mayer and Evers2002; Briggs and Closs, Reference Briggs and Closs2003; Graham et al., Reference Graham, Harrison, Nelson, Lorimer and Fisher2003; Gohel et al., Reference Gohel, Taylor, Earnshaw, Heather, Poskitt and Whyman2005; Gloviczki and Gloviczki, Reference Gloviczki and Gloviczki2009), and therefore the focus on healing may not always be appropriate for this group of patients.
Many nurses indicated that with repeated exposure to patients in pain they became desensitised to it, supporting earlier findings (Grootenhuis et al., Reference Grootenhuis, van der Wel, de Graaf-Nijkerk and Last1996). This may be a coping mechanism as others have found that exposure to people in pain is likely to arouse emotional distress that may interfere with their ability to manage pain effectively (Brough, Reference Brough1991; Nagy, Reference Nagy1999). This survey found that only 35.1% (n = 39) of the nurses felt confident about managing pain for this patient group and a large majority wanted more training (82%, n = 91). Interestingly, nurses who had undergone some form of pain management training were not statistically more likely to be confident. This is in conflict with the literature that suggested that nurses who had undergone some form of pain management training demonstrated improvement and increased confidence (Ferrell et al., Reference Ferrell, Grant, Ritchley, Ropchan and Rivera1993; Francke et al., Reference Francke, Garssen and Abu-Saad1996; Lasch et al., Reference Lasch, Wilkes, Lee and Blanchard2000; Arber, Reference Arber2001). This may have been because those nurses who had attended pain management training did not have management of leg ulceration included. As the nurses surveyed appeared to have a limited understanding of neuropathic pain, the training they had received may have been less than adequate.
Study limitations
This was a small local study, piloting a questionnaire designed to explore nurses’ knowledge and beliefs towards the pain associated with leg ulceration. Findings cannot therefore be generalised; rather, they present areas of concern that require larger studies to explore further, and the questionnaire further refining.
Other limitations of the findings presented are principally due to the potential biases from nurses’ self-report and the low response rate.
The main limitation is that nurses provided a report of their own activity. It did not measure their activity objectively using observational methods to collect data. There may well have been a difference between what the respondents stated they were doing and what they actually did.
The study sample was self-selected, with a response rate of 32%. It is possible that the low response rate created some kind of response bias. It is possible that nurses who were more interested in the topic of research or wound care and who were better educated were most likely to complete the questionnaire (Dillman and Frey, Reference Dillman and Frey1974; Cartwright, Reference Cartwright1978; Clarke and Rees, Reference Clarke and Rees1989). The low response rate is common with postal questionnaires, especially when they are aimed at health-care professionals (Cartwright, Reference Cartwright1978; Bowling et al., Reference Bowling, Jacobson, Southgate and Formby1991; Myerson, Reference Myerson1993). Other studies of community nurses have had similar response rates (Hollinworth and Collier, Reference Hollinworth and Collier2000; Kammerlander and Eberlein, Reference Kammerlander and Eberlein2002).
Summary
In summary, the nurses in this study acknowledged the pain that patients with leg ulceration may have. They were aware of the possibility that compression may cause pain, but did not acknowledge that this could be related to the neuropathic component. Rather, they suggested that pain caused by compression could be caused by incorrect or inappropriate bandage application. The data suggest that the nurses were using severity of pain and pain triggers as tools for diagnosis of complications or deterioration, as well as an aid to the diagnosis of the aetiology of leg ulceration. Unfortunately, the current practice guidelines support this. The community nurses are in a difficult situation as their reported practices adhere to current UK (SIGN, 1998; RCN, 2006) leg ulcer management guidelines, which appear to promote the use of pain as a clinical indicator. The leg ulceration guidelines need to acknowledge that the aetiology of an individual's leg ulcer may not determine their pain intensity. Guidelines need to have a greater emphasis on symptom management, which includes pain assessment and management. The guidelines need to acknowledge and give permission for nurses to use a palliative care model for those patients who warrant it, informed by good-quality evidence. Current pain management practices identified by this study suggest inadequate pain management practices, particularly with regard to pain assessment. The reported pain assessment practice was not homogenous, which may suggest that there were no formal pain assessment procedures in place within the primary care trust surveyed. Nurses did not report that they were assessing for neuropathic pain. Clinical guidelines need to include guidance that enables a more holistic approach; the guidance should consider depression, sleep hygiene and social isolation.
The nurses appear to have an insight into their coping mechanisms, in that they acknowledged that they might become desensitised to patients’ pain over time. The respondents indicated that they were aware that they required more education in pain management and also appeared to have insight with regard to lacking in confidence when managing pain for this patient group. This study further demonstrated that community nurses view healing, rather than symptom management, as a primary aim. It also supports the suggestion that these nurses may not be using effective pain management techniques. Furthermore, aspects of the nurses’ reported practices are not conducive to effective pain management. In conclusion, the successful treatment of leg ulceration requires careful, individualised assessment of pain, both its type and related symptoms together with appropriate interventions to manage not only healing, but also the pain and its consequences. Community nurses may require educational programs to be able to achieve this, and guidelines for the management of leg ulceration should be expanded to emphasise the importance of effective pain management.
Acknowledgements
The authors acknowledge the participants who were so generous with their time and opinions.
We are grateful to Pfizer pharmaceuticals who funded this work.
