The neglected role of distress in pain management: qualitative research on a gastrointestinal ward
Authors: Drake Gareth , Williams Amanda C. de C. 
Published: May 2018

Abstract

Background and aims
Pain management for hospital inpatients remains suboptimal. Previously identified barriers to optimal pain management include staff communication difficulties, confusion around pain management roles and a lack of suitable resources for clinical staff. The emotional, relational and contextual complexities of gastrointestinal (GI) pain create particular challenges for frontline clinical staff attempting to implement a biopsychosocial approach to its management. The current study took place over 2 years, comprised an ethnographic and a feedback phase, and aimed to examine pain management processes with clinical staff in order to generate hypotheses and initiatives for improvement. This paper focuses on two overarching themes identified in the ethnographic phase of the study, centred on the neglected role of both staff and patient distress in GI pain management.

Methods
Grounded theory and thematic analysis methods were used as part of action research, which involves collaborative working with clinical staff. The study took place on a 60 bed GI ward in a university hospital in London. Participants were clinical staff who were either ward-based or involved in the care of particular patients. This latter group included doctors, nurses, psychologists and physiotherapists from the Acute and Complex Pain Teams. Qualitative data on pain management processes was gathered from staff interviews, consultation groups, and observations of patient-staff interactions. Recruitment was purposive and collaborative in that early participants suggested targets and staff groups for subsequent enquiry. Following the identification of initial ethnographic themes, further analysis and the use of existing literature led to the identification of two overarching pain management processes. As such the results are divided into three sections: (i) illustration of initial ethnographic themes, (ii) summary of relevant theory used, (iii) exploration of hypothesised overarching processes.

Results
Initially, two consultation groups, five nursing staff and five junior doctors, provided key issues that were included in subsequent interviews (n=18) and observations (n=5). Initial ethnographic themes were divided into challenges and resources, reflecting the emergent structure of interviews and observations. Drawing on attachment, psychodynamic and evolutionary theories, themes were then regrouped around two overarching processes, centred on the neglected role of distress in pain management. The first process elucidates the lack of recognition during pain assessment of the emotional impact of patient distress on staff decision-making and pain management practice. The second process demonstrates that, as a consequence of resultant staff distress, communication between staff groups was fraught and resources, such as expert team referral and pharmacotherapy, appeared to function, at times, to protect staff rather than to help patients. Interpersonal skills used by staff to relieve patient distress were largely outside systems for pain care.

Conclusions
Findings suggest that identified “barriers” to optimal pain management likely serve an important defensive function for staff and organisations.

Implications
Unless the impact of patient distress on staff is recognised and addressed within the system, these barriers will persist.