Psychiatric Patients: How Can We Decide if You Are in Pain?

Abstract

How do psychiatric nurses make decisions about pain management for hospitalized psychiatric patients? This is the question addressed by this research. Using an exploratory, naturalistic interview approach, 20 nurses and managers in varied settings described their decision making when providing pain relief. Analysis of these narratives indicates that decision making about pain, in this unique context, is influenced by a number of intrapersonal and interpersonal factors such as the patients' needs, history, and diagnosis; nurses' beliefs about pain tolerance and drug addiction; collegial pressure; and unit safety. For example, diagnosis and patient history impact pain relief negatively, while the responsibility to maintain a safe environment imposes pressure to administer medication. Although, in a psychiatric unit, the nurse-patient relationship is essential to the healing process, nurses often face a dilemma as to whether the pain medication will contribute to healing or exacerbate the patient's issues. In psychiatric wards, the means of recovery are far less clear, tangible, and immediate than in other clinical settings. Recommendations are made for better preparing and supporting nurses to work effectively in these practice settings where pain relief is confounded by addiction and psychiatric diagnoses.

An Integrative Literature Review of the Factors That Contribute to Professional Nurses and Midwives Making Sound Clinical Decisions

“…The factors that were most strongly influential were the physical and clinical status of the patient and the experience of the nurse or midwife. Factors were identified in a variety of settings, including obstetric units (Cheyne et al., ; Oduro‐Mensah et al., ; Wu et al., ), intensive care units (Aitken, Marshall, Elliott, & McKinley, ; Marshall et al., ; Tai, ), acute or critical care units (Bucknall, ; Cioffi, Conwyt, Everist, Scott, & Senior, ; Currey & Worrall‐Carter, ; Currey, Browne, & Botti, ; Hancock & Easen, ; Hirsh et al., ; Hoffman, Donoghue, & Duffield, ; Lavellea & Dowling, ; McNett, Doheny, Sedlak, & Ludwick, ; Rattray et al., ; Thompson et al., ), coronary care units (Bakalisa et al., ; Currey & Botti, ), emergency departments (Chung, ; Garbez, Carrieri‐Kohlman, Stotts, Chan, & Neighbor, ; Gerdtz & Bucknall, , ), psychiatric units (Dewar, Mullett, & Langdeau, ; Lindsey, ), medical/surgical wards (Harper, Ersser, & Gobbi, ; Hasegawa, Ogasawara, & Katz, ; Helmrich et al., ; King & Macleod, ; Ludwick et al., ; Pantazopoulos et al., ), and palliative and oncology wards (Searle & McInerney, ).…”

Factors Associated With Opiate Use Among Psychiatric Inpatients: A Population-Based Study of Hospital Admissions in Ontario, Canada

“…The psychiatric care team must consider the person's social context, mental and physical health conditions, and risk of addiction when collaborating with the patient to achieve pain control. 45 Comprehensive assessments such as the RAI-MH would support this process by considering the interplay between physical, mental, functional, and substance-related issues. Of course, addressing the context of opiate use and pain among persons with mental health conditions relies on the availability of integrated systems of support for pain and substance use.…”

Identification and Management of Prescription Opioid Abuse in Hospitalized Patients

“…Having the attitude that the treatment is a temporary respite and not curative can help. Frustration develops when the nurse may not feel valued and appreciated in efforts to help the patient with pharmacological and nonpharmacological pain management, especially when the patient demands opioids (Dewar et al, 2009). An adversarial relationship between providers and patient often revolves around obtaining opioids (Weaver, 2006).…”

“…Patients in recovery from abuse of opioids or other substances and health practitioners may be concerned about "triggering an opioid addiction" if the patient requires opioid analgesics for medical treatment such as after trauma or surgery (Dewar et al, 2009). If the patient in recovery has pain that is not adequately treated, he may return to illicit use of opioids or change to legal drugs such as alcohol or prescription sedatives to ease the pain (Gourlay, Heit, & Almahrezi, 2005).…”

“…Personal experience with pain can engender more empathy-or erroneous beliefs-about the patient's pain threshold and tolerance to opioids. Pain threshold and tolerance is very individualized (Dewar, Osborne, Mullett, Langdeau, & Plummer, 2009). …”