J R Soc Med 2004;97:432-433
doi:10.1258/jrsm.97.9.432
© 2004 Royal Society of Medicine
Assessment of patient pain at colonoscopy: are nurses better than endoscopists?
S Ramakrishnan MB MRCP
J Y Yiannakou MB MRCP
W R Ellis DM MRCP
I M Bain MB FRCS
Department of Gastroenterology, University Hospital of North Durham,
Durham DH1 5TW, UK
Correspondence to: Dr S Ramakrishnan E-mail:
subramaniamram{at}yahoo.co.uk
 |
SUMMARY
|
|---|
The pain that patients recollect having experienced at colonoscopy
is
likely to influence uptake of the procedure. We used visual
analogue scales to
assess recollected pain shortly before discharge,
and compared these scores
with assessments by the endoscopist
and the attending nurse.
Data were complete for 426 procedures (90%). The mean perceived pain score
for patients was 3.2, for endoscopists 2.8 and for nurses 3.1. On multivariate
analysis, the endoscopists' assessments of pain had little predictive
value over and above those of nurses, whereas nurses' assessments
remained significant when adjusted for endoscopists' assessments.
Nurses were more accurate than endoscopists in gauging the pain of
colonoscopy. This may be because endoscopists are focused on the video monitor
while nurses are focused on the patient. More active use of nurses'
assessments might help keep pain to a minimum.
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INTRODUCTION
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Most patients expect a colonoscopy to be painful, and this reputation
adversely
affects uptake. Moreover, the patient who remembers a painful
colonoscopy
may decline to have a repeat procedure. This matter will become
even
more relevant in the UK if a national screening programme for
colon
cancer is instituted. Previous studies have shown disparities
between
patients' reported pain at colonoscopy and the pain
that medical staff
perceived them to have
experienced.
1–5
However,
the numbers were small and the investigations were subsidiary
to the
main purpose of the studies. We have looked prospectively
at the performance
of endoscopists and nurses in assessing pain
during colonoscopy.
|
METHOD
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Data were collected prospectively for twelve months during which
474
patients agreed to undergo outpatient colonoscopy in our
district general
hospital. All those who could complete a simple
questionnaire were included.
At the start of the procedure patients
received intravenous midazolam and
Buscopan (hyoscine butylbromide),
and pethidine was used as an analgesic at
the discretion of
the endoscopist.
Pain scores were recorded on a visual analogue scale of 0–10 on which
0 represented no pain and 10 the worst imaginable pain. Just before discharge
from the endoscopy unit patients recorded the pain they had experienced during
the procedure. Pain scores as assessed by nurses and endoscopists were
recorded soon after completion of the procedure. All were blind to the
others' scoring.
Pain scores were expressed as mean and standard error (SE). Complete data
were assessed by multivariate linear regression analysis.
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RESULTS
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Data were complete for 426 (90%) of the procedures:
Box 1 summarizes
the
indications and results. Patients' mean perceived pain score
was 3.2 (SE
0.13). The pain score assessed by the endoscopist
was 2.8 (0.1) and that
assessed by the nurse was 3.1 (0.1).
Comparison of pain scores of endoscopists
and nurses with those
of patients gave correlation coefficients of 0.42 and
0.59,
respectively.
Figure 1
indicates that, even for nurses, there
was much scatter. On multivariate
analysis, endoscopists' assessments
were no longer significant when
adjusted for nurses' assessments
(
P=0.39) whereas nurses'
assessments were significant when adjusted
for endoscopists' assessments
(
P<0.01).
|
DISCUSSION
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The main point of interest from this study derives from the
multivariate
analysis, indicating that endoscopists could reach
a more accurate assessment
of the patient's pain by consulting
the nurse, whereas the reverse was
not true. We must, however,
acknowledge a weakness of research of this
kind—that the
effect of sedation and analgesia could have influenced not
only
the pain assessments by the endoscopists and nurses but also
the
recollection of perceived pain by the patients. In the case
of the health
workers, the assessments do represent a collective
judgment on the pain
experienced by the patient throughout the
procedure irrespective of the doses
of sedation and analgesia
used.
Why should nurses outperform endoscopists in this respect? We suspect it is
because endoscopists are procedure-focused, aiming to complete the procedure
successfully in a high proportion of patients. Nurses on the other hand are
mainly patient focused. We suggest, therefore, that nurses' assessments
should be actively used during colonoscopy, to achieve the best possible
compromise between success rate and patient discomfort.
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REFERENCES
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- Hull T, Church JM. Colonoscopy—how difficult, how painful?
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Clin Gastroenterol2001; 32:69
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of patients' experiences during imaging tests of the colon.
Gastrointest Endosc2001; 54:67
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- Redelmeier DA, Kahneman D. Patients' memories of painful
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invasive procedures. Pain1996; 66:3
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SUMMARY
INTRODUCTION
