Nurses have an ethical imperative to minimize procedural pain.
Subject: Anesthesia (Management)
Anesthesia (Ethical aspects)
Nurses (Ethical aspects)
Nurses (Practice)
Pain (Care and treatment)
Pain (Methods)
Authors: Shaw, Susan
Lamdin, Rain
Pub Date: 08/01/2011
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2011 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: August, 2011 Source Volume: 17 Source Issue: 7
Topic: Event Code: 290 Public affairs; 200 Management dynamics Advertising Code: 91 Ethics Computer Subject: Company business management
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 266344840

It is common for clinicians to be participating in or witnessing situations that cause patients pain. While there is a good deal of discussion within health professional literature about pain, it generally remains poorly understood and inadequately managed. In particular, inflicted or procedural pain needs some attention. We must consider the roles and responsibilities of practitioners in relation to the pain we cause in the course of our practice.

This article considers procedural pain in relation to three specific areas: children, urinary catheterisation and influenza immunisation. Research regarding each of these clinical interventions is considered and the role of practitioners in relation to procedural pain is discussed.

Understanding pain

Pain is ubiquitous and one of the most common experiences of people seeking health care. Logically it is, therefore, one of the most common symptoms health practitioners encounter. However, it is not difficult to find literature about the inadequate management of pain. Down through the ages there have been many approaches to pain. It has variously been seen as a form of social control (torture), a way of building character ("stiff upper lip") and a normal part of life. In recent rimes, research into the causes and treatment of pain has proliferated. This has led to definitions and documented standards for managing acute pain and, while there is still a good deal of work to be done in relation to chronic pain, (1) the experience of regular or constant pain is now much better understood than it has previously been.

Practitioners may technically understand pain in terms of how to define what patients experience, but there is a moral and professional imperative for us also to confront the pain we inflict on patients. Procedural pain is often acknowledged but practitioners tend to pay little attention to addressing it. Procedural pain is the pain patients experience during the course of diagnosis and treatment. This type of pain has clear links to both acute and chronic pain as, while the pain experienced during the procedure may be considered acute, there is increasing evidence that unmanaged procedural pain can impact on how patients experience pain in the future.

A large proportion of the work carried out by practitioners carries the potential for causing pain to patients. Because this pain can generally be reduced or alleviated, it carries with it a moral and ethical imperative (2) to address the cause and to provide the best care possible. In short, this means if there is a way to reduce or eliminate the pain caused during procedures, we are morally bound to ensure we do so.

Incorrect knowledge about pain and inadequate attitudes towards those experiencing it are at the heart of ineffective pain management. (1,3) These deficits in the knowledge and attitudes of nurses about pain have been found in many areas. Examples have been published in relation to large teaching hospitals, (4) orthopaedics (5) and paediatrics. (6) Education aimed at improving knowledge about pain does not necessarily have a positive impact on practice. (7) The challenges of pain management in practice are complex and involve many contextual issues (time, cost, culture) and attitudes. Political and social barriers (8) and problems with relationships between practitioners and patients (9) impact on the care patients receive and, therefore, pain management. While any number of complexities and contextual issues may affect pain management, it is unacceptable for these factors to be formulated into excuses for poor care. The acknowledgement and management of procedural pain may not attract the same attention as other issues, such as major complications or staff errors. (10) However, it requires individuals and teams choosing to make it a priority and acting accordingly.

Procedural pain presents a considerable conflict for health professionals, as there is an assumption that providing care involves alleviating pain and giving comfort, rather than causing pain. This conflict is acknowledged as a cause of stress for clinical staff. (11,12) Responses to procedural pain comprise pharmacological, technical and interpersonal interaction. Pharmacological responses include sedation and local and topical anaesthetic agents. Technical mechanisms for managing this type of pain include choosing the least invasive equipment, eg short and small gauge needles or catheters. Interpersonal techniques include distraction, reassurance and reconceptualisation of the painful event. The arguments for not managing procedural pain include cost, logistical concerns such as time, excuses that the pain will only be present for a short period, and debates about the risks of medication, such as side-effects and physiological ability to metabolise anaesthetic agents.

Painful procedures on children

There are many procedures carried out on children that inflict pain. Particular attention is paid in the research literature to neonatal care and visits of children to emergency departments (EDs). Many of these painful, procedures are generally considered minor, such as immunisations, skin prick tests, cannulation, venipuncture and the insertion of catheters. However, these procedures are painful and stressful for children.

Neonates are subjected to painful experiences on a daily basis. There is evidence these procedures are painful and the pain associated with them may influence experiences of pain as children grow. (13) Neonates are highly sensitised to pain. (14) Premature infants and those requiring periods of special care have been found to have increased neural responses to pain when compared with children who were not born prematurely. (15) While clinical staff appear to understand that many of the procedures they carry out on their youngest patients are painful, they only use analgesia in a relatively small proportion of procedures (14) and policy is lacking. (16) Infant circumcision is an example of a painful procedure carried out on infants. There has been much debate about the pain it causes and the use of anaesthetic agents. The practice of not administering anaesthetic agents for infant circumcision is based on beliefs that children do not experience pain to the same degree as adults, that they do not remember pain and that anaesthetic medications are not safe for them. All of these beliefs are incorrect; infant circumcision is extremely painful and the effects of such painful experiences can affect children later in life. (14,17)

Practice in emergency departments

There are identifiable gaps between the treatments available to relieve procedural pain and actual practice within EDs. Inadequate education and inaccurate appreciation of contextual issues and constraints such as availability of time have been identified as contributing to this theory-practice gap.

A study of 1727 painful procedures (including venipuncture, insertion of intravenous (IV) lines, finger prick tests, injections and urethral catheterisation) carried out on 1210 children identified a tendency to rely on non-pharmaceutical interventions, concerns that analgesia or anaesthetic agents may mask symptoms and inaccurate assumptions about time-frames. (18) In that study, the median timeframe between the order being made to insert an intravenous cannula and the procedure being undertaken was 30 minutes, (18) which is sufficient time for a topical, anaesthetic to have been applied and to have taken effect. In addition to the obvious physical causes of procedural pain, the noisy and busy ED environment adds to the stress and therefore sensitivity of children to pain. Despite all these factors and the availability and effectiveness of rapid-onset local anaesthetics, these products are underused. (13)

Many of the painful interventions performed on children in EDs are relatively short in duration and that is one of the apparent reasons why pain is not managed or even properly acknowledged. Other barriers to adequately acknowledging or treating procedural pain in children include the incorrect belief that the nervous systems of children are inadequately developed and therefore do not sense pain the same way as adults, that they do not remember painful stimuli or experiences to any great extent, and that they may tack the physiological capacity to adequately and safely metabolise anaesthetic agents.

From time to time other debates within health care influence choices in relation to pain relief in children. The concerns that paracetamol and other commonly used pain and fever medications may be linked to asthma (19) is a good example of this. This debate invariably leads to the suggestion that pain in children may be more safety managed with less use of analgesics, in order to avoid other potential risks. Such concerns may also become excuses for inadequately managing procedural pain in children.


One of the most routine invasive procedures in health care is immunisation. While this is a relatively safe procedure, there is evidence a proportion of the population choose not to be immunised, as they either have a fear of needles or choose to avoid the pain of immunisation inflicted upon them. (20,21,22) These concerns are often poorly appreciated by health professionals, who see immunisation as a simple and routine procedure. Intramuscular injections are the most common route for immunisation, requiring a relatively large needle to introduce the medication. Technology and research about other, less invasive, methods of immunisation have led to the availability of an intradermal delivery option for influenza vaccines. Intradermal techniques are available with a needle of between 1 and 3 mm in length, and with similar or better serum-measured effectiveness than from higher doses of intramuscularly administered medications. (23,24)

During winter 2010 in Aotearoa New Zealand, the option of having an intradermal immunisation for influenza ('Intanza') was advertised in the media as available to people who were prepared to pay the additional cost for this method of delivery. There is, apparently, a legitimate argument that the intradermal administration route of influenza vaccines is more expensive than the traditional intramuscular route, and therefore it is not feasible to make it available free to the general public. However, once the cost comes down, it would arguably be unethical not to use the delivery method that inflicted the least pain. In the future, even less invasive procedures for vaccination are possible, such as dissolving polymer needle patches. (25)


The insertion of urinary catheters has been a relatively contested area of practice. Over time, various "rules" and traditions have arisen and been debated in relation to this procedure. These have included rules about who should insert them--doctors and specialty trained nurses could catheterise men, while anyone could catheterise women. There have also been different standards for the use of lubricant medications. It has long been established that men should be catheterised following instillation of anaesthetic gel, while this was often seen as an optional extra for women. One explanation for this was that women have shorter urethras and therefore did not warrant the use of anaesthetic lubrication.

There are a number of perspectives from which these issues could be analysed, including feminism and mate hegemony. The place of women in the construction of knowledge about health care practice has long been debated. Assumed difference and similarities between men and women have been evident in research for decades. Male subjects have been favoured for samples in clinical trials because of concerns that hormonal cycles would have an impact on the data. While the presence of hormonal and sex-related differences in relation to pain experience is a reality, there was also a belief that the information from male populations could be generalised to women, despite differences in physiology. (26)

Studies into the pain of inserting urethral catheters provide insights into practice regarding male and female patients. Two particular studies, both published in 2004, are good examples of this. The first looked at pain scores during catheterisation of women and reported no significance in discomfort for women, regardless of whether plain or anaesthetic gel was used. (27) The research protocol stipulated the use of 2% Lidocaine gel in situ for one minute before insertion. This very short lime frame was acknowledged as a limitation of the study but was defended on the basis there is limited time available in busy EDs to carry out the procedure. The authors concluded female urethral catheterisation was not a very painful procedure (despite having acknowledged at the beginning of the paper that patients rated it as painful) and that the use of anaesthetic gel did not reduce pain.

The second research study compared plain and anaesthetic gels in male catheterisation. (28) As for the previous study, the choice of anaesthetic was 2% Lidocaine. In this study, the Lidocaine was left in situ for 15 minutes prior to insertion of the catheter. The findings were that the anaesthetic gel was more effective at reducing pain of the procedure than plain, unmedicated gel. These authors acknowledged that, it the medication had been left for less time, it may have been less effective, and, it left for longer, it may be more effective.

Ongoing discrepancies

The contradictions within and between these studies about whether urethral catheterisation is painful, whether men or women experience more pain, and whether or not anaesthetic gel should be used (and the period of time it should be in situ) illustrate the ongoing discrepancies between how patients and practitioners view this painful procedure and the tendency for the procedural pain related to it to be inadequately acknowledged and treated.

The procedural pain experienced by children when having a urethral catheter inserted was explored in another study. (29) This study compared plain lubricating gel with 2% Lidocaine gel. In this study, the gel was left in situ for two to three minutes before the procedure. These authors also acknowledged that waiting longer may have been more effective but defended their decision on the grounds it was not realistic or practical to do that. They concluded the anaesthetic gel was not necessarily helpful in alleviating the procedural pain of catheter insertion.

Best practice would seem to be acknowledging that the insertion of urethral catheters is painful for men, women and children and that anaesthetic gel should be used in all instances, (unless there are obvious contraindications), and left in situ for a period of time (greater than three minutes) before inserting the catheter. One nurse researcher notes that instilling anaesthetic gel five minutes prior to catheter insertion reduces pain and makes the procedure easier to perform. (30)

Roles of practitioners The management of pain requires technical skill and a moral commitment. (31,32) Indeed, the undertreatment of pain has been described as a moral failure. (33) In the case of procedural pain, the overriding imperative is that, as health professionals, we have the responsibility to recognise and adequately manage this type of pain, because we are responsible for inflicting it. The role of practitioners in relation to procedural pain may be seen from the perspective of an advocate. (34) The importance of distinguishing advocacy from paternalism has also been identified. (35) The increasing prevalence of technology in practice (36) and the value placed on "being busy" (37) are apparent in modern health care. The resulting reduction in staffing levels and increasing pressure on practitioners have been blamed for poor practice and errors leading to injury of patients. (38,39)

While painful procedures cannot be avoided, the level of distress involved in performing them can be. This requires challenging the tendency to minimise or dismiss this type of pain by believing it is short-lived and therefore of minimal concern, or that we are too busy or lack other resources to manage procedural pain any differently.

That painful experiences are remembered by patients and influence their future experience of pain means we are responsible, not only for managing pain during invasive procedures, but for setting the scene for future distress, if we do not take it seriously. Addressing procedural pain requires challenging some of our knowledge and attitudes about neurology, sex differences and traditions. It also requires that we choose to behave differently and use the rime between the decision to carry out a procedure and the actual performance of it to apply topical or local anaesthetic agents, in order to reduce procedural pain and ongoing problems with painful experiences.

There will probably come a time when the failure to inadequately manage procedural pain (when we have the resources at our disposal to do so) will be considered neglect and practitioners will be called to account for failing to minimise the pain they inflict on patients. The adequate management of procedural pain is at the heart of our role as health professionals. How we choose to behave in these situations speaks volumes about what we think about our work and how we care for our patients. Perhaps one of the key considerations here is to understand the differences between "doing to" (40) and "being with" (41) our patients.

* References for this article are available online at:

Susan Shaw, Dip Tchg, RN, BN, MEd (Admin), EdD, is associate dean (undergraduate), Faculty of Health and Environmental Sciences, AUT University. Rain Lamdin, MBChB, GradDip Ed (Adult and Higher Ed), PhD, is a clinical lecturer in the Centre for Medical and Health Sciences, Faculty of Medical and Health Sciences, University of Auckland.
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