Quality and Pain
Article Outline
‘High quality health care should be a right for every patient…’ (DoH, 1997). The importance of quality in service delivery is evident across both public and private sector services. In healthcare, quality is central to care delivery, and to service modernisation. Clinical governance, a framework for continuously improving quality in service provision, is integrated into all aspects of the health service, and standards are established to ‘measure’ quality, and compare performance.
However, quality is still poorly defined, and as such difficult to measure. It is argued that defining quality is pointless as it means different things to different people: patients, clinicians and organisations (Ludwig-Beymer et al., 1993). Muntlin’s paper on quality in emergency care, published in this issue, reinforces this argument, finding that patients want different things, dependent on age, clinical presentation, and level of education. As such, a patient might have different expectations of the service across their lifetime or dependent on their personal care needs at any one point in time. Surgical patients, and those admitted, scored quality of care in relation to nutrition lower than other groups, in Muntlin’s study, probably because they were in the emergency department, starved, for longer periods than other patients. The perception of quality is relative to personal expectation and experience. The patient with very high expectations will be much more difficult to satisfy than someone with little knowledge or expectation of the service. Equally, the patient who has had a good experience of the service may be more tolerant than someone who has only had poor service in the past. Media reporting of clinical errors, or cuts to services also influences public perception and confidence in the health service, at both a local and national level.
Quality care is also multi-dimensional, and may be different for patients, clinicians, and organisations. Muntlin uses a tool looking at four different dimensions of care; medical–technical competence, physical–technical conditions, identify-orientated approach, and socio-cultural atmosphere. This accounts for multiple aspects of direct care, but does not include any evaluation of value for money, which may be important for patients in healthcare systems that are not publicly funded. Also, clinicians will evaluate quality in relation to the evidence-base for care of which patients may, or may not, have knowledge. These patient-centred, cost-effective, and evidence-based aspects of care will all be important to organisations who want to measure themselves against public expectations, and look at trends in performance.
How then can we aspire to provide quality healthcare, if quality itself in so subjective, and context-laden?
This dilemma could be compared to the difficulties we face with pain management. Pain is a highly personal experience, bound up in expectation, previous experiences, and understanding. It is a mixture of complex physiological, emotional and social interactions. McCaffery (1979) famously implied that pain is whatever the patient says it is, happening whenever the patient says it does, and patient self-report remains central to pain management. The patient is the one who experiences the pain, so the pain must be understood from the perspective of the patient, from initial assessment through to treatment evaluation.
In much the same way, the patient is the one who experiences our service, and as such, the quality of the service must be understood from the perspective of the patient, or service user.
The unique perspective of pain makes objective assessment difficult (Strout and Kendrick, 2008). A number of assessment tools are available, measuring either a single aspect of pain intensity, e.g. visual analogue scores, verbal descriptions, or behavioral indicators; or combining these in multi-dimensional tools to quantify various aspects of pain (Burton and Miner, 2008). Although multi-dimensional assessment is thought to provide better overall understanding of the experience of pain, no one tool is accepted as gold standard.
Equally, assessment of quality is multi-dimensional and dependent on many variables. It is essential then that key indicators of quality be defined, so that they can be measured. Patients should be involved in identifying key indicators essential to direct care, as should clinicians, or management teams in defining their own quality markers. Making these explicit to care, or service provision, is integral to quality improvement, with patients and staff understanding the parameters of quality for that organization.
Continuous assessment and re-assessment is the key to effective pain management, and also to quality control. There is little point in assessing pain, if, firstly, it is not going to be acted on, or, secondly, re-evaluated. In assessing pain, it is implied that the needs will be met, i.e. analgesia provided. If we ask the question, we must be prepared to act on the answer. Evaluation of any analgesic intervention allows us to measure its effectiveness, and to change our management plan as necessary. If we measure quality, then we need processes in place to act on the results of this assessment, and to evaluate any changes implemented as a result. Care and service quality measurement is, therefore, a cyclical process of assessment, implementation, and evaluation.
If we are to complete this analogy, then we imply that quality is whatever the patient says it is, happening whenever the patient says it does. It is their experience, judged in relation to personal expectations and previous experiences. The same is true of clinical or organisational quality. Dependent on the aspect being evaluated, quality indicators must be defined, against which either individual care, or whole services, can be measured.
References
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- McCaffery, M., 1979. Nursing management in the patient in pain. Cited in McQuillan, K.A., Von Rueden, K.T., Hartsock, R.L., Flynn, M.B., Whalen, E., 2002. Trauma Nursing: From Resuscitation through Rehabilitation, third ed. Philadelphia, Saunders.
- . Nursing considerations in emergency department procedural sedation and analgesia. In: Burton JH, Miner J editor. Emergency Sedation and Pain Management. New York: Cambridge University Press; 2008;
PII: S1755-599X(08)00099-2
doi:10.1016/j.ienj.2008.09.001
© 2008 Published by Elsevier Inc.
