Beyond the Pain Scale

Provider Communication and Staffing Predictive of Patients' Satisfaction With Pain Control

Judith Shindul-Rothschild, PhD, MSN, RN; Jane Flanagan, PhD, RN, ANP-BC; Kelly D. Stamp, PhD, ANP-C, RN, FAHA; Catherine Y. Read, PhD, RN


Pain Manag Nurs. 2017;18(6):401-409. 

In This Article

Abstract and Introduction


This paper examined hospital characteristics, staffing, and nursing care factors associated with patient perception of poor pain control by conducting a secondary analysis of the Hospital Consumer Assessment of Health Care Providers Systems (HCAHPS) survey in California, Massachusetts, and New York hospitals. Analysis of variance was used to analyze the relationship between nurse, hospitalist, physician, and resident staffing and patients' perception of pain control. Twenty-one factors correlated with patients' reports of pain control were included in the stepwise linear regression analysis. Patients' perception of pain control significantly improved with higher numbers of registered nurses (p = .045), nursing staff (p = .005), and hospitalists (p = .035) and worsened with higher numbers of residents or interns (p = .010). Six predictors explained 79% of the variance in patients' self-reports of pain control. Four factors increased the likelihood that patients reported their pain was poorly controlled: (1) patients did not receive help as soon as they wanted (p < .001), (2) poor nurse communication (p < .001), (3) poor medication education (p < .001), and (4) teaching hospitals (p < .001). Two factors decreased the likelihood that patients reported their pain was poorly controlled: (1) higher numbers of nursing staff (p = .001) and (2) nonprofit hospitals (p = .001). Nurse staffing and nurse-patient communication are highly predictive of patients' perception of pain management. In teaching hospitals, with rotating intern/resident assignments, patients reported less satisfaction with pain management. This study provides new evidence for the importance of continuity of care in controlling the pain of hospitalized patients.


Intuitively one might assume that patients reporting higher levels of pain would report lower satisfaction with pain management, as well as the reverse. Studies are inconsistent in finding a relationship between the level of pain a patient experiences and his or her perception of the adequacy of pain management (Phillips, Gift, Gelot, Duong, & Tapp, 2013). These findings have led pain experts to argue that there is a powerful biopsychosocial aspect to pain and that outcome measures of pain control should include both pain intensity scales and patient satisfaction with pain management (Phillips et al., 2013).

Studies on patients known to be vulnerable to the experience of pain and/or breakthrough pain suggest assessments of patients do not consider covariate factors. Further, this lack of assessment of all contributors to the experience of pain leads to inadequate pain control. One study found that in patients with chronic obstructive pulmonary disease, coexisting symptoms of depression, fatigue, and multisite pain (i.e., back, chest, and head) correlated with higher levels of reported pain (Christensen et al., 2016). Others found that patients who had breakthrough pain despite regular pain medication experienced despair and depression. They suggest the health care team provide patients with education about pain control, alternatives to medicine, empathy, and support to alleviate pain (Pathmawathi et al., 2015).

Collectively these studies indicate that health care providers' education and knowledge related to assessment and treatment of pain is an important consideration in improving the patient experience of pain. Despite this, there continues to be a lack of adequate pain management education for health care providers across disciplines. Findings on pain management education across health professions in Canada reported veterinarians receive up to five times more pain management education than colleagues in dentistry, medicine, and pharmacy and about one third more than nursing, occupational therapy, and physical therapy (Watt-Watson et al., 2009). Other work in the United Kingdom reported that veterinarians receive twice as much education as their colleagues in nursing or medicine and that the only profession to receive more than veterinarians was physical therapy (Briggs, Carrl, & Whittaker, 2011). These findings are consistent with findings from work in the United States that also reports a lack of educational preparation of health care professionals in the area of pain management (Doorenbos et al., 2013, Tauben and Loeser, 2013).