28 How pain-rating scales work (and do not work) in real life practice – a small conversation analytic study of five video-recorded hospice consultations

Abstract

Background Assessing pain is a key palliative care task. Structured tools to assess pain intensity are commonly used, but patients report challenges in responding to these. Aims The study aimed to analyse real-life episodes of pain scale use within hospice care, and develop communication training resources based on the findings. Methods Pain scale use was identified in a dataset of video-recorded hospice consultations involving 37 patients and five doctors in a large UK hospice. The video data was subjected to Conversation Analysis - a direct observational approach to describing the challenges, structure and functioning of people’s interactional behaviours. Results Pain rating-scales were used in 5/37 consultations. We found that patients capitalise on scale use: taking it as an opportunity to communicate multiple aspects of pain - not just intensity. Video-clips exemplifying this are included within ‘Real Talk’ training materials (www.realtalktraining.co.uk), alongside learning points detailing how practitioners can support and encourage patients to do so. We found instances (2/5) of numerical scale misunderstandings. The experienced doctors we recorded handled these carefully. A video-clip demonstrating how a doctor and patient resolve a misunderstanding with caution and sensitivity is included in the Real Talk materials. Analysis-based learning points describe how practitioners can avoid resolving the misunderstanding in ways that imply the patient is to blame, and also consider how misunderstandings can take considerable time and interactional effort to resolve. Conclusions Our analysis shows that pain rating-scales get used to report features besides their official target. Our findings directly underpin communication training resources for face-to-face training events - showing how professionals can support patients‘ maximal responses and how they can handle numerical rating misunderstandings in ways that avoid demeaning or disempowering patients.