Pain Talk Research Articles

Real and Imagined Places in the Diary of Gabriella Trebits

Gabriella Trebits was a prisoner of the Bergen-Belsen concentration camp between November 1944 and April 1945. The spaces present in her diary include both the places of the camp and her typhoid hallucinations. Gabriella described venues through their sensuous dimensions. Since the sensory experiences of everyday life mingled with her visions, her diary became a “textual journey” between real and imagined places. Her narratives helped her to express the difficulties caused by her physical environment and the confusion caused by her hallucinations. As a result, the references to changes in her sensory impressions created a discursive space for the diarist to express her feelings. Since her narrative depicts a suffering and painful condition, we use Joanna Bourke’s concept of pain talk in our analysis. Moreover, the diary demonstrates that it was possible for typhoid patients to connect with their environment despite their isolated situation. Even on the periphery of the camp space, social life persisted. This exploration will not only uncover the narrative strategy of one diarist but also contribute to a deeper understanding of the ways in which tens of thousands died of starvation and diseases―without mass executions or gas chambers―in the Bergen-Belsen concentration camp during the spring of 1945.

Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

RationaleImplicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment.MethodsWe conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians’ implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions.ResultsAs hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT.ConclusionUsing SP methodology, physicians’ implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

"Pain talk": A triadic collaboration in which nurses promote opportunities for engaging children and their parents about managing children's pain.

Effective communication with children about pain is important and has the potential to mediate the short‐ and longer‐term effects of pain on children. Most communication studies relating to children's pain have focused on language children use to describe everyday pain experiences. However, little is known regarding how health professionals, particularly nurses, communicate with children in healthcare settings about pain. This study aimed to explore how nurses talk to children and their parents about pain and what factors influence nurses’ use of language and non‐verbal communication. A cross‐sectional mixed‐methods (predominantly qualitative) survey (“pain talk”) was conducted, comprising qualitative items about pain communication and four vignettes portraying hypothetical cases of children representing typical child pain scenarios. Participants were recruited via email, social media, newsletters, established networks, and personal contacts. A total of 141 registered (68.1%) or in‐training nurses across 11 countries with experience of managing children's pain completed the survey. Textual survey responses were analyzed using conventional qualitative content analysis. Qualitative content analysis generated a meta‐theme “Being confident and knowing how to do ‘pain talk’” and four main themes that described the functions, purpose, and delivery of “pain talk”: (a) “contextualizing and assessing,” (b) “empowering, explaining, and educating,” (c) “supporting, affirming, and confirming,” and (d) “protecting, distracting, and restoring.” “Pain talk” was a triadic collaborative communication process that required nurses to feel confident about their role and skills. This process involved nurses talking to children and parents about pain and creating engagement opportunities for children and parents. “Pain talk” aimed to promote the agency of the child and parent and their engagement in discussions and decision‐making, using information, support, and comfort. Nurses shaped their “pain talk” to the specific context of the child's pain, previous experiences, and current concerns to minimize potential distress and adverse effects and to promote optimal pain management.

Interpretations of partners' responses to pain behaviours: Perspectives of patients and partners.

ObjectivesPartner’s responses to pain behaviours play a pivotal role in the patient’s adjustment. This study aims to further our knowledge regarding patients’ and partners’ interpretation of partners’ responses to pain behaviours, and the possible discrepancies between patients’ and partners’ perceptions. Further, this study examines patients’ preferred responses to pain behaviours and possible discrepancies between received and preferred responses to pain behaviours.DesignA qualitative research design based on a semi‐structured in‐depth interview.MethodsPatients with chronic low back pain and their partners (n = 54) were recruited through purposive sampling and interviewed. Data were analysed based on an inductive analytic approach.ResultsPatients as well as partners indicated a number of different interpretations of partners’ responses to pain behaviours, including invalidation, relieving pain, validation, encouragement, caregiving exhaustion, and expressing resentment. Patients and partners revealed similarities in the interpretation of response categories that they associated with validation, invalidation, and expressing resentment. Discrepancies between patients and partners indicated that partners interpreted some responses as caused by caregiving exhaustion while patients did not. Patients perceived partner responses that included the active involvement of the partner (e.g., encouraging pain talk) more positively than responses that showed less active involvement of the partner.ConclusionPatients and partners are likely to make various interpretations of a certain partner response to pain behaviours. Our findings underscore that patients’ interpretation about a certain behaviour might determine whether that behaviour is rated as desirable or aversive.

Pain talk in hospice care: a conversation analysis

BackgroundA large number of the hospice patients have been reported to be with symptoms of pain. Thus, managing the patient’s pain is one aspect of hospice care provision. The delivery of pain care services could be facilitated through effective communication. However, little has been done to explore the interactional details of the delivery of pain care services in palliative care.MethodsConversation analysis is a useful method to explore the interactional details of interaction by hospice care providers and terminally ill patients. Using the method of Conversation Analysis (CA), this study aims to demonstrate how the hospice care provider employs different types of interactional practices to address the patient’s pain concerns. The data showed in this study are collected from the Alexander St website http://ctiv.alexanderstreet.com, an educational resource presenting a large collection of psycho-therapeutic videos.ResultsIn this study, an illustrative analysis is demonstrated to show the potential of conversation analysis for research on pain talk in palliative care. It has been shown that conversation analysis could contribute to unfolding the interactional details regarding “pain talk” in hospice care settings. Specifically, conversation analysis could provide a detailed description and interpretation of the conversational practices, which are used to construct hospice care provider participation in delivering pain talk. In addition, conversation analysis could also demonstrate the interactional resources by which patients disclose their experiences of physical or spiritual pain to the hospice care provider and the way how the hospice care provider responds to the patient’s troubles talk or feelings talk.ConclusionsThis study identifies five types of interactional resources which are used to deal with the patient’s pain concerns in hospice care setting. A conversation analytical study of pain talk in hospice care could provide a turn-by-turn description of how the hospice care provider communicates with the terminally ill patient in terms of the patient’s pain concerns. The findings in this study could inform how the hospice care provider initiates, delivers and develops a pain talk with the terminally ill patient effectively.

The politics in/of pain

Pain, pain talk and pain ascriptions seem to be universal features of human experience and to have little to do with politics. It is often assumed that pain is always bad, a sign of a malfunctioning machine, that pain talk describes this malfunction and that the humane thing to do is to seek to ameliorate or excise pain. I argue that this viewpoint is one-sided at best and imperialistic at worst. In section I, I outline what I term the ‘prima facie model of pain’ and adumbrate later Wittgenstein’s criticism of it. In section II, I marshal ethnographic evidence that deepens Wittgenstein’s reimagining of pain and acknowledgment. In section III, I link this to ‘progressive’ politics and its normative understanding of the self. Finally, in section IV, I turn to Martin Luther King’s writing and discuss a use of pain that undermines this normative conception of the self and aligns with Wittgenstein’s account.

Gender and the language of pain in chronic and terminal illness: A corpus-based discourse analysis of patients' narratives

Drawing on the notion of gender as a socially constructed category performed inter alia through language, this study examines the ways in which women and man use language to do person-in-pain in real-life interactions about chronic and terminal illness. It is based on a secondary analysis of a large corpus of health and illness narratives collected by the Health Experiences Research Group at the University of Oxford and published by the DIPEx charity. Sixteen chronic and terminal conditions were identified in which men and women talked about physical pain and their narratives examined using the linguistic approach of a corpus-assisted discourse analysis. Our study shows that there are significant quantitative and qualitative differences in the ways in which women and men report pain pointing to the existence of distinctive feminine and masculine lexical repertoires of pain talk. While these repertoires conform to some of the dominant societal stereotypes surrounding masculinity and femininity, they also transgress those. Women refer to pain more frequently and have a wider lexical repertoire for pain reporting. They use more specific and factual references as well as cognitive and psychological words in their pain talk. In contrast, men tend to use fewer descriptors in general, most of which are highly emotive suggesting that they report pain when it becomes unbearable enduring it until this point. There is also a conspicuous absence of references to psychological processes in the male narratives and the focus is on pain killers. Understanding this nuanced role of gender in communicating pain can help health professionals respond effectively to people's talk about pain and develop more holistic practices in pain consultation, assessment and treatment leading potentially to the reduction of gender biases and inequalities in healthcare.

Developing symptom management quality improvement reports with data from a registry-based patient reported outcomes (PRO) collection method.

180 Background: Symptom management is critical to quality cancer care, affecting treatment completion, functioning and quality of life. We describe the use of the Commission on Cancer’s Rapid Quality Reporting System (RQRS) to ascertain cases for PRO collection, identify key PRO quality indicators, and provide actionable symptom management quality improvement (QI) reports to community cancer centers (CCC). Methods: The Patient Reported Outcomes Symptoms & Side Effects Study used RQRS to sample patients (pt) 4-12 months from diagnosis with locoregional breast/colon from 17 National Cancer Institute Community Cancer Centers Program centers. Surveys were mailed with web option. Pts were asked if they talked to a health professional about pain (Talk about) and, separately, if the health professional gave advice about what to do if pain started, got worse, or came back (Advice). Similar questions were asked about fatigue and emotional distress (ED). QI reports were designed with CCC staff feedback and produced for each CCC providing crude and case-mix adjusted CCC-specific rates, and study-wide rates. Direct standardization methods were used to adjust CCC-specific rates for cancer type and education. Results: 2,487 eligible participants responded (RR=61%). This table shows overall study-wide estimates and the range of adjusted CCC-specific estimates for six key indicators. (See Table.) Conclusions: This pilot study shows the registry-based method for PRO collection was successful and has potential for wider dissemination. Study-wide, 20-45% of pts did not report discussing or getting advice about three common symptoms from their healthcare team. CCCs varied significantly on these indicators, suggesting room for improvement. Quality reports were well received by hospital staff, who report sharing them with clinicians, navigators and cancer committees. CCC-specific reports may promote efforts to improve care through professional/patient education and applying standards of care. [Table: see text]

Reciprocal Suffering: Caregiver Concerns During Hospice Care

Context For many hospice caregivers, the constancy and difficulty of caregiving impact their physical quality of life and cause depression, psychological distress, guilt, loneliness, and restrictions on social activities. Objectives Deviating from traditional unidimensional research on hospice caregivers, this study explored the transactional nature of reciprocal suffering by examining caregiver concerns through four dimensions: physical, psychological, social, and spiritual. Methods Researchers analyzed audiotapes of intervention discussions between hospice caregivers and research social workers. Results Results indicated that, of the 125 pain talk utterances, most referenced psychological concern (49%), followed by physical (28%), social (22%), and spiritual (2%) concerns. Reflections on concerns revealed a global perspective of caregiving, which highlighted the patient’s needs juxtaposed to the caregiver’s recognized limitations. Conclusion By examining the reciprocal nature of suffering for caregivers, this study reinforced the need for assessing caregivers in hospice care, with specific emphasis on the importance of providing caregiver education on pain management.

Can Cancer Patients Influence the Pain Agenda in Oncology Outpatient Consultations?

Pain in cancer patients is common, yet it is often inadequately managed. Although poor assessment has been implicated, how patients contribute to this process has not been explicated. This study aims to uncover patients' contributions to discussions about pain during oncology outpatient consultations. Seventy-four medical encounters were observed and audiotaped. Verbatim transcriptions of pain talk were examined using conversational analysis. Thirty-nine of 74 patients talked about pain with 15 different doctors during consultations for follow-up or active treatment. Patients' talk about pain varied consistently according to how pain talk was initiated. In 20 consultations where pain was put on the agenda by patients, they used communication tactics that emphasized their pain experiences, seemingly to attract and maintain their doctors' attention. These tactics appear necessary, as the cancer treatment agenda restricts opportunities for patients to have supportive care needs addressed. On the other hand, in 19 consultations where doctors elicited information about pain, patients used communication tactics that minimized their pain experiences, seemingly to conceal potential disease progression or recurrence, the very focus of these specialist consultations. Where cancer was implicated as the source of pain, chemotherapy or radiotherapy was offered, and where cancer was suspected, referrals for investigations were made. Two of the 20 patients appeared to influence the treatment-focused agenda and were given referrals to pain clinic rather than further cancer therapy as initially recommended.

Barriers to Pain Management: Caregiver Perceptions and Pain Talk by Hospice Interdisciplinary Teams

As patients are cared for in their homes by family caregivers, several challenges arise in effective pain and symptom management. Despite hospice's reputation as the gold standard for terminal care, there is still a need to improve pain management practices, including challenges that caregivers face, related to pain assessment, reluctance and fear of administering medication, noncompliance with pain medicine regimens, and hesitance to report pain. The hospice philosophy of care promotes service for both patients and their family by an interdisciplinary team, and total pain management is a goal of this care. The aim of this control phase of a larger National Cancer Institute-funded mixed methods study was to understand the current practice of hospice assessment and collaboration on informal caregiver issues related to pain management. This study of 30 hospice caregiver–patient dyads from one rural hospice found that 87% of caregivers indicated concern with at least one question on the Caregiver Pain Medicine Questionnaire. Interdisciplinary team discussions for 23 of the dyads were recorded over nine months for a total of 86 sessions. Although caregiver concerns were identified with the Caregiver Pain Medicine Questionnaire by the research team, there was only one discussion of caregiver pain-related concerns during the hospice team meeting. This despite the finding that 38% of the time involved in a patient discussion is spent on pain-related talk. These findings indicate an opportunity for improvement by hospice teams through focusing on caregiver assessment and intervention.

The role of peer communication in the socialization of adolescents' pain experiences: a qualitative investigation

BackgroundRecurrent pain is a common complaint among adolescents. Children learn to resolve or cope with pain largely through family dynamics, particularly maternal influences. By adolescence, young people possess an array of pain behaviors, the culmination of multiple opportunities for modeling and reinforcement of attitudes and beliefs about pain. Adolescence is a time of increased autonomy characterized by, among other complex factors, significant increases in peer influence. Although peers are influential in health-risk behavior, little is known how peers impact adolescents' pain experience. The present study explored the role of peers in adolescents' attitudes toward pain, pain behaviors and over-the-counter analgesics.MethodsSixty-minute focus groups were conducted with a sample 24 junior high school students from Halifax, Nova Scotia, Canada (11 male: mean age = 13.45 years, range = 12–15 years; 13 female: mean age = 13.31 years, range = 12–15 years). Participants were randomly assigned to one of five same-gender focus groups designed to explore a wide breadth and depth of information. Sessions were run until theoretical data saturation. Textual data, from transcribed audiotapes, were analyzed with the constant comparative method.ResultsPeer influences were apparent in how adolescents communicate about pain and how those communications effect pain expression. Overt pain responses to injury were primarily contextual and depended on perceived threats to peer-time and pain severity. Adolescents were intolerant of peers' pain behaviors when the cause was perceived as not severe. These attitudes impacted how adolescents responded to their own pain; males were careful not to express embarrassing pain in front of peers, females felt no restrictions on pain talk or pain expression. Evidence for peer influence on attitudes toward OTC analgesics was apparent in perceptions of over-use and ease of access. Findings are discussed within the context of social information-processing and gender role expectations.ConclusionLittle research has addressed how young people experience pain within the context of the psychosocial influences that dominate during adolescence. The findings provide some insight into the role of peer influences via verbal and non-verbal communication, in adolescents' pain experience. This exploratory study is a necessary first step in understanding the socialization of adolescents' pain experiences.

“Pain talk” in hospice and palliative care team meetings: An ethnography

Background Specialist palliative care nurses have considerable expertise in pain management and this expertise can contribute to tension in the boundary between specialist nurses and non-specialist doctors. Objectives This article reports on how specialist palliative care nurses contribute to team talk about pain and the rhetorical strategies they use to develop their reputation and credibility in pain management. Design and settings This is an ethnographic study involving the collection of naturally occurring data from eight palliative care team meetings. The study is concerned with team meetings in hospice, community and hospital palliative care settings. Methods Data was collected by audio recording eight team meetings in hospice, hospital and community palliative care settings. The data were analysed using a grounded theory approach followed by application of the tools of discourse and conversation analysis. Results The findings indicate that specialist palliative care nurses use rhetorical strategies such as contrastive rhetoric, telling atrocity stories, veiled criticism and neutralism as a platform for building a reputation in managing pain. Furthermore they situate their expertise in pain management by direct contrast with problems related to non-specialist practice in pain management. Conclusions The team meetings are a safe place, a collegial setting for specialist nurses to challenge non-specialist medical practice and to manage the specialist/non-specialist boundary. The findings have implications for further research related to the specialist nurse/non-specialist doctor boundary and for education of specialist nurses and GPs.

Chronic pain couples: Perceived marital interactions and pain behaviours

Patient adjustment to chronic pain is well known to be influenced by the spouse and his or her response to patient expressions of pain. However, these responses do not occur in a vacuum, and the aim of the present study was to investigate patient–spouse interactions in chronic pain in detail. Ninety-five patient–spouse dyads completed questionnaires relating to mood, marital satisfaction and communication, and 80 couples also took part in semi-structured interviews. Data were analysed using quantitative and qualitative methods. Results showed that spouses of chronic pain patients reported engaging in a far wider repertoire of responses to pain behaviours than has been recognised to date. New response categories of ‘hostile-solicitous’ and ‘observe only’ were identified. Patients generally interpreted solicitous responses less favourably than spouse responses which encouraged task persistence. Male spouses identified fewer pain-related situations than female spouses but were more likely to report responding solicitously to patient pain behaviours. Marital satisfaction was significantly higher in patients who rated themselves as talking more frequently about their pain. Spouse perceived frequency of pain talk was not related to spouse marital satisfaction. There were no gender differences in marital satisfaction. The results of this study challenge some of the assumptions that have been held regarding chronic pain patient–spouse interactions.

The ‘right kind’ of pain: talking about symptoms in outpatient oncology consultations

Despite improvements in cancer management over the past 25 years, unrelieved symptoms continue to be reported. Little is known about how patients' problems and concerns are communicated to professionals during oncology treatment. This qualitative study investigates the process of communication between cancer patients and oncologists during consultations in outpatient clinics of a regional teaching hospital. Data were collected by nonparticipant observation and audiotaping consultations. Analyses were by qualitative content analysis and conversation analysis. An objectives, strategies and tactics model was applied to organize the findings. Seventy-four consultations between cancer patients and 15 doctors were observed and audiotaped. Pain talk is defined and identified as a substantial topic, occurring in 39 out of 74 consultations. Doctor-initiated questions are the predominant discourse feature and are prominent not only in initiating discussions but also in directing further talk (e.g. over three-quarters of doctor-initiated questions are in a closed form which focus narrowly on limited physical aspects of patients' pain). This limited information exchange is used alongside other communication tactics to identify the 'right kind' of pain that may benefit from cancer therapy and to truncate talk of problems perceived to be outside of this specialist remit. Although individualized, holistic care is the expressed philosophy of the clinic, our data show that doctors tightly control the agenda to focus narrowly on pain which was amenable to radiotherapy, chemotherapy, surgery or hormone manipulation. Inadequate exploration of patients' pain is likely to be detrimental to symptom control.

Pain Talk: The Expression of Suffering in the Medical Consultation

L'auteur s'interesse a la facon dont s'installe et dont se gere l'interaction patient-medecin pendant des periodes de douleur et de souffrance. L'analyse de fragments d'enregistrements video de consultations medicales permet d'aboutir a des premieres conclusions en particulier en ce qui concerne la revelation de la douleur

The influence on patients' pain intensity ratings of antecedent reinforcement of pain talk or well talk

This study sought to determine whether positive verbal reinforcement for pain talk or well talk could effectively influence chronic pain patients' subsequent ratings of pain intensity. Four female chronic pain inpatients were each exposed over seven consecutive days to two conditions within an alternating treatments design. Inter-rater reliability analysis from the audiotapes on occurences of pain and well talk, verbal reinforcement and appropriate reinforcement of verbal behavior across conditions resulted in agreement values from 91 to 100%. Findings revealed that subjects' pain intensity ratings were consistently and significantly lower after verbally reinforcing well talk compared with verbally reinforcing pain talk.