Long before pain was declared the fifth vital sign, nurses were at the forefront of pain management. Day after day and year after year, nurses continue to assess and intervene to minimize pain; it is their responsibility. But are nurses doing their part-or are they biased in how they care for a patient in pain?

"It was a wake-up call that we as nurses are part of the problem," said Betty Ferrell, Ph.D., RN, FAAN, research scientist with City of Hope Pain/Palliative Care Resource Center, Nursing Research and Education in Duarte, Calif. Ferrell has extensively studied how nurses manage patients' pain, with surprising results.

In a series of small studies and surveys, Ferrell worked with her colleague Margo McCaffrey, MS, RN, FAAN, lecturer and consultant on the care of the patient in pain, in relation to how nurses make decisions about pain management. The results showed that nurses focus on age, gender or patient behavior. For example, the patient who is smiling would not receive as much analgesic as the patient who is moaning, even though they both complain of pain.

"So often we say it's the doctor's problem," Ferrell said. "We found that even when there was an order for pain medication, the nurse would give a lower dose with less frequency than the doctor ordered. As nurses, our personal opinions affect how we treat pain. We need to become more objective and educated," Ferrell said.

Ferrell has worked in oncology nursing for the past 25 years. She was a staff nurse on an oncology unit for three years, then went into home care and hospice. She started to read literature about the best way to treat pain. She went back to graduate school, finished her Ph.D. in 1984, and has been exploring nursing topics ever since. She has written more than 230 research papers and four books.

"We are improving, thanks to JCAHO's mandatory requirement for assessment of pain. A typical chart used to read, 'c/o pain. Med. given,' without mention of the patient's response. Now, we have more standard assessments and chart whether or not it worked," Ferrell said.

The impact of cancer pain on family caregivers is great, Ferrell said. In 1984, she recalls seeing a patient as a home care and hospice nurse. "The patient's pain went from an assessment level of 10 to a 1. However, the patient was incredibly sedated, constipated, nauseated, had a husband who hadn't slept in four days, and children who were panicked to see their mother in that condition. We made the pain better, but everything else was worse. The pain outcome is only a small part of the picture," Ferrell said. "We need to look at the whole person, so we started to study the quality of life, including the patient's physical, psychological, social and spiritual qualities."

"Pain is also a metaphor for death," Ferrell said. People often fear pain, she said, and because they often associate pain with dying, patients or their family frequently deny pain. "When patients ring a call bell and say they are in pain, it can also mean they are scared or that they are worried about dying. We need to look at pain not as a single symptom but as a whole-person experience. The pain outcome is only a small part of the picture. We need to go to the next level of assessment and look at the spoken and unspoken information," Ferrell said.

Take, for example, a home care nurse going to see a patient. The family says the patient is fine. Meanwhile, the nurse can hear their mother moaning from the other room. Another illustration is when pediatric patients complain of pain, their parents think the pain (hence the cancer) is getting worse. If the parents are not prepared for the child to die, they could deny their child's pain.

Ferrell said people are living longer with cancer, and there can be many sources of pain for the survivor-therefore, nurses need to ensure that quality of life is maintained. As the gate outside of the City of Hope reads, "There's no profit in curing the body if in the process we destroy the soul."

Are your pain assessment skills and interventions up-to-date? Take a quiz and find out at http://prc.coh.org. Click on the instruments button and choose from several learning tools, including "Pain Knowledge and Attitude Tool."