Pain Management And Analgesia Survey - British Veterinary ...

Factors Affecting the Attitudes and Opinions of Veterinary
Nurses towards Pain and Analgesia
By
William O’Connor
Royal Veterinary College
University of London
A dissertation submitted in partial fulfilment of the requirements for the degree of BSc in Veterinary
Sciences at the Royal Veterinary College, University of London
May, 2011
Abstract
In February 2011 a survey was disseminated to the readers of the Veterinary Nursing Journal. The
survey was designed to assess the opinions and attitudes of veterinary nurses towards pain and
analgesia, as well as investigate the factors that influenced those opinions and attitudes. The survey
ran for seven weeks and 148 completed questionnaires were returned. As had been shown in
previous studies pain in dogs was perceived as higher than pain in cats. However, the pain scores
received were consistently lower than those received for the same procedures previously. The age of
respondents had also changed to include a greater number of older respondents than had previously
been seen. 85.5% of respondents felt that they invested emotionally to a large degree in their
patients, whilst 52.4% said that they strongly considered their patients as people. Furthermore,
85.8% of respondents reported having provided what they felt was inadequate analgesia at some
point due to pressure from their colleagues. The survey also highlighted a number of factors that
affected those opinions. Age was one of these, older nurses tended to perceive pain as higher. The
same was true of nurses who were more confident in their own abilities. Whilst nurses who did not
feel their opinions were valued were les confident in their abilities and did not invest as heavily
emotionally in their patients compared to their colleagues who felt their opinions were more valued.
The study shows that nurses are confident and empathetic in their care of painful patients and
should take a leading role in pain management postoperatively.
Acknowledgments
Firstly many thanks to my supervisor Christopher Seymour for his guidance and encouragement. My
thanks also to the British Veterinary Nursing Association and the Veterinary Nursing Journal and in
particular to Angela Mariconda for organising the dissemination of the survey. Finally and most
importantly to all the nurses who took the time to complete the survey and provide many insightful
and engaging comments.
1

Contents
Introduction 3
Materials and Methods 5
Results 8
Discussion 12
Future Work Arising 15
Bibliography 15
2

Introduction
The assessment of people’s attitudes, beliefs and opinions is a useful tool for analysing the reasons
behind why people do the things or think the way they do. It is often the case that ingrained beliefs
can count more than fact and evidence in the formation of opinions. This applies to medicine both
human and veterinary as much as any other area human endeavour. The case of Ignaz Semmelweis
(1818 - 1865) provides an example. He is credited with the introduction of antisepsis to modern
medicine (Britannica Online Encyclopaedia 2011) but despite the evidence he gathered at the time
his findings were ignored and even ridiculed because they contradicted the beliefs of the age.
In veterinary medicine the opinions of both veterinary surgeons and nurses are of even greater
importance due to the limited nature of communication with patients. However beliefs within the
profession vary markedly, which may lead in turn to many different opinions in practice. One area
which is particularly affected by such opinions is pain management.
Acute nociceptive pain is a vital adaptation for survival, as shown by examing the lives of those with
congenital analgesia to appreciate its value in protecting us from harm (Nagasako et al. 2003). There
are times, however when its effect is detrimental to the wellbeing of both human and veterinary
patients. Excessive pain can increase the recovery times of patients, inhibiting effective healing
(Hellyer et al. 2007). And when pain occurs without obvious cause it can become in itself a pathology
(so-called maladaptive pain). The debilitating effect of chronic persistent pain can also result in a
decrease in quality of life. Not only is pain a concern on a personal or individual level but also at a
population level. In the United States pain is the largest cause of visits to the family doctor (Turk &
Dworkin 2004).
Attitudes towards pain and its alleviation have altered over the years. Until recently the belief that
animals did not feel pain or at least animal pain was somehow different to human pain was
widespread (Hellyer et al. 2007). This change in opinions has accelerated over recent decades as
research and advancements in medical science have changed how pain is treated in humans and
animals, for instance the introduction of the concept of perioperative analgesia (Capner et al. 1999;
Hellyer et al. 2007; Lascelles et al. 1999). Pain is now seen as a complex multifactorial and
multimodal phenomenon and whose effective treatment is a vital part of good medical and
veterinary practice.
Studies into the opinions, beliefs and attitudes of veterinary nurses and veterinary surgeons have
given us an insight into how pain management is handled in veterinary practice and the opinions
which underlie this. This information is particularly important in the veterinary community as
information on treatments and particularly drug use is sparse and often not at all uniform.
A series of studies have revealed differences in opinions to pain, analgesia use and pain
management in general between veterinary surgeons and veterinary nurses as well as within each
profession by itself.
Among veterinary surgeons opinions vary with gender, age and the species being treated. Females
are more likely to provide analgesia then males and dogs’ pain associated with neutering procedures
being ranked higher than in cats for those same procedures (Capner et al. 1999; Lascelles et al.
1999).
Length of time in practice was also shown to influence attitudes to pain management albeit in
different ways. Nurses who had been in practice longer demonstrated a higher perception of their
patient’s pain (Coleman & Slingsby 2007). Conversely this was not true of veterinary surgeons,
where those who had graduated most recently were more likely to have a higher pain perception.
3

30% of veterinary surgeons questioned considered that some degree of pain was beneficial after
surgery, as it was thought to limit the patient’s movement (Capner et al. 1999). Colman & Slingsby
(2007) in their paper investigating the attitudes of veterinary nurses also found that 24% of nurses
also felt that some degree of pain was required to prevent the animal being to active post surgery.
This is despite evidence that when an animal is given appropriate analgesia it tends towards sleep
and inactivity and recovery times are shortened (Hellyer et al. 2007). However there was very strong
agreement from nurses that animals benefited from both perioperative and post operative analgesia
and only 1.4% of nurses questioned believed that surgery usually did not result in sufficient pain to
require analgesia (Coleman & Slingsby 2007).
Pain perception was found to be higher in nurses than in veterinary surgeons (Coleman & Slingsby
2007; S. E. Dohoo & I. R. Dohoo 1998) as well as this Dohoo & Dohoo (S. E. Dohoo & I. R. Dohoo
1996a) showed that pain perception increased among veterinary surgeons who worked with AHTs
and that their concerns about analgesic use lessened. This was also shown to be the case among
AHTs themselves, who also rated pain higher in their as the number of their AHT colleagues at their
practice increased. Conversely pain scores did not increase as the number of veterinary surgeons
working at practice incresed (S. E. Dohoo & I. R. Dohoo 1998). A fundamental difference in teaching
and beliefs between vets and AHTs was one of the reasons postulated to explain the difference.
It was also found that veterinary surgeons either tended to prescribe analgesics either for all their
patients postoperatively, or for none of them. Moreover vets who worked with nurses were more
inclined to provide analgesics (S. E. Dohoo & I. R. Dohoo 1996b; S. E. Dohoo & I. R. Dohoo 1996a).
The majority of attention has focused on the attitudes and opinions of veterinary surgeons, although
nurses often provide the bulk of care for patients postoperatively. The role of nurses is vital to
ensure that patients are comfortable and free from pain. These studies demonstrate the key role
nurses play in pain management and how their presence in a practice affects the way patients are
cared for as well as the status granted to pain management and analgesia. This importance is
recognised in the fact that 71% of practices in one study said that nurses played the predominant
role in post operative monitoring (Lascelles et al. 1999). Despite this, vets were not necessarily
confident in the practice’s nursing staff’s abilities and knowledge of analgesia, with 68% considering
it insufficient. However, 75% of veterinary surgeons in the same study did not consider their own
knowledge adequate. This highlights one of the main issues facing pain management, that while the
infrastructure and knowledge may exist to treat pain effectively, it is not always transferred to
individual vets and nurses and so many animals may unnecessarily be receiving inadequate or
inappropriate analgesia.
The responsibility for this could lie with the instruction that vets and nurses receive on pain
management during the course of their training. Many respondents reported that they were not
confident in their ability or knowledge about pain management, ranking higher education as a poor
source of information on the subject (Lascelles et al. 1999; S. E. Dohoo & I. R. Dohoo 1996b).
Unsurprisingly experience in practise was regarded as the best way to learn about pain
management.
As yet no investigation into the underlying factors that influence nurses’ opinions on pain
management has been attempted. So far information has been collected revealing some opinions as
well as how nurses influence veterinary surgeons. Previous studies have all been constructed with
reference studies on veterinary surgeons. Whilst understanding the dynamic between these two
closely allied professions is important, the vital role that veterinary nurses play in caring for painful
patients makes the underlying factors affecting their attitudes and beliefs an area that deserves
4

closer investigation. To that end, this study was devised to investigate the opinions of veterinary
nurses as well as how those opinions were shaped and the factors that are important in that
process. The survey used to collect data was intentionally designed to relate back to and hopefully
build upon the previous work done by Dohoo & Dohoo (1998) and Coleman & Slingsby (2007) in
investigating the attitudes of veterinary nurses.
The results of this study will hopefully provide an insight into how and why the opinions of
veterinary nurses are affected by factors such as age, qualification and experience as well as
highlight areas for further study.
Materials and Methods
Questionnaire design
A questionnaire was developed in order to assess the beliefs, and some of the underlying attitudes
behind them, of veterinary nurses towards pain in their patients.
The questionnaire contained 6 sections of questions, containing from 1 to 7 questions, and a 7 th
section where respondents could make comments.
The first section, entitled ‘A bit about you’, contained 3 questions looking at demographic factors
thought to be of possible relevance: gender, whether the respondent was a registered veterinary
nurse or not, and age.
Gender was not questioned in the 2007 Coleman and Slingsby article as the Veterinary Nursing
Manpower Survey revealed that 98.7 of those surveyed were female and it was therefore thought
that a viable and representative sample of male nurses would not be obtained. Despite this, it was
decided that gender would be included in this questionnaire because it was considered that if
enough male nurses did respond to produce useful results it might highlight some interesting gender
differences as indicated by earlier surveys of a similar nature in veterinary surgeons.
The second section contained a single question consisting of 8 surgical procedures, 4 each in cats
and dogs. The respondents were asked to pain score each procedure 12 hours after surgery on a 10
point numerical rating scale, with a score of 1 indicating no pain and a score of 10 indicating the
worst pain imaginable. This question was purposely identical to one asked by Coleman and Slingsby
(2007) so that direct comparison between the two surveys could be made, and also because it was
considered that the procedures included provided a good spread of surgeries likely to produce both
low and high pain scores. See Table 1.1 for the list of procedures.
The third section contained 2 questions asking for the
nurse’s qualification and what sources of information
on pain management they felt had been most useful to
them. The sources included were formal education,
colleagues, journals and texts, seminars, lectures and
clinical experience. The nurses were asked to rank
those 5 from least to most useful. These 5 areas were
chosen to cover as complete a range of information
sources as was possible.
Table 1.1 surgical procedures contained
in section 2
Fracture repair in a dog
Bitch spay
Dog castrate
Cruciate repair in a dog
Cat spay
Cat castrate
Cat dental
Repair of ruptured diaphragm in cat
Section 4 investigated the nurse’s experiences during
practice and consisted of 7 questions chosen to cover a
broad array of factors. These were the type of practice the nurse currently worked at or their last
5

practice if they were currently not in practice, their role in that practice, the type of non-analgesic
therapies available at that practice, the nurse’s relationship with their patients and colleagues and
their satisfaction with their role in practice. Several of the questions in this section were chosen to
complement each other and measure different aspects of the same issue.
Section 5 contained 2 questions on the nurse’s personal experience. The first asked them to rate
their own worst experience of pain on a 10 point numeric rating scale, with 1 being no pain and 10
indicating the worst pain imaginable. The second question enquired about their last experience of
having a pet go through surgery.
The last compulsory section, Section 6, contained 6 questions inquiring about the beliefs of the
nurses concerning the pain experienced by their patients, their own understanding of pain and
analgesia, the effectiveness of drug therapy and to what extent they viewed their patients as people
with regard to their comprehension of any pain they may be suffering.
Section 7 was optional and contained an open box where respondents were encouraged to make
comments and observations relating to pain management which the questionnaire had inspired.
In total twenty two questions were asked, including the open remarks and comments section at the
end. The questions were in several formats. 5 point Likert scales were used to allow respondents to
communicate differing strengths of opinion. The questions for these scales were written in a variety
of different ways, some with positive and some with negative biases and in all cases trying to avoid
the more familiar ‘to what extent do you agree with the following statement’ format in order to try
and make the respondent consider their response more carefully. A 10 point numerical rating scale
was used for pain scoring. Conversely to the Likert scale questions 10 points of differentiation where
used precisely because it was thought that it would foster familiarity it in the hope of respondents
providing a more immediate ‘gut’ score for the pain rating which it was felt might produce a more
accurate response.
The online survey tool Survey Gizmo was used to construct the questionnaire and disseminate it.
Advantage was taken of Survey Gizmo’s ability to randomly order questions, within a category and
the order of answers to individual questions with the idea to reduce any response bias.
Circulation
Several sources were approached to ask for help with circulation. Of these, the Veterinary Nursing
Journal (VNJ) the British Veterinary Nursing Association’s (BVNA) monthly journal agreed to circulate
the questionnaire to its members. An electronic format was decided upon, as not only would it
eliminate the cost of printing the questionnaires out and providing return envelopes, but would also
keep the information neat and ordered without the need to convert paper copies to an electronic
format. Due to earlier experiences with questionnaires and corresponding response rates it was also
hoped that the electronic format would encourage a good number of responses as all a respondent
would have to do would be to fill out the questionnaire and everything else would be done
automatically. The survey went online on the 1 st of February 2011. Links to it were posted on the
BVNA website and Facebook page and also included in the monthly e-news letter, along with a short
article describing the survey and its aims. The VNJ also provided some space in the corresponding
February issue to advertise the survey. Initially it was decided to run the survey for a month but this
was extended to 7 weeks to allow more time for responses.
6

Data Analysis
The data obtained via Survey Gizmo was then exported to Microsoft Excel and then analysed using
IBM SPSS version 18 and 19. In all cases significance was assumed if p < 0.05.
The basis of the analysis would revolve around a pain perception rank for each individual. To
produce this rank the 8 surgical procedures the respondents had been asked to pain score in Section
2 of the questionnaire were used to produce a pain perception scale. The mean of each
respondent’s scores for the individual procedures was used to provide a scale score which was then
used as that individual’s pain perception rank.
As no analysis of the internal consistency or the scale used to compose the pain perception ranks
was reported by Coleman and Slingsby in their study, Cronbach’s alpha coefficient was employed to
assess the reliability of the scale in the current study. Internal consistency is used to investigate the
degree to which all components of a scale are measuring the same variable. In the case of this pain
scale a very high internal consistency was expected and could well be the reason that no such
analysis was included in the Coleman and Slingsby study. Cronbach’s alpha values above 0.8 are
generally accepted as indicating good internal consistency, with values above 0.7 acceptable. Lower
values could indicate that not all items in the scale are measuring the same factor, which could
compromise the utility of the scale. The pain perception ranks were also tested for normality using
the Kolmogorov-Smirnov statistic backed up by an analysis of a histogram of the scores and a normal
Q-Q plot.
Spearman’s rank order correlation was used to investigate the relationships between respondent’s
pain perception rank and age, confidence in their pain management abilities, the worst pain they
had personally suffered and how heavily the respondents invested emotionally in their patients. The
correlations between emotional investment and age, the degree to which nurses considered their
patients as people and confidence were also tested. In all cases preliminary analysis was performed
to ensure that the data satisfied the assumptions of linearity and homoscedasticity.
Analysis of the degree to which respondents felt their views on pain management were valued by
other members of the practice against their confidence score, was again performed by Spearman’s
rank order correlation. As was the correlation between perceived opinion value and the degree to
which pressure from colleagues caused respondents to provide inadequate analgesia. The
relationship between age and personal worst pain experience was also investigated.
Table 1.2 component questions
Confidence Satisfaction Empathy
How do you Do you feel your To what extent
rate your own opinions and do you feel you
understanding role in caring for invest
of pain and painful patients emotionally in
analgesia? is valued and your patients?
Do you feel respected by To what extent
that through other members do animals
your own of the practice? understand the
understanding
nature of the
of pain and Do you feel you pain they are
analgesia you have ever in?
are able to provided To what extent
contribute inadequate or do you consider
7

positively to
the welfare of
your patients?
Do you feel
you possess
adequate
knowledge to
identify subtle
changes in
your patients
that could
indicate pain?
e.g.
Differentiating
tachycardia
due to stress or
pain?
To analyze nurses’ confidence in their
pain management abilities, empathy
towards their patients and satisfaction
with their jobs, three other scales were
constructed each consisting of 3
components. For a list of the component
questions in each scale see table 1.2. The
internal consistencies of these scales
were then analysed by Cronbach’s alpha
as well as by inter-item correlation as due
to the small number of component parts
to each scale alpha values were expected
to be low.
Independent samples t-tests were used to
analyse the difference in pain perception
rank between groups. The groups
consisted of RVN and non-RVNs,
ownership of a pet that had undergone
surgery and those that had not, and whether the type of practice the nurse worked in was first
opinion or referral.
To investigate the differences in pain perception rank between categories containing more than 2
groups, a one way, between groups of analysis of variance (ANOVA) was used. The categories tested
were the nurse’s role in their practice and their qualification.
Demographic data was analysed by descriptive statistics including medians, inter quartile ranges and
cumulative frequencies. Descriptive statistics were also used to assess what sources of information
on pain and analgesia they found to be most valuable.
Results
A total of 180 questionnaires were returned, of which 148 were returned completed and 32 partially
completed. Only completed surveys where used for analysis.
Demographics
inappropriate
analgesia due to
the opinions of
or pressure from
your colleagues?
On a scale of 1
to 5 how
fulfilled do you
feel with your
current
responsibilities?
your patients as
people?
As expected, almost all (142 of
148) respondents were female,
accounting for 95.9 % of all
respondents. Whilst a higher
number of respondents were
male, 4.1% as opposed to the
1.3% that might have been
expected by looking at the
veterinary nursing manpower
survey (Lantra 2006), they did not
form a large enough cohort to
make statistical analysis using
gender worthwhile. Registered
veterinary nurses (RVN) also
8

made up 87.2% of the respondents.
The majority of the nurses, 52.1%, were aged between 26 and 39 years with the upper quartile
beginning at 39 although ages ranged from 19 to 58 years. The mean age of respondents was 33
years however the median was younger at 31 and the mode was much younger at only 24 indicating
that results were skewed towards younger respondents. Nurses over 50 made up 8.8% of
respondents. Fig 1.1 shows a histogram of the ages.
The most common qualification possessed by respondents was the NVQ accounting for 45.3% of the
nurses. The next most common group accounting for, 16.2% of respondents consisted of nurses who
qualified as RVN before the
current NVQ was introduced. The
BSc followed closely with 14.9%.
8.1% were currently students and
2% had the foundation degree.
The remaining 13.5% reported
possessing some other
qualification. Theses can be seen
in Fig 1.2.
The majority of nurses (52%)
reported their role in practice as
general nursing, 27% were head
nurses. Critical care and
anaesthesia nurses accounted
for 5.4 and 4.1% of nurses
respectively with the remainder
(11.5%) reporting other roles
mostly management and
teaching. 82.4% of respondents
worked in first opinion practices
as apposed to referral practices.
These are displayed in Fig 1.3.
9

Pain Perception Rank and Influencing Factors
The mean pain perception rank for the whole population was 6.48 out of 10. The mean pain scores
for each procedure are displayed in table 2.1. The highest mean pain score of 8.39 was attached to
bone fracture repair in dogs and the lowest, 4.28, was assigned to cat castration. The sum of mean
pain scores in dogs was higher than in cats, 28.3 compared to 23.6. Neutering procedures were also
assigned higher pain scores in dogs than in cats: mean scores for spaying were 6.69 and 5.80 in dogs
and cats respectively: for castration 5.19 and 4.28 in dogs and cats respectively. Individual’s pain
rankings ranged from 2.38 to 9.88 although 50% lay between 5.53 and 7.38. Only two respondents
had pain perception rankings above 9. In the current study the Cronbach alpha coefficient of the
pain scale as a whole was found to be 0.914 indicating a very high internal consistency. Normality
analysis revealed that the pain perception ranks were normally distributed.
Of the three other scales constructed using questions from the survey, only the confidence scale was
found to have adequate internal consistency for use so the other two scales were deconstructed and
their component parts used for analysis instead.
Table 2.1 descriptive statistics for pain scores and pain perception rank
Cat spay Cat castrate Cat dental
Repair of
ruptured
diaphragm in
cat
Fracture repair
in a dog
Bitch spay
Dog castrate
Cruciate repair
in a dog
Pain
Perception
Rank
N Valid 148 148 148 148 148 148 148 148 148
Mean 5.80 4.28 5.49 8.03 8.39 6.69 5.19 8.01 6.4848
Std. Error of Mean .160 .149 .155 .131 .118 .140 .142 .128 .11139
Std. Deviation 1.945 1.811 1.890 1.599 1.441 1.706 1.724 1.554 1.35518
Percentiles 25 4.00 3.00 4.00 7.00 8.00 6.00 4.00 7.00 5.5313
50 6.00 4.00 6.00 8.00 8.00 7.00 5.00 8.00 6.6250
75 7.00 6.00 7.00 9.00 10.00 8.00 6.00 9.00 7.3750
Table 2.2 summery of the correlations involving pain perception rank by Spearman’s rank order
correlation
Age
Emotional
Investment
Worst
Personal
Pain
Experience
Spearman's Pain Perception Correlation .200 * .138 .202 * .209 *
rho Rank
Coefficient
Sig. (2-tailed) .015 .094 .014 .011
N 148 148 147 147
*. Correlation is significant at the 0.05 level (2-tailed).
Confidence
10

Table 2.3 correlation between age and worst personal experience of pain
Worst Personal Pain
Experience
Spearman's rho Age Correlation Coefficient .462 **
Sig. (2-tailed) .000
N 147
**. Correlation is significant at the 0.01 level (2-tailed).
There was a slight but significant positive correlation between pain perception rank and age (table
2.2), indicating that as age increases an individual’s pain perception rank also increases. A similar
small positive correlation was also found between pain perception rank and personal worst pain
suffered (table 2.2). A robust positive correlation was revealed between age and worst personnel
pain experience (table 2.3). However no significant correlation was found between age and level of
emotional investment (table 2.4) or between pain perception rank and emotional investment (table
2.2) although 85.8% of respondents felt that they invested emotionally to a large degree in their
patients and none felt that they did not have any emotional investment. This was paralleled in the
52.4% of nurses who strongly considered their patients as people and supported by the significant
positive correlation between these two factors (table 2.4), although in comments made at the end of
the questionnaire many nurses clarified that they did not feel that the animals they treated were
literally human but that they possessed a similar capacity for pain and distress. A significant and
robust positive correlation was also found between emotional investment and confidence (table
2.4).
Table 2.4 summary of correlations that involved emotional investment by Spearman’s rank order
correlation
Age Confidence Personification
Spearman's rho Emotional Correlation .095 .401 ** .262 **
Investment Coefficient
Sig. (2-tailed) .251 .000 .001
N 148 147 147
**. Correlation is significant at the 0.01 level (2-tailed).
Table 2.5 correlations involving the value that they fell their opinions are given by colleagues
Pressure from
Confidence Colleagues
Spearman's rho Opinion Value Correlation Coefficient .211 * -.314 **
Sig. (2-tailed) .010 .000
N 147 148
*. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).
Again a significant but small positive correlation was found between pain perception rank and a
respondent’s confidence in pain management (table 2.2). Also, a small positive correlation was
found between confidence in pain management ability and the value the respondents thought their
views were given by other members of the practice (table 2.5). A more robust negative correlation
11

was found between the same perceived opinion value and the degree to which pressure from
colleagues caused respondents to provide inadequate analgesia (table 2.5).
No significant difference in pain perception ranks were found between RVNs and non-RVNs. This was
also the case for those nurses who had owned pets that had undergone surgery and those that had
not. Incidentally the vase majority (88%) of respondents reported that they did or had owned a pet
that had undergone surgery. There was also no significant difference in pain perception ranks
between those nurses who worked in first opinion or referral practices.
Neither a nurse’s role in their practice nor their qualification had any effect on their pain perception
rank. Although the value obtained from the ANOVA indicated that there was a significant difference
between qualifications, post-hoc analysis by Turkey HSD revealed no significant differences.
50.4% of nurses ranked clinical experience as the most valuable source of information on pain
management followed by colleagues. Formal education was regarded 25% of the respondents as the
least important.
Discussion
Compared to the earlier survey by Dohoo & Dohoo (1998) and Coleman & Slingsby (2007) the age of
nurses who responded seems to have increased. In the earlier surveys the majority of respondents
(roughly the interquartile range) were both from a younger and narrower age band (24 - 30 and 21 -
30 for Dohoo & Dohoo and Coleman & Slingsby respectively). The current study had an inter quartile
range of 26 to 39, both older and broader than the previous studies. Particularly noticeable is the
difference in the proportion of over-fifties who responded to the current survey, 8.8% of the total
respondents, as opposed to the Coleman & Slingsby survey where they only made up 1.7%.
This discrepancy is even more remarkable as both studies had the readers of the Veterinary Nursing
Journal as their core demographic, a publication with a young readership, (90% of readers are aged
between 16 and 35. Statistics taken from the 2011 VNJ rate card). Why such a large change should
have occurred in the intervening 7 years between the two surveys is not at all obvious. The major
difference between the two surveys is that the current one was completed entirely online where as
only 26.2% of the Coleman & Slingsby survey was, the majority of responses being completed in a
hard format. Originally when the survey was being developed its entirely electronic format was of
some concern as it was postulated that it might be a source of bias as older respondents might not
have found it as accessible. Possibly an increasing computer literacy extending into older
populations might have gone some way to ablate this and has led to a more diverse age
demographic. It could also be the case that younger populations in the past felt more invested in
pain research, as an up-and-coming field, than older populations. That interest has continued in time
with people who became interested with the subject at a younger age maintaining and interest later
in life. At the same time the subject still appeals to younger nurses broadening the age band of
people who were interested enough to respond. Also possible is a general increase in pain-related
research leading to a greater interest across the population of veterinary nurses.
The mean pain scores recorded by the present study for each of the 8 procedures were lower than
those recorded by Coleman & Slingsby. They did however follow the same broad trends, dogs
received higher pain scores than cats and the order of the scores from fracture repair in dogs as the
most painful to cat castrate as the least was also the same apart from dog castrate and cat dental
which swapped places. This seems to suggest that there is a consensus about the relative pain
caused by procedures and that nurses are able to consistently predict the pain caused by these
procedures. The lower scores for cats when compared to dogs also seems to support ideas that
12

there is a higher empathy for the pain of dogs over cats, possibly this is due to dogs expressing pain
in a way that is clearer to observers. Why overall the mean pain scores are lower in this study is
difficult to define. Possibly the seven year gap between the dissemination of the two surveys could
mean that the two should not be so closely compared, however it could also reflect a broader
change in opinions. It might be possible that new techniques during surgery and the increase in
perioperative analgesia may have reduced the pain associated with the procedures.
The small positive correlation between age and pain perception rank seems to corroborate earlier
findings by Coleman and Slingsby (2007) who noted a similar slight positive correlation between the
number of years a nurse had spent in practice and the mean pain score they recorded. This seems a
reasonable assertion, as on average older nurses are likely to have spent more time in practice,
although this may not always follow as some nurses might have been employed in non-clinical areas
such as practice management or have started nursing later in life as the results of a career change.
Furthermore, these two correlations go some way to strengthen each other despite their individual
weakness and would seem to suggest that with experience, the nurse’s empathy with regard to their
patients’ pain becomes more acute. However these results alone do not explain why this may be the
case or which is more important in its formation, experience in practice or experience in life. In other
words, is the increase in empathy due to long exposure to painful animals at work or just something
that occurs naturally as one experiences life?
To investigate this relationship further the respondent’s pain perception rank as well as their age
was plotted against their own assessment of the worst pain they have personally experienced. A
small positive correlation was found between a respondent’s pain perception rank and their own
worst pain experience and a robust positive correlation found between age and worst personal pain
experience. Together, these findings lend support to the hypothesis that experiences in life produce
a greater empathy in practice. One explanation for this could lie in the potential for older
respondents to have suffered a more painful experience than younger respondents over the course
of their lives, for instance childbirth. An alternative explanation could be that as people age their
tolerance of pain lessens, a sensitivity which is also passed on to their assessments of patients.
Although not significant the small correlation between emotional investment and pain perception
rank suggests that nurses who invest more emotionally in their patients may also tend to have a
higher pain perception rank. The correlation was small however, and when emotional investment
was plotted against age, the correlation was too small to be meaningful indicating that nurses as a
whole might have a very distinctive empathetic streak. The fact that no meaningful correlation was
found with age suggests that merely long exposure to practice does not make nurses more
empathetic.
A possible alternative explanation could lie in the effect of socially desirable responding. In this case,
nurses might feel that they ought to invest heavily emotionally in their patients and so respond to
the question accordingly whether they do or not. Support for this idea might be found in the mean,
mode and median values for emotional investment which lie at 4.17, 4 and 4 (out of 5) respectively,
with 85.8% of respondents ranking their emotional investment at 4 or higher showing little variance
in scores.
Another explanation is that the scores reflect the level to which veterinary nurses as a profession
commit to their individual patients. This may find potential support in the large number of nurses
that consider there patients as people in terms of treatment. The correlation between this and
emotional investment suggests that they are linked and that if attitudes towards animals are closer
to those for humans this may be beneficial for their care. This may point to a key difference between
the attitudes of nurses and vets and it would be interesting to put the same questions to vets to see
13

if they put the same level of emotional investment into their individual patients. A scale with a
greater number of degrees of differentiation may improve the sensitivity of the scale and provide
greater information on this point. Also the robust correlation between emotional investment and
confidence could indicate that nurses who invest more heavily in their patients are more confidence
in their abilities which lends more weight to the argument outlined above that if nurses feel able to
invest emotionally in their patients this may also produce a greater level of concern for their
patients’ wellbeing.
The increase in pain perception rank with increased confidence is interesting as it is not necessarily
obvious that this would be the cases, as lower ranks could have been equally likely as nurses did not
feel they had to inflate pain scores in order to ensure adequate analgesia. One explanation could be
that nurses who are less confident in their abilities are more likely to take their lead from the vets
working in the practice when assessing pain. Other studies have shown that vets do not rate pain as
highly in their patients as nurses (Capner et al. 1999; Coleman & Slingsby 2007; S. E. Dohoo & I. R.
Dohoo 1996b; S. E. Dohoo & I. R. Dohoo 1998; Lascelles et al. 1999). It could also be that less
confident nurses feel under more pressure to downgrade the pain of their patients. This is an
assertion supported by the 85.8% of respondents who felt that they had provided inadequate
analgesia due to pressure from their colleagues. This pressure from colleagues correlated with how
valued a nurse thought their opinion was by their colleagues, indicating that as nurses felt under
more pressure from their colleagues the less they felt their opinions were valued. This in turn
correlated with confidence, this suggests that nurses who felt that their opinions were valued were
more confident in their own abilities and less likely to be pressurised into providing analgesia that
they thought insufficient or inappropriate.
Most of the different qualifications produced very similar mean pain perception ranks, this could
suggest that the actual qualification that nurses receive is relatively unimportant in the formation of
their beliefs and opinions on pain and analgesia. Support for this can be found in the 25% of
respondents who ranked formal education as the least important source of information on pain
management.
The decision to solely use the British Veterinary Nursing Association (BVNA) and its Veterinary
Nursing Journal (VNJ) as the vector for disseminating the survey was considered carefully. The
potential bias towards nurses who may have been more interested in pain management was
considered acceptable due to the large circulation of the journal, a readership of around 9000
nurses, which would hopefully encompass a large spectrum of the veterinary nursing population.
Although a more holistic circulation consisting of both paper and electronic questionnaires and a
grater proportion of nurses would have been preferable, time and budget constraints made this
impossible.
The number of responses was less than had been anticipated. One possibility for this is that not all
readers might frequent the BVNA website, so that although they may have been aware of the survey
they did not answer it because the actual questionnaire was not presented to them and they did not
seek it online. One way of combating this may have been to include paper questionnaires inside the
VNJ.
Many of the comments that were made by nurses after completing the questionnaire were
concerned with the major difficulties involved in getting vets to prescribe analgesia. Vets often
seemed to not consider the pain of their patients after they had completed surgery a situation which
leads many nurses to feel like they had to badger vets to get them to take pain management
seriously and provide analgesia. Another comment was the lack of knowledge that some vets and
nurses seem to possess, a problem that was predominantly blamed on a lack of inclusion of pain
14

management in teaching. Nurses often felt that among older vets, there was a lack of empathy and a
degree of ignorance on current pain management techniques. Often this was coupled to a lack of
willingness to try new analgesic treatments among vets in general. Indeed poor pain management
was cited as a reason for nurses to leave a practice.
The results of this study indicate the factors most likely to influence a nurse’s opinions and beliefs
about pain management. These include the practice environment they work in and interactions with
their colleagues, the nurse’s age is also a factor. Furthermore, the survey reveals that nurses feel
confident in their abilities and are empathetic in their treatment of their patients. Arguably nurses
need to be given greater responsibility in the area of postoperative pain management and both
nurses and patients may benefit from an increased autonomy afforded to nurses to care for their
patients using their own judgment.
Future Work Arising
In the future it may be interesting to pose some of the questions that have been asked of veterinary
nurses in this study to veterinary surgeons. Results from previous comparisons between the two
professions suggest that there might be some striking differences between the attitudes vets and
nurses. Emotional investment and to what degree veterinary surgeons consider their patients as
people, in particular may provide interesting findings. These finding may also help discern what
correlations are incidental and which are more causative when compared with the findings for
veterinary nurses.
The failure of the Satisfaction and Empathy scale, due to low internal consistency, meant that
alternative ways of measuring the influence of these two factors had tom be found. This largely
proved successful, however in future the presence of these types of scales that reliably measured
these factors might prove beneficial. The development and potential utility of these types of scale
should be considered before further research is conducted.
Education was seen as a poor source of information on pain management, a sentiment that has been
echoed in other papers. An investigation into the teaching of pain management, for the various
veterinary nursing qualifications and an assessment of the merits of each one, may provide an
insight into where they are failing to provide adequate training. Potentially this may also aid in
improving the teaching of pain management which may in turn provide a benefit to the wellbeing of
animals in veterinary care.
Bibliography
Britannica Online Encyclopaedia, (2011). Ignaz Philipp Semmelweis (German-Hungarian physician).
Available at: http://www.britannica.com/EBchecked/topic/534198/Ignaz-Philipp-Semmelweis
[Accessed May 30, 2011].
Capner, C.A., Lascelles, B.D.X. & Waterman-Pearson, A.E., (1999). Current British veterinary attitudes
to perioperative analgesia for dogs. Vet Rec., 145(4), pp.95-99.
Coleman, D.L. & Slingsby, L.S., (2007). Attitudes of veterinary nurses to the assessment of pain and
the use of pain scales. Veterinary Record, 160, pp.541-544. Accessed May 22, 2011
15

Dohoo, S.E. & Dohoo, I.R., (1998). Attitudes and concerns of Canadian animal health technologists
toward postoperative pain management in dogs and cats. The Canadian Veterinary Journal, 39(8),
pp.491-496.
Dohoo, S.E. & Dohoo, I.R., (1996a). Factors influencing the postoperative use of analgesics in dogs
and cats by Canadian veterinarians. The Canadian Veterinary Journal. La Revue Vétérinaire
Canadienne, 37(9), pp.552-556.
Dohoo, S.E. & Dohoo, I.R., (1996b). Postoperative use of analgesics in dogs and cats by Canadian
veterinarians. The Canadian Veterinary Journal, 37(9), pp.546-551.
Hellyer, P. et al., (2007). AAHA/AAFP pain management guidelines for dogs & cats. Journal of the
American Animal Hospital Association, 43(5), pp.235-248.
Lantra, (2006). Veterinary Nursing Manpower Survey.
www.lantra.co.uk/vetnursing/documents/veterinarynursingmanpowersurvey.pdf. Accessed May 22,
2011
Lascelles, B.D.X., Capner, C.A. & Waterman-Pearson, A.E., (1999). Current British veterinary attitudes
to perioperative analgesia for cats and small mammals. Veterinary Record, 145(21), pp.601 -604.
Nagasako, E.M., Oaklander, A.L. & Dworkin, R.H., (2003). Congenital insensitivity to pain: an update.
Pain, 101(3), pp.213-219.
Turk, D.C. & Dworkin, R.H., (2004). What should be the core outcomes in chronic pain clinical trials?
Arthritis Research & Therapy, 6(4), pp.151-154.
16