Welcome to our WIKI! July 5, 2010

Hello everyone and Welcome to our WIKI presentation. Our group has efficiently collaborated to bring you this presentation…

• Description of a practice scenario presenting pain management as a nursing issue
• Definition of pain
• Definition and description of pain management according to the RNAO
• Significance of Pain Management in a New Graduate’s Practice
• Summary of scholarly articles
• Description of nursing theory and the application of theory to pain management issues and clinical scenario
• Possible solutions related to the clinical scenario
• Conclusion of how current practice for a new graduate can be influenced by implementation of these solutions
• Discussion questions related to pain management issues which promote reflection

In addition, we have also included additional resources…..Myths and Misconceptions, Pharmacological and Non-pharmacological Treatment Options, and several Pain Assessment Tools.

Group Members: Ayan Abdi, Pamela Boyer, Seana Brandon, Meashell Campbell, Jennifer Chhangur, Tenzin Choesang, Michelle Gunning, Vicki Kukielka, Alysha Savji, Kailey Snider, Juan Suarez, Carla Techera

Hypothetical Clinical Scenario

Below is a hypothetical clinical scenario that any of us could encounter during our nursing practice. We have used this scenario as the basis for our site and have used a wide variety of resources to come up with possible solutions for this situation.

 

Mrs. H is a 51 year old woman who has lupus and several pressure ulcers. She has stage two pressure ulcers on her coccyx and hip in addition to a stage four pressure ulcer on her left heel.  She has chronic pain due to her diagnosis and cries out in pain every time the nurses attempt to provide care for her.  The nurses often have much difficulty providing morning care for Mrs.H because it causes her too much pain.

 

Mrs. H always expresses that she is in extreme pain when the nurses are in her room but she is able to lie quietly when she is left on her own which has caused some of the nurses on the unit to suggest that Mrs. H is “overreacting” when she is touched.  When any of the nurses ask her, she rates her pain as 10 out of 10.

 

Mrs. H is receiving 10 mg of hydromorphone PO and 6 mg of morphine IV PRN.  After a recent visit by the doctor, her hydromorphone is reduced to 6 mg PO and her morphine to 4 mg IV q6h.  The nurses do not feel that a decrease in Mrs. H’s medication is the correct course of action but when they question the doctor, he explains that Mrs. H did not appear to be in much pain during the assessment and only rated her pain as 4 or 5 out of 10.

 

The nurses on the unit are unsure how to proceed because they have experienced that Mrs. H is very difficult to care for due to her pain.  The nurses are also concerned about Mrs. H’s pressure ulcers.  When they attempt to change her dressings she screams so loudly that it causes increased anxiety and discomfort to other patients on the unit and the nurses themselves.  Mrs. H is also very resistant to being repositioned and when she finds a position she is comfortable in she will not allow the nurses to reposition her for many hours, putting her at increased risk of developing additional pressure ulcers and preventing the ones she already has from healing.

 

Mrs. H’s family is also very concerned and are constantly at the nursing station asking to speak with various doctors and nurses because they feel that Mrs. H is not receiving the same level of care as other patients on the unit.  They are very angry at the care Mrs. H is receiving and have expressed their frustration to the nurses repeatedly.

 

 

What is Pain?

According to the IASP (1994): “pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage, or described in terms of such damage by any individual” (p. 1). McCaffery and Pasero (1979) define pain as “whatever and whenever the person says it is” (as cited in Ersek & Poe, 2006, p. 134). “Pain is always subjective” (IASP, 1994, p .1) as the sensation and description of pain is learned from a very young age and is considered an emotional experience (IASP, 1994).

 

 

     In Mrs. H’s situation, we are able to identify that some of the health care professionals do not believe that Mrs. H is in as much pain as she is reporting. The health care professionals are not taking into account that they do not know or understand how much pain Mrs. H is experiencing and that her experience of pain is personal. Under no circumstance should a patient’s description or report of pain be ignored or written off as untruthful by any member of the health care team (IASP, 1994). Once the report of pain is made, the appropriate steps for assessment and management should be taken to provide the patient with necessary treatment (IASP, 1994).

 

     Another point worth mentioning, although it does not apply to our scenario, is that the “inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment” (IASP, 1994 p.1). In these situations health care professionals must utilize a variety of different pain assessment tools to ensure that patients are provided with the best possible treatment options (IASP, 1994). The importance of advocating on behalf of these patients in particular can not be understated (IASP, 1994).

RNAO description of Pain and Pain Management

     The RNAO (2007) states that “(p)ain is one of the most frequent reasons for which individuals seek the assistance of a health care professional” (p. 35). As a result, a newly graduated nurse working in almost any clinical setting is bound to come into contact with individuals experiencing pain. Unfortunately, effectively managing patients’ pain has proven to be a significant problem for nurses, patients, their families, and the health care system as a whole (RNAO, 2007).

 

     Evidence has shown that pain that is not effectively managed can have severe physiological and psychological effects on patients and their families (RNAO, 2007). However, significant rates of inadequately addressed pain continue to be reported across all patient populations (RNAO, 2007).

 

Here are some examples cited by the RNAO (2007, p. 35):

 

• “It is estimated that persistent pain caused by metastatic disease is inadequately treated in up to 50 per cent of cancer patients” (Cleeland et al., 1994; VonRoeen Cleeland & Gonin., 1993; Young, 1999)

 

• “25-50 per cent of community dwelling older people suffer significant pain and approximately 70 per cent of patients in nursing homes experience unrelieved pain problems” (Ferrell, 1991; Helm & Gibson, 1997; Turk & Feldman, 1992).

 

• “Studies indicate that 50-80 per cent of patients had moderate to severe pain ratings following the administration of analgesics” (AHCPR, 1994; McCaffery & Pasero, 1998)

 

     Despite the fact that the possibility of completely eliminating a patient’s pain is slim “patients (still) have the right to the best pain relief possible” ((Watt-Watson, Clark, Finley & Watson, 1999, as cited in RNAO, 2007, p. 36). This is an important point to apply to Mrs. H’s scenario. Mrs. H’s pain report is not being taken at face-value and her pain is not being adequately addressed. “The knowledge and resources exist to provide satisfactory pain relief and to improve quality of life for those experiencing significant pain” (RNAO, 2007, p. 36) and it will be important for the nurses caring for her to advocate on her behalf to ensure that her pain medications are increased, perhaps even to a level higher than they were initially. The doctor should be invited to observe the patient while the nurses are attempting to provide care and re-assess her pain levels at that time.

RNAO Guideline for Pain Management

The RNAO (2007) Best Practice Guideline for Pain Management outlines several principles meant to guide nurses’ practice as they assess and manage patients’ pain.

1. Patients have the right to the best pain relief possible.
2. Unrelieved acute pain has consequences and nurses should prevent pain where possible.
3. Unrelieved pain requires a critical analysis of pain-related factors and interventions.
4. Pain is a subjective, multidimensional and highly variable experience for everyone regardless of age or special needs.
5. Nurses are legally and ethically obligated to advocate for change in the treatment plan where pain relief is inadequate.
6. Collaboration with patients and families is required in making pain management decisions.
7. Effective pain assessment and management is multidimensional in scope and requires coordinated interdisciplinary intervention.
8. Clinical competency in pain assessment and management demands ongoing education.
9. Effective use of opioid analgesics should facilitate routine activities such as ambulation, physical therapy, and activities of daily living.
10. Nurses are obligated to participate in formal evaluation of the processes and outcomes of pain management at the organizational level.
11. Nurses have a responsibility to negotiate along with other health professionals for organizational change to facilitate improved pain management practices.
12. Nurses advocate for policy change and resource allocation that will support effective pain management.

Significance of Pain Management in a New Graduate’s Practice

     In the past, Fothergill-Bourbonnais, & Wilson-Barnett, (1992) identified two of the main factors that influenced and effected the management of a patient’s pain as being: 1) the nurse’s attitude, and 2) the nurse’s knowledge of pain management. It was determined that one of the main reasons nurses did not take part in patients’ pain control was because they were not aware of its importance (Fothergill-Bourbonnais, & Wilson-Barnett, 1992). Not being aware of its importance was a significant practice issue because nurses were not taking the necessary steps towards providing their patients with the care they needed. Ultimately, this resulted in extended hospital stays and negatively skewed patients’ perspective of the health care system (Fothergill-Bourbonnais, & Wilson-Barnett, 1992).

 

     A historical study showed that of “64 nurses from orthopaedic and gynaecological wards… 27% had not received any theory on the use of analgesic, while 81 % had not received any information on the theoretical basis of pain nor on methods of pain relief other than analgesia” (Fothergill-Bourbonnais, & Wilson-Barnett, 1992, p 363). Another study showed that the knowledge many nurses had about analgesics was gained from clinical experiences they had after graduation (Fothergill-Bourbonnais & Wilson-Barnett, 1992). These two studies show that the reason for inadequate pain control in the past was due to nurses’ limited knowledge about the concept of pain itself and their poor understanding of the variety of pharmacological and non-pharmacological options available for pain management.

 

     Today, nursing school curriculum covers the concept of pain, and teaches students how to assess it (Sigsby, 2001). It also provides students with a basic working knowledge of a variety of techniques used for managing pain and, as a result, today’s new grads are able to identify different types of pain and understand the possible effects they could have on a patient (Sigsby, 2001). However, it is impossible to fully prepare a new graduate for all of the potential situations that they will encounter in their clinical practice and so the goal is provide them with enough background knowledge that they will be able to use their critical thinking skills to make good decisions when the time comes (Sigsby, 2001). “Student nurses may never realize the importance of pain control until faced with a patient suffering severe and uncontrolled pain, for which neither their training nor previous experience has prepared them” (Fothergill-Bourbonnais & Wilson-Barnett, 1992, p. 363).

 

     Fothergill-Bourbonnais & Wilson-Barnett (1992) have stated that nursing as a whole as has made great progress in the management of pain. In the past, nurses simply followed the doctor’s orders for pain management without involving any critical thinking in the process. Today, having the knowledge of the different methods of pain management is important to nursing practice because it allows nurses to provide patients with the best possible options for pain management, and avoids unnecessary and unpleasant side-effects. This progression has given nurses the empowerment needed to voice their expert opinions and to advocate for their patients as needed (Fothergill-Bourbonnais & Wilson-Barnett, 1992).

 

     Under today’s education system, most nursing students will be involved in caring for patients in severe pain before they graduate. These experiences will enable new graduates to be far more comfortable managing patients’ pain once they are practicing independently (Sigsby, 2001).

Summary of Scholarly References

Persistent pain is the most common symptomatic cause of patients seeking healthcare. Chronic noncancer pain can be related to a diverse range of complaints, including low back pain, osteoarthritis, rheumatoid arthritis, postherpetic neuralgia, ischemic pain, migraine headache, and diabetic polyneuropathy (Galvez, 2009).

 

Pain is a complex clinical problem. Assessment depends on verbal report, and the patient’s physical perceptions may be modified by cognitive and affective factors. The productivity of pain research and analgesic development since 1973 has not altered the truth of one clinical fact: no one treatment works for every patient, even for pain of the same type and etiology (Meldrum, 2003).

 

There is no way to tell how much pain a person has. No scale or test can measure the intensity of pain, no imaging device can show pain, and no instrument can locate pain precisely. Scales are helpful but pain is a personal experience (NIND, 2009).

 

Pain treatment inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include: lack of educational emphasis on pain management practices in nursing and medical schools, inadequate or nonexistent clinical quality management programs that evaluate pain management, not enough studies of populations with special needs experiencing pain, clinician’s attitudes toward opioid analgesics, unappreciated cultural and sex differences in pain, and bias and disbelief of pain reporting according to racial and ethnic stereotyping (Rupp & Delaney, 2004).

 

Nurses regularly work with patients experiencing pain and changes to healthcare services have seen nurses increasingly responsible for overseeing care the care of patients with chronic conditions. Nurses are the first ones to witness patients pain experience (Shaw & Lee, 2010).

 

“Pain is challenging for the people experiencing it and the healthcare professionals helping them to manage it. Awareness is needed of the treatment options available and strategies to alleviate suffering” (Hinchy, 2010, p. 26).

 

In a study by Shaw & Lee (2010), the authors find that like qualified and practicing nurses, nursing students hold misconceptions about adults with chronic non-malignant pain, representing inaccurate knowledge and inappropriate attitudes, and these are not addressed to properly during their undergraduate education. Educational processes that enable students to explore their own attitudes and engage the perspectives of colleagues and patients should be encouraged.

 

Theory of Human Caring as Applied to the Clinical Scenario

In nursing theories guide practice. Many theorists while they believe in the biomedical model of nursing believe that nursing is an art and science. The art in nursing is the ability to use the scientific knowledge to frame the intuitive aspect of care that is provided to patients. In the scenario, the nurse is practicing the art of nursing while the Doctor was more focused on the science. ‘The explanatory and predictive power of general knowledge is pivotal in diagnosing and treating diseases,’ (Cooper, 2001 p.6) however putting the patient’s pain in perspective and how to treat the whole being of the patient delves further than the scientific. The nurse is more present with Mrs. H and therefore is able to understand the pain that she feels.

 

When applying a framework based on nursing theory as a possible solution to the issue of Mrs. H’s pain, a definition of pain is relevant. ‘Pain is whatever the experiencing person says it is,’ (Ross-Kerr & Wood, 2006 p. 1237) and therefore the attitude that the nurse has must be an attitude of care. Watson (1991) believes that ‘caring is an endorsement of professional nurses identity.’ In identifying ourselves as caring being then that transfer of care to the patients must include the patient’s being holistically.

 

The Theorist Jean Watson believes that as nurses we should explore and expose the core of the patient’s being, which are mind, body and spirit. Jean Watson (1991) theorized that the ‘nurse’s role is to treat patients as holistic being [and] promote health through knowledge and intervention.’ Watson believes that these three must be in unison before health and wellness can be achieved at an optimal level.

 

Framing the issue of pain from the perspective of Watson, the nurse needs to understand that there is a direct relation between the patient and the nurse and this relationship emerges the moment the nurse enters that patient’s room. ‘When the nurse enters the patient’s room a feeling of expectation is created,’ (Watson, 1991) and the nurse’s ‘attitude and competence,’ (Watson, 1991) can ‘threaten or secure,’ (Watson, 1991) that patient’s well being. The nurse is in relation with Mrs. H and therefore the intervention that used to treat Mrs. H’s pain must reflect the type of trusting relationship that developed between the two.

 

Watson’s Seven Caring Assumptions:

1. Caring can be effectively demonstrated and practiced only interpersonally.
2. Caring consists of carative factors that result in the satisfaction of certain human needs.
3. Effective caring promotes health and individual or family growth.
4. Caring responses accept person not only as he or she is but as what he or she may become.
5. A caring environment is one that offers the development of potential while allowing the person to choose the best action for himself or herself at a given point in time.
6. Caring is more ‘healthogenic’ than is curing. A science of caring is complementary to the science of curing.
7. The practice of caring is central to nursing.
Application of these seven assumptions will help the nurse in finding a solution to the issue with the use of nursing theory.
(Watson, 1991)

Possible Actions in this Scenario

When determining the best course of action to take for providing Mrs. H with optimal pain management, a newly graduated nurse could utilize the CNO’s (2008) decision tree to determine possible solutions.

 

Decision Tree: A Guide to Practice Decision Making for the Entry-Level Registered Nurse (Retrieved from CNO, 2008, p. 27)

 

The first step of this process would involve asking Mrs. H how she would like to manage her pain and presenting her with all possible treatment options. This information would need to include all possible pharmaceutical and non-pharmaceutical options (i.e. music, warm or cool packs, imagery, distraction, relaxation, therapeutic touch, massage therapy, aromatherapy, or reflexology). Mrs. H’s ultimate pain goal, the level of pain she feels she could comfortably tolerate, would need to be established. The next step would be to provide Mrs. H with whichever option(s) she has chosen. This knowledge-based practice would ensure that Mrs. H is receiving the most up-to-date information about her illness and all of her possible treatment options. This is also in line with nursing’s professional and ethical responsibilities.

 

The CNO National Competencies in the context of entry-level Registered Nurse practice (2008) provides a list of competencies a newly graduated RN is expected to have mastered. The CNO has presented these competencies in a conceptual framework centered around five categories (p.6):

1. Professional responsibility and accountability
2. Knowledge-based practice
3. Ethical practice
4. Service to the public
5. Self-regulation

 

Many of the possible solutions a new-grad could utilize in this situation stem from Knowledge-Based Practice although they are also in line with Professional Responsibility and Accountability, Ethical Practice, and Service to the Public. These possibilities include:

1. Providing the patient with analgesics 30 min prior to attempting to initiate AM care in order to ensure the medication has time to take effect
2. Initiating a flow chart to record the patient’s pain scales in order to determine if a pattern exists that reveals when the pain scales are the lowest and pin-point an ideal time to provide care. This would also ensure that Mrs. H is receiving on-going holistic assessment.
3. Advocating to the doctor that Mrs. H’s pain meds should not be reduced. The flow chart of the patient’s pain scores could prove to be invaluable in this process.
4. Providing the patient with an air mattress to help prevent pressure from being placed on the patient’s wounds.
5. Collaborating with PT/OT/Chaplin Services to optimize use of all possible pain relief techniques
6. Developing a care plan that eliminates unnecessary movement – i.e. does she need to have a bed-bath every day due to excessive perspiration?
7. Doing a literature search for Lupus and holding an in-service to educate the nurses and staff on the floor about the misconceptions of subjective pain.
8. Utilizing the same literature search to determine pain management techniques used in similar situations and ensure the patient is aware of these options.
9. Finding out if there is a room that Mrs. H could be taken to that is away from the other patients for dressing changes. This would be demonstrating a service to the public, the public being the other clients on the floor.  A special room designated for sensitive procedures like this can be a decorated in a tranquil fashion and have relaxing music playing softly in the background.
10. Holding a family meeting to ensure that all members of the family are aware of the patient’s condition, treatment options and treatment choices.

What can YOU do as a new RN?

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