Supporting nurses to manage patients' pain: pain is complex, highly subjective and endlessly fascinating, says nursing team leader at Wellington Hospital's acute pain management service, Julia Barton.
Author: Manchester, Anne
Pub Date: 07/01/2003
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2003 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: July, 2003 Source Volume: 9 Source Issue: 6
Accession Number: 114700353
Full Text: NURSE CONSULTANT and nursing team leader of the acute pain management service at Capital and Coast District Health Board, Julia Barton, is passionate about pain. She's been working in this area for ten years and still finds it endlessly fascinating.

"Pain is very complex. Basically it's a very subjective experience and is what a person says it is. Nurses find it hard to assess pain because we have been taught to assess what we see and pain can't be seen. Some patients are not good at describing their pain or they don't want to admit to pain, as they see it as a sign of weakness. Patients with chronic or persistent pain often don't feel believed. Our society really values people who can 'take' their pain."

Pain assessment is the key to pain management, says Barton. Pain is an integrated experience, requiring attention to physical, psychological, cultural and spiritual issues. Many factors need to be considered in an assessment, including age, developmental level, cognitive function, gender and social background. "Some patients want the health professional just to cure their pain, but it's not as easy as that. For some people, psychological strategies might give them greater relief from symptoms than drugs, but getting to the point of being able to accept that, can be difficult for some people. Drugs may only deal with one aspect of pain and can even create more problems than the original pain. Judging how much a person's pain is due to psychological, emotional and spiritual distress and how much to physical symptoms takes real skill and perception. Some patients get relief simply by having their pain acknowledged."

The acute pain management service is headed up by a consultant anaesthetist or anaesthetic registrar and includes two full-time clinical nurse specialists, as well as Barton, who provide a seven-day-a-week service, from 8am to 10pm during the week and 8am and 4.30pm at weekends. Some weeks there is insufficient cover, as the nursing resource is thinly spread. The nurses' role used to be confined to patients who had had surgery or suffered major trauma but it has expanded in recent years to include almost any ward or department in the hospital, including medical services, emergency and intensive care, obstetrics, paediatrics and the assessment, treatment and rehabilitation service. The service can be described as an anaesthesia-based, interdisciplinary service that, in collaboration with nursing, provides epidural, intravenous, patient-controlled analgesia and other advanced analgesia techniques, primarily to patients in the perioperative or post-traumatic period.

Pain management nurses require expert skills and knowledge in order to take a leadership role in clinical and research practice, education and quality assurance activities associated with pain management. The nurses form an important link between nurses on the ward, anaesthesia and other disciplines throughout the hospital.

The first hospitals to establish an acute pain management service in New Zealand were Middlemore and Auckland Hospitals, with services set up between 1988 and 1989. Wellington Hospital followed in 1992, with Barton being appointed a clinical nurse specialist in pain management the following year. When she first began working in the then recovery unit (now called the post anaesthetic care unit), nurses were not able to administer intravenous (IV) morphine. She has vivid memories of patients emerging from anaesthesia after surgery, in agony. Often there would be delays in getting an anaesthetist to administer the morphine. Once the protocol was changed to allow nurses to administer IV morphine, patient care improved markedly and there was significant stress reduction for both nursing and anaesthesia staff.

However, it wasn't until 2000 that Barton was able to employ additional nurse specialists. "It is wonderful nurses now have a much more professional career pathway, though this is yet to be developed in pain management. Ongoing professional development is vital for nurses in this role and must be expanded," she said.

Patients who have had negative experiences with pain management in the past present a challenge to those who care for them. Some carry with them disturbing memories of previously unsuccessful interventions or insensitive behaviour from health professionals. A further complication is patients with an existing drug addiction. This issue adds to the complexity of their care. Patients who have had a limb amputated may develop phantom pain. These patients will have major disfigurement issues to deal with, as well as coping with the changes an amputation brings to their whole lives.

Trouble-shooting

Barton is emphatic the pain nurse specialists must not take over from the nurses on the wards. The specialists' role is to support the nurses in managing patients' pain. "The nurse on the ward is the key person in caring for the patient with pain. They are there 24 hours a day and know the patients well. We are a trouble-shooting service. We will offer advice to nurses or house surgeons over the phone and will visit those with particular pain problems whenever we are needed. At present, we have about 40 patients throughout the hospital whom we try and visit every day, with referrals made to us by the medical/surgical teams. These patients may have advanced analgesia techniques that we need to monitor for effectiveness and side effects. We also liaise with the chronic pain service where they are presently two doctors short. We don't want to deskill the existing staff. We are there to support and educate the nursing teams and the house surgeons, who must also learn to manage patients' pain."

Effectiveness of service

Barton has done some research into the effectiveness of an acute pain service and is able to show it does have a very positive influence on nurses' knowledge and effectiveness. However, this sort of service only exists in major hospitals in New Zealand. In regional hospitals, eg Hutt and Dunedin, pain nurse specialists are based in postanaesthetic care units and will work part-time with patients in the ward using advanced anaesthetic techniques, eg patient controlled analgesia, epidurals and nerve blocks.

Every patient the nurse specialists see at Wellington Hospital is audited to assess the effectiveness of the techniques used, the levels of pain intensity, any complications and patient satisfaction. Work is presently being done on formalising the hospital's pain management policies, so a consistent approach to pain assessment is used, with all interventions documented. Part of the policy will ensure patients are involved in making decisions around their pain.

Although health professionals now have more options for pain relief than in former times, Barton believes choices are still quite limited, with some drugs causing unfortunate Side effects. Both the specialists and the nurses on the ward know how frustrating it can be when they are not able to get on top of someone's pain. "Nurses can experience distress along with their patients and this can make them feel very anxious and, at times, frustrated. There is nothing worse than going home at the end of the day feeling despondent that your efforts have failed. Neuropathic pain is particularly difficult to manage. In these cases, when morphine and panadol are simply ineffective, specialist advice must be sort, usually from the chronic pain service.

"On the other hand, it is really satisfying when you can relieve an individual's pain quickly. You need those successes to stay in this role."

Barton completed a master's thesis in 2001 on nurses' knowledge of and attitudes towards pain. One of the conclusions she drew from her research and random survey of 286 nurses and midwives from two New Zealand tertiary hospitals was that a review of pain management practice and its teaching in nursing and midwifery education programmes was needed. There is good evidence nursing education programmes need to review their curricula on pain and some educators may be out of date with current management principles. Discussion of the powerful role of health professionals in assessing pain and administering analgesia needs to be considered at the undergraduate and graduate level. Nurses also need to reflect on their personal biases, cultural beliefs and attitudes towards people in pain, and how this affects their practice."

Barton has considered beginning a doctorate in the pain management field but is now more drawn to becoming a nurse practitioner (NP), as it would enable her to stay in a clinical role. She has begun compiling her portfolio and intends applying for NP status later this year.

Being president of the New Zealand Pain Society (she was elected in March this year) gives her contact with members from a wide variety of disciplines throughout New Zealand. Although most members are from medicine, the focus of the society is on the holistic management of pain. Members include occupational therapists, acupuncturists, psychologists, physiotherapists, anaesthetists, rehabilitation specialists and palliative care physicians. Around 60 members (20 percent) are nurses, who have formed a pain nurses' special interest group. The group is currently working on establishing pain management nursing standards, based on the American nursing standards, as adapted by nurses in Australia. They hope these standards will be adopted by nurses across New Zealand and intend having them ready by the next meeting of the pain nurses' group next April in New Plymouth. "I some areas of the country, nurses working in pain are quite isolated. We need these standards in order to ensure pain management is safe, effective and consistent," said Barton.
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