1 Pain Management in Advanced Practice Nursing What this means to me According to the American Academy of Pain Medicine (AAPM) pain affects more Americans than diabetes, heart disease and cancer combined (American Academy of Pain Medicine website, 2011). It is therefore critical to reflect on the topic of pain management and how I will prepare myself for serving clients with pain issues. Pain, both chronic and acute, by itself or in association with a wide range of injuries or diseases, exerts a tremendous cost on all stakeholders involved. For patients it directly affects the perception of their health status as well as their quality of life. It places an enormous emotional and financial burden on patients as well as their families. For our country and the individual states, it results in tremendous health care costs; business corporations suffer in terms of lost worker productivity and the high cost of rehabilitation. In health care itself, unrelieved pain can result in longer hospital stays, increased rates of rehospitalization, increased outpatient visits, and decreased ability to function fully, leading to lost income and loss of insurance coverage. It has been reported that: (a) most pain sufferers (63%) see their primary care provider for help, (b) up to 40% of patients with pain, have consulted a health care specialist, (d) almost as many (38%) have consulted more than one medical practitioner or specialist and, (c) up to 25% have consulted with a health care provider specializing in pain management (AAPM, 2011). Pain occurs across all ages, ethnicities, genders, and income. It may present as the chief complaint or concern during a patient visit, but also as an associated finding when patients seek care for other reasons. As a future primary care provider, I regard myself as serving on the frontlines when it comes to pain management. For most patients the primary care setting or emergency room will be the first point of service visited for a pain concern. For that reason it is of vital importance that primary care health professionals expand their knowledge regarding pain and hone their skills in pain management while at the same time, work to educate and empower their patients in order to achieve optimal pain care.
2 Related Course Outcomes My interpretation of how the course outcomes (Washburn University School of Nursing, 2011a) relate to pain management in advanced practice nursing, are summarized in Appendix A, table 1. Related Program Outcomes All of the desired program outcomes (Washburn University School of Nursing, 2011b) for nurse practitioners in this advance practice nursing program can be related to pain management. These relations are reflected in Appendix B, table 1. How this topic relates to my current practicum My current practicum situation in a rural primary care clinic offers a very realistic picture of the nature of pain management in primary care. For many of the patients this clinic and their trusted primary care providers are the obvious first choice of where to go in case of significant pain. Whether pain is the actual main complaint, or associated with another complaint, patients present here regularly with requests to receive care. The provider staff consisting of two family physicians, two physician assistants and one nurse practitioner, has the opportunity to assist patients with acute and chronic pain. They have the opportunity to complete initial pain assessments, to provide prompt, appropriate pain control and when needed, refer the patients to appropriate specialty care. They also assess and treat patients with chronic pain over extended periods of time and continue to provide primary health care services for patients who are being followed by pain specialists. During my clinical hours I have had the opportunity to observe a wide variety of pain management scenarios. The majority of patients presented with pain as an associated finding to another disease, injury or condition. In these cases, treatment of the primary cause of the pain as well as symptomatic treatment occurred. For example, an adolescent with severe otitis externa was treated for the infection as well as prescribed some otic analgesic to treat the pain; patients with diabetic neuropathy were managed for their diabetes as well as the pain. Patients with chronic inflammatory diseases which were fairly well controlled were managed with a mindset of preventing flare-ups thus preventing the pain associated with disease
3 exacerbation. A few patients were seen purely for the purpose of pain control; most of them as chronic pain patients where a fairly extensive treatment history indicating treatment failures and successes had been recorded. Some patients did not yet achieve relative treatment success but were still in the process of exploring and trying different treatment options. Patients where primary care treatment options were exhausted were promptly referred for evaluation and treatment by a pain specialist. Some patients who already receive their pain management care from pain specialty practices were seen in the clinic for other reasons but in accordance with their pain contracts, no analgesic treatments were prescribed by the primary care team. In a few isolated cases, patients who had lost treatment privileges with pain specialty providers were accepted back for pain treatment in the primary care clinic. These patients were treated in accordance with the pain contract they established with the specific primary care provider and in one case a patient was denied further treatment at the facility due to non-adherence to the stipulations of the pain contract. The providers at the clinic ensured the relevancy of their treatment recommendations through frequent collaboration with each other and other specialists, continuing education, review of evidence based practice recommendations and resources clarifying legal and ethical principles. How my future advanced practice will be influenced by this topic In my practice I hope to demonstrate the significant role advanced nurse practitioners can play in the improvement of pain management for patients from all walks of life. As part of an interdisciplinary team I hope to provide a medical home for patients with acute and chronic pain where they can receive holistic, individualized, culturally appropriate and socially acceptable pain management care. I regard the following principles and the application of each as crucial in the delivery of successful pain care: a. The patient should be the central focus. Assessment, planning, education, implementing and evaluating the plan of care should be individualized to the patient s specific needs, abilities and circumstances and should be culturally appropriate. b. Pain should be accurately and adequately assessed and quantified. The perception of pain is highly individualized and a sincere interest in how this patient perceives his/her pain is necessary to accurately assess the pain.
4 c. Pain should be treated adequately. It is unethical to deny a patient adequate treatment of pain or the attempt to adequately treat pain. A treatment plan which takes all the consequences of treatment (or withholding treatment) into consideration should be negotiated with the patient as an active participant. d. The patient s ability to function normally should be maximized. Considering the tremendous cost associated with unrelieved pain, treatment should attempt to preserve, restore and maximize optimal level of functioning. e. Pain management should account for gender and culture differences. The influence of perceptual biases should be recognized and avoided in the design of pain management. f. Warning signs should be identified early. Any findings which may suggest potentially serious underlying cause of the patient s pain or factors which may adversely affect the desired outcome, should be recognized early and in such cases, prompt referral to clinical specialists should be made. g. Understand and differentiate tolerance, dependence and addiction. A better understanding of the differences between tolerance, dependence and addiction should be cultivated among health care professionals, patients, family members and policy makers. Patient education and advocacy is crucial to improved understanding and better acceptance of different treatment options. h. Minimize side effects. The benefits of treatment should be weighed against the adverse effects and a viable compromise should be negotiated. If pharmacological treatment cannot be fully utilized due to the adverse effects, alternative and complementary treatments should be considered. i. Increase familiarity and utilization of complementary therapies. These treatments offer a major contribution in expanding the spectrum of possible treatments and may render more holistic care. j. Adhere to high ethical and legal standards of practice. Strict adherence and frequent knowledge updates on the most current ethical and legal standards safeguards against allegations of inappropriate practice. Accurate documentation is of the essence.
5 k. Require patients to adhere to a clear and carefully negotiated contract for pain treatment. This is especially important in cases where fraudulent use of analgesics and prescription medications is a concern. In conclusion, I know that as I proceed towards advanced nursing practice, I will frequently and diligently reflect on this topic. Consistent knowledge updates in the most current treatment recommendations will become a regular activity (as it is already) as will regular review of ethical and legal standards regarding pain management. References American Academy of Pain Medicine website. (2011). http://www.painmed.org/ Buttaro, T.M. Trybulski, J., Bailey, P.P. and Sandberg-Cook, J. (2008). Primary care: A collaborative practice (3 rd ed.). St. Louis, MO: Mosby Washburn University School of Nursing (WUSON). (2011, Fall). Course syllabus: NU602 Adult Health Practicum I. Retrieved September 12, 2011 from Washburn University Angel website: https://angel.washburn.edu/section/home/ Washburn University School of Nursing (WUSON). (2011). MSN Student Handbook 2011-2012. Retrieved September 12, 2011 from Washburn University Angel website: https://angel.washburn.edu/section/content/default.asp?wcu=crscnt
6 Appendix A Table 1 Relation of course outcomes to pain management in advanced practice nursing Course Outcomes 1. Integrate knowledge from previous courses to care for diverse adults in primary care settings. 2. Apply critical thinking skills in the development of differential diagnoses related to select health problems encountered by adult populations. 3. Exhibit advanced communication skills in interdisciplinary settings. 4. Develop culturally appropriate, individualized patient education programs. 5. Design therapeutic interventions to maximize health and wellness in diverse adult populations. 6. Evaluate diagnostic test results in collaboration with interdisciplinary teams. How I relate this to Pain Management 1. Integrating knowledge facilitates better understanding of the pathophysiology of pain, how to appropriately assess pain and which treatments may be appropriate. Knowledge of nursing theories shape approaches toward pain management and knowledge of ethical principles guides professional conduct. 2. Application of critical thinking skills assist in considering the many different causes of pain and which treatment modalities would be most useful under certain circumstances. It is also of the utmost importance when evaluating the efficacy of treatment and managing cases of treatment failure. 3. Effective communication is vital in the accurate assessment of pain and in constructive collaboration with other professionals. Advanced written communication skills is especially important when documenting pain assessments, treatments, evaluation of treatments, setting up pain contracts with patients and in cases where non-traditional approaches are being implemented. 4. Patients experiences of pain are highly individual and may be intricately affected by their cultural backgrounds and practices. Both the pain management strategy/approach/plan and educating the patient regarding pain and pain management must be both culturally appropriate and individualized in order to be viable. 5. Therapeutic interventions to reduce pain contribute to the quality of life of patients and directly impact their health and wellness. The challenge with pain management is not to stop after the first treatment - especially when addressing refractory pain but to continue designing and redesigning therapeutic interventions until optimal wellness (pain control) is achieved. 6. It is vital to evaluate diagnostic tests (to identify possible etiologies) or a patient s response to treatment in collaboration with other team members. Several different treatments/attempts and the involvement of several different professions may be needed for successful pain management.
7 7. Apply ethical and legal principles to care of adults in primary care settings 8. Utilize research in providing culturally competent care. 7. Adhering to ethical codes of conduct and legal principles is of absolute importance in the management of pain. Failure to do so may have serious consequences such as disciplinary action, loss of licensure, legal liability and loss of patient confidence/trust. Adherence to these principles/standards/codes of conduct should also be reflected in all documentation regarding pain management. 8. Current evidence base practice standards, standards of care, protocols and recommendations should be utilized in the design of pain management for each patient. Capitalize on the knowledge gained through research to offer the best possible solutions to patients pain concerns.
8 Table 1 Appendix B Relation between MSN program outcomes and pain management in advanced practice nursing Program outcomes 1. Provide organizational leadership demonstrating knowledge of health policy and health care systems 2. Integrate knowledge and theory into evidencebased practice and research. 3. Collaborate with interdisciplinary groups within the role and scope of advanced practice nursing. 4. Demonstrate sound critical thinking and clinical decision-making. 5. Provide holistic care that is culturally proficient with diverse groups and communities. 6. Incorporate ethical and legal principles in health care policies. 7. Integrate effective communication in advanced nursing roles. Relation to Pain Management 1. Knowing and understanding the policies, laws, recommendations and codes of conduct applicable to pain management allows for organizational leadership in this field and prevents unlawful use of analgesics. 2. Successful integration of knowledge and theory benefits pain management practices as it introduces new evidence on how to best identify, assess and treat pain, as well as how to best evaluate the results of pain management. 3. Effective interdisciplinary collaboration increases the quality of pain management. The complexity of pain, it s etiology and treatment often negate referral to pain management specialists and close collaboration with these specialty providers when these patients are seen in the primary care setting. 4. Critical thinking and sound judgment is of utmost importance especially in the realm of complex pain management. Achieving this outcome enables advanced practice nurses to critically analyze all findings and relevant information and to design a plan of treatment; or to recognize the need for consultation with and/or referral to other professionals. 5. Effective pain management requires skillfully tailoring different evidence based treatment options/recommendations to the individual, culturally acceptable, needs of the patient. All factors which may influence the practicality of a pain management plan should be considered in order for it to address all the needs of the patient. 6. Involvement in pain management should never be attempted without thorough knowledge and application of ethical and legal principles. Pain management practice should always occur within the ethical and legal boundaries of our profession as well as that of the community and state in which practice occurs. 7. Effective communication is key to accurately assessing pain, collaborating with other health care providers, planning a pain management regime and communicating it to all stakeholders involved. Additionally, effective written communication skills are critical in documenting care and justifying need for special approaches to pain management.
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