Pain Resource Nurses Are Advocates For Patients, Educators for Staff
Pain Resource Nurses Are Advocates For Patients, Educators for Staff
A postoperative patient has pain of 10/10 2 hours after an injection of Demerol® (meperidine hydrochloride, Sanofi Pharmaceuticals). Due to pain, the patient is not moving well or breathing deeply. Obviously, something must be done, but the physician is resistant to changing the dose of medication. What is needed is a patient advocate.
A cancer patient is admitted with bone metastasis. The physician has ordered morphine sustained release 60 mg q12 hours with morphine sulfate immediate release 10 mg q3h prn. The pain is well controlled, but the patient has not been receiving his laxative on a regular basis and has become constipated. The nurses were focusing on the pain and not the side effects of the treatment, and more education is needed.
A patient with chronic back pain is frustrated and angry because of the pain, the family is angry and the situation is becoming an escalating cycle. What is needed is a nurse with pain management expertise to assist the patient and family in dealing with the chronic pain and begin to regain balance in their situation.
What is needed is a pain resource nurse.
Scope of Problem
Pain is a significant problem for many patients in our hospitals. The problem is being increasingly recognized as a priority by both national and international agencies, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Several agencies, including JCAHO, have produced guidelines or standards for pain assessment and management. The provision of adequate pain management is a 24-hour a day responsibility for health care professionals.
Nurses play a crucial role in pain assessment and management, and pain is one of the most frequently listed nursing diagnoses. Research shows that this is due in part to lack of knowledge in pain education and knowledge by nurses. The average nurse receives only 4 hours of education in pain management in nursing school.
Pain is a complex problem and requires skill in assessment and management in order to achieve positive results for our patients.
One Possible Solution
Hospitals across the country are now focusing their attention on improving pain management for all their patients. One of the creative approaches to improving pain management throughout a hospital is the development of a pain resource nurse (PRN) program. James A. Haley Veterans' Hospital, Tampa, FL, began a PRN program in 1998 with 25 PRNs.
PRNs are specially educated in pain assessment and management. The PRNs at James A. Haley Veterans' Hospital received 32 hours of pain education. This included information on anatomy and physiology of pain, pain assessment, opioids, adjuvant medications, side effect management, non-pharmacological treatment, addiction, pain management in the elderly, postsurgical pain, equianalgesic conversion, cancer pain, non-malignant pain, nerve blocks, use of radiation therapy for pain, and the role of advocate.
After the education, the PRNs returned to their clinical setting to actualize the role. The role of the PRN includes educator, consultant, resource and advocator for staff and patients in pain management. In addition to the added knowledge, the 25 PRNs bring their own talents and interests to the role.
Development of the Role
Initially, each of the PRNs chose a topic, developed a lecture and shared it with nurses throughout the hospital. These were designed to be short, 10-15 minute lectures to share the highlights of the material gained during the 32 hours of education. The nurses shared these lectures with nurses at change of shift to begin disseminating the information they had learned in their classes. The primary focus initially was on pain assessment and barriers to pain management. Other nurses focused on concerns that were of prime interest to their fellow nurses.
Two of the nurses developed an 8-hour CE course, which they presented in 1-hour blocks on a rotating basis. These classes utilized a combination of videos by Margo McCaffery enhanced by lecture and discussion. This course was developed to offer CE credits in the pain area for nurses throughout the medical center. This course was later changed to a 4-hour self-study with just the videos so every staff member would have freer access to the information. One of the PRNs continues to facilitate this program for the staff.
Several of the other PRNs have developed bulletin boards as an educational tool for staff. Some of the topics included on these are results of quality improvement projects in pain management on the unit, postoperative pain and emergency room pain management.
In addition to staff education, the PRNs serve as advocates for patients on their units related to pain management. They consistently raise the question of pain during change-of-shift report, ensuring that the nurses are consistently assessing and treating the pain of every patient. They also serve as patient advocates with the physicians by presenting the need for alteration in pain regimens.
Impact on Preparation for JCAHO
The PRNs are currently actively involved in helping ensure that the hospital is fully compliant with the new JCAHO standards on pain management. Some are involved with the chart auditing and quality improvement activities. Some are working on preparing the patient education materials and distribution system. Some are working to ensure that all areas of the hospital, clinics and nursing home are documenting pain assessment, plan and education.
The addition of a group of nurses who have special preparation and interest in pain has improved the pain management for all our patients, and we work to continuously improve the quality of pain management at James A. Haley Veterans' Hospital. The PRNs are playing an important role in our effort to provide excellence in pain management for our patients.
The pain resource nurse program is part of our effort to improve our care for patients in pain. As part of the program, we are looking at the impact these nurses are having on nurse knowledge and attitudes and patient outcomes. The official outcome data have not all been collected, but we see their presence in the care our patients are receiving through the advocacy for those in pain and their efforts at continually improving the care for all our patients.
Ferrell, B.R., Grant, M., Ritchey K.J., et al. (1993). The pain resource nurse training program: A unique approach to pain management. J Pain Symptom Manage, 8(8), 549-556.
McMillan, S.C., Tittle, M., Hagan, S., et al. (2000). Knowledge and attitudes of nurses in veterans hospitals about pain management in patients with cancer. Oncol Nurs Forum, 27(9), 1415-1423.
McMillan, S.C., Tittle, M., Hagan, S., et al. (2000). Management of pain and pain-related symptoms in hospitalized veterans with cancer. Cancer Nurs, 23(5), 327-336.
Susan Hagan is coordinator of pain programs at James A. Haley Veterans' Hospital, Tampa, FL.