- Email: [email protected]
Consensus: Pain management ineffective
Education Consensus: Pain Management Ineffective "II-tE "VERDICT IS IN"
and health profes.
sionals agree that pain management is ineffective. They propose various strategies, including research and curriculum content in nursing and medical schools, to deal with the problem. It is clear that accountability by all health professionals should improve. (Meinhart and McCaffery believe "the failure to treat pain is inhumane and constitutes professional negligence. ''1) The setting was the 55th National Institutes of Health (NIH) Consensus Conference entitled '~,n Integrated Approach to Pain Management" and it was my honor to be the first nurse to act as panel chair. Fellow parkelists included nurses* (education, oncology, research), physicians (pharmacology, anesthesiology, neurology, psychiatry, pain clinic director), a dentist, a lawyer, a clinical biostatistician, and a theologian. Prestigious individuals from a wide spectrum of professions served on the planning committee as well as part of the roster of speakers. Dr. Margaret R. Dear, senior nurse scientist, Nursing Department NIH Clinical Center, was the planning committee chairperson.
Conference Questions. (1) How should pain be assessed? (2) How should pharmacologic agents be used in an integrated approach to pain management? (3) How should nonpharmacologic interventions be used in an integrated approach to pain management? (4) What is the role of the nurse in the integrated approach to pain management? (5) What are the directions for future research in pain management?
What Is the Consensus Development Program? NIH states it initiated the program "because there was no formal process within the research community to assure that medical research discoveries were identified and evaluated to determine if they were ready to be used by doctors and other health care workers." Because NIH is the nation's principal health research agency, "it was felt that it should assume the responsibility of more fully reporting biomedical research findings to the practicing community and the public." It aims to provide "current, responsible information on the pros and cons of medical technologies. ''2 The lntegratedAppmach. There is a new commitment to using multiple modes of treatment, and employing the skills ofa mul* Nurse participants included the following: PanelistsCatherine Hogan, MN; Jean Johnson, PhD; Marilyn Obserst, EdD; Jeanne Steele, PhD; Carolyn Williams, PhD; Laurel ArcherCopp, PhD. Planners--Ann Bavier, MN; Ada Jacox, PhD; Margaret Dear, PhD. Speakers--Mary Ellen Jeans, PhD; Ann Gill Taylor, EdD;Joann Elan& PhD; Nessa Coyle, MS; George Heidrich, MA; Carol Ash, PhD; Marilee 1. Donovan, PhD. 272
tidisciplinary team of health professionals has come to be known as the integrated approach to pain management.
Tlse Spectrum of Pain. Speakers addressed pain in three categories: acute pain, chronic pain associated with malignant disease, and chronic pain not associated with malignant disease. Researchers and clinicians discussed pain assessment, pain treatment using pharmacologic and nonpharmacologic methods, and the role of the nurse in each of these aspects of pain. Implications to the Sufferer
The persons in acute pain were found to be undertreated. Messages sent by Marks and Sacher regarding the undertreatment of medical inpatients with narcotic analgesics a dozen or more years ago are just now being heard. 3 Cohen's research documenting the problem a half dozen years ago is compounded.4 Physicians undetprescribe, and nurses give only a portion of what narcotic or nonnarcotic analgesics would have been available to them. Pain relief is all too often by patient demand only, indicative of questionable pain assessment and failure to manage pain-actions that well may be the essence of professional nursing.
Implications to Nursing Practice. The nurse may be influenced by stereotypes of powerlessnes s and reinforce them by a kind of"they o r d e r - I give" self-ascribed role or mental set. Innovative, accountable professional nurses refuse to think of themselves as "a large syringe with legs." NIH consensus, in brief, was that in the acute care settings "the nurse occupies a central position" in pain management. For those individuals with chronic pain, "nurses are in a pivotal position to assess the congruence between the person's condition, need for care" and the health resources available. 2 For the nurse caring for individuals with chronic malignancy, related pain skill in repeated assessments and tailoring analgesia to individuals and their special needs are essential.~
The Nurse As Questioner The nurse should be ever questioning pain management and suggesting alternatives. Some of these questions are for sufferers: On a scale from 1 to 10, how is your pain now that you've had medication? Can you show me where it hurts? What words best describe the kind of pain you feel? Will you teach me how you cope? Will you let me help you keep a pain diary? Some of the questions are about questionable practice. Why is children's pain not assessed? 7 Why are they not medicated? Is the terminal cancer patient reaching tolerance on this drug? 6 Could we try titration or other methods and routes of analgesic administration-epidural and intrathecal routes? Subcutaneous infusion? Oral formulations with slow release and absorption? Patient-controlled analgesia? Why not try nonpharmacologic interventions during diagnostic tests, injections, and in
JOURNAL OF PROFESSIONAL NURSING
Continued on page 333 SEPTEMBER-OCTOBER 1986
333
From Our Columnists, continued
Legal and Ethical Issues, Continued from page 274.
Education, Continued from page 272. conjuction with responsible pharmacologic nursing, monitoring, and management? Some questions the nurse should address to herself or himself: What do I know about pain management, and how current is that knowledge? What biases, prejudices, and myths do I hold but refuse to face? Is addiction really a clinical problem? Of what proportion? Do I believe that patients who are dozing couldn't be in pain? That children can't express pain? That "it couldn't possibly hurt, it isn't time yet"?
Implications to Education. The panel reached consensus that there is reason for concern that education and training of many health care professionals do not place adequate emphasis on contemporary methods of pain assessment and management. Furthermore, communication among physicians, dentists, nurses, physical therapists, and other health professionals and patients regarding pain relief in clinical settings of inpatient and outpatient types is less than adequate. Dr. Bonica was blunt in stating that in some major-textbooks pain management is missing, inadequate, and inaccurate! So that future generations of students of nursing may be made accountable for unnecessary suffering of their patients, the nurse's role in pain management must be in the nursing curriculum. It must be made clear who teaches the quality of mercy.
References 1. Meinhart N, McCaffery M: Pain: A Nursing Approach to Assessment and Analysis. Norwalk, Conn.: Appleton-Century-Crofts, 1983 2. The NIH Consensus Statement "An Integrated Approach to the Management of Pain'" will appear in a forthcoming issue ofJournal of the American Medical Association. 3. Marks RM, Sachet EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 78:173-81, 1973 4. Cohen F: Postsurgical pain relief.' Patients' status and nurses" medication thoices. Pain 9:266-274, 1980 5. Copp LA: Perspectives on Paln. New York and Edinburgh, ChurchiU-l-ivingstone, 1985, pp. 3-16 6. Coyle N: Pain management: Extending the expertise of a cancer center to the community. PRN Forum (4):1-3, 1985 7. Eland J: Minimizing pain associated with prekindergasten imtamuscular injections. Issues in Comprehensive Pediatric Nursing 5:361-372, 1981.
LAURELARCHERCOPP, PHD, RN
Dean School of Nursing University of North Carolina at Cbapd Hill 107 Carrington Hall Chapd Hill, NC 27514
possible care. In addition, such board action would increase public willingness and obligation to report violations unknown to agencies and would open the door for further consumer involvement and responsibility.
COUNTERPOINT. No, consumers should not be informed in this matter. Making public the disciplinary actions taken by a state board of nursing would increase anxiety and fear in the consumers and create additional stress regarding consumer health care choices. In addition, such action would be inappropriate, as the public is inadequately prepared to interpret the situations and board actions. Question 2: Do consumers have a right to know the identity of nurses who violate the nursing practice act? POINT. Yes, the identity of nurses who violate the nursing practice act should be made public. Revealing the identity of violators would provide a mechanism for protecting the public against persons who do not provide safe nursing care. Persons engaged in nursing should be accountable for alloftheir activities, including those that may be considered unsafe. The public has the right to know the quality of care provided by individual nurses within agencies. In addition, such action may serve as a deterrent to nurses tempted to engage in practices that violate the nursing practice act, may provide a stimulus to nurses to maintain updated skills and knowledge, and may cause some nurses to seek assistance or treatment prior to the onset of an actual problem (chemical dependency or abuse).
COUNTERPOINT No, this information should not be made public. It is the responsibility of the institution or agency to monitor the actions of the nurse who has a license with restrictions, and notification of the public could have negative effects on the institution. This action would cause undue harassment and represent a breach of privacy to the individual nurse who has already been disciplined by the board of nursing. In addition, such action would inhibit individual nurses from admitting problems and seeking treatment. The public need not be informed, because if the nurse has been disciplined and if a rehabilitation plan is in effect or completed with the license reinstated, the nurse is capable of delivering an acceptable level of nursing care. Because nursing takes a holistic approach, taking such actions against an impaired nurse would violate the respect, worth, and dignity of the individual nurse. We suggest that all nurses and state boards of nursing examine mechanisms currently being used to protect consumers from hurses whose practice is unsafe. Positive efforts toward safeguarding the public's health are being made by some state boards of nursing, which are periodically publishing a list of the names of licensees who are disciplined in a newsletter that is sent to all licensees and agencies employing nurses. This newsletter in-
and health profes.
sionals agree that pain management is ineffective. They propose various strategies, including research and curriculum content in nursing and medical schools, to deal with the problem. It is clear that accountability by all health professionals should improve. (Meinhart and McCaffery believe "the failure to treat pain is inhumane and constitutes professional negligence. ''1) The setting was the 55th National Institutes of Health (NIH) Consensus Conference entitled '~,n Integrated Approach to Pain Management" and it was my honor to be the first nurse to act as panel chair. Fellow parkelists included nurses* (education, oncology, research), physicians (pharmacology, anesthesiology, neurology, psychiatry, pain clinic director), a dentist, a lawyer, a clinical biostatistician, and a theologian. Prestigious individuals from a wide spectrum of professions served on the planning committee as well as part of the roster of speakers. Dr. Margaret R. Dear, senior nurse scientist, Nursing Department NIH Clinical Center, was the planning committee chairperson.
Conference Questions. (1) How should pain be assessed? (2) How should pharmacologic agents be used in an integrated approach to pain management? (3) How should nonpharmacologic interventions be used in an integrated approach to pain management? (4) What is the role of the nurse in the integrated approach to pain management? (5) What are the directions for future research in pain management?
What Is the Consensus Development Program? NIH states it initiated the program "because there was no formal process within the research community to assure that medical research discoveries were identified and evaluated to determine if they were ready to be used by doctors and other health care workers." Because NIH is the nation's principal health research agency, "it was felt that it should assume the responsibility of more fully reporting biomedical research findings to the practicing community and the public." It aims to provide "current, responsible information on the pros and cons of medical technologies. ''2 The lntegratedAppmach. There is a new commitment to using multiple modes of treatment, and employing the skills ofa mul* Nurse participants included the following: PanelistsCatherine Hogan, MN; Jean Johnson, PhD; Marilyn Obserst, EdD; Jeanne Steele, PhD; Carolyn Williams, PhD; Laurel ArcherCopp, PhD. Planners--Ann Bavier, MN; Ada Jacox, PhD; Margaret Dear, PhD. Speakers--Mary Ellen Jeans, PhD; Ann Gill Taylor, EdD;Joann Elan& PhD; Nessa Coyle, MS; George Heidrich, MA; Carol Ash, PhD; Marilee 1. Donovan, PhD. 272
tidisciplinary team of health professionals has come to be known as the integrated approach to pain management.
Tlse Spectrum of Pain. Speakers addressed pain in three categories: acute pain, chronic pain associated with malignant disease, and chronic pain not associated with malignant disease. Researchers and clinicians discussed pain assessment, pain treatment using pharmacologic and nonpharmacologic methods, and the role of the nurse in each of these aspects of pain. Implications to the Sufferer
The persons in acute pain were found to be undertreated. Messages sent by Marks and Sacher regarding the undertreatment of medical inpatients with narcotic analgesics a dozen or more years ago are just now being heard. 3 Cohen's research documenting the problem a half dozen years ago is compounded.4 Physicians undetprescribe, and nurses give only a portion of what narcotic or nonnarcotic analgesics would have been available to them. Pain relief is all too often by patient demand only, indicative of questionable pain assessment and failure to manage pain-actions that well may be the essence of professional nursing.
Implications to Nursing Practice. The nurse may be influenced by stereotypes of powerlessnes s and reinforce them by a kind of"they o r d e r - I give" self-ascribed role or mental set. Innovative, accountable professional nurses refuse to think of themselves as "a large syringe with legs." NIH consensus, in brief, was that in the acute care settings "the nurse occupies a central position" in pain management. For those individuals with chronic pain, "nurses are in a pivotal position to assess the congruence between the person's condition, need for care" and the health resources available. 2 For the nurse caring for individuals with chronic malignancy, related pain skill in repeated assessments and tailoring analgesia to individuals and their special needs are essential.~
The Nurse As Questioner The nurse should be ever questioning pain management and suggesting alternatives. Some of these questions are for sufferers: On a scale from 1 to 10, how is your pain now that you've had medication? Can you show me where it hurts? What words best describe the kind of pain you feel? Will you teach me how you cope? Will you let me help you keep a pain diary? Some of the questions are about questionable practice. Why is children's pain not assessed? 7 Why are they not medicated? Is the terminal cancer patient reaching tolerance on this drug? 6 Could we try titration or other methods and routes of analgesic administration-epidural and intrathecal routes? Subcutaneous infusion? Oral formulations with slow release and absorption? Patient-controlled analgesia? Why not try nonpharmacologic interventions during diagnostic tests, injections, and in
JOURNAL OF PROFESSIONAL NURSING
Continued on page 333 SEPTEMBER-OCTOBER 1986
333
From Our Columnists, continued
Legal and Ethical Issues, Continued from page 274.
Education, Continued from page 272. conjuction with responsible pharmacologic nursing, monitoring, and management? Some questions the nurse should address to herself or himself: What do I know about pain management, and how current is that knowledge? What biases, prejudices, and myths do I hold but refuse to face? Is addiction really a clinical problem? Of what proportion? Do I believe that patients who are dozing couldn't be in pain? That children can't express pain? That "it couldn't possibly hurt, it isn't time yet"?
Implications to Education. The panel reached consensus that there is reason for concern that education and training of many health care professionals do not place adequate emphasis on contemporary methods of pain assessment and management. Furthermore, communication among physicians, dentists, nurses, physical therapists, and other health professionals and patients regarding pain relief in clinical settings of inpatient and outpatient types is less than adequate. Dr. Bonica was blunt in stating that in some major-textbooks pain management is missing, inadequate, and inaccurate! So that future generations of students of nursing may be made accountable for unnecessary suffering of their patients, the nurse's role in pain management must be in the nursing curriculum. It must be made clear who teaches the quality of mercy.
References 1. Meinhart N, McCaffery M: Pain: A Nursing Approach to Assessment and Analysis. Norwalk, Conn.: Appleton-Century-Crofts, 1983 2. The NIH Consensus Statement "An Integrated Approach to the Management of Pain'" will appear in a forthcoming issue ofJournal of the American Medical Association. 3. Marks RM, Sachet EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 78:173-81, 1973 4. Cohen F: Postsurgical pain relief.' Patients' status and nurses" medication thoices. Pain 9:266-274, 1980 5. Copp LA: Perspectives on Paln. New York and Edinburgh, ChurchiU-l-ivingstone, 1985, pp. 3-16 6. Coyle N: Pain management: Extending the expertise of a cancer center to the community. PRN Forum (4):1-3, 1985 7. Eland J: Minimizing pain associated with prekindergasten imtamuscular injections. Issues in Comprehensive Pediatric Nursing 5:361-372, 1981.
LAURELARCHERCOPP, PHD, RN
Dean School of Nursing University of North Carolina at Cbapd Hill 107 Carrington Hall Chapd Hill, NC 27514
possible care. In addition, such board action would increase public willingness and obligation to report violations unknown to agencies and would open the door for further consumer involvement and responsibility.
COUNTERPOINT. No, consumers should not be informed in this matter. Making public the disciplinary actions taken by a state board of nursing would increase anxiety and fear in the consumers and create additional stress regarding consumer health care choices. In addition, such action would be inappropriate, as the public is inadequately prepared to interpret the situations and board actions. Question 2: Do consumers have a right to know the identity of nurses who violate the nursing practice act? POINT. Yes, the identity of nurses who violate the nursing practice act should be made public. Revealing the identity of violators would provide a mechanism for protecting the public against persons who do not provide safe nursing care. Persons engaged in nursing should be accountable for alloftheir activities, including those that may be considered unsafe. The public has the right to know the quality of care provided by individual nurses within agencies. In addition, such action may serve as a deterrent to nurses tempted to engage in practices that violate the nursing practice act, may provide a stimulus to nurses to maintain updated skills and knowledge, and may cause some nurses to seek assistance or treatment prior to the onset of an actual problem (chemical dependency or abuse).
COUNTERPOINT No, this information should not be made public. It is the responsibility of the institution or agency to monitor the actions of the nurse who has a license with restrictions, and notification of the public could have negative effects on the institution. This action would cause undue harassment and represent a breach of privacy to the individual nurse who has already been disciplined by the board of nursing. In addition, such action would inhibit individual nurses from admitting problems and seeking treatment. The public need not be informed, because if the nurse has been disciplined and if a rehabilitation plan is in effect or completed with the license reinstated, the nurse is capable of delivering an acceptable level of nursing care. Because nursing takes a holistic approach, taking such actions against an impaired nurse would violate the respect, worth, and dignity of the individual nurse. We suggest that all nurses and state boards of nursing examine mechanisms currently being used to protect consumers from hurses whose practice is unsafe. Positive efforts toward safeguarding the public's health are being made by some state boards of nursing, which are periodically publishing a list of the names of licensees who are disciplined in a newsletter that is sent to all licensees and agencies employing nurses. This newsletter in-