Pain management nurses: Are they helping to enhance pain management within the acute hospital setting?

This week’s EBN Twitter chat will deal with the role of a link or support nurse. While this blog post focuses on the role and evidence related to pain, nurse practitioners, champions or resource nurses are common to many specialties and I hope you’ll join us to discuss pain, infection control, breast care, stoma care, palliative care, tissue viability and plenty of other areas during which a highly specialized nurse seeks to enhance patient care through a chosen link to a ward or other clinical area.

I can be chatting on June 6 between 8:00 p.m. and 9:00 p.m. (GMT). To join the chat, add #ebnjc to your tweets.

Nurses and undoubtedly other healthcare professionals feel powerless after they are unable to assist someone in pain (Slatyer et al. 2015). There are countless barriers to providing effective health care, with poor knowledge, poor communication, and lack of shared team goals being key themes (Table 1).

Table 1: Some aspects contributing to poor pain management

Specialist nurses are individuals who have higher than normal education in a given field. These nurses have the responsibility to coach staff and patients and undertake more complex assessment and management activities. The system is predicated on a cascade effect, during which the knowledge and skills of the next level specialist nurse are transferred to people working more closely with the patient. This often involves identifying a link nurse, key nurse, resource nurse or champion in a clinical area who has received additional training and has a detailed relationship with the specialist. The nurse link has the responsibility to boost the profile of a specific issue, influence, educate and motivate staff, thereby improving practice.

This system has been in use for a few years and has demonstrated advantages in specialties reminiscent of infection control, diabetes, dysphagia, and palliative care. In many cases the role of link nurse/resource nurse has helped to enhance local practice, but there may be some doubt concerning the extent to which this is occurring and the role of influencer or change agent is complex and demanding.

A preferred pain management model is the pain management nurse (PRN) model. Ferrell et al. (1993) developed a 40-hour didactic program to organize nurses for this role. Those who accomplished the course were assessed after 3 months and reported that they felt more confident, were more aware of patients’ pain, and were higher capable of manage pain. An integrated review by Crawford et al (2016) suggests the next advantages of a pain management nursing program:

• Improving nurses’ comfort when administering opioids
• Improved documentation
• Increased assessment and reassessment of pain
• Increased administration of painkillers/pain relief interventions/appropriate use of painkillers
• Improving the knowledge of patients and nurses
  • Better patient perception of pain control
• Increased local pain education and use of protocols
• Better cooperation between doctors and nurses
• Reduction of postoperative complications
• Greater job satisfaction/lower worker turnover
• Greater ability to support patients

While this feels like a transparent endorsement, the extent of evidence supporting each of those advantages is slim and sometimes only anecdotal. Ladak et al. (2013) added a leadership component to their pain nursing program. 18 months after completing this system, they conducted a qualitative assessment using the PRN and located that they were doing a variety of direct work with patients, for instance explaining medications to them and supporting and solving problems for nursing staff. The PRNs on this study didn’t feel valued on account of the extra training they’d received. Other nurses wished they might prescribe medications but were frustrated after they couldn’t achieve this, and there was tension between medical and nursing goals for the patient and pain.

This calls into query whether the PRN can effectively disseminate good practice or whether it’s taking over elements of the specialist role that might previously require referral. Although general nurses are usually not necessarily losing their qualifications, there may be little evidence that their skills are being developed under the present practice model of specialist and linkage nurses (Jack et al 2002, Mytton and Adams 2003).

Questions for our chat…

1. Will the introduction of joint/resource nurses increase the knowledge, confidence and competence of general nurses?
2. Is a pain management nurse program an excellent model?
3. Why doesn’t education cascade to the broader team?
4. What are the continued challenges which will prevent a PRN from achieving higher pain management in a selected area?

Bibliography

Crawford, C. L., Boller, J., Jadalla, A. and Cuenca, E. (2016) An Integrative Review of Pain Resource Nurse Programs. Critical Care Nursing Quarterly, 39(1), 64-82.

Ferrell, B. R., Grant, M., Ritchey, K. J., Ropchan, R. and Rivera, L. M. (1993) Pain nurse training program: a singular approach to pain management. Pain and symptom management journal, 8(8), 549-56.

Jack, B., Oldham, J. and Williams, A. (2002) Are palliative care clinical nurse specialists in hospitals downskilling general staff? International Journal of Palliative Nursing, 8(7), 336-40.

Ladak, S.S., McPhee, C., Muscat, M., Robinson, S., Kastanias, P., Snaith, K., Elkhouri, M. and Shobbrook, C. (2013) The journey of the Pain Resource Nurse in Improvement pain management practices: understanding role performance. pain management nursing, 14(2), 68-73.

Mytton, EJ and Adams, A. (2003) Do palliative care clinical nurses improve or empower general practice nurses? International Journal of Palliative Nursing, 9(2), 64-72.

Slatyer, S., Williams, A. M. and Michael, R. (2015) Exploring options for comforting patients affected by severe pain: a grounded theory study from a nurse’s perspective. International Journal of Nursing Studies, 52(1), 229-39.

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