Home care patients suffer needlessly
JCAHO turns spotlight on pain assessment
How often have your nurses visited a regular client only to be surprised when the patient divulges that he or she has had chronic pain? The patient never bothered to mention this before, perhaps assuming the nurse could do nothing about it.
Most home care agencies would be surprised to find they have a significant problem with unmanaged pain within their patient population, says Carol Curtiss, RN, MSN, OCN, clinical nurse specialist consultant in Greenfield, MA, and past president of the Oncology Nursing Society in Pittsburgh.
Patients also can fail to mention their pain to physicians, which means the home care nurse might be the first to learn of it. "Patients assume clinicians know they have pain, and if we don’t ask regularly at every visit, then it’s very easy for their pain to be under-reported," Curtiss says. "It seems pretty incredible to me that we have known how to manage acute pain for over 20 years, and yet the management of acute cancer pain and chronic non-malignant pain is poor. People suffer needlessly.
"I believe that linking pain to the quality improvement process will be key to our ability to provide better care in the management of pain," Curtiss continues.
Recently, the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, began to focus on pain management assessment in home care, making pain management an even higher priority for agencies, she says.
Quality managers should focus on proper pain assessment, communication, and their staff’s own attitudes about pain, says Colleen J. Dunwoody, MS, RN, clinical coordinator for management at the University of Pittsburgh Medical Center and president of the board of directors of the Chronic Pain Association in Rockland, CA.
"People need to recognize their own values and their own belief system about pain," Dunwoody says. "You can imagine that if one of the care providers is someone who values stoicism, it may be difficult for them to care for a patient whose value system is markedly different, and includes open expression of pain."
Curtiss and Dunwoody give these guidelines for quality managers setting up a pain management QI project:
1. Create a pain management standard.
Home care agencies need to identify whether they have a standard for pain management, and it should be in writing, Curtiss says.
If there is no standard, then agencies could refer to national standards for cancer pain as established by the American Pain Society of Glenview, IL. Also, quality managers could obtain a resource manual, called Building an Institutional Commitment to Pain Management, from the Wisconsin Cancer Pain Initiative in Madison. (The manual costs $30 plus $5 shipping and handling. See source list for address and phone number, p. 35.)
"It’s difficult to maintain competency if you’re not sure what you’re supposed to be competent about," Curtiss says.
An agency’s standard could be simple and straightforward, such as this suggestion by Curtiss: The agency requires the systematic and ongoing assessment of both pain and pain relief, including using medicines systematically and adjusting them to the individual’s response. The agency combines non-drug interventions with medications as part of the plan. Staff communicates the plan to other professionals, as well as to the person who has pain.
2. Establish an assessment tool.
Both Curtiss and Douglas suggest quality managers ask these questions:
• Is there a systematic assessment system in place?
• What is the minimum frequency of pain assessment required for all clients?
• How often are nurses required to ask patients about pain?
• How often has the agency’s care helped to relieve a patient’s pain?
A variety of pain management scales can be used. Most of these have a rating system with a range from zero, meaning no pain, to 10, meaning the worst possible pain. These types of scales are subjective, but they give the clinician a good idea of whether a patient’s pain is decreasing or increasing.
"Another good area to evaluate for quality improvement is the circumstances when pain is relieved," Curtiss says. For instance, what happens when a patient’s pain stays above a level five for a longer than acceptable period, and how long a period is acceptable?
Curtiss recommends agencies require nurses to assess patient’s pain on every visit, making it a part of the normal routine the same way they would ask the patient about eating, elimination, and mobility at each visit.
3. Show staff how to talk with doctors about pain.
Social biases often get in the way of providing patients with effective pain management, Curtiss says. One of these is the misconception, which some physicians and nurses have, that patients might become addicted to pain medication.
"It’s an issue, because physicians are afraid to prescribe. In addition, nurses are afraid to give medications, and patients are afraid to take them because of this fear of addiction," Curtiss says. "Yet the incident of addiction in individuals appropriately prescribed medicines for pain is less than .1%."
Home care nurses can help their patients overcome pain and help physicians overcome this misconception by improving their communication skills.
Dunwoody suggests quality managers help nurses improve their ability to communicate with physicians about pain management by following these guidelines:
• Identify the problem, such as what kind of pain the person has, and be factual and specific. Avoid generalizations.
• When documenting or communicating a patient’s pain, organize the information in a logical way. Have nurses always follow the same assessment order.
• Teach nurses they should never apologize when calling a physician to discuss a patient’s pain problem.
• When nurses make suggestions to physicians for a change in a patient’s pain management, they should use written sources, published reports, and other data to support their recommendation.
The last guideline is very important, Dunwoody says. "When you’re meeting with resistance, it’s helpful to say, I just read an article about that. May I send it to you?’"
Quality managers and nurses first should do their homework and come up with specific examples and data. Then they should communicate their suggestions in terms of this information.
"It’s better to say, The patient needs more pain medication,’ than to say, What you’ve prescribed is not working,’" Dunwoody adds.
Also, physicians like to see graphs and numbers; that’s why it’s important to use a pain rating system. "A nurse can say, We talked about this pain problem three days ago, and you recommended such and such, and it has dropped the patient’s pain from a nine to a seven, but the patient still isn’t satisfied. What more can we do?" Dunwoody wonders.
4. Teach staff to communicate with patients about pain.
Pain is not a visible symptom, which is why communication is especially important when nurses deal with patients who have pain. "Pain is easily overlooked unless it’s prominent in the person’s life," Curtiss says.
Nurses and other home care field staff need to know how to communicate with patients about their pain. Having the patient rate the level of pain is the first step. But, Dunwoody says, there are also other guidelines they may follow, such as these suggestions:
• Collect specific information about a patient’s pain, including the location, the severity, and quality of pain. "By that, we mean word descriptors like burning,’ throbbing,’ and aching,’" Dunwoody says. "The words the patient uses help the nurse and physician identify the type of pain a patient feels."
• Ask the patient when the pain started and how long it lasts. If the pain varies, what seems to make it feel better or worse. For example, a patient with degenerative arthritis is more likely to have pain at the end of the day after activity, Dunwoody says. "Whereas an individual with rheumatoid arthritis is more likely to have pain at the beginning of the day when they are stiff, and it’s hard to get moving."
• Next, listen to how the patient expresses his or her pain, and watch for visual clues to pain. Patients might exhibit a change in gait patterns, difficulty in coughing, and problems with activities of daily living. Home care nurses, for instance, might observe whether a post operative patient is having trouble with coughing and deep breathing because that could indicate complications from the surgery, Dunwoody says.
• Find out what causes a patient’s pain to increase and what helps to relieve it. Nurses can ask the patient what they have done to make their pain feel better. "A patient might say they used yoga, relaxation techniques, exercise, or a distraction," Dunwoody says. "We want to know the full gamut of what an individual might use to relieve pain and find out if there is anything they can identify that makes it worse."
• Finally, nurses need to assess the effects of the patient’s pain. For example, the pain might affect patient’s emotional or psychological state, perhaps causing depression. In addition, acute pain may cause a lack of appetite or nausea and also may interfere with sleep.
Quality managers could set up some team meetings where pain is discussed by all of the health professionals involved. "It takes a team effort, and nobody can do it alone," Dunwoody says.
Sources
• American Pain Society, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (847) 375-4715. E-mail: info@ ampainsoc.org. Web site: www.ampainsoc.org.
• Carol Curtiss, RN, MSN, OCN, Clinical Nurse Specialist Consultant, 73 James St., Greenfield, MA 01301. Telephone: (413) 774-5238. E-mail: [email protected].
• Colleen J. Dunwoody, MS, RN, Clinical Coordinator for Management, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213. Telephone: (412) 647-7117.
• Wisconsin Cancer Pain Initiative, 1300 University Ave., Room 4720, Madison, WI 53706. Telephone: (608) 262-0978. Web site: www.wisc.edu\wcpi.
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