Pain management initiatives improve care: the identification of pain as the fifth vital sign and the standardisation of the pain intensity scale have helped improve practice throughout MidCentral District Health Board.

OVER THE last four years, there have been some dramatic and far-reaching developments in pain management at MidCentral District Health Board (DHB). These have evolved largely as a result of moves to strengthen and support the nursing workforce.

The changes began in 1998 when Sue Wood was appointed director of nursing and Jenny Carryer professor of nursing. Collaboration with the incumbent clinical nurse leaders and establishment of numerous other key clinical nurse leadership positions was seen as critical to fulfilling identified nursing goals.

One of the initial steps in preparing senior nurses to meet the challenges required to support their peers was to develop a group of clinical nurse specialists (CNS) with master's degrees relevant to their individual scopes of practice. The appointees were required to have or be well on the way to completing a master's degree. As a newly appointed CNS in pain management, I embarked on a rapid and now nearly completed journey through a master's degree. The most important skills I have developed through this education include the ability to critique practice and outcomes from a wider perspective, the ability to advocate more confidently on behalf of those I am responsible for, and the ability to use an advanced level of knowledge to shape future health outcomes.

As a CNS, I practise across all services. I receive patient referrals from both inpatients and patients in the community with complex pain management issues. Key components of my practice include assessment, education (both undergraduate and postgraduate), advocacy, consultancy, research, collaboration, planning, documentation and evaluation. Often my main role is to translate information the patient already has into something meaningful that can help the person achieve and maintain their health independently. This process really needs to be facilitated in the community.

To influence health outcomes effectively, nurses must work collaboratively with a range of health care disciplines. In 2002, a multidisciplinary pain management team was developed. This has continued to meet monthly since its inception. The team's aim is to communicate around identified pain management issues, plan improvements, implement change and monitor outcomes. The team is sponsored by the director of nursing and involves clinical directors from the emergency department, rehabilitation, medical oncology/hospice, anaesthetists, GPs, pharmacists, physiotherapist, psychologist, occupational therapists, nurses from the acute pain service, rehabilitation, paediatrics, elder health, alcohol and drug services, surgical services, palliative care and after hours clinical co-ordinators. I am proud to chair this team of committed people who are focused on issues so fundamental to health. Positive outcomes to date include:

[] The development and facilitation of multidisciplinary education for clinical staff, focusing on identified pain management issues

[] Monthly multidisciplinary pain management education forums and development of monthly pain management updates

[] Development and facilitation of annual pain management awareness weeks

[] Standardisation of pain intensity scales

[] Development, distribution and promotion of pain intensity assessment tools across the DHB

[] Regular, informal multidisciplinary case review

[] Development of a pain management intranet site

[] Promotion of a pain component into all medical and nursing orientation programmes

[] Review of pain management procedures, policies and guidelines

[] Facilitation of patient pain management satisfaction questionnaire

[] Clinical pain assessment practice audit

[] Fifth vital sign documentation audit

[] Co-ordinated case management for complex pain management patients

[] Pilot of pain management discharge planning framework and community support

[] Development of pain management education forums for GPs and practice nurses

[] Completion of clinical research projects.

Pain management should be an integral component of health care, as pain is frequently cited as one of the most common symptoms leading people to seek health care. (1) For us at MidCentral DHB, the accuracy, consistency and quality of pain assessment is vital.

Pain was originally identified as the 5th vital sign by the American Pain Society in 1995. (2) Inclusion of the assessment of a patient's pain intensity score at the same time as recording blood pressure, pulse, temperature and respiratory rate ensures a patient's pain is monitored on a regular basis. Implementing pain as the 5th vital sign was intended as both a screening mechanism for people in pain and an initiative to standardise pain assessment practice. The standardisation of the pain intensity scale across the DHB has been one of the most significant factors in monitoring the effectiveness of initiatives aimed at improving pain management care.

Standardising pain scales

Organisations that fail to have a planned and coherent approach to pain management face major obstacles to consistent care. In 1999, it was identified that a patient could enter hospital with a letter from the GP stating that s/he had "pain ++". Emergency department staff did not document the patient's self-reported pain intensity. If that same patient then transferred for surgery, staff would be asked to rate their pain on a 0-5 scale. If they had cardiac complications, the patient might be transferred to coronary care where a 0-10 pain intensity scale was used. Once stabilised and transferred out onto the surgical ward, the 0-5 scale would be used again. If, prior to discharge, the patient spent a week in the rehabilitation ward, pain intensity was not documented. On return to the GP six weeks later, the patient may still have "pain ++".

It was clear the various health services had no way to measure whether a patient's pain had been effectively relieved or not. Standardising to a 0-10 pain intensity scale across the DHB relieves barriers to communication and allows a definitive reference point for measuring the effectiveness of analgesic interventions. The poster above was developed to raise awareness of the importance of pain management and to educate both the public and health care professionals about this initiative. At the same time, all clinical staff were issued with orange cards, which were attached to their ID badges. On one side was the "smiley face" pain intensity scale and on the other the ten core components we wished to promote as integral to pain assessment. Those components included cause (if known) and physiological response, location/s, intensity (at rest and on movement), quality of the pain, onset and duration, precipitation factors, modifying factors, psychological response, behavioural response and, of course, reassessment.

To monitor the effectiveness of this initiative, a clinical audit in 2001 identified that 86 percent of clinical staff used the 0-10 pain intensity scale. The same clinical audit repeated a year later following distribution of the posters and orange cards, combined with various other marketing initiatives, identified all clinical staff were now using the 0-10 pain intensity scale. Last year, a patient pain management satisfaction questionnaire sent to 300 patients following discharge identified that nearly 89 percent had experienced pain, yet another clinical audit identified little documented evidence of pain assessment having occurred. It was evident to both the multidisciplinary and the nursing teams that strategies to improve documentation of pain assessment were required. The observation chart was amended to include pain intensity, the nursing assessment form was amended to include pain assessment, a specific form for documenting paediatric pain management was developed and collaboration with the hospital documentation policy group identified other generic documents that would benefit from including pain assessment criteria.

The multidisciplinary team ran a workshop for senior medical and nursing staff on the rationale for the initiative, including evidence collected from the previous year on admission rates, patient questionnaires and clinical audits. A toolkit for implementing the 5th vital sign was developed to assist clinicians and managers in implementing the initiative.

To support the vital role of nursing in the effective management of pain, the acute pain nurse clinician position (working alongside the clinical nurse specialist role) has recently been augmented by two nurses. These nurses, both trainee nurse practitioners, bring with them expertise in complementary pain management. Traditionally, pain management in secondary and tertiary care has relied almost exclusively on pharmacological intervention. While an integral component of pain management, pharmacological interventions must be supplemented with a variety of healing strategies known for their analgesic properties. These include application of heat and cold, massage, relaxation, transelectrical nerve stimulation (tens) and guided imagery. Incorporating these components into care is not only effective for the patient but professionally satisfying for the nurse. Health care facilities in America today must provide evidence of incorporating these therapies into care to gain accreditation from governmental agencies. (2)

To date, we do not have recognised nor agreed national standards of pain management in New Zealand, although advocacy groups such as the New Zealand Pain Society support such developments. Accreditation of health care facilities, in the absence of such standards, therefore involves little measurable data collection specific to pain management.

As resources to support health initiatives become sparser, some have suggested that linking the traditionally independent chronic, acute and palliative pain management services could provide a new model of care and improved use of resources. Within MidCentral, however, the challenge now facing the multidisciplinary team is the development of pain management services that effectively meet identified public need. The future of effective care is based in the community where the majority of those suffering pain require assistance. What is required is the development of community chronic pain care co-ordinators, integration of pain clinics into primary health organisations, closer links between non-governmental organisations and improved pain management education for all health care providers. If pain could be managed successfully in the community, resulting in fewer hospital admissions, the savings to our health care budget could be quite significant.

Nurses are the keys to unlocking the pain experience for people within our communities. I would encourage all nurses to look at pain management practice individually and within their teams and organisations, and ask the question: Is this the level of care you would wont for yourselves or your loved ones? Nurses finding answers less than satisfactory are encouraged to speak with their local nurse leaders. They are also welcome to contact me as a representative of the Nursing Issues Group of the New Zealand Pain Society at [e-mail] for assistance.

REFERENCES

(1)) Clark, E., French, B., Bilodeau, M., Capasso, V., Edwards, A. and Empoloiti, J. (1996) Pain management knowledge, attitudes and clinical practice: The impact of nurses' characteristics and education. Journal of Pain and Symptom Management; 11: 1, 18-31.

(2)) American Pain Society, Quality of Care Committee. (1995) Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA; 274: 23, 1874-1880.

--Judy Leader, RGON, BN, is the clinical nurse specialist in pain management at MidCentral District Health Board.