Nursing Notes Live delves into the world of the pain management nurse. This month’s featured “Get to Know Nurse” Esther Bernhofer is a Pain Research Nurse at the Nursing Institute of Medicine and Digestive Inpatient Cleveland Clinic. I asked her how she decided to become a nurse and what drew her to focus on the management of patient pain on how reducing pain affects patient health and lifestyle.
MP3 Audio Podcast
Pain Management Nurse Interview
Jamie: Esther, tell us a little bit about how you became a nurse. What led you to the nursing profession to begin with?
Esther: Well, I pretty much always wanted to be a nurse. I remember as a little girl reading Clara Barton books and Florence Nightingale things. That was always something that I always wanted to do. It was an easy decision after high school to go right into a nursing program at the University of Akron and wanted to get my BS done right away and that was in the late seventies when BSN programs weren’t as popular, of course, as a starting point for Nursing as it is now. But I knew I wanted to do in a very professional way and move my career along right away so that’s what I did. There was never really much doubt otherwise.
Jamie: It’s interesting to talk to people about how they get into nursing and so many just – have always been drawn in that direction. It’s interesting to hear that you have a similar experience. What about pain management nursing? Can you tell us a little bit about what types of nursing fields you participated in before you got into patient management and how that led you to focus on pain management?
Esther: Sure. Well, when I first graduated, I took a job at the Visiting Nurse Association here in the Cleveland area and really enjoyed that tremendously. I remember going to patients’ homes and thinking, “I can’t believe I get paid for this. I can’t believe I have this marvelous job where I get to take care of patients in such a very real way, in a very real setting, really get to know them and do and fulfill the nursing process as I was taught in school.” Later on, I got to the hospital and worked at a medical-surgical unit. Of course, things were a lot more hectic there. I didn’t get to know patients the way I remember enjoying getting to know them as a visiting nurse. It was a different setting but still very good. I was always interested in comfort of patients. That was sort of an overarching thing no matter where I was working. After I had my first child – well, my children, I had twins first – I began to become more involved with childbirth education. The whole idea of natural childbirth and pain management for laboring women in the most effective way with the least amount of side-effects for women who were delivering. That kind of started me thinking the whole idea of how do we take care of people with pain and anxiety, how do we deal with that medication-wise, drug-wise, side-effects; in that case, of course, with mother and baby. One thing led to another and I became a Lamaze instructor. I helped a lot of women with that. It was very, very focused on taking care of pain and comfort and safety, of course, in the optimal outcome and delivery of the children. That was kind of where I started with the idea of pain management. I took years off then, a couple of decades almost, to raise my own children, my own family. Then went back to work at the Cleveland Clinic taking a job as a parent-shift nurse to accommodate. The shift was great and it worked around my family time. I got back at the Cleveland Clinic, back into nursing after all those years and really started looking at research and patients and their comfort levels and what I could do for them and what nursing really meant. So that’s where I got started again.
Jamie: That’s very interesting that you stepped away from nursing but still came back and were able to jump back in. It’s always great to hear nurses that have done that. It’s an interesting aspect of the nursing career that we have the ability to step away for some time and come back.
Esther: Right. And when I say “step away” I don’t mean completely. I worked for a one-day-a-month that kind of thing for a homecare agency, maintain my life and continued with continuing education units, always keeping a finger in it so to speak. Not completely – you know what I mean, not completely getting out.
Jamie: I think once you’re a nurse, you never are not a nurse. I know so many nurses that say, “Well, I’m retired,” but they’re volunteering in different aspects of healthcare in the community and in their churches in different places. I don’t think nurses just stop being nurses ever.
Esther: I think that’s very true. Even when I wasn’t working fulltime, people would always say, “Oh, you’re a nurse? What’s [unintelligible] for this? How should I treat that? My mom has these symptoms?” those kinds of things. You’re right. You never really are not a nurse, again.
Jamie: We’re such important navigators of the healthcare system that people really value our opinions and our advice on how to best navigate things that are going on in their lives with their health. It’s just amazing that pain management has taken such a long time to become part of that process. We’ve always managed pain, especially as nurses, when we talk about patient comfort and care but it seems to me that there’s still just not enough focus on pain management. That some caregivers are thinking that pain management is still secondary to so many other things in the care process.
Esther: I think you’re exactly right and that’s exactly what I saw when I went back. Even though what nursing does is comfort and care and, of course, very skillful management of many conditions, people come to the hospital, people come to healthcare professionals many, many times; oftentimes, because of pain. Pain is one of the main reasons people come to the emergency room. Pain is one of the main things that folks complain about when they’re in the hospital. I don’t mean “complain” as in “bothering someone,” I mean, “expressing a need for.” And it is interesting that it has taken so long for us to recognize that this is a huge issue. Starting with a joint commission back in 2001, when pain became the fifth vital sign, even though it isn’t quite like all the other vital signs, we can give it a number on that zero-to-ten scale but it still requires a whole lot more assessment than taking a temperature or a blood pressure. That number really doesn’t have much meaning unless it’s for their assessment behind it. But, at least, that whole idea of pain as a fifth vital sign brought the awareness to the forefront, to nursing, and to other healthcare providers that we need to pay attention to this. Pain management is an extremely important indicator of health and well-being and functionality. Whether it’s outside the hospital with chronic pain or inside the hospital with chronic and acute pain, it’s one of the things that nurses do. The other thing is that, I think pain management is not something [that] can be owned by a discipline. No discipline owns any concept. Nursing is a discipline that I think that really manages pain the best because we see the picture. We see the entire picture of the patient. The holistic paradigm of nursing looks at the entire person and a little bit more so than some of the other ones – maybe it’s a time constraint, maybe it’s part of a paradigm of a different profession or a different discipline. Nursing really does the best job with pain. When we do it well, we do it very well.
Jamie: I think consequently if we don’t manage the patient’s pain well, we really drop the ball.
Esther: Exactly. We really drop the ball. The patients, especially in the hospital setting where I am now, the patients are looking to nurses to be their gatekeeper to better pain management. They can talk with doctors. Sometimes when doctors are rounding, it’s very quick. They have so many things on their mind. The doctors are telling about new tests coming up, things that are happening today. Unless their pain is excruciating, sometimes they just, “I don’t want to bother the doctor. I don’t want to” – but when the nurse comes back in and really talks to the patient, they’ll say, “Oh, yes. I feel so bad.” The nurse then becomes the advocate to the physician to really explain the big picture. You’re right. When the nurse drops the ball on that, then the patient has a much harder time getting that message across and getting the care that they need.
Jamie: Physiologically, the patient diverting resources to deal with pain, their anxiety levels are up and everything else that really inhibits their healing process.
Esther: Absolutely, we know that under-treated pain can influence the endocrine system, can influence the respiratory system, the cardiac system. Really, and especially post-surgically, folks don’t want to get up and move. They’re not breathing as well. Their GI function is not coming back as well because they don’t feel like moving. It can precipitate depression. It can really have a big impact on quality of life; whether it’s a quality of life for the couple of days that they’re in the hospital or continuing quality of life later on. Acute pain that’s not treated also we know can precipitate chronic pain syndromes later on. When we’re not paying attention as nurses or physicians or the caregivers to a patient’s need for a better acute pain control, we may be setting them up for a lifetime of difficulty with managing neuropathic pain. It’s a big responsibility.
Jamie: Yes. It’s interesting. I came in to the healthcare profession as a paramedic initially and I was looking at some research that pointed to the fact that you manage pain more effectively early on in an injury process. They are better able to manage their own pain later on. That, for some reason, it hyperactivates their nerves, their pain response, if we don’t get on top of that pain quickly.
Esther: That’s very, very true. Exactly right. Many folks who are not educated to that point may say, “Well, you know, I’ve always heard ‘Start low and go slow.’” Start with the Tylenol and if that doesn’t work, they will bring in a Percocet. They will bring this. They’ll bring that. When none of that is working, then we’ll go to the morphine, the other opiates. However, that does work if we’re trying to set up a treatment for chronic pain issue, something we know it’s going to be long-term, how we’re going to manage this with the least amount of side-effects. But when we have an acute pain issue – like you said, if a paramedic, you see a trauma an injury, something going on, really important to use that – it’s called the “WHO letter” from the World Health Organization – that “Start low and go slow.” We actually need to reverse that in an acute situation. That hasn’t always been well understood. The [unintelligible] for that has been set with post-operative pain where we will start a patient right after surgery on pretty high opioids or whatever can be tolerated by the patient and then expect that as that acute surgery heals, that pain will go down and will go down and they will need less pain medication. So that precedent has been set but sometimes if someone comes to the hospital with medical pain or pancreatitis or cellulitis something like that and they’re complaining of 10/10 pain and it’s really excruciating, sometimes we have that mentality of “let’s start low and go slow” and we do the patient quite a disservice.
Jamie: Pain is such a personal thing. When I talk to patients about their pain levels, I really have to distance myself from my own personal experience because one person’s experience of headache pain or some other type of specific body pain may not be the same as another. So if someone can’t tolerate the same amount of pain you can then they’re going to experience an 8, 9, or 10 out of 10. Whereas, you might have said, “Well, I’ve had that same problem and it was only a 4/10.” They’re blowing it all out of proportion. But pain is a very personal thing and it can relate back to previous pain experiences.
Esther: That’s exactly right. That’s interesting you say that, you have to distance your own personal notions and biases when you are trying to assess the pain of a patient. Very, very important part and I do start most of my slides on assessment with that when I’m talking to nurses in saying, “Your own biases are the things that maybe holding you back some really good pain assessment.” The same exact thing for someone to say, “Well, I have surgery on my foot. It wasn’t that bad. I just took a few Tylenol. Why is this person responding so poorly to just plain old Tylenol? They require so much.” If we don’t put those personal biases aside then we do the patient such a disservice. I think if we can look into other areas of nursing care such as taking care of a diabetic or taking care of someone with COPD, we don’t use our own personal biases for that. We treat the problem as it is. We look at the evidence. We look at the objective and the subjective. Gather data that we’ve got. We talk to the patient and we don’t put those personal biases in. But in pain, sometimes we feel like we need to for some reason. Like we need to make some kind of a judgment call and taking that need to make a judgment call off the table really will enable us to do better assessment and treatment.
Jamie: Well, how is the advent of PCA pumps and other patient-controlled pain management improve the process? Does it take pain management nurses out of the picture when they do that or is that all part of the process?
Esther: Oh, no. It certainly doesn’t take that pain management nurses out. In fact, we need them more whether it would be for education or just how to use that pump better. One of the big things that nurses will always say is, “I don’t have time. I don’t have time to do that. I don’t [unintelligible] through that.” Patients who are in pain, if they are asking for pain medication every hour, every couple of hours, and they get that sense that “The nurses doesn’t have time. I’m really bothering her. I’m really bothering him. I don’t want to be such a bother.” They may be reticent to continually ask for better pain – that’s just one barrier, one problem that may happen. The PCA pump really helps with a lot of issues. It helps the nurse to be more efficient about it. They help the patient to feel a sense of control over their own pain. Since pain is such a bio-psycho-social phenomenon, it – really the idea of being able to control my own pain when I need it and press the button is a big part of decreasing that painful experience. The nurse is still obviously incredibly important. Still has to make assessments. Still has to look at the patient. Look at sedation. Look at comfort. Look at control of the person’s pain. It doesn’t take the nurse out of the assessment picture. But it does help free up time in a way that still contributes to better pain management and the patient has better control. It has worked very successful here at the Cleveland Clinic. Those patients who get PCA pumps generally are much happier with their pain management.
Jamie: We talked a lot about medications but there are a lot of ways to control pain and manage pain. I know locally – remember during my nursing school time in a pediatric facility, they really focused on the importance of distraction. Certainly medications were used but they found it with children playing games and sometimes watching TV could just pull them away from their pain, distract them from their pain.
Esther: Absolutely. Distraction is just one of non-pharmaceutical ways of managing pain. I think it’s important to understand that distraction isn’t just – even for pediatrics, it’s not just a game, it’s not just trying to trick the patient into not needing to take as much but it actually works in the brain. Remember that pain and the mind, it’s so inextricably linked. Pain and emotion, it can never be taken apart. Pain is always [unintelligible] in the mind. I know when I talked to some residents they will say, “Well, I think her pain is all in her head.” Yes, it is. It is always in the head. It is always experienced in the brain. When the brain has something else to focus on – a TV show; looking through a book of pictures; family photos; a card game, they have to concentrate in a card game – it does do something in the sensory-awareness areas of the brain that does really bring down that pain experience and can often result in less use of opioids – we call that an “opioid sparing experience.” We use other things too – distraction music, music works on a lot of levels. Distraction increases mood. We know that when mood increases, pain decreases. So there’s a lot of other things out there than just a pharmaceutical.
Jamie: Well, we’re going to have a larger panel discussion talking about this next week. But just to wrap up this discussion with you, Esther, tell us a little bit or give us some advice for that nurse that may be saying, “You know, I’ve always been fascinated with helping my patients with pain. Maybe I would like to look into a specific career as a pain management nurse.” Could you give a piece of advice or something that they might want to do and head in that direction?
Esther: Sure. I would say to a – first of all, just keep doing the best you can advocating for your patients right where you are, right wherever you are working and paying attention to that person’s pain needs and doing all you can. I would talk to whomever, whatever institution, whatever organization you’re working with. There should be someone there that does some kind of pain management even if it’s just pain management physicians or pain management team. Let them know that you’re really interested and where you should go. Sometimes the local folks can direct you to the best materials and that would be a start. I would get involved with an organization just either online or make a quick phone call to some – an organization like the American Society of Pain Management Nurses. Look at their CEUs, their Continuing Education offerings. One thing that’s really lacking in nursing and in medical school is that we really don’t have courses on pain management. There’s not that many class offerings out there. It’s not like you can take an elective at your local college on pain management. We need to seek those things out in other areas. But getting involved in organizations, talking to others who are on pain management, letting it be known that that’s what you’re interested where you are, is probably the best way to get started. When folks know that that’s your interest, they’ll start coming to you. Then you can move on if you’re just in your education getting on to the, I don’t know, wherever this person would be – on to the Master’s level, on to the Doctorate level – whether it would be in clinical practice or research.
Jamie: There is the American Society for Pain Management Nurses if they’re looking for a specific organization to belong to. I always urge people to become a member of their professional organization in nursing whatever that may be. But pain management, really, as you said, you start where you are being an advocate for your patient. Pain management spans the nursing career path.
Esther: Right. Interestingly enough, here at the Cleveland Clinic, we started a couple of years ago with a group called the “Pain Champions.” We had eight-hour Pain Champion class. The [idea] at the time was that nurses that are really interested in being the pain champions for their floor, a little but more education than everybody else, someone that their colleagues could go to for a little bit of extra advice should attend this class. It was interesting that the feedback we got after every class was: “Wow, why didn’t I know this sooner?”; “Wow, this is for every nurse.”; “Wow, I think everybody should be taking this class.” We’re really looking at making it a mandatory thing. That everyone who comes, every nurse that comes to the Cleveland Clinic should have this extra education in pain management. That it’s not just for someone who wants to be a pain champion but that every nurse is a pain champion and every nurse needs to be aware of these things on how to treat their patients optimally for their pain. Of course, those who are further interested can go on and, like I said earlier, find out other ways to increase their education, Continuing Ed, talking to those experts in their organization.
Jamie: I really like that that every nurse is a pain champion. I was thinking that as you were describing that class, “Wow, maybe I need to come out and sit in on one of those classes sometime.” There are a lot of resources even though we don’t take specific classes in our college pathways. There are a lot of resources to educate yourself about pain in journals, in professional publications and websites. People should definitely start looking out there and there’s a lot of material.
Esther: That is one thing that I didn’t mention and that you brought up that’s very important too is also to look at your professional journals. I found so much wonderful information just on scholar.google and you’re putting in whatever pain issues or whatever you’re looking at that will bring some things up – CINAHL for nursing journals specifically. That’s how we as nurses stay on top of things in all areas. That’s what we have to do in pain management as well. We may have to be a little bit more self-starters when it comes to pain management because there aren’t those – we don’t get it in our undergrad nursing but it’s certainly out there and it’s becoming even more important than ever to an aging population, with patients’ satisfaction scores for institutions, and that kind of thing.
Don’t forget to check out the entire September 2011 issue of Nursing Notes, looking at careers and research in pain management nursing. This month’s Nursing Notes newsletter includes articles on how nurses continue to advance research into patient pain management and nursing care, the growth of career opportunities for nurses in pain management and how you can vote on our Amazing Nurse nominees.
You can read the entire issue online at www.discovernursing.com and don’t forget to catch the other Nursing Notes Live episode this month featuring a panel of pain management nurse leaders and how they seek to improve awareness about pain and its role in health. You’ll find this and other podcast episodes at www.NursingNotesLive.com, the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.