Nursing Notes Live delves into the world of the pain management nurse. This month’s panel discussion includes Barbara St. Marie, Palliative Care Supervisor at Fairview Ridges Hospital, Ann Schreier, President of the American Society for Pain Management Nursing, and our “Get to Know Nurse” Esther Bernhofer, a Pain Research Nurse at the Nursing Institute of Medicine and Digestive Inpatient Cleveland Clinic. I asked them about their nursing careers and about the future challenges facing pain management nursing.
MP3 Audio Podcast
Panel Discussion on Pain Management Nursing
Jamie: Ann Schreier, I’d like to start with you. Let’s start with just asking how you became a nurse? What led you into the nursing profession and what led you into pain management as a career path there?
Ann: Okay. Well, I sort of always wanted to be a nurse when I was a young girl. I got into nursing school at Boston University and really felt like, “Oh, this is where I want to be.” As I started in my first job in nursing, I was on a general medical unit, and I got to know some patients that were suffering from leukemia and really understood that there was a lot of distress that they had in their life. So that really was, “How am I going to, as a person, help them with that distress?” Then I moved to California and, lo and behold, I got a job at Stanford University in the Cancer Research Center. I found that in doing that job that I really became involved with patients. I sort of felt like I found my home in terms of these were patients that I could relate to and I thought I was doing something very important for them. To get into pain management it’s sort of began in that way because with cancer – and with cancer treatment in particular – often pain is a component of that. I gradually had an opportunity then to some research with helping patients in terms of education about their conditions and about the symptoms that they had. Moved on from there to starting to teach in nursing and then took some time to work in hospice. I think that it was really when I began working in hospice that I really got involved with pain management as an essential component. It evolved in that way. As I became an educator – more when I moved to North Carolina at East Carolina University – really came to see the impact of pain in all areas in which my students were experiencing patients and that there was a lot of misunderstanding about pain and about pain medications and risks of addictions. So there was clearly a real need for nurses to know more about that. Eventually, I became after taking a course at City of Hope for Nurse Educators and putting pain management into the curriculum really became involved with ASPMN. It was there, in fact, that Barbara St. Marie was on the phone call too and really became involved in that organization. As we have moved on as an organization, there’s been a lot in terms of people having real access to pain management and the nurses’ role in that. Our organization really has moved forward in that area of advocacy which is getting patients to have their pain managed well.
Jamie: That’s a good segue to talk to Barbara St. Marie. Barbara, welcome to the show. Tell us a little bit about your path to nursing.
Barbara: Well, actually, I started out my career path as a music maker. It wasn’t nursing at all. Then I became ill, quite ill, and needed a blood transfusion. I was hospitalized and I had a reaction to the blood transfusion. Throughout that whole reaction, it just was imprinted in my brain what happened. There were a lot of people around my bed but there was one nurse that was sitting in a chair by my bedside holding my hand. I needed that. I was scared. I was having things happen to me that I didn’t know and just having that peaceful presence was very important. At that moment, I realized that nurses are the closest healthcare provider to the patient. That pain, as a nurse – in my career, pain was something that I saw all the time. So as my career path went and gone the direction of nursing, I knew that relieving the suffering of individuals was the most important thing a nurse could do.
Jamie: It’s amazing you say that story. I know so many people who have had similar experiences with a nurse. I know I was in a very severe car accident as a teenager. Because of the injuries, my eyes were covered. The only voice that I can remember from that trip to the trauma center in preparing for surgery was the nurse who sat there telling me what was going on because I was blind and couldn’t see what was happening because of the bandaging. It was that nurse’s calm and caring voice that carried me through a very traumatic period. Isn’t it amazing how nurses are so important and integral in affecting everyone’s life when they come into a situation where they need that acute healthcare?
Barbara: Definitely. Very important role having that peaceful presence there is something that I’ve wanted to teach. I’ve wanted to carry it forward myself and that was from an event that occurred 35 years ago.
Jamie: Esther, you and I had talked previously about the importance of nurses really being there for their patients in so many ways but especially for being advocates for managing their pain. I know the Pain Champions thing you’ve set up at Cleveland Clinic had such a great reception from the nursing staff there.
Esther: Yes, actually, it really has. We’ve been offering the Pain Champion class now for about two years. We’ve had probably over 800 nurses or so in those couple of years attend, which is really quite a good number regarding attendance on these types of optional classes that we offer for bedside nurses. There are a lot of interests in it. One of the really great pieces of evaluation on our evaluation sheets is that most nurses will write something like: “Why didn’t I know this sooner?”; “How come I didn’t get this when I first started working here?”; “When are the doctors going to learn this stuff?” They really eat it up because as was put it out to – pain is something that nurses come into contact with every day. We might not see decubitus ulcers or wounds every day or sometimes not even – even though diabetes is so prevalent now, sometimes you don’t see a diabetic every day but most nurses at the bedside will see someone with pain every day. This really speaks to a lot of nurses at the core of why they became a nurse.
Ann: Yes. I really have learned over time that, yes, nursing and pain affects all our patients no matter where we are. As we talk about specialties, really pain is everywhere and affects all our patients so all nurses need to know about that whatever their practice area is.
Esther: Exactly, Ann. We’ve seen nurses from every area come to the Pain Champion classes so it’s not just inpatient medicine or med-surg. We’ve got from pediatrics, ambulatory care, orthopedics, everything you can think of come there. They all pretty much have very similar reactions. It’s very exciting. We’re actually trying to change it for next year. Not just having these Pain Champions, those who want to be Pain Champions on their unit kind of thing, but to have it as option that nurse managers can require for certain nurses or require for all of their staff or use it in orientation for new nurses coming in, that kind of thing. We really are trying to broaden it out realizing that all nurses are Pain Champions.
Barbara: I think that a wonderful program that you have when you consider that more than 116 million people in the US live with pain on a daily basis and about half of them receive no treatment at all, the total cost to that person, whether it’s healthcare expenses, lost income, lost productivity at work and at home, the quality of life being impacted, but even on a societal level when we’re in the era of healthcare reform, costs
$635 billion to our society. That type of information that you’re passing forward in your class is an important one; as well, just knowing that the nurses can know that they’re not alone in treating pain. They do have support like your program, like the American Society of Pain Management Nurses, like other resources are available so that they don’t have to feel that they’re all alone in trying to work with somebody who’s suffering in pain.
Esther: I think that’s a really big, important, and well-utilized part of this program and that is that nurses don’t feel all alone like they think they used to. They didn’t know where to turn before. They’re trying to advocate for a patient, the physicians either blowing them off or just kind of dismissing them. Now they have information at hand. They know their [unintelligible] analgesic dosing. They know the importance of pain management. They know how to advocate for a patient well. It’s been very encouraging for me to see that on our units.
Ann: Excellent work.
Esther: We have a long way to go. I don’t want to make it sound like this. [Laughter] Like, “Oh, here. We’ve got everything down.” It’s not like that. We certainly have a long way to go. But we have made some headway and some units more than others, and with some nurses more than others, but it is being much more well-accepted that this is an issue that needs to be taken seriously.
Barbara: Before 1990, the medical research on pain was less than 1/10th of the medical budget. We are in an area right now that’s just advancing so quickly the knowledge of nurses and advocating for our patients and the needs of our society. We’re in a research realm of pain management. It’s been supported. We’re establishing networks for support for nurses in clinical practice. We’re basically responding to the changing field of pain management nursing. That’s an exciting time to be doing this.
Ann: Yes. I was going to say, Barbara, the nurse statistics that you were quoting was, I assume, coming from that IOM report which came out that really has put this to the forefront. Yes, it is that sort of getting identification from a national level how important it is that we address this public health problem and we address it in all sorts of ways. What we’re talking about here is the role of the nurse which is really crucial because I think as you really said, Barbara, about having that person that was at your side, that nurse that presence, it really is so much so the nurse who is knowledgeable not only to be the presence but knowledgeable about what she can do for you – she or he can do for you – and that there is support in the institution as well as nationally as this being an important issue.
Barbara: Yes. The publication that you refer to is correct. That’s where the statistics came out of. It’s a publication that was released in August and it’s from the Institute of Medicine and it’s called “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.”
Esther: That document actually helped us to underscore a lot of our efforts here at the Cleveland Clinic as well. When talking to physicians or meeting with them, just having that one document actually really made some difference in saying, “Pain is a big issue. It’s a not a side issue to your treatment of whatever it’s going but it is often THE issue.” That was quite a good thing when that came out in August.
Jamie: 116 million people, that’s 1/3 of the population in the United States living with chronic pain. It’s an astounding figure when you think about in those terms. Why has it been taking us so long to get around this blindside we have towards handling pain aggressively?
Ann: Well, I think some people is sort of in an invisible condition like we know, for instance, that the diabetic is at risk for peripheral neuropathy which is painful. But when you look at the person, you don’t necessarily see that unless we ask about it and how they’re functioning. I think part of it has to be with the visibility. I also think in our healthcare system, we’ve been really focused on the cure – the diagnosis and then the cure – and not so much with the functioning of the patient of which pain is a part of that.
Barbara: We know now that there are changes in the brain that occur when pain is not relieved. So pain is no longer considered a symptom but rather in some cases a disease itself.
Esther: I also think that one of the problems is that pain is so ubiquitous. Everybody experiences some pain between birth and death. Therefore, because something is just so common, as a public, we tend to interpret others pain by our own standards. If we never really had a lot of – if we’ve always been able to control our pain with the Tylenol or had surgery and those two Percocet worked just fine, thank you. Then we have a different way of viewing others’ pain and maybe not take it so seriously. We are often the most biased of our shortcomings when we look at another’s pain because you can never feel it for another and you can never measure it objectively. You can’t put a number on it like we do with a blood pressure or a blood sugar. We can’t see it. We just interpret it according to our own biases.
Ann: I think that’s true. I also think the other factor in there is that we really have to alert our patients that they need to tell us about it because I think sometimes with some illnesses they just think it is part and parcel of not being well. So they don’t necessarily bring it up unless the healthcare provider brings it up than us nurses bringing it up and asking those questions. So they don’t always felt free to bring pain forward.
Esther: That’s true and I see that on our units in the hospital. Patients that don’t feel like they can tell the doctor about the pain but they’ll tell the nurse. I always like to encourage the nurses to be there when the doctor rounds and ask Mr. So-and-so, “Please tell the doctor how you’ve been feeling today and where your pain is,” so that the doctor hears it directly from the patient and it’s not the nurse calling an hour later saying, “Yes, but I know he seemed to be fine an hour ago.” It is important to encourage patients to describe what they’re feeling.
Barbara: I think in nursing now too we have tools that we can use to assess pain better, and there are many. No matter what tool though that we use, our goals are still the same – that is, address the issue of pain, maximize the relief, and minimize the side-effects.
Barbara: Nurses are well-positioned to do that.
Esther: We’re really are at the forefront. Nurses really are at the forefront of pain management. I think it was Dr. Jo Eland who said “nursing owns pain” at the last conference that morning. Inasmuch as no domain, no discipline owns the concept, but I think that nursing really does – nursing is there 24/7 when physicians aren’t. Maybe family can’t even sometimes be there 24/7 so the nurse is the one they’re helping, seeing, really making that global holistic assessment of what’s going on.
Ann: They hear the voice of pain and they see the face of pain. That’s what nurses bring forward is allowing that voice to come forward. So while patients may not feel they’re heard, the nurses are well-positioned at the bedside to hear that person’s pain and to bring that forward and to advocate for them.
Barbara: Yes. I think what you have said after about encouraging the nurse to be there when the physicians round really helps in order to have that interdisciplinary coordination because, as we know, as being in the healthcare, we all have to work together as a team and it’s important that we bring up things that may be overlooked at times.
Jamie: Pain management really transcends all the nursing specialties but when you’re specifically working as a nurse in pain management, how important is it for you to really be an active part of that interdisciplinary care team that the pharmacist, the physician, the surgeon, the care planner for home, the discharge and everything else working with that bedside nurse to help them have the tools that they need to do the job right?
Barbara: Yes. I think it’s essential. One of the things why American Society Pain Management Nursing – why we are moving forward in terms of education and having educational material available, we write position papers on certain areas that will help nurses in practice be able to utilize that information and share it with the other members of the team and really being the kind of focal point for disseminating this information about pain management and doing the work of that so that we provide, as pain management nurses, the tools that all of the nurses need in their area. That’s what we frequently respond to in terms of education of what it is those nurses identify that they need to help them in their practice. In my job every day, I attend multidisciplinary rounds. There are two things that I think I bring to the table and – well, I know I bring to the table – one is I always ask the question: “How’s the patient’s pain?” So I’m asking the entire team how did they go the last 24 hours from when we’ve seen that patient. The other thing that I bring to the table is evidence-based pain management. That is the strength of the American Society of Pain Management Nurses because I get those tools, I get that knowledge, and I continue to build on my knowledge so that I’m no longer speculating. I actually know because the science is there and the science is telling me how to do this.
Jamie: Barbara, do you find that the other professionals out there, the physicians and these people who the patients come in contact with, are they starting to get the picture on all of the research that’s going on focusing on how pain affects healing, how pain affects long-term reaction to future pain, all these things that physiologically happen when we have pain?
Barbara: It has been a long time to have that evolved in everybody’s thinking. In my particular environment through Fairview pain is a very important part of patient care. We make sure that the patient knows that so that they’re not holding back on us. We do know that the benefits of pain are there and the side-effects of pain are there. I do believe in the entire multidisciplinary team that rounds on our patients that we are aware of that and we’re also aware of the need to control the pain.
Esther: I think the awareness of the – I too attend multidisciplinary rounds and totally appreciate the evidence-based practice, things that I get from ASPMN, certainly other resources, and bringing that to the table saying that there is science behind this – repositioning and tuning out the relaxation channel is not just a nicety but there really is science there that will help that patient with their pain management. Some of the other things too that I bring up on those rounds, when I can put a reference or a position statement or something behind what I’m saying, everyone sort of perks up. They’re like, “Oh, wow, there’s really something to this. It’s not just…” – managing a person’s pain is not just like getting them a cup of coffee. It’s not just the nicety but there’s really, really an important part of healing that needs to happen and managing that pain is part of that.
Ann: Yes. I think when Barbara started out talking about the fact that there has been an explosion of information since the 1990’s where there was very little – that there really is so much more research out there that that has really helped the interdisciplinary team to understand and the public-at-large to understand how important it is to manage pain and that managing acute pain can help us prevent some people from living in chronic pain conditions. So I think there’s more and more knowledge out there in general for us to use and it’s a matter of making all of our nurses aware of that and all of our other healthcare providers. I think programs such as the one that Esther was talking about really help move along that process because for each person that we reach, they will reach other members of the interdisciplinary team and those will reach others. So it goes out from that center [force] of the nurse.
Esther: What I’ve been excited to see is that sometimes it’s just an awareness that pain is important priority here that makes the difference. When people talk about, “Well, we have this class and why is that” – just the chit-chat about that. Even among physicians, “Oh, yes, we need to do that.” Raising the awareness of it among providers here at the hospital really has its own impact.
Jamie: Ann, we’re getting kind of winding down here towards the end. I want to just kind of throw something out there for you to share some ideas – each of you actually – to share some ideas with that nurse that’s listening to this or perhaps that student nurse that’s saying, “Wow, I really feel like I could be a champion for my patients and for a larger patient population as a nurse specializing in pain management.” What some pieces of advice you might offer to that individual?
Ann: One of the things that I offer is, yes, becoming familiar with what it is that the American Society for Pain Management Nursing offers and one of the ways you can do that is become familiar with our website which is www.aspmn.org and there are lots of material on there that’s available to you to take opportunities such as those that Esther is talking about in her institution. I think if you look nationwide there are lots of institutions that offer that. There are also patient organizations that pair with nurses such as the American Pain Foundation that allows the nurse to grow in terms of how you can advocate, upgrade a level in terms of when things come up in legislation issues that really will affect the ability of individuals to get access to care. The whole being interested in the topic, looking at the literature, working with other individuals, just increasing your knowledge about it goes a long way in becoming a champion.
Barbara: I will oftentimes receive phone calls from nurses that are just interested in seeing what I do as a pain management nurse. I invite them to join me and they spend a day or two or three with me and see how the nurse actually can make a difference in intervening with people in pain. One of the main points so that I do try to get across is “Listen to what the patient is telling you and if you know what the patient’s telling you, move that forward. Don’t ignore it. Don’t go back and just forget it. Go out there and advocate for that person in pain.” I was thinking about some other resources that are available too – there is the American Headache Society; there’s the Arthritis Foundation; the American Pain Society; the American Chronic Pain Association are also available. Oftentimes what nurses will do is they’ll go to the website, they’ll print it out and they’ll bring it to me and say, “Well, what do you think of this and this?” So it really does provide people with good information and most of those websites have evidence-based information so that they’re not just plugging into Google and getting just anything. We really want to make sure that the information that people receive is accurate information.
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 our “Get to Know” nurse Esther Bernhofer. 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.