Nurses' Role in Improving the Pain Management Culture

Added on Aug 23, 2016

Nurses' Role in Improving the Pain Management Culture
By Diana Mahoney
From Industry Edge August 2016

The recent proposal by the Centers for Medicare & Medicaid Services (CMS) to remove HCAHPS pain management questions from the hospital payment scoring calculation is designed to alleviate concerns that linking reimbursement to patients’ perceptions of how well their pain management needs are being met might encourage irresponsible prescription practices among providers seeking improved patient experience ratings.

The preponderance of available data suggests that no such relationship exists. In fact, such a connection during a time when the country is in the grips of an unprecedented epidemic of opioid addiction takes attention away from the value of pain management scores as an important indicator of quality that should be measured and improved continually. Fortunately, the proposal aims to satisfy proponents and opponents of the pain management debate. Although the three pain management questions on the HCAHPS survey would no longer factor into the Hospital Value-Based Purchasing Program payments from Medicare, starting in fiscal year 2018, they would remain on the survey.

“This is important, because the pain management questions do not exist in a vacuum,” according to Press Ganey Chief Nursing Officer Christina Dempsey, MSN, MBA. “Study after study looking at patients’ perceptions of pain management during hospitalization and their overall experience of care indicate that patient experience scores were more strongly correlated with their perception that caregivers did everything they could to help manage their pain than with whether or to what degree their pain was actually controlled.”

This culture of pain management influences, and is influenced by, multiple other considerations, particularly those related to the responsiveness of and communication with nurses, who are the front-line caregivers spending the most time with patients.

“Patients want to be acknowledged and they want us to understand that they are in pain. They want to be reassured that we are doing everything we can do for them and with them to address their pain,” said Dempsey. “When we as caregivers listen to them and involve them in their care decisions, their perception of the quality of the pain management experience improves, as does their perception of their overall experience. It’s also important that we are transparent in our discussions with our patients and their families. When zero pain is not an option and is, in fact, an unrealistic expectation, our patients need to know that and help us determine what a reasonable amount of pain for them is so that we can manage to that level, understanding that we cannot get to zero. That honesty and transparency builds trust and improves the overall experience of both the patient and the caregiver.”

Meeting Patients’ Pain Care Needs

Nurses, in large part, are the drivers of patients’ perception of the pain management culture, not only because they spend the most time with patients and have a key role in the assessment of symptoms, but also because nurses are the primary patient educators, Dempsey said. “It is generally through nurse communication that patient expectations are established, and it is through nurse communication that caregivers are able to ascertain whether those expectations are being met.”

The most important things nurses can do to establish a positive culture of pain management are to listen actively to patients when they are describing their pain, solicit as much detail as possible about the nature of the pain and how it is influencing their lives, acknowledge the pain and value the patient’s and family’s perspectives.

Because inadequate assessment of pain is frequently identified as one of the most significant barriers to adequate pain management, “it’s also essential to determine where the patient is on the pain spectrum and let them know how we will work together to address it,” said Dempsey, who frequently uses an example from one of the Denver-based Sisters of Charity Leavenworth hospitals to make this point. “They have made pain assessment a highly interactive process,” she explained. “They use a ‘pain menu’ that has lots of choices for pain management and support. Having options gives patients a sense of control. They receive the menu at admission, and nurses and physicians reference it every time they ask patients about their pain level.”

The menu details the comfort items (such as a warm compress, a heating pad, extra pillows) and comfort actions (such as repositioning, showering, stretching) that are available to patients, along with specific information about how and when to ask for medication.

Additionally, the menu offers a pain assessment scale that is more detailed than the standard “rate your pain from 0 to 10.” It includes such descriptors as “agonizing,” “horrible,” “dreadful,” uncomfortable” and “annoying” to help patients accurately express where they fall on the scale and to assess progress over time.

This approach aligns well with those that emerged at the 2016 Membership Assembly of the American Nurses Association in June, during which members agreed that nurses and other care providers need new ways to measure and assess pain. Among the recommendations discussed by the attendees, the reassessment and retirement of the 0 to 10 pain scale topped the list. Other recommendations included the following:

  • A greater emphasis on physical and functional status assessment
  • Inclusion in the curriculum of schools of nursing and schools of medicine of strategies to help patients manage pain needs
  • Understanding that patient-centered care means providers must be more in tune with their patients’ true level of pain and they must help patients take an active role in the understanding and planning of their care
  • Increased focus on patient education and awareness to help define patient expectations and help patients manage pain, particularly understanding medications, how they work and how best to take them
  • Additional provider and patient education around non-opioid pain management
  • Interventions that help manage expectations for pain and recovery, such as perioperative education, discharge planning and post-op phone calls

“Pain management is more than a health care issue. It is a personal and cultural issue, and we have to begin addressing it in that way,” said Dempsey. “In order to meet patients’ pain management needs, we have to understand what those needs are, both clinically and emotionally, and then rise to the challenge of delivering care that meets them.”

Measuring providers’ performance on pain management survey questions is “an important tool for determining how well we are doing. It is how we know whether we are meeting the goal of improving the care we deliver. And if we’re not doing well, it lets us know where the deficits are so we can target them for improvement,” said Dempsey.

The debate over the pain question is somewhat misguided, Dempsey explained, as pain management is not really a drug question. Rather, it is about “delivering compassionate, connected care that acknowledges and helps patients with their pain. We have shown that patients’ perceptions that their caregivers did everything they could to help with their pain have more influence on their experience scores than whether or how much pain medication they received. We need to keep our focus on the right target.”