Pain management: steps for better care and faster recovery after surgery
Nurses are vital to good pain management – and this starts with a comprehensive assessment
Nurses are vital to good pain management – and this starts with a comprehensive assessment of the patient
- Experts advise nurses take a structured approach to pain assessment, using a multidimensional tool
- Listening to the individual and understanding the impact of pain on their daily life is as important as measuring pain intensity
- RCN’s knowledge and skills framework for pain management can be used by the whole nursing team and is being adapted for use in Australia and New Zealand
For patients having surgery, managing their pain effectively is key to a speedy and full recovery – and nurses play a pivotal role in assessing and treating pain.
‘The impact of persistent pain after surgery is much more highly recognised now,’ says Felicia Cox, lead nurse in pain management and head of pain services at Royal Brompton and Harefield NHS Foundation Trust. ‘Patient discharges were often delayed because of unrelieved pain.’
Lack of focus on pain in preregistration training
Specialist pain services are relatively new. Many were created after the report of a working party in 1990 that examined pain post-surgery, which called its treatment inadequate and a persistent failure.
‘It recognised the need for structured acute pain services in places where surgery was being undertaken,’ says Ms Cox. ‘Before it was published, there was scant provision across the four UK countries, with nowhere having a pain team to my knowledge.’
Yet while well-established inpatient pain teams are now commonplace, it’s not all good news. Ms Cox is concerned about a lack of emphasis in preregistration nursing courses on understanding and managing pain.
‘I’ve had a number of student nurses who are all within six weeks of qualifying, yet none of them could demonstrate the ability to undertake a structured, multidimensional pain assessment,’ she says. ‘They also couldn’t explain how commonly used opioids or anti-inflammatories work, or any of the precautions associated with them. It’s very disappointing.’
Her experience is reflected in a survey carried out by the British Pain Society, which looked at how much time is allocated to study pain in undergraduate curricula.
‘It shows that in some cases, nurses have less than two hours and definitely less than ten,’ says Ms Cox.
Time will tell whether the new NMC education standards, to be implemented shortly, will address Ms Cox’s concerns. However, one standard does make clear: ‘At point of registration, the nurse will be able to demonstrate the knowledge and skills required to identify and initiate appropriate interventions to support people with… pain’.
Top tips for pain management
- Take a structured approach to pain assessment, using a multidimensional tool, advises Felicia Cox, lead nurse in pain management and head of pain services at Royal Brompton and Harefield NHS Foundation Trust. ‘Don’t just look at pain intensity but its qualities and the impact on a patient’s ability to function,’ she says
- Consider using a mnemonic to help you remember key aspects of pain assessment. For example, SOCRATES – Site, Onset, Characteristics, Radiation, Associations (any other signs or symptoms), Time course, Exacerbating or relieving factors, and Severity
- Assess pain regularly, says Worcestershire Acute Hospitals NHS Trust senior clinical nurse specialist in acute pain control Rachael Ward, and know when to escalate. ‘Pain scoring should be done at least every time you do a set of obs,’ she says
- Remember that pain scoring should complement what else is happening in the patient’s life, advises Antony Chuter, chair of charity Pain UK. ‘It’s about working with them to help find the pain score that’s true, without being impatient,’ he says. ‘Sometimes the temptation can be to say it’s worse than it is, because you want to be taken seriously’
- Actively listen to what your patient is telling you. ‘And look at whether there might be a psychological or social component to their pain,’ says Ms Cox
- Remember that an intervention doesn’t have to be medicine. ‘It can be listening, talking, being reassuring or even a hot pack,’ says Ms Cox
- Assess and document the effectiveness of any intervention
Skills framework for the whole team
In 2015, in her role as chair of the RCN pain and palliative care forum, Ms Cox led work to create a knowledge and skills framework on pain for the whole nursing team, from healthcare assistants to nurse consultants.
Before its publication, there were no nationally agreed standards, competencies or frameworks for pain management nursing in the UK. The document looks at understanding pain and assessing it, strategies to manage pain – including physical, self-management and pharmacological – as well as service development and complex pain management.
‘It was a major piece of work,’ says Ms Cox. ‘It’s been so well received that it’s being adapted for use in Australia and New Zealand.’ Building on its success, senior clinical nurse specialist in acute pain control Rachael Ward has customised some of it for use at her workplace, Worcestershire Acute Hospitals NHS Trust.
This is used to provide a comprehensive introduction for nurses who are joining the acute (perioperative) pain team, moving from band 5 to 6, and who have not worked in this specialty before.
‘We can’t expect nurses coming into post to have done a pain course beforehand,’ says Ms Ward. ‘This gives them something to guide their learning through the first stages.’
Useful resources for nurses
- RCN Pain Knowledge and Skills Framework for the Nursing team
- e-pain – A collaboration between the Faculty of Pain Medicine, the British Pain Society and e-Learning for Healthcare. Based on 12 interactive modules, which look at improving recognition, appropriate assessment, and first-class management. Registration is free for NHS staff
- Pain Concern – Videos, podcasts, interviews and resources to support clinicians and people living with pain
- Opioids Aware – A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain
- Change Pain – Collection of e-learning resources for clinicians
Managing acute pain effectively
Ms Ward qualified in 1991 from the University of Surrey. After working in general surgery for a couple of years, she joined Worcestershire in 1993, taking up her current band 7 post in pain management four years later.
Over the years, Ms Ward has witnessed a growing focus on the importance of managing acute pain effectively. ‘It’s slowly climbing up the radar,’ she says. ‘Staff are becoming much more aware of the need for pain relief, but I think there will still be an education need for a long time.’
Her team has since expanded to three, with two band 6s. Together they provide a stand-alone service that operates independently at the trust, ensuring that all surgery, trauma, orthopaedic, vascular and gynaecology patients with acute pain receive the best treatment, care and support.
First assess the patient’s pain relief
When the team is asked for help, their starting point is finding out whether the patient has been given regular pain relief – with the emphasis on regular.
‘Start with that first,’ says Ms Ward. Some patients remain reluctant to take medication, fearing addiction or side effects. ‘They need reassurance,’ she says. ‘It’s about listening and talking to them. Sometimes relief may be positional or environmental too.’
The patient’s perspective: ‘Part of me didn’t feel believed’
For Antony Chuter, being believed by healthcare staff is key to good quality care.
‘I’ve had a whole mixed bag of experiences,’ he says. ‘Some of the worst have been when staff, including nurses, either haven’t listened or questioned whether I am in pain. When you already feel fragile, that doubt can be very hurtful.’
Mr Chuter lives with a range of painful conditions, including osteoporosis, spondylolisthesis (a slipping of vertebra, usually at the base of the spine) and inflammatory arthritis. He is chair of charity Pain UK and chaired the British Pain Society’s patient liaison committee until last year.
In one incident, a consultant told him bluntly that a pain-blocking procedure hadn’t worked. ‘As he walked out, I burst into tears,’ Mr Chuter recalls. ‘Fortunately, the nurses were amazing, telling me my pain was valid. It was important because part of me didn’t feel believed at that point.’
The right messages about opioids
Patients undergoing surgery need better education about pain-relieving drugs and recovery, says Mr Chuter. ‘We need to move away from patients being sent home with a month’s supply of strong opioids,’ he says. ‘Some will follow the instructions to the letter and take them three times a day – ending up with chronic pain or addiction.
‘Opioids have their place, but use them for two or three days at most, then seek help if you’re still in pain. That message doesn’t get out there.’
Being on the receiving end of care that prioritises form-filling over listening can be particularly unwelcome, he says. ‘If I’m asked “how’s your day going?” that’s the sign of a good nurse for me,’ says Mr Chuter.
‘It all boils down to feeling cared for. There’s a sea of difference between the nurse who is just going through a checklist and those who take the time to actively listen and build a relationship.’
Good management is the goal
While the gold standard may be to get rid of all acute pain, that may not be realistic with every patient, Ms Ward admits. ‘We aim to get them to a comfortable level, where they can at least function with activities of daily living while they’re in hospital. And by the nature of the procedure they’ve had, their pain should improve with time,’ she says.
Left untreated or poorly managed, there is evidence that acute pain can become chronic. According to the charity Pain Concern, on average 30% of patients experience chronic pain following surgery, ranging from mild to, in around 5% of cases, severe intensity pain.
Delayed recovery and discharge due to pain
It can also lead to a much more protracted recovery and discharge. ‘You can have patients who won’t move,’ says Ms Ward. ‘They say they’re fine if they lie still. Even asking them to take a deep breath can be a problem.
‘That has knock-on effects clinically, such as clot formation in the legs and chest infections, with the potential for much longer-term impacts. Poor pain relief slows everything down.’
Nurses may not always fully understand the impacts of acute pain, she believes. ‘But if they’ve cared for patients in pain before, I think it heightens their awareness of the importance of relief.
‘Nurses are vital to good pain management and their understanding is key. They are the patient’s advocate and the link between them and care provision.’
Lynne Pearce is a health journalist