Quality pain management has taken on greater importance in today’s healthcare environment. Effective pain control leads to fewer postoperative complications and potentially prevents long-term chronic pain. 1 Many healthcare organizations in Canada and abroad have implemented or are considering implementing an acute pain service (APS) to address the issues associated with poorly controlled pain. 2 APS teams are typically multidisciplinary and include roles such as medicine, nursing, and pharmacy. The importance of the role of the APS nurse has been recognized in the literature. 3–5 Nurses are in a unique position to provide leadership within organizations to improve pain management practices. Advanced practice nurses (APNs) in specialties such as oncology, nephrology, surgery, and cardiology have begun to describe their roles. 6–11 However, minimal examination has been documented about the specialized role of the nurse in acute pain management. This article describes the roles, qualifications, and responsibilities described by nurses who specialize in acute pain management throughout Canada.
Advanced Nursing Practice in Canada
There has been much discussion and controversy concerning the definition of advanced nursing practice (ANP). The Canadian Nurses Association (CNA) defines ANP as “an advanced level of nursing practice that maximizes the use of in-depth nursing knowledge and skill in meeting the health needs of clients.”12 Nurses in advanced practice offer a unique contribution to the specialty of pain management. These nurses use their experiential and scientific knowledge to provide a more comprehensive nursing model of care. Pain, as a multidimensional experience, often requires a multimodal approach to the plan of care. Specialized pain practices, which are grounded in nursing and other theoretical foundations, experience, and research, reflect the CNA definition of ANP and the advanced role of nurses in acute pain management. 12
The CNA recognizes the acquisition of competencies for ANP through experience and education programs. However, it supports formal graduate nursing studies, which provide a “credential that can be evaluated for equivalency across jurisdictions” and “encompasses a theoretical base of nursing, which promotes nursing research practice and evaluation.”12(p8) Currently, some registered nurses practicing in acute pain management in Canada are diploma-prepared nurses who informally and formally developed their expertise through experience, in-services, short courses, and literature reviews. Although some of these nurses are considering advanced education, their undeniable expertise is a valued contribution to everyday pain management. For the purposes of this article, in recognition of the CNA definition of ANP, nurses with a baccalaureate or higher preparation were examined. This article focuses on the emerging role of APNs in acute pain management in Canada.
A target population of nurses with specific acute pain management responsibilities (n = 64) was identified through the Canadian Pain Society (CPS) and International Association for the Study of Pain (IASP) membership, anaesthesiologists/hospital directories, and colleagues. Inclusion criteria included baccalaureate- or master’s-prepared nurses working in acute pain management within a hospital in Canada. Excluded from the analysis were 18 respondents for the following reasons: 5 did not have direct responsibilities for acute pain and worked in education (n = 2) or chronic pain (n = 3). One respondent was not a nurse but a respiratory therapist who worked in an APS coordinator role, and the other 12 respondents were not baccalaureate prepared. The total number of respondents included in the analysis was 24. Data were entered into an Excel database. Descriptive statistics were calculated and response distributions were used to represent individual answers to the questionnaire items.
A 6-page questionnaire was self-administered and included 14 fixed-choice and 5 open-ended questions. Questions also were asked about demographic data, sources of pain education, role characteristics, role responsibilities, positive outcomes of role, and current challenges. The questionnaires were mailed in December 1998 with a cover letter and return envelope. Reminder letters were mailed in March 1999. The total number of returned questionnaires was 42/64, for a response rate of 66%.
Nurses responded from all across Canada, with the majority practicing in Ontario (n = 12) (Table 1).
Respondents’ mean age was 40 ± 8 years, and 23 out of 24 were women. The average years since graduation from their nursing program was 16 ± 9, with 3.5 ± 1.9 years’ experience in their current role. Eleven nurses were educated at the master’s level, and 13 were at the baccalaureate level, 4 of whom were pursuing graduate studies. The majority of nurses worked in a university teaching hospital (Table 2).
Nurses reported obtaining pain education from a variety of sources, most commonly their colleagues, journals, and conferences. Fifteen respondents were members of the CPS, the professional pain organization in Canada.
The majority of nurses (n = 16) were employed full-time. On average, 1.4 (range 1 to 5) nurses per institution were working with the APS. The role title varied from clinical nurse specialist/nurse practitioner (n = 8), nurse clinician (n = 6), coordinator (n = 6), educator (n = 1), or other (n = 3) (Table 2). Nurses reported primarily to both nursing and anesthesia (n = 11) or to nursing only (n = 10). A formal job description had been developed for most nurses (91%). Respondents indicated that their roles primarily included (a) clinical, (b) educational, and (c) administrative responsibilities.
Pain management clinical responsibilities were focused primarily during daily patient visits. The following populations were most commonly seen: vascular, orthopedic, general surgery, gynecology, oncology, and urology. The number of patients seen on a daily basis varied between institutions, with an average of 27 ± 17.8 per week (range 5 to 60). The majority of nurses participated in daily patient visits primarily to assess patient’s concerns, monitor pain relief and opioid use, obtain in-depth histories, explore treatment options, and modify treatment plans.
Respondents identified important aspects of these visits as: assessing patient self-report of pain intensity, presence and treatment of adverse drug effects, and patient satisfaction with pain management. Daily visits also included an assessment of patient activity, bowel function, and readiness for transition to oral analgesia. As necessary, routine opioid/anesthetic drug administration devices were routinely verified for accuracy and usage. Patient rounds were performed by the nurse independently often or always 52% of the time. Collaborative rounds included anaesthesia (76%), pharmacy (10%), and occasionally other disciplines (14%).
In Canada, nurses practicing in the hospital setting require additional regulatory authority (medical directives) to prescribe medications, order diagnostic tests, and communicate a diagnosis. Thirty-four percent of respondents had in place medical directives for the provision of advanced care.
Nurses described providing pain management education for staff (92%), patients (100%), and outside organizations (63%). As well, patients were provided with pain education at several time periods during their hospitalization. Initiation or reinforcement of pain education was provided during rounds (96%). Thirty-three percent identified providing pain management education to patients before their surgical procedure, and 38% were involved in providing pain management education before admission to the hospital.
Most nurses (92%) stated that they were involved in policy and procedure development, and 79% also included quality improvement initiatives. The majority (78%) tracked patient satisfaction data regarding pain management to evaluate the effectiveness of the care. It is not known what tools or methods were used. Sixty-seven percent were involved in pain research. Studies ranged from opioid comparisons for managing pain to evaluating the effectiveness of pain management education. Only 25% percent of nurses evaluated their roles. Nurses also identified responsibilities related to the purchasing and maintenance of equipment.
Challenges of the Role
The nurses were asked to describe the challenges they faced in the APS role. Respondents were also asked to rate how they believed each discipline accepted their role. Challenges identified fell into 4 broad categories: lack of support, complexity of pain problems, role definition, and role acceptance. Support issues included lack of accountability of health professionals to improve pain management, general hospital politics, anesthesiologist inconsistencies in practice and anaesthesia personnel shortage, minimal performance feedback, insufficient secretarial support, and part-time status for some APS nurses. The complexity of pain problems encompassed issues such as inadequate pain education of healthcare professionals and patients, lack of time to adequately cover all pain management issues, and inadequate or lack of equipment such as patient-controlled analgesia (PCA) pumps to support pain management practices. Role definition issues reflected a lack of clarity, understanding, and respect for the role; multiple demands; feelings of isolation in the role; and inadequate tools such as medical directives to practice independently.
This highly collaborative role necessitates a close working relationship with several disciplines. When asked to rate the degree to which respondents believed different professional groups accepted their role, nursing, anaesthesia, and administration were seen as very accepting of the role. Other healthcare professionals were seen as moderately supportive, and surgeons were believed to be the least supportive (Table 3). Irvine et al 13 similarly found nursing and administration the most supportive for implementation of an acute care nurse practitioner role.
Positive Outcomes of the Role
Almost all nurse respondents (96%) answered the positive outcomes open-ended questions. Three key areas were reported and categorized as patient, interdisciplinary team, and nursing outcomes. Patient outcomes included continuity and holistic care, advocacy, education, and increased satisfaction. The role promoted interdisciplinary collaboration and coordination, improved pain documentation, and increased opportunities for quality improvement and education. The APS role provided the opportunity for nurse-to-nurse consultation for difficult pain management issues. The APS nurse acted as a resource, disseminated research findings and provided staff nurses with ongoing education. The APS nurse also acted as a role model and advocated for greater accountability within nursing for pain management.
The CNA advocates that ANP requires post-basic education and expertise in a specialized area of nursing and meshes the roles of practitioner, educator, consultant, and researcher while providing leadership. 12 ANP competencies fall within clinical, research, leadership, collaborative, and change-agent domains. We found the role of ANP in pain management to be evolving throughout Canada. Two thirds of the nurse respondents were master’s prepared or completing this degree and specialized in acute pain management. The small sample size and lack of registry for APNs working in pain management throughout Canada also reflects this evolution and are two limitations of this study. As a result of this study, nurses throughout Canada who specialize in pain management now meet through a Web-based e-mail group. The authors suggest that this group continue to build and include any new APNs. A similar Web-based group is also being developed for acute care nurse practitioners to share information and discuss clinical practice issues. Both of these initiatives have provided excellent resources and support for evolving roles in ANP, and they continue to grow.
As part of the broader competencies listed above, the CNA 12 recognizes that the ANP role incorporates coordination, consultation with colleagues and clients, evaluation and documentation of outcomes, use of experience and research to generate knowledge, and dissemination of research. The literature identifies a lack of knowledge regarding pain and its management with both healthcare professionals and patients. This problem further highlights the necessity for increased pain education and greater access to resources, something that nurses in advanced pain practice can provide. We recommend providing a pain-theories course with clinical application for all levels of nursing education, both undergraduate and graduate. Although the University of Toronto provides such a course at the graduate level for those with an interest in pain management, we recommend that advanced pain education be a required component of the core curriculum for ANP.
Nurse respondents indicated that many of the CNA role components were major components of their role in the APS. APNs throughout Canada specializing in acute pain management said their roles contributed to positive outcomes such as continuity of care/holistic care, collaboration and coordination of pain management services, provision of consultation, and resources to patients and staff. They provided ongoing education in pain management to staff, patients, and families and were involved in the dissemination of research, quality improvement initiatives, and patient advocacy. The most frequently identified major outcome of this role was increased patient satisfaction, although the basis for this outcome was not evident. Other studies have focused more directly on outcomes with positive results.
Mackintosh and Bowles 4 found that the introduction of a clinical nurse specialist in a nurse-led APS positively influenced pain management practice within the institutions. Specifically, they found that patients reported less pain, and that the clinical nurse specialist was able to standardize postoperative analgesia prescribing practices. These changes led to an improvement in the quality of pain management that patients received. Rawal 3 stated that specialized nurses with training in pain management bridged the gap between doctors and nurses, directed resources, provided pain management education to staff and patients, and helped to initiate and monitor analgesia.
Three key responsibilities of the role identified by the sample included patient rounds and staff and patient education. A large portion of the role involved independent practice. Gordon et al 5 described a nurse-run in-patient pain management consultation service in a US hospital. The outcomes of this program were identified as improved pain management, a shift in staff focus from concerns about addiction to questions regarding the improved management of pain, the ability to bring learning to the beside, support provided to staff, and role modeling. 5 ANP respondents to our survey described their ability to support nurses and provide nurse-to-nurse consultations as a benefit to their role. Collaboration with other colleagues, such as anaesthesiologists, pharmacists, physical therapists, social workers, and patoral care continues to be pivotal to quality pain practice.
Although challenges were identified related to insufficient support and role clarification, most identified positive outcomes for themselves, patients, and the interdisciplinary team. Administrative support is necessary for the initial development and implementation of the role. As well, continued support and institution-wide visibility, such as committee, research, and educational involvement, are important to the success of the role. Although some components of the role are shared with medicine, it is important to recognize the unique qualities that nursing brings and to not confuse the role with a physician assistant/replacement.
This article describes the expertise of ANP roles as described by nurses working in pain management throughout Canada. These nurses described their responsibilities and highlighted challenges of this role, including lack of support, complexity of pain problems, role definition, and acceptance. The majority identified the ability to provide continuity of care, patient and staff education, and leadership in pain management as important and rewarding aspects of their role. The emerging APS role in Canada falls within the CNA’s definition of ANP.
This article is the first examination of the ANP role in pain management throughout Canada. Further research is needed to clarify the role responsibilities and related outcomes to evaluate the effectiveness of this role in managing pain. Recommendations include further development of a registry or database for ANP roles in pain management to facilitate networking and mentoring of other nurses and healthcare professionals with designated responsibilities and/or an interest in pain management.