Recently I attended a meeting of the local chapter of the American Correctional Health Services Association and heard a presentation about a program to manage chronic pain in the correctional setting. Even though nurses deliver the majority of care in the correctional setting no nurses were involved in this program; it was a completely physician- driven model of care. It made me wonder why nurses are not collaboratively managing clinical care of patients with chronic pain. What role do correctional nurses have in addressing patient’s chronic pain?
The Institute of Medicine (IOM) identified pain management as an essential responsibility for nurses (Relieving Pain in America, 2011). This responsibility is more than simply carrying out the provider’s treatment orders; it includes implementation of nursing interventions to manage and reduce a patient’s experience of pain. Interventions that are within the independent scope of nursing practice include non-pharmacologic measures to manage symptoms and assist the patient with coping.
The National Commission on Correctional Health Care (NCCHC) adopted a position statement October 2011 recognizing that chronic pain requires more than just determining which medications are appropriate. The position statement emphasizes a multifaceted approach to chronic pain using a biopsychosocial model that includes evidenced based therapeutic options. The NCCHC’s position statement can be obtained at http://ncchc.org/resources/statements/chronic_pain.html. The Institute for Clinical Systems Improvement (ICSI) recommends that treatment plans for chronic pain include:
- The patient’s personal goals regarding quality of life
- Sleep improvement
- Increased physical activity
- Stress management
- Decreased levels but not elimination of pain (2011).
There are a number of non-pharmacologic approaches to improve sleep, increase activity and manage stress but which ones have the best evidence to support their use? The ICSI and the Registered Nurse Association of Canada (RNAO) are two organizations that evaluate the research and publish recommendations regarding chronic pain on a periodic basis. There is strong evidence to incorporate the following interventions into the plan of care for patients who have chronic pain. Each is within the nursing professions’ scope of practice.
Exercise: Exercise provides physical reconditioning, elevates mood, increases functionality and helps maintain mobility. No one type of exercise is more effective than another. Nurses can recommend, teach, coach and supervise patient exercise. No referral to a physical therapist or recreation specialist is needed. No special equipment or facility is needed.
Relaxation: Helpingpatients incorporate relaxation techniques into their daily life has been found to improve treatment adherence, reduce anxiety, and enhance pain tolerance. Relaxation techniques include massage, use of heat or cold, meditation, imagery, diaphragmatic breathing, autogenic training, progressive muscle relaxation and music. Relaxation decreases physical tension, increases oxygenation and circulation, lengthens and relaxes muscle fibers.
Cognitive behavioral change: This intervention is considered by the ICSI to be the most effective non-pharmacologic tool in managing chronic pain. Cognitive change involves restructuring the patient’s view of pain and increases the patient’s coping strategies. It involves finding ways to change habits or beliefs by experimenting with different ways to solve problems. The nurse assists the patient to develop goals for change, a plan to accomplish the goal incrementally and periodic coaching and follow up on progress.
The recommendations and evidence for these interventions can be found at these sites:
- Institute for Clinical Systems Improvement, (2011) Health Care Guideline: Assessment and Management of Chronic Pain. Retrieved 4/15/2012 at http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline_.html
- Registered Nurses Association of Ontario. (2002, Supplement 2007). Assessment and Management of Pain. International Affairs and Nursing Best Practice Guidelines Program. Toronto: Registered Nurses Association of Ontario. Retrieved 4/14/2012 at http://rnao.ca/bpg/guidelines/assessment-and-management-pain
Here are some great resources about non-pharmacologic approaches to pain:
Chapter 13 of the Essentials of Correctional Nursing has more discussion about the nurses’ role in managing pain and the challenges of doing so in the correctional setting. If you would like to share your successes incorporating non-pharmacologic approaches into the treatment of patients with chronic pain please use the comments section of this post? You may also want to attend the session on this subject at the National Conference on Correctional Health Care in Las Vegas on October 22, 2012 (registration information is at http://ncchc.org/education/national.html). If so, see you there!
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