Pain resource nurses: do they help to improve pain management in the acute hospital setting?

 

This week’s EBN Twitter Chat will focus on the role of the link nurse or resource nurse.  Although this blog post focuses on the role and evidence relating to pain, link nurses, champions, or resource nurses are common to many specialities and I hope that you will joint us to talk about pain, infection control, breast care, stoma care, palliative care, tissue viability and a host of other areas where a highly specialised nurse tries to effect improvements in patient care though a nominated link to a ward or other clinical area.

I will be leading the chat on 6 June between 8 and 9pm (GMT).  To join in the chat please add #ebnjc to your tweets.

 

 

Nurses, and no doubt other healthcare professionals, feel disempowered when unable to help someone who is in pain (Slatyer et al. 2015). There are innumerable barriers to providing effective health care, with poor knowledge, poor communication, and lack of shared team goals being key themes (Table 1).

Table 1: Some of the factors that contribute to poor pain management

Nurse

Patient

Other

Poor knowledge

Reluctance to assess pain

Fear over use of pain drugs

Suspicion over patient motives

Other priorities/workload

Lack of awareness of patient needs

Fear of side effects

Fear of toxicity/overdose

Fear of addiction

Anxiety about cause of pain

Stoical nature

Anxious to be a good patient

Poor communication

Unhelpful ward ethos/hierarchy

Workload

Lack of staff (medical and nursing)

Poor prescribing practices

Institutional constraints

 

Specialist nurses are those who are educated to a higher than normal level in a particular field.  These nurses have a responsibility to educate staff and patients and to undertake more complex assessment and management activities.  The system relies of a cascading effect where the higher level knowledge and skills of the specialist nurse permeate to those who work more closely with the patient. This usually involves specifying a link nurse, key nurse, resource nurse, or champion in the clinical area, who has additional training and a close relationship with the specialist.  The linking nurse carries a responsibility to raise the profile of the specific issue, to influence, to educate, and to motivate staff, thereby enhancing practice.

This system has been in place for many years and has shown benefits in specialities such as infection control, diabetes, dysphagia, and palliative care.  In many cases the link nurse/resource nurse role has helped to improve local practice but there are some doubts about the degree to which this happens and the role of influencer or change agent is complex and challenging.

A popular model in pain management is that of the pain resource nurse (PRN). Ferrell et al (1993) developed a 40-hour didactic programme to prepare nurses for this role. Those who completed the course were evaluated at 3 months and felt more confident, more aware of patients in pain, and were better able to facilitate good pain management.  An integrative review by Crawford et al (2016) suggest the following benefits of a pain resource nurse programme:

  • Improved comfort of nurses with opioid administration
  • Improved documentation
  • Increased assessment and reassessment of pain
  • Increased analgesia administration/pain interventions/appropriate use of analgesia
  • Improvements in patient and nurse knowledge
    • Improved patient perception of control over pain
  • Increased local pain education and use of protocols
  • Improved collaboration between physicians and nurses
  • Reduced post-operative complications
  • Enhanced job satisfaction/reduced staff turnover
  • Improved ability to advocate for patients

While this sounds like a ringing endorsement the level of evidence in support of each of these benefits is slight, and sometimes only anecdotal.  Ladak et al (2013) added a leadership element to the pain resource nurse programme they used.  They undertook a qualitative evaluation with the PRNs 18 months after the programme and found that they were doing a lot of direct work with patients, for example explaining medication to them, and supporting and trouble-shooting for nursing staff.  The PRNs in this study didn’t feel acknowledged for the additional training they had undertaken.  Other nurses wanted them to be able to prescribe and were frustrated when they couldn’t do this, and there was tension between the medical and nursing goals for the patient and pain.

This calls into question whether the PRN can disseminate good practice effectively or takes over elements of the specialist role that would previously have triggered a referral.  While generalist nurses don’t necessarily de-skill there is little evidence that their skills are developed by the current model of specialist and link nurse working practices (Jack et al. 2002, Mytton and Adams 2003).

Questions for our chat…

  1. Does the introduction of link nurses/resource nurses improve levels of knowledge, confidence and competence in generalist nurses?
  2. Is the pain resource nurse program a good model?
  3. Why does education fail to cascade to the wider team?
  4. What are the continuing challenges that might prevent a PRN from achieving improved pain management in a specified area?

References

Crawford, C.L., Boller, J., Jadalla, A. & Cuenca, E. (2016) An Integrative Review of Pain Resource Nurse Programs. Critical Care Nursing Quarterly, 39(1), 64-82.

Ferrell, B.R., Grant, M., Ritchey, K.J., Ropchan, R. & Rivera, L.M. (1993) The pain resource nurse training program: a unique approach to pain management. Journal of Pain & Symptom Management, 8(8), 549-56.

Jack, B., Oldham, J. & Williams, A. (2002) Do hospital-based palliative care clinical nurse specialists de-skill general staff? International Journal of Palliative Nursing, 8(7), 336-40.

Ladak, S.S., McPhee, C., Muscat, M., Robinson, S., Kastanias, P., Snaith, K., Elkhouri, M. & Shobbrook, C. (2013) The journey of the pain resource nurse in improving pain management practices: understanding role implementation. Pain Management Nursing, 14(2), 68-73.

Mytton, E.J. & Adams, A. (2003) Do clinical nurse specialists in palliative care de-skill or empower general ward nurses? International Journal of Palliative Nursing, 9(2), 64-72.

Slatyer, S., Williams, A.M. & Michael, R. (2015) Seeking empowerment to comfort patients in severe pain: a grounded theory study of the nurse’s perspective. International Journal of Nursing Studies, 52(1), 229-39.

 

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