\n| Poor knowledge<\/p>\n Reluctance to assess pain<\/p>\n Fear over use of pain drugs<\/p>\n Suspicion over patient motives<\/p>\n Other priorities\/workload<\/p>\n Lack of awareness of patient needs<\/td>\n | Fear of side effects<\/p>\n Fear of toxicity\/overdose<\/p>\n Fear of addiction<\/p>\n Anxiety about cause of pain<\/p>\n Stoical nature<\/p>\n Anxious to be a good patient<\/td>\n | Poor communication<\/p>\n Unhelpful ward ethos\/hierarchy<\/p>\n Workload<\/p>\n Lack of staff (medical and nursing)<\/p>\n Poor prescribing practices<\/p>\n Institutional constraints<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n <\/p>\n Specialist nurses are those who are educated to a higher than normal level in a particular field.\u00a0 These nurses have a responsibility to educate staff and patients and to undertake more complex assessment and management activities.\u00a0 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.\u00a0 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.<\/p>\n This system has been in place for many years and has shown benefits in specialities such as infection control, diabetes, dysphagia, and palliative care.\u00a0 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.<\/p>\n 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.\u00a0 An integrative review by Crawford et al (2016) suggest the following benefits of a pain resource nurse programme:<\/p>\n \n- Improved comfort of nurses with opioid administration<\/li>\n
- Improved documentation<\/li>\n
- Increased assessment and reassessment of pain<\/li>\n
- Increased analgesia administration\/pain interventions\/appropriate use of analgesia<\/li>\n
- Improvements in patient and nurse knowledge\n
\n- Improved patient perception of control over pain<\/li>\n<\/ul>\n<\/li>\n
- Increased local pain education and use of protocols<\/li>\n
- Improved collaboration between physicians and nurses<\/li>\n
- Reduced post-operative complications<\/li>\n
- Enhanced job satisfaction\/reduced staff turnover<\/li>\n
- Improved ability to advocate for patients<\/li>\n<\/ul>\n
While this sounds like a ringing endorsement the level of evidence in support of each of these benefits is slight, and sometimes only anecdotal.\u00a0 Ladak et al (2013) added a leadership element to the pain resource nurse programme they used.\u00a0 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.\u00a0 The PRNs in this study didn\u2019t feel acknowledged for the additional training they had undertaken.\u00a0 Other nurses wanted them to be able to prescribe and were frustrated when they couldn\u2019t do this, and there was tension between the medical and nursing goals for the patient and pain. <\/em><\/p>\nThis 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.\u00a0 While generalist nurses don\u2019t 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).<\/p>\n |
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