Curbing Patients’ Pain

In May, a patient on an in-patient unit at Cleveland Clinic’s main campus who was upset about his pain management began to verbally abuse the nursing staff. Fearing a physical confrontation, they called a crisis intervention team to assist with the agitated patient. When the unit’s clinical nurse specialist reviewed the prescribed pain regiment, she discovered the patient was receiving 30 percent less medication via the patient-controlled analgesia (PCA) pump compared to what he gets at home from his oral medication.

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The CNS knew where to find the equianalgesic conversion between intravenous and oral medication delivery because of training she received in Cleveland Clinic’s pain mentor program and convinced the physician to increase the dosage. Once the dose was increased, the nursing staff had no more incidences with the patient.

“The mission of pain mentors is to provide bedside nurses with state-of-the-art evidence to best manage patients in pain,” says Catherine Skowronsky, MSN, RN, ACNS, CMSRN, a clinical nurses specialist and pain mentor coordinator. The mentors are frontline nurses who have been on their units for at least one year and have attended a full-day class on pain management. They serve as resources to their colleagues. “If a nurse is having a particularly difficult time managing a patient’s pain, he or she can consult the mentor on the unit,” says Skowronsky. “The mentor offers suggestions to nurses and physicians and can intervene directly with the patient.”

Esther Bernhofer, PhD, RN-BC, a nurse researcher at Cleveland Clinic, teaches the pain mentor training classes quarterly. She covers basic pain physiology, pain assessment and information on acute, chronic and recurring acute pain. She also discusses pharmacologic and non-pharmacologic treatments and the needs of special patient populations, such as children, older adults and people with addiction and substance abuse issues.

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“When nurses become more knowledgeable about pain, its implications, treatments and resource options, they are better able to manage their patients’ pain,” says Bernhofer. “Providing a pain mentor on a unit who is able to go into more depth regarding current pain management issues provides a ready resource in the form of a go-to expert for all nurses.”

Aside from the class, pain mentors also participate in monthly meetings where they receive further education. They might learn about a policy change in the way analgesic orders can be entered by physicians or hear a Reiki instructor talk about how this type of massage can help alleviate pain. But the best part of the meetings is when pain mentors share experiences and ideas. For instance, a bedside nurse in the ICU shared rounding sheets she developed that indicate the patient’s pain regimen and non-pharmacologic intervention options, plus has room for comments. Nurses in the cardiovascular stepdown units adopted the rounding sheets.

Ultimately, pain mentors benefit patients. “Mentors can sit down with patients, develop a plan to manage the pain and offer alternative therapies aside from medication,” says Kelly Haight, MSN, RN, ACNS-BC, a clinical nurse specialist in Cleveland Clinic’s Heart & Vascular Institute (HVI) and a pain mentor coordinator. This, in turn, helps staff nurses. “So much effort can go into managing a single patient’s pain, and that has repercussions for all my other patients,” says Jennifer Colwill, MSN, RN, CCNS, PCCN, who is also a clinical nurse specialist in the HVI and a pain mentor coordinator. “Having someone else there to help out is very important.”

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In 2013, pain mentors rounded on 1,694 patients in 11 HVI units and the surgical ICU at Cleveland Clinic’s main campus. “Eliminating pain is very rarely a reasonable goal. But how low can you go? Nurses really struggle with this gray area,” says Skowronsky. “Pain mentors can educate nurses and help them feel confident to establish a mutually agreed upon acceptable pain level with the patient.”