Testimony delivered by Ann Purchase, Associate Director, New York State Nurses Association Practice & Governmental Affairs Program to the NYS Assembly Health Committee Hearing, Wednesday, Jan. 26, 2005.
On behalf of over 33,000 registered nurses represented by the New York State Nurses Association (NYSNA), I appreciate the opportunity to address the subject of pain management, an issue that is of great concern to us as well as to the Assembly Health Committee. NYSNA supports efforts to develop policy for pain management, as well as to address barriers to effective pain control. There are concerns and limitations with the proposed legislation, however, that I would like to discuss.
While we acknowledge providers’ concerns about possible criminal liability or professional discipline related to their prescriptive practices for pain control, we offer comments on the proposed legislative approaches.
A number of initiatives have been mounted in the recent years in an effort to provide all patients better control over various sources of pain. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added pain as the “fifth vital sign,” which should be diligently monitored along with blood pressure, pulse, and temperature (JCAHO, 2004). Nurses assess, evaluate, and document levels of pain at regular intervals throughout the day. The JCAHO standards support the premise that all patients have a right to ongoing assessment and management of pain. These include the following:
The JCAHO standards emphasize an organization-wide commitment to pain management and place the responsibility for education of patients, residents, and family members with the healthcare organization. JCAHO accreditation is designated to healthcare organizations that are in compliance with standards and includes not only hospitals, but home health, hospice, nursing homes, behavioral health, and outpatient clinics (JCAHO, 2004).
We have reviewed fourteen states in which pain management has been addressed, either in statute, code, or regulation. Most of the states restricted the context of pain management to that of “intractable” pain, generally defined as a pain state in which the cause of pain cannot be removed or otherwise treated and for which no relief or cure has been found after reasonable efforts by a physician.
The proposed New York legislation does not define pain, so we assume that lawmakers recognize that all pain should be treated vigorously. Nurses are educated that pain is personal for each patient, which emphasizes the importance of treating all types and levels of pain. Pain management, and education about pain management, should not be limited to pharmacological intervention. Given the myriad of sources for pain and the individuality with which a patient responds to pain and its treatment, pain standards should not be confined to one national set of standards or guidelines.
Both California and Tennessee view effective pain management and involvement in decisions about pain control as a patient’s right. Tennessee statute states that a patient “…who suffers from severe chronic intractable pain has the option of choosing opiate mediations to relieve severe chronic intractable pain without first having to submit to an invasive medical procedure (such as surgery, implantation of a drug delivery system or device or nerve or other tissue injury) as long as the prescribing physician acts in conformance…with the provision of Tennessee law regarding the prescription of opiate medications” (Tennessee Intractable Pain Treatment Act, 2001).
It is also interesting to note that New Mexico and Tennessee address medical documentation. In New Mexico, the Medical Board of Examiners determines the appropriateness of prescriptive practices for pain, based upon documentation; appropriate diagnosis and evaluation; appropriate medical indication for the treatment prescribed; change or persistence of the medical indication; and follow-up evaluation with appropriate continuity of care. The Board judges the validity of the prescribing based on the practitioner’s treatment of the patient and available documentation, rather than on the quantity and chronicity of prescribing. Tennessee also has language that references guidelines for maintaining accurate and comprehensive medical records when treating for acute and chronic pain. Effective communication can serve to reduce the healthcare provider’s fear of civil litigation and possible professional discipline, keeping in mind that each patient’s pain is unique, as is their response to pain protocols.
NYSNA supports the belief that patients should be active participants in determining the most effective management for their pain. We concur that “appropriate assessment and management of pain is a patient right as well as a professional and ethical responsibility” ( Massachusetts General Hospital , 2003a & 2003b). This belief is also supported by the American Nurses Association, which has stated, “increasing titration of medication to achieve adequate symptom control, even at the expense of maintaining life or hastening death secondarily, is ethically justified” (ANA, 1991). It is also expected that healthcare professionals will educate family members about methods of pain relief and include them in the patient’s plan of care.
Nurses engage in practices that prevent illness; alleviate suffering; and protect, promote, and restore the health of individuals, families and populations (ANA, 2003b). In fulfilling their professional obligations, registered nurses are most often in the best position to assess the need for pain control and management.
Not unlike physicians, registered nurses learn about pain and pain management as part of their basic education. NYSNA recently conducted a survey of New York nursing schools, including diploma, associate degree, baccalaureate, and master’s degree programs (with a response of 30). Findings revealed that pain management is integrated throughout the curriculum, with the majority stating that pain management content is included in every nursing course. Some programs provided experiences and seminars in hospice settings, while others devoted an entire course to effective pain management. The director of one nursing program stated, “Nursing education does a stellar job at teaching the role of nurses in pain management,” and added that there is no need for a legislative mandate for nursing education in this area.
Of the 14 states that have pain management legislation or regulations, just one mandates medical education. Tennessee requires providers to have available documentation that reflects specialized training in pain management. A proposed New York provision for provider exemptions from mandated education could prove to be burdensome.
NYSNA supports lifelong learning as an essential component of continued professional competence. We believe that continuing education should be a mandatory requirement for all RNs applying for re-registration. Furthermore, NYSNA believes that continuing education in nursing should be directed to the RN’s area of practice (ANA, 2003, p.11.) Rather than prescribing the type or content for professional continuing education, NYSNA and ANA support the concept that nurses are self-regulated. Between self-regulation and the professional obligations associated with licensure, RNs have a personal accountability for the knowledge base necessary for their professional practice. We suggest the choice of continuing education courses should be the responsibility of the healthcare professional rather than a mandate by the state.
It has been suggested that attitudes, on the part of both healthcare professionals and patients, are barriers to effective pain management. Education may not be the best method of improving compliance with pain management if attitudes and beliefs are hindering appropriate use of analgesia. As early as the 1960s, social psychologists found that education alone does not result in a change of attitudes or behavior (Myers, 2002).
Avoid mandating specific education requirements for pain management. Initial education of healthcare professionals is the responsibility of professional education programs. After entry into practice, the obligation rests primarily with the licensee to seek the necessary education and training required for safe, competent practice and quality patient outcomes. Healthcare providers have an ethical and professional obligation to be knowledgeable about current pain standards and guidelines in their areas of practice. Healthcare organizations also are obligated to their patients and to the professionals they employ to demonstrate a commitment to ongoing and effective pain assessment, management, and evaluation. The choice of which pain management programs a healthcare professional completes should be the decision of the practitioner, based upon their area of specialization and the needs and desires of the patients they serve.
Support professional and specialty organizations in continued research and development of evidence-based pain standards and guidelines for acute pain, chronic pain, cancer pain, arthritic pain, burn pain, and all pain. It would be impossible for one national body to develop a pain management education program that would include all of the pharmacologic and non-pharmacologic methods for effective pain management. The Robert Wood Johnson Foundation recently awarded a $350,000 grant to a New Jersey facility that made an impact on end-of life care by making palliative care a vital part of care provided in the ICU (Trossman, 2004).
The End-of Life Nursing Education Consortium (ELNEC) is a nation-wide consortium funded by the Robert Wood Johnson Foundation and the National Cancer Institute and partnered with the American Association of Colleges of Nursing and the City of Hope National Medical Center. The consortium is responsible for creating a core of nursing educators that are integrating end-of life care into the basic nursing curriculum. In just four years, faculty from approximately one third of undergraduate nursing programs in the U.S. have participated and more than 500 clinical educators, pediatric palliative educators and oncology nurse educators have been trained (American Association of Colleges of Nursing, 2004).
Effective pain management is much more than pharmacological agents; considerations must be given to alternative and complementary therapies with support for additional research and development of standards. Standards and guidelines developed and shared with healthcare professionals should be extended to non-pharmacological, complementary, and alternative methods for pain management including massage, acupuncture, chiropractic, physical therapy, Reiki therapy, yoga, and aroma therapy. The use of complementary therapies has increased dramatically in recent years and research funding is supported by the National Institute of Health at its National Center for Complementary and Alternative Medicine, established by Congress in 1998 (National Center for Complementary and Alternative Medicine, 2005). The use of medicinal marijuana for pain that is uncontrolled by other pharmacologic and non-pharmacologic means is supported by NYSNA. The proposed legislation’s mandate for pain education falls short in the area of non-traditional methods. A failure of professionals to recognize alternative and complementary methods for pain management will result in patients seeking care from unlicensed individuals, leaving them vulnerable to inadequate care.
Acknowledge the importance of patients in the process of managing their pain. Consider this a patient’s right to choose. Patients are the ultimate authority on the effect of pain on their physical, social, spiritual, and psychological health. They are the best judges of the success of treatment in terms of their quality of life. Assessment of the individual needs of patients and support for their personal beliefs and rights should be the emphasis of policy related to pain management.
Appropriate staffing levels and the elimination of mandatory overtime are critical to effective pain assessment and management. Much of pain assessment and management begins in a healthcare setting such as a hospital or nursing home. It is the RN who assesses for evidence of pain, communicates with the provider, executes the provider’s order for pain, monitors the patient’s response to the intervention, evaluates for the effectiveness of the intervention, and provides documentation in the medical record. Nurses also provide education to patients and families about their pain and pain management. Inadequate staffing and mandatory overtime reduce the likelihood that patients will receive timely assessments and interventions.
In conclusion, NYSNA believes that professional licensure gives a healthcare provider the responsibility to attain the knowledge essential to the provision of safe, competent care. Although we support mandatory continuing education, selection of education should be made by the professional. Research to gather evidence-based data should continue to be encouraged to support prescribers’ selection of pain regimens while protecting patients’ choices and responses.
Nurses are essential to effective pain management through their role in assessment; provision of interventions, both pharmacological and non-pharmacological; monitoring and evaluating response to interventions; and documenting and communicating findings with the prescriber. Inadequate staffing interferes with optimal pain management and desperately needs to be addressed.
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Myers, D. (2002). Social psychology. Boston , MA : McGraws-Hill.
National Center for Complementary and Alternative Medicine. (2005). About the National Center for Complementary and Alternative Medicine. Retrieved January 20, 2005 from http://nccam.nih.gov/about/aboutnccam/index.htm
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Tennessee Intractable Pain Treatment Act, 63 Tennessee Statutes, Chapter 6, Part 11 – Intractable Pain Treatment (2001).
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For more information, contact Governmental Affairs at 518.782.9400, ext. 283 or by e-mail.