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PRACTICE COMMENT

'Pain care: overhaul education for the next generation'

Pain is the main reason people seek healthcare. It has a devastating effect on patients and families.

Chronic pain affects one third of adults in England; half of all cancer patients experience moderate to severe pain, and acute pain in all settings continues to be a challenge.

In recent years, international bodies have called for pain assessment and treatment by adequately trained health professionals to be a fundamental human right.

Nurses and other professionals need to be able to competently assess, support and provide interventions for pain management. So, are we educating undergraduates, and what is “adequately trained”?

A 2011 survey of UK universities suggests pre-registration programmes devote an average of only 12 hours to the subject, with learning through lectures and assessment through exams. A similar survey of medical schools in Europe found limited teaching hours, rote learning and a lack of consistency within and between countries.

This is not enough - 12 hours of lectures does not constitute “adequate training”.

We need pain education that enhances skills, knowledge and attitudes, and challenges misconceptions or negative attitudes. It should develop skills in pain assessment, problem solving, clinical decision making, empathy, communication, compassion, critical reflection, advocacy, patient education and teamwork. We need to examine both the process and outcomes of education, ensuring competence in managing pain across the clinical team.

Pain management is interprofessional, it is important that students from different professions learn together and understand each other’s roles in managing pain. Three years ago, King’s College London introduced the UK’s first interprofessional pain training. As well as enhancing knowledge, it provides opportunities to rehearse and refine skills.

There are developments at a national level. Last year, the RCN hosted a roundtable discussion on pain and advancing practice, involving national nursing leaders in pain and RCN forum leaders. They are now working on three areas: evidence for change; pain education; and pain in vulnerable groups. This year, the British Pain Society is to publish guidelines for universities on interprofessional pain education.

Despite these, we still need to engage people in all areas, including non-specialists, clinical nurse specialists, interest groups, universities and the Nursing and Midwifery Council. Improving pain education will need partnerships and a multimodal approach. Partners and local champions have a role in ensuring students have excellent role models, and that pain assessment and management are priorities.

Pain management promotes recovery, prevents deterioration, allows people to fulfil their normal roles and provides comfort. We need to work together to reduce the high incidence of pain and its impact on patients, families and the NHS. Let’s ensure the next generation of professionals are not just “adequately trained” but fully educated and competent to achieve this.

 

Emma Briggs is lecturer and King’s teaching fellow, Florence Nightingale School of Nursing and Midwifery, King’s College London

 

Readers' comments (17)

  • I work in Learning disability nursing. I started some training last year to educate others of the needs of this vulnerable group. I cannot believe that paid carers have no training what so ever in recognising and treating pain. I am also staggered at some of the things people say to me about pain thresholds in this client group. I will continue to educate others as I feel passionate about what I do. I would like to link up with anyone in the Surrey area who is doing similar work?

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  • This is an important issue.
    Several years ago I fractured my tib and fib which needed plates, pins and screws. A fairly common procedure in an orthopaedic ward. At the time, I worked in an orthopaedic ward in another hospital, so was confident that I would receive adequate analgesia. I couldn't have been more wrong! I was in terrible pain from around 2 hours post op until I as discharged the next day. Long story short, I had to ask to see the pain control nurse, who couldn't understand why I had not been given the analgesia as prescribed or offered different prn painkillers. She and I discussed my discharge analgesia and I got on top of my pain when I got home later that day. When I told my colleagues about practice in a similar ward in a hospital only a few miles from us, they couldn't believe it.
    Shortly after, I changed job and worked in a programme working with people with chronic physical and mental health conditions. Chronic pain was one of the biggest issues which was (and is) poorly addressed.
    "Overhaul" is exactly what is required.

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  • there are very few exceptions where pain cannot be adequately managed. this sounds like another typical NHS story of slip shod care. other advanced healthcare systems across Europe and around the world manage it. where are the problems this time with those in the NHS providing 'care'? Their training, attitude and the whole system need investigating and addressing as a matter of the utmost urgency.

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  • i think patients need to be more educated and let professionals know when their pain treatment is not effective enough... so many are given the wrong painkillers for their condition, and suffer from nasty side effects with no medical advantage...
    a family member of mine was crippled from severe sciatica caused from a crumbling spine, and was prescribed co-codamol and naproxen (without PPI) which left her with 95% pain and caused her to lose 4 stone in a few months as the naproxen was ripping her gut apart. I work in oncology and after forcing her to demand some gabapentin from her GP, she can now mobilise comfortably. (she is awaiting rod insertions in her spine).

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  • Anonymous | 18-Jan-2014 12:08 pm
    from
    Anonymous | 18-Jan-2014 11:01 am

    I agree. The correct (not necessarily stronger) analgesia and pain control regime are important.
    Some patients are indeed reluctant to talk about their true level of pain. In my case, I was coherent and explicit about my pain level and suggested the solution which (despite being prescribed adequate analgesia) was consistently ignored by staff who felt that giving me stronger analgesia would keep me in hospital longer and they needed the bed (like I said, I cut a long story short, but that was said to me).
    I also feel strongly that medication is not the only answer. Awareness of causes of exacerbation, teaching self management, etc. are very important especially in chronic pain. We don't learn enough about these things during our Training, and very little subsequently unless we specialise in pain.

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  • michael stone

    Pain 'assessment' is an interesting concept - I am in pain if I'm feeling pain. Pain is patient-assessed, if you follow the logic of everyone being different: I could fairly easily 'go off on one', I suspect, here.

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  • I attended study days as long ago as the early eighties, when I was told that terminal pain, in particular, should always be controlled and that there was no reason for it not to be the case.
    Since then, I have seen many people in dreadful pain, with no apparent attempt to control it. My own Mother was refused her prescribed analgesia by a carer in a care home because he did not think it necessary. I believe that patients in care homes are a vulnerable group as there is a lack of staff with formal training and are at real risk of suffering uncontrolled pain. Anyone being treated for pain should have supervision from personnel trained in pain control.

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  • all pain should have specialist audit, and intervene where ineffective treatment is prescribed. there is no excuse in any area of treatment where this should happen. how can patients think rationally and contribute to their care when they are in pain?

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  • Anonymous | 20-Jan-2014 3:22 pm

    in this day and age we should no longer be hearing accounts such as this.

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  • I don't think nurses can really focus on pain when they are in the middle of giving day to day care. But collecting patient information on patient experience helps.

    We audited pain among post op patients across several wards and found that one particular group having a particular procedure had much worse pain that others and it lasted for longer after surgery. None of the ward nurses, even the most experienced, had been aware of this group having such a bad experience.

    While it was a disturbing finding, we were able to take our results to surgeons and anaesthetists and pain specialist teams. Working together, they were able to find a solution for a problem none of us had realised before we collected formal data. Patient experience is improved now.

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  • michael stone

    Anonymous | 20-Jan-2014 9:29 pm

    I agree - although if someone refuses pain relief, they have made a decision which is theirs to make. But:

    'Since then, I have seen many people in dreadful pain, with no apparent attempt to control it.'

    simply isn't on, if patients are asking for pain relief and effective pain relief isn't being provided.

    But there is an unresolved [legal] issue with terminal pain relief, which is complicating things:

    http://www.dignityincare.org.uk/Discuss_and_debate/Discussion_forum/?obj=viewThread&threadID=680&forumID=45

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  • MS

    from Anonymous | 20-Jan-2014 9:29 pm

    where in my post did I mention patients who refuse pain relief. that is an entirely different matter and their right to do so! don't cloud the issue.

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  • michael stone

    Apologies Anonymous | 22-Jan-2014 9:14 pm - I misread the post at Anonymous | 20-Jan-2014 3:22 pm

    I thought I read 'my mother refused pain relief' instead of what it actually said - 'My own Mother was refused her prescribed analgesia by a carer in a care home because he did not think it necessary.'

    I had incorrectly scanned that as 'My own mother refused her prescribed analgesia because she did not think it necessary' - my fault entirely.

    It is not the role of a carer, to decide that prescribed pain relief is not necessary - totally out of order.

    I also apologise to Anonymous | 20-Jan-2014 3:22 pm for my misreading.


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  • MS

    from Anonymous | 20-Jan-2014 9:29 pm

    thanks for the clarification

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  • michael stone

    Anonymous | 24-Jan-2014 1:33 pm

    I'm perplexed by how easily I can misread things, and it isn't invariably down to rushing, either.

    I'm also baffled by why I find it easier to spot my typos and bad spelling, AFTER I've sent the e-mail !

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  • It is vital that patients are properly assessed and listened to. Having lived with chronic pain for many years I am shocked by what I have found when admitted to hospital and following surgery. Frequently I have been told I don't need any additional pain relief for acute pain, others think they know best and try to alter my regular medication for chronic pain. Drugs are rarely given on time, especially if prescribed controlled ones. I dread being admitted and have had to become resourceful in not handing over medication so that if able can take it at the correct time to control the pain. I have met excellent nurses who are happy to hand over control, only to be stopped by a pharmacist locking the box. How are we expected to manage once discharged?
    It is vital that pain management education is given to all staff. Where feasible the patient should be able to self medicate, and better ways must be found to give drugs on time, including refilling syringe drivers. Expert help must be available at evenings, weekends and bank holidays. It is vital that pain assessment is carried out and acted on, and better ways found to help vulnerable patients.
    There is reluctance by some to use morphine type drugs for fear of dependence though evidence to show that this is unlikely when used for acute pain. Some are reluctant to send people home on it, but with early discharge being the norm, it is vital that its use should be considered with careful instruction on how to cut back when pain levels allow.
    There are some who think that generic versions of analgesic drugs are all the same, but even the side effects of many are different , especially longer acting preparations . More research is needed in this area on patient reported outcomes on pain control and side effects especially in their use in chronic pain. Local restricted formulary insisting on generic prescribing plays havoc with good pain control and ability to function.

    Hopefully things will improve!

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  • michael stone

    Anonymous | 24-Jan-2014 4:17 pm

    I am pretty-much 100% with you. That is why my first comment to this piece was:

    'Pain 'assessment' is an interesting concept - I am in pain if I'm feeling pain. Pain is patient-assessed, if you follow the logic of everyone being different: I could fairly easily 'go off on one', I suspect, here.'

    The point you make here falls in to the 'very difficult to measure - hence frequently ignored by the NHS' category, I suspect:

    'There are some who think that generic versions of analgesic drugs are all the same, but even the side effects of many are different , especially longer acting preparations . More research is needed in this area on patient reported outcomes on pain control and side effects especially in their use in chronic pain. Local restricted formulary insisting on generic prescribing plays havoc with good pain control and ability to function.'

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