Helen Taylor, BA (Hons), RN.
Acute Pain Control Co-ordinator, Warwick Hospital, Warwick
The Acute Pain Service (APS) at the 400-bed Warwick District General Hospital achieved a Charter Mark in February 2000. This was in recognition of identifying the patient as the main user of the service and of involving the patient in further development and monitoring. The importance of good patient information took on a new meaning and, as a result, the APS team has implemented a more open and responsive approach. This article describes the development of the pain service and what we consider constitutes good patient information. It also evaluates the outcome of providing good information to patients undergoing surgery.
The development of specialist acute pain services has been structured by the aims and recommendations of a Royal College of Surgeons and the College of Anaesthetist’s (1990) report on the provision of surgical services, which found that pain control after surgery was inadequate (RCS/CA, 1990). The aim of the working party report was to improve the treatment of postoperative pain in hospitals. Their recommendations included:
- To improve staff education and challenge traditional attitudes to postoperative pain relief
- To assess and record pain systematically, involving the patient whenever possible
- To introduce new methods and utilise existing ones more effectively, giving due regard to safety.
Bringing about any change in clinical practice is a challenge. Like many other pain teams the APS implemented the recommendations of the working party report through a process of consultation and choice that was driven by the clinical audit cycle. Audit data was collected in order to highlight existing good practice and also to identify pain-management problems. The audit results were then shared with the clinicians involved, and the APS facilitated problem-solving by negotiating agreed protocols and developing staff training programmes.
A communication network was established to ensure that good communication between the APS and between all staff caring for surgical patients was maintained. Repeat audits evaluated any change in practice and the results of these demonstrated that safe improvements in pain control had taken place.
The positive outcome of the work of the APS motivated an application for the Charter Mark. To achieve a Charter Mark, public services are required to meet 10 criteria (Box 1).
Focusing on patients
The philosophy of the Warwick APS is to empower the staff at the patient’s bedside to manage pain effectively. Consequently, the Warwick APS, while acknowledging that the patient is central improving pain control after surgery, initially focused on staff as the main users of the APS and felt that all 10 of the Charter Mark criteria were met as far as staff were concerned.
However, the criteria were not met if patients were viewed as the main users of the APS. For example, although patient-information leaflets were available on specific pain-relief techniques, patients were not given open and full information about the APS and were not consulted and involved in the development of the service. On reflection, this was illogical. Pain is a primary concern for patients undergoing surgery (Audit Commission, 1997) and they appreciate written as well as verbal information, which can reduce both anxiety and pain postoperatively (Audit Commission, 1998). Informing patients of the aims and objectives of the APS can reduce their anxiety about how pain will be managed after surgery and help ensure that they make use of all available resources to relieve pain.
The patient information provided
To address the need to provide open and full patient information the APS produced a booklet (Warwick Hospital Information Service, 1999), with the assistance of a pharmaceutical company, that was distributed to all GP practices and community nurses in the area and made available on the Internet (www.swpgc.org.uk/surgical/pain). The booklet explains both the aims of the APS and the specific pain-management strategies that were available to patients after surgery. This allows doctors and nurses in the primary sector to talk to their patients in an informed way about how pain will be/was managed after surgery. The website is due to be extended, with links to the hospital intranet, which has an extensive APS site that includes all protocols and patient information.
A second document was devised to inform patients about the intended outcomes of the ward standard to manage pain after surgery (Warwick Hospital Acute Pain Service, 1999) (Box 2).
This document also explains the pain score used by staff in the surgical wards to assess pain and patients are encouraged to use it. General information about the options that are available for pain relief after surgery is also included, along with APS contact details and an invitation to offer suggestions and comments on the service. The ward staff are invited to make this information available to patients - some wards send it out with the admission letter and others make it available in the ward after admission. A specific patient-information leaflet is available once the method of pain relief has been chosen during the anaesthetist’s pre-operative assessment.
Patient information guidance
Since the introduction of The Patient’s Charter (DoH, 1991) and The Health of the Nation (DoH, 1992), there has been a requirement to provide written information for patients. There are now NHS guidelines available for conveying good patient-information (DoH, 2001). These state that all communication must follow NHS values and be clear, cost-effective, straightforward, modern, accessible, honest and respectful.
The NHS identity guidelines include sections on the structure of patient communications to ensure that information will be complete, easy-to-read and understand. Several trusts now produce their own patient-information leaflet templates that are designed to be consistent with the new NHS identity and give them a professional image.
Many trusts are members of the Clinical Negligence Scheme for Trusts (CNST), which provides a lower insurance premium for level 1+ status. Level 1+ status requires patient information to explain appropriate risk and benefit information and must be evidence-based. The CNST recommendations are based on guidance from several professional bodies, including the General Medical Council (1998) (Box 3).
The cost of providing good patient information is high in terms of both money and time. Decisions need to be made about how the information is to be funded, supplied, presented, stored and distributed. Professional interest groups, charities, companies and the Internet are potential resources. It is worth looking around to see what is already available before producing in-house information from scratch.
It is important that all concerned, including the patient, are involved in the approval of the final text to ensure that the information is accurate, readable and understandable. As a general rule, words and sentences should be short with only one or two clauses where possible. Jargon must be avoided and medical terms explained in plain English. The Plain English Campaign offers advice on this. In order to satisfy equal opportunity requirements, analysis should be undertaken to identify the need for patient information in foreign languages, in Braille or on cassette tape.
Plans should also be prepared to evaluate the outcome of providing the patient information and to ensure that patients continue to receive and understand it. An annual review is advised to ensure that information remains up to date.
The APS distributes a questionnaire to patients before discharge, which includes information on the aims of the service. Patients are asked if they were given verbal and written information on pain control and if they understood the information given. In addition, they are asked:
- Was the pain assessed?
- Was the assessment tool easy to use?
- How effective was the pain relief received?
Patients are also asked about staff attitudes, such as whether staff are helpful and polite. Communication skills are an important part of pain assessment, so staff attitudes are significant.
Patients are also asked for their opinions on planned changes, such as patient self-administration of analgesia and there is space for comments at the end of the questionnaire. This has allowed the APS to make appropriate changes at the patients’ request, such as including a diary facility with the information leaflet on the self-administration of oral painkillers.
The results of the audits are made available in the wards and are displayed in the corridors of the main hospital. This is intended to reassure patients that their pain will be recognised and managed. The audits have allowed the APS to demonstrate that the trust meets the RCN clinical practice guidelines for the recognition and assessment of acute pain in children (RCNI, 1999). This work appears as an example of best practice on the Modernising Public Services Group website (www.servicefirst.gov.uk). The benchmarking of pain assessment is also being facilitated.
Clinical audit has demonstrated the positive outcome of establishing acute pain teams. Acute pain teams are in an ideal position to promote good patient information on pain control after surgery and it has long been accepted that good patient information can reduce anxiety and pain postoperatively. When this is expanded to include full and open information about the acute pain service and patients are involved in service development, the result is a more responsive service that demonstrably meets patients’ needs.
Guidelines on the development of patient information are available to ensure that the information provided follows NHS values. Providing good patient information can be costly and requires careful planning. However, the benefits to the patients and service providers can be numerous and well worth the effort.
The author would like to thank J.H.L Antrobus, Consultant Anaesthetist, responsible for the APS; The Trust Board, Warwick Hospital; The Department of Clinical Effectiveness; John Stack and Carl Holland, Department of Nursing and Quality; Keith Reynolds, Risk Manager; and all members of the multidisciplinary team caring for surgical patients.
Details on Charter Mark Awards may be obtained from The Cabinet Office, Horse Guards Road, London SW1P 3AL. Website: www.servicefirst.gov.uk
Audit Commission. (1997)Anaesthesia Under Examination. London: Audit Commission Publications.
Audit Commission. (1998)Managing Pain after Surgery: A booklet for nurses. London: Audit Commission Publications.
Department of Health. (1991)The Patient’s Charter. London: The Stationery Office.
Department of Health. (1992)The Health of the Nation: A strategy for health in England. London: The Stationery Office.
Department of Health. (2001)NHS Identity Guidelines. London: The Stationery Office.
General Medical Council. (1998)Standards of Practice. London: GMC.
Modernising Public Services Group.Service First. Charter Mark Guide for Applicants. London: Cabinet Office.
Royal College of Surgeons of England/College of Anaesthetists. (1990)Commission on the Provision of Surgical Services. Report of the Working Party on Pain after Surgery. London: RCS/CA.
Royal College of Nursing Institute. (1999)Clinical Practice Guidelines. The recognition and assessment of acute pain in children. London: RCN.
Warwick Hospital Acute Pain Service. (1999)Managing Pain After Surgery. Warwick: Warwick Hospital Acute Pain Service.
Warwick Hospital Information Service. (1999)Introduction to the Acute Pain Service. Warwick: Warwick Hospital Information Service. Also available at: www.swpgc.org.uk/surgical/pain.