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What’s happened to pain management?

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Pain management has been slipping off the nursing agenda and is no longer taught to all nurses. Jennifer Taylor finds out what is being done to give it greater standing

‘If you’ve got an interest in pain, you’ll do a pain module.’ That’s been the situation for nursing students up until now, says Sharon Wood, lecturer in nursing at the University of Leeds.

Leeds is ahead of the game, since nurses taking a diploma or advanced diploma must take a module on pain management – this was previously optional and remains optional for nurses on the degree course.

In Bournemouth, pain in pre-registration training has ‘gradually disappeared’, according to Mandy Layzell, lecturer practitioner for the acute pain service at Poole Hospital/Bournemouth University. The hospital now provides four workshops for nursing students, which are voluntary.

Before Ms Layzell started working at the university there was a structured curriculum for pain, which ran each year. But the style of learning at universities has changed, she says, with an emphasis on e-learning and projects where students choose their own topics and report on their discoveries.

The result is that basic education on day-to-day topics such as pain and diabetes has been squeezed out. Ms Layzell says: ‘There needs to be better teaching in the early stages so they can start learning at a basic level then build up to a more advanced level about pain management.’

A nursing curriculum for pain has been developed by the US-based International Association for the Study of Pain, a body to which the British Pain Society is federated. Nick Allcock, a nurse by profession and an associate professor at the School of Nursing at the University of Nottingham, has a student surveying schools of nursing in the UK to look at uptake of this curriculum. Mr Allcock says it could be used as a guide for determining the essential components of pain management that should be taught to all nurses.

The move will be welcomed. Nurses are ‘desperate for education on pain’, says Ms Layzell. ‘It’s always something nurses, when they’re training and when they first qualify, say that they feel ill-prepared to manage.’

The effect is ‘a huge amount of strain’ when students get their first jobs, since some of the basic knowledge that nurses would have been equipped with years ago is absent. Ms Layzell says: ‘It can be quite a lot to take on in those first few months.’

The situation with pain management education for nurses is indicative of the issue generally, with no national guidance in place and patchy provision of care. Pain is also absent from many national and local policy documents, including those for older people. The situation is at odds with the fact that more than two-thirds of people aged over 65 have some sort of pain issue.

Why the omission? Mr Allcock says: ‘The problem with pain is it’s still essentially viewed as a symptom, so it’s secondary to a lot of the way that we think about healthcare.’ The result is that the national frameworks tend to focus on illnesses such as cancer and coronary disease. ‘Because pain is an element of all those, it doesn’t seem to get flagged up as well,’ he adds.

In 1990 the Royal College of Surgeons of England and the Royal College of Anaesthetists published a report that stimulated the introduction of acute pain teams across the UK. While that improved the provision of acute pain services, with specialist nurses taking a lead in much of the work, it has focused on post-operative pain. On the whole, according to Mr Allcock, services for acute pain management ‘are variable’.

Efforts are being made to push pain up the priority list. Ms Layzell is part of a British Pain Society working group that is developing recommendations for nurses at pre-registration, for HCAs and for advanced nurses, which they plan to have ready for its annual meeting next year.

Ms Layzell hopes the guidance will be practical and link to the Knowledge and Skills Framework ‘so that nurses at all levels can relate to how pain fits into their practice’.

Meanwhile, the RCN Pain Forum is developing an online pain community for RCN members, which will be ‘like a professional Facebook’, says RCN nurse adviser Celia Manson.

The forum is also backing a campaign by the Chronic Pain Policy Coalition to see pain regarded as the fifth vital sign, so its measurement has the same priority as that of temperature, pulse, respiration and blood pressure.

To this effect, the forum has submitted a resolution for consideration by the RCN Congress agenda committee around adopting pain as the fifth vital sign, and they will be holding a fringe event on this topic at congress with the coalition.

The idea originated with the American Pain Society. Mr Allcock says that in the US, pain assessment is included in the standards by which all healthcare facilities are judged. He wants the Healthcare Commission to look at pain and for outcome measures on pain to be included in the standards when services are commissioned from trusts.

At the moment, PCTs assume pain management is within the package of an operation they’ve paid for and there is no clear funding stream for services. Mr Allcock says: ‘As far as the acute trust is concerned, it gets money for doing that operation. So there’s no clear accountability for the pain services to go in there.’

Ms Wood agrees. ‘The PCT would assume that pain was part of the package. But if you have nurses and medics on the ward who haven’t received any education, they may not have the knowledge or the skills or the attitude to be able to give adequate care.’

The lack of outcome measures means that, when managers are faced with competing priorities, pain management can be an easy target of cuts.

NHS reorganisation has added to pain management being in a state of flux, with uncertainty about where services should be based. How should chronic pain management services be balanced in the community and in outpatients? How should services be reconfigured?

Mr Allcock stresses that if more pain management moves into the community, support, training and education will be needed ‘so that it’s not just another thing that’s added on to practice nurses’ roles’.

Ms Wood would like to see more research on pain post discharge from hospital, since patients are tending to go home earlier after surgery and other medical problems.

A shift in attitude is also needed as pain is seen as a natural phenomenon associated with getting older, says Mr Allcock.

Nurses with a specific interest in pain acknowledge that they will always want pain management to have a higher priority.

Ms Manson says: ‘The rewards are terrific, particularly for patients but also for nurses. This is all about job satisfaction, and reminds people of why they became nurses in the first place.’


Pain management in nursing today

- Pain management education for nurses is often optional
- There is no clear funding stream or outcome measure for pain management, so services can be patchy
- Questions remain as to whether pain services should be provided in the community or in outpatients
- Good pain management is rewarding for both patients and nurses
- The Chronic Pain Policy Coalition is campaigning to have pain adopted as the fifth vital sign
- A nursing curriculum for pain has been developed by the International Association for the Study of Pain, and its uptake in the UK is being investigated
- The British Pain Society is developing pain management recommendations for nurses
- The RCN Pain Forum is developing an online pain community
- Nurses who want to submit ideas about what they want the RCN Pain Forum to be doing can email

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