30th Anniversary Invited Editorial reflecting on: Copp L.A. (1993) An ethical responsibility for pain management. Journal of Advanced Nursing 18, 1–3
We were challenged ‘to manage pain as an ethical and professional imperative’ in Copp's (1993)JAN Editorial. Since this call to action, we now have high quality evidence about what works in pain management (Bandolier 2006), but patients still experience moderate to severe pain (Dolin et al. 2002, Watt-Watson et al. 2004a) and the consequences of this can be long lasting and severe (Perkins & Kehlet 2000). It is clear that we are not consistently meeting the challenge of optimal pain management for a variety of reasons, including lack of knowledge; the values and beliefs that affect our judgements; how we make decisions and use evidence about pain management; and a lack of prioritization of pain and its management both at an individual and institutional level.
Inadequate practitioner knowledge about pain management continues to be documented. Pain education for health professionals at all levels has been identified repeatedly as an important step towards changing ineffective pain management practices. Effective pain management can be complex, requiring approaches that exceed the expertise of any one profession. For health professionals to collaborate in meeting patients’ needs, they must understand each other's role and expertise. This understanding is the foundation for valuing and respecting others’ contributions to the management of complex problems, particularly for people with persistent pain. Such collaboration is best achieved by creating opportunities for trainees and practitioners from diverse professions to work together to develop a shared understanding of effective pain management approaches and the contributions that each profession can make in helping people with pain. However, students in health professional programmes usually have a few collaborative learning experiences, despite evidence that these opportunities help students to balance socialization into their own profession with learning about interprofessional collaboration. Pain curricula have been developed by the International Association for the Study of Pain that are both core- and discipline-specific (IASP 2005, 2006). The challenge is to use these curricula as a basis for integrating pain content into health training programmes despite their time constrictions and priority biases. To this end, interprofessional pain curriculum models are beginning to be evidenced in the literature (Watt-Watson et al. 2004b).
Knowledge on its own is not enough – good pain management is underpinned by competent decision making. Clinical decision-making is a highly complex activity that occurs in a dynamic and often stressful environment. The complexity of pain management decision-making is compounded by the subjective nature of pain, the necessary communication between patient and clinician to understand and treat the pain problem, and the dependent relationship promoted by the healthcare system. Although more informed patients demand quality care, patients remain relatively passive in managing pain problems. Even when the pain problem is understood and treatable, the outcome occurring after an action still can be determined by chance, despite a ‘good’ decision being made. Treatment interventions often require a balance between benefits and side effects, regardless of the technological and pharmacological treatment advances of the last decade.
The ability to decide on the basis of available evidence is only one component to making a clinical decision. Scientists have long been offering information for clinicians to use, yet the information alone is insufficient to affect their behaviour. Pain management is vulnerable to intrinsic nurse variables, such as professional knowledge and experience, situational knowledge, and personal values and beliefs. Extrinsic variables also influence pain management; for example, the patient situation and complexity, the physical environment, staffing resources, and the interpersonal relationships between clinicians, patient and families. These influences can lead to biases and heuristics in decision-making that potentially can impact on patient outcomes.
Pain management is still opportunistic, simplistic and frequently interrupted (Manias et al. 2004). Increasing decision-making triggers, such as practice prompts and equi-analgesic tables, can only serve to remind nurses to assess and manage pain more effectively. While human fallibility cannot be entirely eradicated, measures targeting the identified problems will promote improved pain management.
There are grounds for optimism. We do have good research evidence, and most nurses and other healthcare professionals are committed to reducing pain. We hope that drivers for change will come from within the health professions but, if not, litigation will compel institutions to include a commitment to adequate pain management as part of their risk management strategy.
The challenge for pain management is about needs: we need to care about it; we need to take responsibility for it; we need to know about it; we need to know what to do, and do it competently; and we need to collect evidence to show how we are doing. That way a partnership with the person in pain can be developed to meet their needs for pain management.