Introduction
Nurses play a major role in the context of pain management. However, they must learn to acquire new skills when it comes to terminally ill patients and clients with fatal conditions (Macintyre & Schug, 2007). A dying patient needs more than a typical pain management program. In the case of elderly patients suffering from fatal conditions – pain management must be enhanced using palliative care. Barriers exist and challenges abound with regards to effective deliver of palliative care, the best way to deal with it is to increase the capability of nurses and they must learn to acquire new skills and new mind-sets in order to improve their efficiency with regards to delivery of palliative care.
The Role of Nurses in Palliative Care
Pain management comes in several stages. The first stage is all about the assessment of pain. The second stage is the understanding what the different reactions to pain. Patients have different pain thresholds. The third stage deals with the patient’s perception of the type of pain they are suffering (Bijur et al., 2008, p.1). The fourth and final stage, which is known as pain behaviour, focuses on the various behavioural expressions that people with painful conditions exhibit (MacLellan, 2006, p.3). In most cases, nurses are able to deal with pain successfully with the effective use of pain relievers if needed. In many cases, patients recover as expected (Fosnocht & Swanson, 2007, p.791-792; Hager & Brockopp, 2007, p.9). However, terminally ill patients have different needs.
Nurses must be trained to understand that pain treatment strategies that can result in negative outcomes such as anxiety, depression, hypochondriasis as well as somatisation (Todd, Ducharme, & Choiniere, 2007). Problems in pain management must encourage nurses to improve their assessment methodologies. They need to acquire the ability to determine patients’ emotional status before they embark on treating these painful conditions. This is usually considered in a case wherein a patient appears to be extremely depressed, demands high level of opioids, ignores examination procedures or is totally non-compliant (Price, Fogh & Glynn, 2007, p.12).
This kind of behavioural characteristic is common in patients with acute painful conditions and such conditions point to the onset of a bio-psychosocial pain disorder, which is multidimensional and requires a level of expertise to achieve correct diagnosis (Fosnocht & Swanson, 2007, p.791-792).
The Importance of Education, Training, and Experience
Nurses must be able to deal with different types of pain but when it comes to terminally ill patients, a different skill-set is needed. Ill-equipped nurses can contribute to barriers in effective pain management and it can be broken down into three major parts:
- insufficient knowledge;
- lack of skills when it comes to basic palliative care techniques; and
- lack of skills when it comes to standard assessments (Deandrea et al., 2008, p.1986).
Insufficient knowledge with regards to effective and efficient pain management strategies would result in underutilization because the focus is usually on the use of aggressive interferences that does not guarantee ability to prolong life but simply add more pain and suffering to the lives of patients and their families (Deandrea et al., 2008, p.1986). They have to understand that palliative care is “medical care focused on relief of suffering and support for the best possible quality of life for patients facing serious, life-threatening illness and their families” (Hong et al., 2010, p.854).
Nurses must learn to master the requirements needed to deliver the following:
- availability of palliative care services;
- timely identification of the need for palliative care; and
- family concordance around the illness prognosis (Ahluwali, 2007, p.38).
The common denominator is awareness and expertise; these can be acquired through education, training, and experience.
The following are some areas that nurses must look into when it comes to a continuous learning process:
- describing pain;
- identifying aggravating and relieving factors;
- determining the meaning of pain;
- determining its cause;
- determining individual’s definition of optimal pain relief;
- deriving nursing diagnoses;
- assisting in selecting interventions; and
- evaluating efficacy of interventions” (Yarbro, Frogge & Goodman, 2005, p.650).
Nurses must also how to evaluate the impact of the analgesic regimen on the patient and the family’s quality of life (Yarbro, Frogge & Goodman, 2005, p.650). This requires constant assessment of the effectiveness of the analgesic applied and the amount of relief obtained as well as constant communication with members of the family.
By carefully following several guidelines nurses are able to effectively gauge the reaction of the patients towards a particular analgesic; however, someone must model to them how to do it. Nurses must learn to collaborate with other health workers.
The training and education of nurses must not be limited to reading books and case studies. There is a wealth of information that they can access by learning in a collaborative environment wherein there is horizontal and vertical interactions with other nurses, hospital staff and other key players in the palliative care department of the hospital or hospice.
Nurses must be aware of a standardized approach to determine if a patient is suffering from pain. At the same time they must has access to an evaluation strategy to enable to know if a patient has experienced optimal pain relief. They must also know how to assess if a certain analgesic is causing addiction or overdose. Thus, an effective use of assessment tools would enable nurses to eliminate the fear of addiction and overdose when it comes to their patients (Yarbro, Frogge & Goodman, 2005, p.650).
The standardized approach could be enhanced by adding the concept of whole patient assessment because it involves “a complete assessment of a patient’s medical, psychological, spiritual and social history” (Hong et al, 2010, p.854). Nurses must learn to augment standard assessment strategies that includes “assessment of chief complaint; history of the present illness; past medical and surgical history” and then moves towards exploring patient’s “social and community support, impact of the cancer diagnosis and treatment on patient’s quality of life, spiritual and social well-being” (Hong et al., 2010, p.854). Aside from increasing a nurse’s knowledge regarding the individual needs of the patients the whole person assessment approach also enhances the communication between nurse and patient.
The managers of a hospital or hospice must invest in a training program that not only increases the knowledge of nurses when it comes to palliative care but also their ability to communicate to the patients. It is imperative to learn how to communicate to a dying patient and nurses must be able to see beyond the pain and discomfort. Terminally ill patients may be depressed or angry. Nurses must learn to deal with these issues as well as the capability to make observations and pass it along to physicians and fellow nurses who are working with them.
In addition, nurses can help enhance the delivery of palliative care if they are trained to detect caregiver strain among the members of the family that are providing support and help solve that problem. Their ability to detect strain helps to mitigate the impact of a burnout. They could help intervene and tell physicians and others to immediately provide counselling and other helpful strategies to alleviate the suffering not only of the patient but also the caregivers and family members assigned to take care of loved ones.
It must be made clear however, that nurse must be trained to communicate effectively. Nurses must communicate well to gather information with regards to what the patients are feeling with regards to the pain and the analgesic given to them. Effective communication is necessary to understand all the pertinent information regarding past history especially when it comes to dealing with pain and other medical needs. Effective communication also enables nurses to work closely with the family in order to satisfy all the requirements. Therefore, insufficiency in knowledge regarding effective assessment, standardized approaches in pain management and effective communication must be identified as one of the primary barriers to effective pain management and palliative care.
Conclusion
End of life-care requires expert help from nurses and physicians. Nurses play a major role in palliative care. Nurses must be trained about the different aspects of palliative care including delivery, and effective assessment of patient as well as caregivers. Nurse must be trained to see beyond the negative behaviour of the patient and family members so that they can provide observations and assessment that could help other health workers to provide the necessary assistance or treatment. Nurses must learn new skills that would enable them to deal with the barriers to effective pain management. Lack of knowledge can be defeated through deliberate training and collaboration with other health workers within a hospital or hospice.
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