Changing Practice: The Real Challenge

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Changing PracticeThe Real Challenge
Paula Forgeron RN MN Clinical Nurse Specialist
Pediatric Pain Management Co-investigator
Teasdale Corti Research Team
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Learning does not necessarily practice change

• Past experience, attitudes beliefs
• Organizational Culture
• Pain care takes an interdisciplinary approach

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But the children I cared for always got better
without analgesics (or did they)?

• Research has proven that ineffective pain control
  increases the risk of pneumonia and blood clots
  post operatively
• Children heal faster when pain is controlled
  (sleep and eat better)
• Studies suggest that effects of unmanaged pain
  may not show up until later in life
• If pain was not controlled how do we know they
  were OKdid we assess their pain?

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But children behave better when their parents are
not present

• Quiet children still may have painful or
  distressing memories (could be more scared next
  time)
• Research found that children want their parents
  present parents want to be present during
  painful procedures
• Parents are a childs safe person and therefore
  the child is comfortable to display his/her
  displeasure
• Who are we really making it easier forchildren
  or staff?

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Learning does not necessarily practice change

• Past experience, attitudes beliefs
• Organizational barriers
• Pain care takes an interdisciplinary approach

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We are short staffedit takes too much time to
assess pain

• When you do vitals signs you can simply ask do
  you have pain how much pain by using a tool
• Parent can help in assessing pain if we teach
  them to use a validated pain tool
• Children who are not in pain get better quicker
• Children who have less pain cooperate more and
  take less nursing time

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DistractionWe dont have time or resources

• Give written instructions to parents
• Parents can be the coach (free up the nurse to
  concentrate on the procedure)
• Have school children paint or draw pictures to
  put in procedure rooms
• Ask parents to bring in books or toys that
  interest their child
• Distract adolescents with non procedural talk

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But the policy says we cannot do that here?

• Many policies are outdated
• Who rights the policy? Are they knowledgeable?
• Misguided belief that opioid infusions 11
  nursepatient ratio (depends on equipment)
• Pain relief is a standard of care and a human
  right so we must provide pain care

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Learning does not necessarily practice change

• Past experience, attitudes beliefs
• Organizational barriers
• Pain care takes an interdisciplinary approach

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But the doctor only orders the medication prn

• What does prn really meanwhen necessary.
• Nurses can assess the child and determine that it
  is necessary to give the medication around the
  clock
• Request that physicians order scheduled
  analgesicsmore steady state of pain control
• Educate parents about the benefits of regular
  analgesics

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Regular assessmenthow often?

• When admitted
• Beginning of every shift and throughout the shift
  (usual minimum every 4 hours)
• Before every analgesic
• After every analgesic (1 hour post oral
  medication 15 minutes post IV medication)

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But no one else will change

• Become a pain champion
• Assess pain in your patients, tell the
  physicians, document the results
• Physicians ask nurses and residents about the
  childs pain
• If analgesics ordered prn and the patient has
  pain give the medications around the clock
• If acetaminophen and morphine ordered prn give
  both if needed (they both work on different pain
  pathways)
• Educate colleaguesshare your knowledge
• Make links with others who shared your interest
  and share the work!!!

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Challenges to Pain Management

• Lack of formal education for nurses, doctors and
  pharmacists
• Unfounded fears of opioids
• Too busy to assess pain
• We think we are too busy to assess pain
• Too busy to give opioids
• We think we are too busy to give opioids
• Continued beliefs of myths

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