A Position Statement on Pain Management
 
The American Society of PeriAnesthesia Nurses (ASPAN) has the responsibility for defining the practice of perianesthesia nursing. An integral part of this responsibility involves identifying the educational requirements and competencies essential to perianesthesia nursing practice and the educational needs of the patients and family regarding pain assessment and management.

ASPAN sets forth this position statement to promote the optimal level of practice and to present a consistent standard of care that documents sound clinical judgement in the management of postoperative pain.


Background
ASPAN has defined a standard for pain management (Standard XI) with the intent of providing guidelines, which represent what is believed to be an optimal level of practice. To assist members in achieving this standard, ASPAN published pain management competency material in the Competency Based Orientation and Credentialing Program. In response to continued concerns from perianesthesia nurses, ASPAN's Standards and Guidelines Committee conducted a review of literature to identify current issues related to pain assessment and management. The following issues were identified:
  1. As many as 50% of postoperative patients in both hospitals and outpatient surgical centers are undermedicated and suffer unrelieved pain. 1,2,3,4
  2. The practice of undermedicating for pain occurs regardless of the patient's age. 5,6 
  3. Frequently the patient's self-report of pain is not taken into consideration when choosing the dosage of medication to give for pain relief. 7,8
  4. Inadequate pain management affects postoperative recovery and behaviors associated with that recovery. 5,6,9
  5. A prevalent cause of ineffective pain management is the professional's lack of knowledge related to pain physiology, medications, and protocols. 4,10
  6. There is still an overriding concern that the use of opioids in the treatment of acute postoperative pain control will contribute to psychological dependence. 11
  7. Patient and family education addressing postsurgical pain management remains inconsistent. 12
  8. Pain management should begin preoperatively with patient and family education addressing use of a pain scale as well as methods of postoperative pain control.
  9. The Agency for Health Care Policy and Research (AHCPR) suggests that practitioners are too rigid when managing acute postoperative pain and should set goals to reduce its incidence and severity. Guidelines have been published by this agency for acute pain management. 13


Position
It is, therefore, the position of ASPAN that a collaborative plan should be developed between the anesthesia department and the perianesthesia nurses to address pain management within the perianesthesia setting. The following points of action should be addressed:
  1. The goal should be to relieve as much pain as possible to allow for activity, relaxation, prevention of complications, and promotion of optimal health and healing.
  2. Areas of education in pain management for health care professionals should include the following:
  1. Physiology of pain management
  2. Assessment techniques
  3. Methods of intervention (pharmacological and nonpharmacological)
  4. Management of side effects and complications related to each intervention
  5. Evaluation of successful management
  6. Ethical considerations
  7. Age and cultural considerations
  8. Patient and family education issues
  1. Whenever possible, the patient's plan of care for pain management should begin during the preoperative interview.
  2. The patient's self-report of pain is the best measurement tool to use when assessing pain.
  3. The use of reliable and valid pain scales should be a standard part of the pain assessment.
  4. Measurement of outcomes should reflect timely, appropriate interventions and achievement of desired effects.


Expected Outcomes
Perianesthesia nurses need to familiarize themselves with this position statement and inform and educate peers, nurse managers, hospital administrators and physicians. 

Anesthesiologists and perianesthesia nurses need to collaborate in the development of a multidisciplinary plan of care (protocol, critical pathway, care map, etc.) to provide safe, appropriate, and effective pain management. 

ASPAN, as the voice of perianesthesia nursing practice, must externalize this information by sharing this position statement with regulatory agencies and professional organizations that interface with perianesthesia nursing areas.


Approval of Statement
This statement was recommended by a vote of the ASPAN Board of Directors on April 16, 1999 and approved by a vote of the ASPAN Representative Assembly on April 18, 1999 in Honolulu, Hawaii.


References
1) Anonymous. (1996). Most patients face pain, often unrelieved, after surgery. American Journal of Nursing 96(3). 68.

2) Campese, C. (1996). Development and implementation of a pain management program. AORN Journal 64. 931-940.

3) Bormann, D., Hansen, K. (1997). Improving pain management through staff education. Nursing Management 28(7). 55, 57.

4) Thornborough, J. (1998). Developing a pain management protocol in the PACU. Today’s Surgical Nurse 20(5). 23-27.

5) Fortin, J., Schwartz-Barcott, D., Rossi, S. (1992). The postoperative pain experience: a description based on the McGill Pain Questionnaire. Clinical Nursing Research 1(3). 292-304.

6) Pasero, C., McCaffrey, M. (1996). Managing postoperative pain in the elderly. American Journal of Nursing 96(10). 38-46.

7) Reid, D., Evans, M., Topiko, J., Ward, H. (1992). Postoperative Pain. Canadian Nurse 88(7). 55.

8) Malek, C., Olivieri, R. (1996). Pain management: documenting the decision making process. Nursing Case Management 1(2). 64-76.

9) Getker-Black, S., Hart, F., Hoffman, J., Geary, S. (1992). Preoperative self-efficacy and postoperative behaviors. Applied Nursing Research 5(3). 134-9.

10) Carr, E. (1997). Overcoming barriers of effective pain control. Professional Nurse 12. 412-416.

11) Aiher, J., Coghlan, A., Martin, K., Worthen, E. (1992). Children win with improved pain management. Canadian Nurse 88(1). 19-21. 

12) Jones, S., Villalobos, J. (1996). Incorporating clinical research findings into practice. Journal of Nursing Staff Development 12(1). 46.

13) Agency For Health Care Policy and Research. (1992). Acute pain management in infants, children, and adolescents: Operative and medical procedures. Rockville, MD. Department of Health and Human Services. 

ANA. (1995). Code for nurses with interpretative statements. Washington, DC. American Nurses Association.

Anonymous. (1996). Surgical patient’s no. 1 fear; Pain. Today’s Surgical Nurse 18(4). 7.

ASPAN. (1997). Competency Based Orientation and Credentialing Program. New Jersey. American Society of PeriAnesthesia Nurses.

Bishop, A., Scudder, J. (1996). Nursing Ethics: Therapeutic Caring Presence. Boston. Jones and Bartlett Publishers.

Heiser, R., Chiles, K., Fudge, M., Gray, Susan. (1997). The use of music during the immediate postoperative recovery period. AORN Journal 65(4). 777-8, 781-5.

Miaskowski, C., Jacox, A., Hester, N., Ferrell, B. (1992). Interdisciplinary guidelines for the management of acute pain: Implications for quality improvement. Journal of Nursing Care Quality (Education of) 7 (1). 1-6.

Schwartz-Barcott, C., Fortin, J., Kim-Hesook, S. (1994). Client-nurse interaction: testing for its impact in preoperative instruction. International Journal of Nursing Studies 31(1). 23-35.

Wong. Video Presentation. Pain Assessment in Children and Infants.