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No Pain, No Gain Rings False for Nurses


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Posted: 9/29/2009

Pain, a frequent fellow traveler with both acute and chronic illnesses, can drive some people to the emergency room or doctor’s office. For others, pain, or fear of it, can keep them from seeking care in the first place. Because they are on the front lines of care, nurses are also in the forefront of pain management, working with patients at the bedside and at the research bench. At the Johns Hopkins University School of Nursing (JHUSON) and the Johns Hopkins Hospital (JHH), research and staff nurses strive to better understand what pain is all about, how it affects body and mind both in the short-term and over time, and how it can be reduced or prevented altogether. They understand that, contrary to the adage, pain actually gets in the way of gain, whether the gain is improved health or the quality of life as a whole.

When We Hurt: Understanding the Interconnections among Pain, Stress, and Illness  Whether acute or chronic, pain is more than a symptom. It is what JHUSON professor and nurse researcher Gayle Page, DNSc, RN, calls an “exquisite stressor” that can have a damaging effect on mood, sleep, and the ability to heal and to fend off infection and illnesses.  Page believes pain management is more than a matter of compassion; it’s a matter of medical necessity. That belief drives her research and that of her colleague, assistant professor Sharon Kozachik, PhD, RN, to explore and help clarify both the nature and the effects of pain on body systems and processes at the most basic level of research: studying animal models at the laboratory bench.

Both Page and Kozachik were drawn to basic pain research after noticing in clinical practice that, too often, insufficient pain management led to co-occurring problems like fatigue, insomnia, and depression, and often also slowed progress toward health. Page is best known for her scientific inquiries into the biological effects of unrelieved pain and stress on cancer resistance and immune function. Her work in animal models is helping to unravel the relationship between pain and the ways in which pain suppresses the body’s immune system – and with it the ability to fend off the development of metastasis. 
The links between pain and disturbed sleep and how they affect recovery from illness are at the heart of Kozachik’s basic research inquiry. She is examining how brain chemicals such as cortisol are affected by pain, by sleep disruptions due to pain, and even by the medications prescribed to battle cancer. “There’s a fine line to walk between pain that’s managed and pain that damages,” Kozachik notes. The challenge inherent in our research is to identify those tipping points so we can avoid them in our clinical care of patients in pain.
Page adds, “The distance from the research bench to the bedside is closer than some think. Our efforts to understand the mechanisms of pain and the body systems affected by pain have made clear both the medical necessity of pain management and its key role in improving human health.”

How We Hurt: A Common Language to Assess and Treat Pain
According to JHUSON professor Fannie Gaston-Johansson, PhD, RN, FAAN, “Pain management begins with pain assessment.”  Gaston-Johansson, a long-time pain researcher, understands pain and how to measure it. Her research has contributed to the growing literature on pain prevalence and severity; coping strategies to reduce pain and collateral issues like stress, sleep disruption, and depression; and ways to improve the quality of life for people with chronic illnesses like heart disease and cancer. She notes that while compassion often drives the desire to reduce a person’s pain, the damaging effects of pain on body and mind provide a solid medical reason for pain control. Before that can happen, a clinician, most often a nurse, must discern both the nature and severity of a patient’s pain. “Not all pain is equal, not all people experience the same kind of pain in the same way, and not all pain control methods work equally for all people and all types of pain,” says Gaston-Johansson. “Nurses need to ask and understand where a patient’s pain is located, how it feels (for example, a stabbing, cramping, dull, or wavelike pain) and just how much of the pain is emotional and how much is physical. Assessment helps us clearly identify and implement individualized pain management strategies.” To bring greater consistency and accuracy to clinical pain assessment, Gaston-Johansson created the Painometer.  An extensively tested set of questions and descriptors, the Painometer gives patients of all ages, races, and ethnicities a common language to describe their pain. Now being retooled for future online use in telenursing, the instrument, in paper and electronic formats, gives nurses important clues to the severity, causes, and, ultimately, best interventions to reduce or eliminate a patients pain. And, because the descriptors remain the same, nurses are better able to track and help a patient manage pain over time, resulting in reduced stress, improved healing, and a better overall quality of life.

Halting the Hurt: Hopkins Making Pain Management Everyone’s Concern
Pain is how body and mind react to a hurt. Not surprisingly, pain is a virtual given in the hospital setting. And, uncontrolled, pain not only adversely affects a patients recovery, but also has a damaging effect on lengths of hospital stays and service effectiveness. Fortunately, the growing body of research on the damaging effects of pain on healing and recovery, on the immune system, on sleep, and on emotional health has underscored a need to improve hospital-based pain management efforts. Working through a 30-member, Interdisciplinary Pain Task Force, The Johns Hopkins Hospital (JHH) has been identifying and implementing new multidisciplinary approaches to pain management to improve patient outcomes and quality of life. With support from the highest levels of leadership, the volunteer Task Force has stepped up to promote care that is as attentive to patients needs in pain control as it is to the treatment of their illnesses. “It’s about more than clinician education; its about teamwork,” observes former Task Force co-chair Lynn Billing, RN, CHPN, B-C, nurse coordinator for the JHH’s Duffey Pain and Palliative Care Service. “Because pain has many causes, effects, and treatments, we’ve found that it ‘takes a village’ to manage a patient’s pain. That’s why our pain management approach spans disciplines and perspectives: the physical, the emotional, and the spiritual.” Nurses, Billing suggests, often can pinpoint the best ways to address a patients pain using their skills as careful listeners and as sleuths to figure out the “why” of the pain and the “what” of its management. “Nurses care for the whole person. We see pain management as one of the important elements in caring for our patients. We know we can get the upper hand on pain before it damages healing, health, and life itself.”