EP12

 

Accountability, Competence and Autonomy EP12

 

  1. Provide one example, with supporting evidence, of a nurse-led (or nurse co-led) collaborative interprofessional quality improvement activity.

 

 

Example: Clinical Nurses Using Authority and Freedom to Make Nursing Care Decisions for Surgical Pain Management

Nursing Scope of Practice
The Greenwich Hospital clinical nurse scope of practice is in alignment with the Connecticut Nurse Practice Act and is defined in the RN job description, which states that nurses:

 

(1.4) “Develop a plan of care upon admission and reviews/updates daily based on multidisciplinary findings and physician orders
(1.5) Manages decision making situations by recognizing the acuity and complexity of patient condition and their environment
(1.10) Demonstrates responsibility and accountability for ensuring best practices and delivery of nursing care according to ANA standards
(1.11) Administers medications, calculates doses when appropriate and maintain current knowledge of medications and IV therapy
(1.12) Assess and reassess pain, intervening with appropriate pain management therapies
(1.14) Provides patient and family education specific to their needs and appropriate to the care, treatment and services provided.
(Evidence EP12-1, Clinical Nurse Job Description)

 

Nursing Care Decisions for Pain Assessment and Management
Assessing and managing pain – the primary symptom for those seeking healthcare – is a crucial element of every nurse’s practice. Greenwich Hospital, a care delivery network in the Yale New Haven Hospital and Health System (YNHHS), follows the YNHHS policy “Pain Assessment and Management.” This policy provides guidance for nurses as they care for patients at risk of or experiencing pain in the inpatient or hospital-based ambulatory settings, and it gives nurses the authority and freedom to make nursing care decisions in the management of pain using a multimodal pharmacological and non-pharmacological approach. This policy is in alignment with “Pain Management Nursing: Scope and Standards of Practice, 2nd Edition,” in which the American Nurses Association (ANA) documents what every RN in the evidence-based practice specialty of pain management needs to know. (Evidence EP12-2, YNHHS Pain Assessment and Management Policy)

 

Greenwich Hospital nurses use evidence-based best practices to work to alleviate pain, improve pain relief, optimize function and maintain quality of life for patients across the life span and in every practice setting. Clinical nurses have the autonomy to use their knowledge, skills and abilities as they employ a multimodal approach to pain management, and they are accountable to assess and reassess the effectiveness of their interventions. It is the role of the clinical nurse at the bedside to decide which pain management tool to use based on her or his quality assessment of the patient at any time in the patient’s hospital stay. These include both pharmacologic and non-pharmacologic tools.

 

Multimodal Pain Management
Every patient’s pain is managed through an individualized, multidisciplinary, multimodal approach using both pharmacologic and non-pharmacologic modalities. The success of this approach depends on the clinical nurse’s ability to accurately assess a patient’s pain and implement the best intervention based on that assessment. Multimodal analgesia combines two or more analgesic agents and techniques that involve different mechanisms or sites of action along the pain pathway and provide additive or synergistic effects for better pain relief.

 

Pharmacologic agents include, but are not limited to, scheduled doses of acetaminophen, NSAIDs, Gabapentin or Lyrica, Exparel, TAP blocks, and peri-articular injections. Nurses understand that opioids are reserved as rescue drugs and are used at the lowest effective dose in combination with the other multimodal approaches. By incorporating different multimodal analgesia agents into pain management regimens, clinical nurses seek to minimize acute opioid side effects that include constipation, ileus, drowsiness, nausea and vomiting.

 

Non-pharmacologic measures include, but are not limited to, comfort actions, comfort items, relaxation therapies, “keeping busy” activities and patient education on all available pain management approaches. These measures are defined in the Greenwich Hospital Comfort Menu, developed by nurses on the Surgery Unit and available and provided to all patients on admission.(Evidence EP12-3, Greenwich Hospital Comfort Menu)

 

Clinical nurses have the freedom and authority to administer appropriate pain-relieving measures based on their ongoing assessments of a patient’s pain and sedation level.  Nurses evaluate the effectiveness of interventions by using validated assessment scales that are clinically and developmentally appropriate in conjunction with performing a functional assessment. Validated scales used to assess pain include the Numeric Pain Intensity Scale; Word Scale; Wong-Baker FACES; Laboring Pain Intensity Scale; Neonatal Infant Pain Scale; Neonatal Pain, Agitation and Sedation Scale; FLACC; Critical Care Pain Observation Tool; Pain Assessment in Advanced Dementia; and Assumed Pain Present Scale.

 

Validated scales used to assess level of sedation after opioid administration include the Pasero Opioid-Induced Sedation Scale (POSS) and the Richmond Agitation Sedation Scale (RASS). Nurses screen pediatric patients for sedation using the State Behavioral Scale (SBS) or the Arousability EPIC drop down screen to assess for LOC.

 

Clinical nurses determine an acceptable pain goal in collaboration with the patient and family. They then administer pharmacologic and non-pharmacologic pain control measures based on their assessment findings and in collaboration with the patient. The overall goal is to use as few opioid and intravenous medications as possible in order to safely and effectively achieve the mutually agreed upon pain goal.

 

Clinical Nurses Demonstrate Autonomy While Providing Multimodal Pain Management – Patient Example
A multimodal approach to pain management includes an accurate assessment of the patient’s pain and the implementation of the best intervention based on this assessment. In February 2020, Melissa Alvarez-Ospina, BSN, RN, Clinical Nurse, Medicine, cared for a postoperative spinal patient with significant pain. This patient’s ordered pharmacologic pain medications included the following:

  • Scheduled:
    • Ketamine IV drip 0.18mg/kg/hr.
    • Tylenol 975 mg po every 8 hours
    • Valium 5mg 3 times daily

    •  

  • PRN:
    • Valium 5mg every 6 hours PRN for muscle spasms
    • Valium 5mg nightly PRN muscle spasms
    • Ultram 50 mg every 4 hours PRN mild pain (Pain Scale 1-3)
    • Dilaudid 0.5 mg IV every 4 hours mild pain (Pain Scale 1-3)
    • Dilaudid 1mg IV every 4 hours moderate pain (Pain Scale 4-6)
    • Dilaudid 1.5 IV mg every 4 hours severe pain (Pain Scale 7-10)
    • Oxycodone 10 mg po every 3 hours moderate pain (Pain Scale 4-6)
    • Oxycodone 15 mg po every 3 hours severe pain (Pain Scale 7-10)

 

Authority for Nursing Care Decision-making
In February 2020, Alvarez-Ospino collaborated with her patient and identified an acceptable pain rating of 5 on the numeric pain scale of one to 10. At 2038, she documented her patient’s pain level as a 6 on the Numeric Pain Assessment tool and her patient’s sedation level as a 1 on the POSS sedation scale. Alvarez-Ospino determined that it was safe to administer an opioid pain medication that affects the central nervous and respiratory systems in a dose required by a moderately high pain scale score. Alvarez-Ospino administered Dilaudid 1mg IV push as ordered. (Evidence EP12-4, RN Pain and Sedation Assessments and Medication Administration)

 

The next day, Sara May, BSN, RN assumed the care of this patient from Alvarez-Ospino. May collaborated with the physician assistant, the patient and the patient’s spouse to inform her decision making in determining the best multimodal approach to use in managing the patient’s pain. She reviewed the Comfort Menu with the patient and spouse and employed non-pharmacologic interventions such as patient education, providing a calming environment, ambulation, ice, family presence and patient positioning to augment pain relief obtained from medications. (Evidence EP12-5, RN Documentation of Comfort Menu Items)

 

Surgical Unit clinical nurses used their authority and freedom for nursing care decisions to successfully manage the patient’s postoperative pain throughout the entire postoperative stay.

 

Before discharge, the patient was weaned off IV medications to a multimodal pain management regimen that included PO medications along with comfort measures including ice packs, positioning, distraction, safe ambulation, rest and education. An acceptable level of pain was reached and maintained during the hospital stay, and the patient was safely discharged home with knowledge of how to manage their pain.