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January/February 2001 Volume 23 Number 1
Tr
Managing Patients’ Pain
New Standards
Role of Ambulatory
Care Nurse is Key
Nancy R. Kowal, MS, RN,C, NP
Advances in Care
‘Cancer Doesn’t
Have to Hurt’
Pamela J. Haylock, MA, RN
Over the past 20 years, unrelieved
Perhaps in no other area of health
pain has been identified as a major pubcare is the continued use of inapproprilic health problem. Unfortunately, many
ate and inadequate medications and
barriers exist for providers, patients, and
adherence to outdated standards of care
families that prevent an objective and
so accepted, tolerated, and ignored as it
open-minded approach to quality pain
is in the management of pain.
management.
There is evidence that tolerance is
Pain is prevalent and costly and
fading: several high-profile court cases
exists in virtually every clinical area.
resulted in decisions against health care
Nurses live the experience daily with
professionals who undertreated or othused with permission, University of
their patients. The quality of pain man- Photos
erwise mismanaged cancer-related pain.
California San Francisco Medical Center.
agement will depend on the knowledge
More changes may occur as a result of
and skill nurses have and the extent to which they
the Joint Commission on Accreditation of Healthcare
assume their role as a patient advocate.
Organizations’ (JCAHO) mandate of effective pain
Recently, the Joint Commission on Accreditation
management for all patients (see article on left).
of Healthcare Organizations (JCAHO) announced the
development and approval of pain standards. These
Cancer Pain
standards set new expectations for patient rights
Many human ailments are linked to pain, but the
regarding pain assessment, monitoring, and managepain
of cancer continues to be a source of fear for peoment. The first scoring compliance will occur in 2001.
ple
who
have or are at risk for developing cancer. And,
While not all institutions or organizations are surwith good reason. Pain is a common experience for the
veyed by JCAHO, these standards set a precedent for
vast majority of people with cancer.
At the time cancer is diagnosed, nearly half of all
continued on page 17
patients have already experienced moderate to severe
pain. Nearly 75% of people with advanced cancer
Issue Highlights
have pain (Jacox et al., 1994).
Cancer-related pain is caused by the cancer itself
Special Features on Pain Also Inside
and/or by the sequelae of many forms of cancer treatScreening Form Helps
President’s Message . . . . . .3
ment. Despite the widespread acknowledgement of its
Score Patients’ Pain . . . . . . .5
presence and severity, cancer pain is generally underFaith in Practice:
treated in both adult and pediatric patient populaEase of Mind:
The Parish Nurse . . . . . . . . .19
Headache Program’s Success . .8
tions. Most confounding of all is the revelation that at
AAACN Election Results,
least 90% of all cancer pain can be controlled via simAssessing Pain in Elderly . .15 Conference News . . . . .22-23
ple means, such as a scheduled oral analgesic alone or
JCAHO Pain Standards . . .18 Passionate About Nursing?
combined with adjuvant or nonpharmaceutical interAAACN Wants You! . . . . . .24
ventions.
This issue of Viewpoint is sponsored through an
unrestricted education grant from Purdue Pharma L.P.
For more information, please visit the PartnersAgainstPain.com Web site.
continued on page 12
Official Publication of the
American Academy of Ambulatory Care Nursing
Plan Now to Attend!
PAIN
2001 Joint Commission
Leadership Summits
A Multidisciplinary Approach to Best Practices
May 3-4, 2001
Phoenix, AZ
September 24-25, 2001
Philadelphia, PA
Attend one of these important
Summit meetings to learn:
• Key strategies for institutionalizing pain management across the
continuum of care, including acute and ambulatory care settings
• How to effectively track outcomes
• Best practices for special population settings, such as sickle cell patients,
cognitively impaired individuals, cancer patients and substance abusers
• Plus much, much more!
For more information call the Customer Service Center at 630-792-5800.
Sponsored by
Summit Co-Convenor
The American
Alliance of Cancer
Pain Initiatives
Joint Commission
RESOURCES
A Subsidiary of the Joint Commission
on Accreditation of Healthcare Organizations
www.jcaho.org
www.painmed.org
www.ampainsoc.org
www.jcrinc.com
This conference is supported by an unrestricted
(Platinum Level Sponsor)
www.partnersagainstpain.com
This conference is also supported by an unrestricted educational grant provided by Triad Technologies, Inc.
(Bronze Level Sponsor)
www.triad-technologies.com
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
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© Copyright 2001 by AAACN. All rights
reserved. Reproduction in whole or part,
electronic or mechanical without written
permission of the publisher is prohibited.
The opinions expressed in AAACN Viewpoint
are those of the contributors, authors
and/or advertisers, and do not necessarily
reflect the views of AAACN, AAACN
Viewpoint, or its editorial staff.
This issue of Viewpoint is supported by an unrestricted
education grant provided by Purdue Pharma L.P. (Web site:
www.PartnersAgainstPain.com). We thank Purdue for recognizing
the value of this newsletter for advertising and informing
customers of their products and services.
Mankind’s most
universal fear is
pain. One of the
factors that can
influence a perShirley Kedrowski
son’s perception of the pain experience is culture. To more effectively manage
pain, clinicians need to conduct culturally sensitive pain assessments
and incorporate patient’s cultural
beliefs and approaches toward traditional healing practices into the pain
management plan.
Inadequate pain management is
widespread, especially among minority groups, and a major reason for
undertreatment is the failure to assess
pain properly in culturally diverse
patient populations. As the United
States continues to become more culturally diverse, clinicians find it
increasingly difficult to care for
patients from various cultures whose
primary language is not English.
Interest in developing culturally
appropriate pain assessment tools is
the first step in preventing undertreatment. You can assess pain in
patients from many cultures by
using assessment tools similar to
those you usually use, and these
will give you results that will have
comparable meaning across cultures. The horizontal 0-10 numerical pain rating scale and the WongBaker FACES Pain Rating Scale ©
(see page 5) can be translated into
different languages. Refer to
McCaffery & Pasero’s Pain: Clinical
Management (1999) where you will
find the 0-10 scale in 18 languages
and the Wong-Baker scale in 8 languages. You may need to adapt
these, for example, Chinese patients
may understand a vertical presentation more readily than a horizontal
one because Chinese is read vertically downward, from right to left.
Also refer to the article Culture,
3
Pain, and Culturally Sensitive Pain
Care (Lasch, 2000) for a sample tool
to elicit beliefs about pain that nurses can use to obtain a culturally sensitive pain assessment.
Pain and its Implications
Because the most accurate way
to assess pain is via patient self
report, health care providers should
provide validation and support.
“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it
does,” (McCaffery, 1999). Patients
should be informed that pain relief
is an important part of their health
care, that information about options
to control pain is available, and that
they are welcome to discuss their
concerns and preferences with the
health care team.
Undertreated pain places
patients at risk. Our cultural attitude
of “no pain, no gain” has proved to
be dangerously wrong. Research
now shows that unrelieved pain can
inhibit the immune system and
enhance tumor growth. Pain causes
increased oxygen demand, respiratory dysfunction, decreased gastroincontinued on page 4
Dreaming
of Certification?
You’ll LOVE this news!!
See Page 22
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
President’s Message
Pain Management Web Sites
continued from page 3
Sites for Health Care Professionals
testinal motility, and confusion. Severe acute pain is a
key risk factor for chronic neuropathic pain (McCaffery,
1999).
www:aspmn.org
American Society of Pain Management Nurses
www.painmed.org
The American Academy of Pain Medicine
www.halcyon.com/iasp
International Association for the Study of Pain
www.guideline.gov
The National Guideline Clearinghouse
http://mayday.coh.org/
Mayday Pain and Resource Center
http://allnurses.com/jump.cgi?ID=2648
University of Iowa, College of Nursing
http://www.pain.com
http://www.nursingcenter.com
http://www1.mosby.com/Mosby/Wong/
Clinicians’ Cultural Beliefs and Values
Just as patients’ attitudes about and responses to
pain are affected by their personal and cultural values,
so are those of their caregivers. The more cultural differences that exist between patient and nurse, the more
difficult it is for the nurse to assess and treat the
patient’s pain. In a study led by Harrison (1996), the
pain ratings of 50 hospitalized patients who spoke
Arabic were compared with pain assessments made by
nurses who spoke Arabic and those who didn’t. The
results revealed that the nurses who shared a language
with patients were much more likely to rate pain similarly to patients than the nurses who didn’t. Thus, it’s
wise to be especially careful when assessing pain in
patients who don’t share your cultural background.
Physicians’ clinical judgements about pain are
influenced by factors including age, gender, race, and
ethnicity. In one study, women were given less pain
medication than men because they were thought to be
more labile emotionally and to exaggerate pain complaints. Both men and women under the age of 61
received more pain medication than their elders did.
Also, younger men were medicated most frequently and
older women least frequently. In another study,
Hispanics were twice as likely as non-Hispanic whites
to receive no pain medication.
Another issue is the balance of power between
provider and patient. As long as the caregiver has control, the patient remains the passive victim of pain. The
standard “prn” regimen requires patients to endure
pain until the next scheduled opportunity to request
medication. Even then the patient may not want to
bother anyone, and the relationship between patient
and nurse can get adversarial.
Two well-established myths in western culture state,
“Enduring pain is a character-building, moral-enhancing
endeavor” and “Patients who receive pain medication
will become addicted to the drugs.” These fears, plus
concerns about legal liability, are reflected in the stringent laws regulating drug prescription and the suspicion
of health care providers who see patient requests for
pain relief as drug-seeking behavior related to addiction.
The result is the undermedication of even terminally ill
patients who may end up experiencing a painful, prolonged, death accompanied by needless suffering. What
patients fear most is a painful death. Those who request
assistance in ending their lives are really seeking their
doctor’s help in ending their pain (Post, 1996).
Sites for People with Pain
www.theacpa.org
American Chronic Pain Association
www.painfoundation.org
American Pain Foundation
www.ampainsoc.org
American Pain Society
J.G., Dibble, S.L., & Minarik, P.A. (Eds.). (1996). University
of California San Francisco, UCSF Nursing Press: CA.
Available: http://nurseweb.ucsf.edu/www/book4.htm] presents an overview of several ethnic/cultural groups and
offers nurses a snapshot of human diversity. It provides a
set of general guidelines to alert nurses to the similarities as
well as the differences within and among cultural groups.
References
Harrison, A. et al. (1996). Does sharing a mother tongue affect how
closely patients and nurses agree when rating the patient’s
pain, worry and knowledge? Journal of Advanced Nursing,
24(2), 229-235.
Lasch, K.E. (2000). Culture, pain, and culturally sensitive pain care.
Pain Management Nursing, 1(3) (Suppl. 1), 16-22.
McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd ed.).
St. Louis: Mosby.
Post, L.F. et al. (1996) Pain: Ethics, culture and informed consent to
relief. Journal of Law, Medicine, & Ethics, 24(4), 348-359.
Shirley M. Kedrowski, MSN, RN
AAACN President • [email protected]
12th Annual Ambulatory Care
Wave of the Future Conference
Bridging Nursing to the 21st Century
May 3-4, 2001
Island Palms Hotel and Marina, San Diego, CA
Sponsored by Kaiser Permanente, Scripps Clinic,
UCSD Medical Center, Veterans Administration
Hospitals of America, and Sharp Health Care
For more information, contact
Ruth Ann Obergon, (619) 641-4137.
Moved to Front Burner
Pain has gained an increasingly salient presence in the
medical, nursing, legislative, research, funding, and advocacy arenas. In the past decade pain has come into its own
and with it the knowledge that pain, more than a mere
physiologic response to a painful stimulus, is a biopsychosocial phenomenon. At all times, pain has held different meanings for culturally disparate groups. The publication Culture and Nursing Care: A Pocket Guide [Lipson,
January/February - 2001 - Volume 23 Number 1
4
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Documenting Pain
Tammy Wade, MSN, RN, FNP
UCSF Uses Patient Report, Special Committee, to Meet New Standards
Treating
Many ambulatory care provider-based
practices are faced with the challenge of
meeting the new Pain Management
Standards set forth by the Joint Commission
on Accreditation of Healthcare Organizations
(JCAHO).
Scoring for these standards began this year. The
standard many ambulatory care practices may have
difficulty with is PE.1.4: pain is assessed in all
patients. The University of California San Francisco
(UCSF) Medical Center recognizes that patients have
the right to be involved in all aspects of their care
including the right to appropriate and timely assessment and management of their pain.
The UCSF pain management policy states that all
patients upon entry into the health care system, as part
of ongoing patient care and assessment and at each subsequent ambulatory visit, when appropriate, will be
asked if they are experiencing pain. If patients answer
“yes” to the initial screening question, they will be
asked to rate their pain using a pain intensity scale (for
example, the 10-point scale or the 0-5 Wong Baker
FACES Scale) and respond to additional questions. (See
Pa in
continued on page 6
PATIENT PAIN SCREENING RECORD
University of California San Francisco (UCSF) Medical Center
Ambulatory Services
Have you experienced any pain within the past week?
No ❏
Yes ❏
(If “No,” stop here and give this to your provider. If “Yes,” please answer the rest of the questions)
Where is your pain? _______________________________________________________________________________________________
Circle a number from 0-10 that best describes how much pain you are having now?
0
No Pain
1
2
3
4
5
6
7
8
9
10
Worst Pain Possible
For a child or non-English speaking adult, use Wong-Baker FACES Pain Rating Scale©. *
Ask the patient to circle the face that best describes how he/she feels:
What does your pain feel like? Circle response:
1
No Hurt
2
3
4
5
Hurts Little Bit Hurts Little More Hurts Even More Hurts Whole Lot
6
Hurts Worst
sharp
dull
burning
aching
throbbing
tender
numb
stabbing
gnawing
shooting
exhausting
penetrating
miserable
unbearable
continuous
occasional
* ©Wong, D.L. (1999) Whaley and Wong’s Nursing Care of Infants and Children, 6th ed.
St. Louis, MO: Mosby. Used with permission.
What makes the pain better? _______________________________________________________________________________________
What makes the pain worse? ______________________________________________________________________________________
Are you currently taking medication(s) or using some type of treatment for pain relief?
No ❏
Yes ❏
If yes, list medication and/or treatment: _____________________________________________________________________________
Provider Use Only
TREATMENT PLAN / RESPONSE: __________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Signature __________________________________________________________________ Date ________________________________
5
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Documenting Pain
continued from page 5
Patients have
the right to be
involved in all
aspects of
their care.
Patient Pain Screening Record
for Ambulatory Services, previous page.)
This form may be used as
part of the new patient intake
process (if the practice does
not have a new patient intake
questionnaire that addresses
pain assessment) and for subsequent ambulatory visits.
Assessing the Pain
Self-reporting of pain by the patient is
the most accurate and efficient way of capturing this information in a busy ambulatory
Photos used with permission, University of California
care environment. If the patient reports pain,
San Francisco Medical Center.
a provider (physician, nurse practitioner,
and/or RN) will further assess and treat, as
appropriate.
organization-wide education and competency proThe patient’s treatment plan/response to pain
grams for staff and physicians in pain assessment
interventions is documented by the provider on the
and management.
patient pain screening record with details of the com• Measurement of baseline performance indicators
prehensive pain assessment in the history and physifor pain management using patient interviews and
cal or visit note. Regular assessments of pain intensity
medical record review. There is continuous meaare completed during an ambulatory episode of
surement of these indicators at regular intervals to
care/treatment when vital signs are taken, based on the
assess ongoing performance improvement.
scope of service and at frequencies appropriate to the
situation.
Tammy Wade, MSN, RN, FNP
Prior to and following the administration of pain
Director of Quality Improvement
medication or a nonpharmacologic intervention, pain
UCSF Medical Center Ambulatory Services
is rated by the patient and is reassessed and [email protected]
ed to measure the effectiveness of the pain medication.
Patients are asked about their satisfaction with pain
management using an institutional patient satisfaction
Contemporary Forums
survey as well as through focused activities such as
Acute Care:
postprocedure and postoperative telephone calls.
Critical Assessment and Interventions
Pain assessments, reassessments, treatments, interJune 14-16, 2001
ventions and outcomes are documented in the medical
New Orleans, LA
record and accessible to all members of the health care
This national conference will help you address the
team. Pain identified during a visit that is not within
critical practice issues that surround the increasingly
the scope of the practice will be referred to an approcomplex acute care patient population that you
priate provider.
manage today. Examine critical assessment and
care strategies, and discover the early warning signs
of system failure and what precipitates them.
Explore innovative post-operative pain management
techniques and how genetic discoveries are influencing the way we practice nursing care.
Pain Committee
UCSF Medical Center achieves this organizational
commitment to pain management through the work of
the Interdisciplinary Pain Committee (a subcommittee
of the Quality Improvement Executive Committee).
The scope of the committee’s work includes, but is not
limited to:
• Conducting an institutional needs assessment.
• Oversight and implementation of policies, standardized procedures, and practice guidelines for
pain management.
• Development of patient education materials and
January/February - 2001 - Volume 23 Number 1
Plan to attend a full-day preconference session on
“Acute Care Legal Practice Issues” to be held June
14, 2001.
Contact: Contemporary Forums, Dept. 658
(925) 828-7100, Ext. 0
e-mail: [email protected]
Web site: www.cforums.com
6
Ambulatory Care Nursing Resources
Ambulatory Care Nursing Self-Assessment (2000)
This valuable resource provides over 200
multiple choice test items covering various
components of ambulatory care practice. You
will be able to test your knowledge of your
specialty and practice by answering multiple
choice questions written in the same format
as the certification exam.
The multiple choice items are grouped
into 5 topic areas.
Ambulatory Care Nursing Certification
Review Course Syllabus
Straight from the live Ambulatory Care Nursing
Certification Review Course to you is this comprehensive course syllabus.
Highlights:
• CONTENT is based on the Test Content
Outline for ANCC's Ambulatory Care Nursing
Certification Exam
• CONTAINS outlines and hand-out materials for each section of the
Review Course including; Overview, Clinical Practice,
Communications, Issues and Trends, Systems, and Client
Education
• PROVIDES a comprehensive bibliography
• CONTENT outlines can be used to design your
individualized study plan for the exam
• Clinical Practice
• Systems
• Communication
• Patient/Client Education
• Issues and Trends
2000 Edition Ambulatory Care Nursing
Administration and Practice Standards
Examination Preparation Guide for
Ambulatory Care Nursing
Certification (1999)
This 20-page, fifth edition of the ambulatory care nursing standards includes sections on
Structure and Organization, Staffing,
Competency, Ambulatory Nursing Practice,
Continuity of Care, Ethics and Patient
Rights, Environment, Research, and Quality
Management.
A 48-page guide designed to help you learn
specifics about the exam, develop your own study
plan, and review test taking strategies.
Nursing in Ambulatory Care:
The Future is Here (1997)
Telehealth Nursing Practice
Administration and Practice Standards (2001)
This 53-page text, a collaborative effort between
the American Academy of Ambulatory Care Nursing
and the American Nurses Association, defines and
describes the multiple roles and functions of nurses
in ambulatory care and identifies the appropriate
education and support needed as nurses make the
transition from inpatient settings to ambulatory care
settings.
This document identifies the practice standards that define the responsibilities of both clinical practitioners and administrators responsible
for providing telephone care across a multitude
of practice settings.
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National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Headache Program Tailors Care
With Specialized NPs
Headache patients don’t
always get the attention they
need and are often
dissatisfied with their care.
This Kaiser Permanente
headache clinic fills the
care gap and has achieved
a remarkable 92%
satisfaction rate.
Migraine is a common disorder that
affects 28 million
people in the United
States. It is estimated that
one in ten people suffer from
migraine headaches (Lipton,
Diamond, Reed, O’Quinn, & Stewart,
2000).
Epidemiological studies have
shown that as many as 17.6% of
women and 5.7% of men report one
or more migraine headaches per
year, yet primary headache disorder
is still underdiagnosed and undertreated in primary care.
It is well established that
patients with headaches generated
nearly twice as many pharmacy claims as other
patients in managed health care systems (Hu, Markson,
Lipton, Stewart, & Berger, 1999; Clouse & Osterhaus,
1994; Ries, 1986; Solomon & Litaker, 1997). These
patients also seek urgent care and emergency room
help more often than non-migraine patients (Barton,
1994). As far as lifestyle is concerned, migraines can
disrupt functional activities at work and home.
Treating
Pa in
Marie Tischio, MSN, NP
Types of Headaches
Primary headache is one of
the leading reasons for primary
care consultation.
The majority of headache
patients seen at Kaiser Permanente
in the Headache Management
Program have a mixed pattern of
tension and migraine headache.
The five main primary headache
types include migraine, tension,
cluster, rebound, and sinus.
The clinical features of primary headaches are as follows:
Migraine
Migraine comes from a French
word meaning “half the head.”
The symptoms of migraine include unilateral
headache that is described as throbbing and pulsatile.
It occurs on an episodic basis with associated nausea
or vomiting. Patients experience light and noise sensitivity. Of these patients, 15% experience an aura of
visual and/or sensory disturbance. Exercise makes
these headaches worse.
Tension
Tension or muscle contraction headaches involve
a daily diffuse pressure behind the eyes, in the neck,
shoulders, or temple area. Patients often describe this
as a vise grip wrapped around their head or a tight
squeezing pressure. Tension headaches generally
occur in the morning and progressively get worse during the day. There is no aura or vomiting. A stressful
event may precipitate this headache. On physical
exam the trapezius and cervical muscles are tender to
palpation.
Improving Care
Research shows that the more time a provider
spends with patients, the more satisfied they are, and
the better the outcome. However, headache patients
are often dissatisfied with the care they receive.
On a positive note, nurse practitioners are able to
spend more time with their patients, and as a result,
can increase patient satisfaction.
In an effort to improve care, Kaiser Permanente in
Southern California has established a “Center of
Cluster
Excellence” for primary headache patients. The center
Cluster headaches are more predominant in males
has developed a Headache Management Program coorbetween 30 and 50 years of age. Patients say they feel an
dinated by a neurologist
“ice pick” sensation
Figure 1.
and nurse practitioner that
through the periorbital
Kaiser Headache Clinic
has achieved a 92% rate of
area; usually a unilateral
patient satisfaction.
stabbing pain lasting 30
Educating patients
Gender Overview
to 90 minutes. The clus19%
about their headache
ter headache often wakes
types, promoting autono81%
a patient from sleep at
Male
my, listening to their
night and has associated
needs, and developing
Female
symptoms of Horner’s
individualized care plans
syndrome. Horner’s synN=213
are crucial to a successful
drome includes ptosis,
headache management
nasal stuffiness, constricprogram.
January/February - 2001 - Volume 23 Number 1
8
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
tion of the pupil, or decreased sweating on the side of
the headache. A patient may experience a cluster
headache every night for weeks to months and then be
headache free for 6 months to a year. Some patients
have reported being headache free for as long as 5 years.
Figure 2.
Kaiser Headache Clinic
Age Overview
Rebound
18%
This type of headache is common in about 30% of
the patients seen in the Headache Management
Program in San Diego, CA. Rebound headache can
occur on a daily basis from excessive use of over-thecounter (OTC) medications or caffeine. As little as one
tablet of Fioricet® a day (30 per month), can cause
rebound headache. The maximum dose of caffeine recommended to avoid rebound is 200 mg or less per day.
As few as three caffeinated beverages a day can lead to
a daily rebound headache. The symptoms of rebound
headache are often characterized as a pounding pain
around the front and back of the head that may be continuous. OTC medication often relieves the pain for a
few hours but then the headache returns, creating a
dependency cycle.
14%
25%
•
•
Headache Type by Percent
9%
6%
2%
2% 2%
in temperature and atmospheric pressure.
Emotional. Emotions, especially stress, are common triggers. Stress can be caused by life changes
such as marriage, birth, death, or divorce. Both
positive and negative stress can act as triggers.
Hormonal. Hormonal fluctuations during ovulation
and before a woman’s menstrual cycle can trigger
migraines. Birth control pills and estrogen supplements may also cause headaches. Headaches usually improve with pregnancy.
Pharmacologic Treatment
It is difficult to find a consensus among physicians
regarding the best treatment approach. Headache prophylaxis is recommended if there are more than four
disabling headaches each month, but there is no agreement yet on which is best: beta-blockers, tricyclic
antidepressants, serotonin re-uptake inhibitors, or anticonvulsants.
At Kaiser’s headache management program, the
patient’s overall health is assessed. For example if
there is pre-existing hypertension, then a beta blocker
or calcium channel blocker is prescribed that will treat
both conditions and allow for monotherapy with
improved patient compliance.
Inderal® works well for migraines if given three
times per day, however its efficacy tends to decrease
after a year of treatment. Tricyclic antidepressants are
effective for migraine and tension headaches. Pamelor®
has fewer side effects than Elavil® and can be used
Mixed (more than 1)
Migraine only
Tension only
Paroxysmal only
Cluster only
Other
n=205
Sinus
A sinus headache is a rare finding. It is caused by
the inflammation of the lining of the sinus cavities.
The pain is often described as a deep dull ache around
the nose, face, and forehead that worsens when the
patient bends over. A sinus x-ray or CT of the sinus
must show fluid in the sinus cavity to confirm the
diagnosis of sinus headache. In our program, we have
diagnosed only five patients out of a series of 500 with
sinus headache.
Chronic sinus headaches are usually due to allergic sinusitis. Acute sinusitis from an infection results
in fever and acute facial pain or headache.
Figure 4.
Kaiser Headache Clinic
Patient Satisfaction
7%
Attack Triggers
•
•
18-29
30-39
40-49
50-59
60 and up
n=213
Figure 3.
Kaiser Headache Clinic
79%
11%
32%
1%
Improved
No change*
Worse*
There are a number of precipitants for migraines:
Dietary. Includes caffeinated food and drinks, alcohol, dairy products, breads, peanuts, nuts, seeds,
processed meats, citrus fruits, monosodium glutamate, chocolate, and hypoglycemia.
Environmental. Subtle changes in the environment
can trigger a migraine. Some of these include
bright lights, loud noise, and strong odors; changes
92%
*=Refractory
n=202
9
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
gist could manage patients with primary headache disorder and increase patient satisfaction.
The program involves three parts: The initial
phase consists of a 2-hour headache class taught by a
neurologist. The class introduces basic information
about different headache types and the various treatments. Lifestyle changes needed, caffeine, OTC medication use, medical and non-medical treatments are
discussed.
Next, patients are scheduled for an appointment
with the NP headache specialist. Each case is reviewed
with the neurologist, and using the headache treatment guideline, an individual preventive treatment
plan is developed. At the initial consultation, an 8week follow-up is also arranged.
After each patient is on a well-established plan of
care, they are returned to primary care with a treatment outline.
Figure 5.
Migraine-Specific Quality of Life
Questionnaire Results
100
90
80
70
60
50
40
30
8 weeks
20
Baseline
10
0
Role-function
restrictive
Role-function
preventive
Results
Emotional
function
Out of the 213 patients who have completed the
headache class, 81% are female and 19% are male (see
Figure 1).
The patients’ ages range from 18-92 years old. Over
half of this population is between 30-49 years old, 32%
are 40-49, 25% are 30-39, 18% are 50-59, 14% are 1829, and 11% are 60 or more (see Figure 2). The majority
of patients (79%) had more than one type of headache,
6% had migraine headaches, 9% had tension
headaches, 2% had paroxysmal headache (this is a very
rare type; it is unilateral and throbbing in nature and is
generally responsive to Indomethacin®), 2% cluster
headache, and 2% other (see Figure 3).
N=173
once a day, and Effexor ® in recent studies shows
promise. Depakote ® is used for refractory cases,
Topamax® and Neurontin® are not as well studied but
have fewer side effects and based on results from the
Kaiser program, are effective (Blumenfeld, YEAR).
Acute treatment needs to be considered in terms of
the type of headache. Patients should be encouraged to
use only triptans for migraine headaches. Injectable
Imitrex ® or nasal spray Imitrex ® is preferred for
patients with vomiting at the start of their headaches.
Long acting Amerge ® is useful for headaches that
require multiple triptans. Reglan® and Naprosyn® are
excellent but if the patient needs triptan for each
headache, we suggest a stratified approach with early
use of the triptan. Zanaflex® can be used for muscle
contraction headaches.
Figure 6.
Personal Health Quality of Life
Questionnaire Results
100
Nonpharmacologic Treatment
90
Our headache program offers alternative therapies
in conjunction with traditional medicine. Some of
these modalities include magnesium and vitamin B2
therapy, biofeedback, massage, and physical therapy.
80
70
60
50
Headache Plan
40
The headache program used at Kaiser includes:
1. Educating patients so they are able to identify
which type or types of headaches they have.
2. All precipitants are identified and addressed.
3. Patients know which treatments to use for acute
treatment and preventative treatment.
4. Rebound issues are not left in place.
30
8 weeks
20
Baseline
10
10
h
y
en
ta
l
He
alt
Vi
ta
lit
M
Pa
di
ly
ni
nc
Bo
tio
io
Fu
ial
So
c
in
ng
l
na
g
ot
m
ay
in
eE
Ro
l
lePl
Ro
un
cti
on
in
ea
lth
lH
Ph
ys
The Kaiser headache program was designed to
determine whether a nurse practitioner specializing in
headache treatment under the guidance of a neurolo-
ica
lF
ne
ra
Ge
NP and Neurologist Roles
January/February - 2001 - Volume 23 Number 1
g
0
N=170
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Blumenfeld, A. (1999). Headache guidelines. Southern California
Kaiser Permanente Medical Group Guidelines. San Diego, CA:
Kaiser Permanente.
Clouse, J.C., & Osterhaus, J.T. (1994, May). Healthcare resource use
and costs associated with migraine in a managed healthcare
setting. The Annals of Pharmacotherapy, 28, 659-663.
Greiner, D., & Addy, S. (1996, March). Sumatriptan use in a large
group-model health maintenance organization. American
Journal of Health System Pharmacology, 53, 633-638.
Hu, X.H., Markson, L.E., Lipton, R.B., Stewart, W.F., & Berger, M.L.
(1999). Burden of migraine in the United States: Disability and
economic costs. Archives of Internal Medicine, 159, 813-818.
Lipton, R.B., Diamond, S., Reed, M., O’Quinn, S., & Stewart, M.F.
(2000). American Migraine Study II. Prevalence burden and
healthcare utilization for migraine in the United States
(Abstract). Headache, 40, 416.
Ries, P.W. (1986). Current estimates from the National Health
Interview Survey, United States, 1984. Vital and Health
Statistics; Department of Health and Human Services
Publication 86-1584, 82-104.
Schappert, S.M. (1992). National ambulatory medical care survey:
1989 summary. National Center for Health Statistics. Vital
Health Statistics, 13(10).
Solomon, G.D., & Litaker, D.G. (1997). The impact of drug therapy on
quality of life in headache and migraine. Pharmacoeconomics,
11, 334-342.,
At their 8 week visit, patients respond as to
whether their headache is much improved, improved,
the same, worse, or much worse. As shown in Figure
4, 92% scored improved, 7% scored no change, and
1% scored worse.
Two questionnaires, one migraine specific and
another that focused on headache status and overall
quality of health, were completed by 173 patients.
These questionnaires were filled out at baseline and at
8 weeks. As seen in Figures 5 and 6, there was a significant improvement in patients’ overall health.
Conclusion
Patients who are treated through the Headache
Management Program show an increase in patient satisfaction and improvement in health status. The
improvement was depicted from each patient’s baseline data questionnaire in comparison with his or her
own 8-week data.
It is inferred that patients who have better outcomes will use the health care system less and therefore decrease utilization costs. A group model of care
with a headache specialist nurse practitioner is a costeffective method of providing care to primary
headache patients.
Marie Tischio, MSN, NP
Headache Management Program
Kaiser Permanente, San Diego, CA
(619) 528-5000 (w)
[email protected]
References
Barton, C.W. (1994). Evaluation and treatment of headache patients
in the emergency department: A survey. Headache, 34, 91-94.
Research and Clinical Practice Sessions
Medical Office). She will be discussing Ambulatory
Care Staffing: A Search for the Right Model. This session will highlight the challenge of providing the right
quality and quantity of nursing support staff in an
ambulatory care setting. The discussion will include
the conceptual framework for developing a staffing
model, tools to benchmark staffing models to national
and regional data, and sources for current and ongoing
information regarding staffing in ambulatory care.
In addition to the research focused sessions,
Practice Evaluation and Research Committee members
invite you to join them at the Networking Lunch on
Friday, March 30, 2001. Members will be available to
offer consultation, advice, and guidance to AAACN
members interested in or currently developing
research or practice evaluation outcomes projects.
continued from page 23
•
referred to the ER by telephone triage.
Job Satisfaction, Organizational Commitment and
Organizational Instability Among Telephone
Triage Registered Nurses. The speaker for this presentation will be Kristin Hardy Wicking, MSN,
RN (Palomar College and Scripps Memorial
Hospital). She will present definitions, methodology, and correlation findings of a study examining
the key concepts of job satisfaction, organizational
commitment, and organizational instability.
Concurrent Session
The second research-focused presentation will be
a concurrent session, Ambulatory Care Nursing
Quality Indicator: AAACN Pilot Survey. The speaker
for this presentation will be AAACN Immediate PastPresident Peg Mastal, PhD, MSN, RN (Health Services
for Children with Special Needs, Inc.). She will review
the results of the AAACN Member Survey on the proposed American Nurses Association quality indicators
for community-based non-acute care distributed during the 2000 Annual Conference. The implications of
the pilot survey results for future AAACN activities
will be explored.
Let us know…
The Practice Evaluation and Research Committee
would also like to hear from AAACN members about
areas of interest for future research programs; projects
and areas you would like to see addressed by AAACN.
We look forward to seeing you at the conference and
hearing your ideas.
Regina C. Phillips, MSN, RN
Chair, 2001 Program Planning Committee
(312) 627-8748
[email protected]
Special Session
The final session features invited speaker Judi
Henry, MS, RN (Kaiser Permanente, Wheat Ridge
11
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Cancer Pain
continued from page 1
Given the many known barriers
to optimal pain management, it
is tempting for a nurse to give
up and go along with the status
quo. But to do so is to abandon
a basic professional tenet – the
nurse as patient advocate.
The Agency for Health Care
Policy and Research (AHCPR)
published Management of
Cancer Pain: Clinical Practice
Guideline (Jacox et al.) in 1994.
It was hoped that these
guidelines, developed by recognized experts, would direct the
management of cancer pain and
be a catalyst for abandoning
outdated attitudes and practice.
Instead, it is apparent that
knowledge and education alone
are not enough to alter practice
behaviors (Max, 1990; Maes,
2000). Knoblauch & Wilson
(2000) found an increased
length of time before a first analgesic dose is given and
between doses provided to pediatric patients after a
mandatory hospital in-service pain management program. Howell, Butler, Vincent, Watt-Watson, & Stearns
(2000) demonstrated that, even though an educational
intervention initially changed knowledge, attitudes,
and behaviors, the effect was not maintained over
time.
Why haven’t pain-related
practice behaviors changed?
While scientific documentation
has yet to conclusively answer
this question, it is speculated
that many variables are at play.
Health care professionals
often lack current knowledge
about pain management. (Jacox et
al., 1994; Miaskowski, 2000;
McMillan, Tittle, Hagan, Laughlin,
& Tabler, 2000a).
Also, lack of organizational
accountability for pain management is commonly cited: traditional institutional structures
and policies have been at odds with optimal pain management (Hollen, Hollen, & Stolte, 2000). Physicians’
response (or lack of) to nurses’ assessments of pain
likely play a significant role in nurses’ efforts to advocate for changes in pain management strategies (Maes,
2000). And finally, regulatory statutes do not consistently support the contemporary approach to addressing pain (Joranson et al., 2000).
The continued mismanagement of cancer pain is
ultimately linked to the dilemma of how to change
attitudes – attitudes of health care professionals, attitudes of people who have the pain, and attitudes of
family members and caregivers. One thing is clear: we
do have at our disposal the knowledge and tools to
manage the vast majority of cancer-related pain.
DIRECTOR OF NURSING
AMBULATORY PROGRAMS
Memorial Sloan-Kettering Cancer Center is the
world’s largest private institution devoted to
cancer prevention, diagnosis, and treatment. Join
our Executive Nursing team and provide clinical
direction for our multisite ambulatory oncology
centers. Oversee nursing care in office practice
and treatment settings, define new models of
nursing practice, identify nursing resource
requirements, and ensure high-quality standards
across systems. Work collaboratively with
administrators and clinicians to develop
successful strategies in a continuously evolving
healthcare environment.
Cancer Pain and Ambulatory Care Settings
The current cancer care delivery system is largely
based in ambulatory settings. It is estimated that about
90% of all cancer-related services occur in such settings as hospital-based clinics and treatment centers;
physician and nurse-practitioner offices; and patients’
homes.
Despite the commonplace use of sophisticated
technology in cancer care – particularly in actual cancer treatment modalities – most of cancer care involves
managing the sequelae of cancer itself and cancer
treatment-related side effects and toxicities (Hewitt &
Simone, 1999). In short, most cancer care falls within
the nursing domain. The logic then follows that nurses
in ambulatory care settings are in fact providing the
vast majority of cancer care services.
To qualify, you must be an NYS licensed/eligible
RN who is master’s prepared with at least 10
years of progressive ambulatory care experience,
including experience at the executive level.
Demonstrated experience in redesign of patient
processes in an outpatient setting is expected.
Oncology experience is highy desirable.
Role of the Ambulatory Care Nurse
Given the many known barriers to optimal pain
management, it is tempting for a nurse to give up and
go along with the status quo. But to do so is to abandon a basic professional tenet – the nurse as patient
advocate.
MSKCC offers an excellent compensation
package including 100% tuition reimbursement.
Visit our employment Web site at:
www.mskcc.org; or forward your resume,
indicating job number, to: Nurse Recruitment,
Job #00194.2N, MSKCC, 633 Third Avenue, 56th
Floor, New York, NY 10017. EOE/AA.
January/February - 2001 - Volume 23 Number 1
Changing Attitudes
12
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
It’s up to the nurse to open
the discussion and counter
patients’ misconceptions
about pain and its
management.
There are several simple interis believing the patient’s report of
ventions any nurse can pursue to
his/her pain. Davies and McVicar
work toward the optimal manage(2000a) suggest the proper assessment of pain:
ment of pain includes the 10
Accept accountability for
parameters highlighted in Table 1.
addressing the problem of pain.
Management – It’s not rocket
Even though the appropriate manscience. The AHCPR Guidelines
agement of pain has yet to be unioffer relatively straightforward
formly codified in nurse practice
pain management strategies (Jacox
acts, several professional nursing
et al., 1994). Analgesics are given
organizations, including the
on an “around-the-clock” schedule
American Nurses Association, the
that maintains a plasma level sufAmerican Association of Critical
ficient to control pain. Short-actCare Nurses, and the Oncology Nursing Society recoging medications can be used on an “as needed” basis
nize the essential role of the nurse in advocating for
to manage pain that occurs between scheduled doses.
and providing optimal management of pain.
Most pain can be managed with oral analgesics comPut simply, each and every nurse who encounters
bined with adjuvant medications and nonpharmaceupeople at risk for pain must accept accountability for
tical pain management strategies.
addressing the essential human need for comfort.
An important strategy will be to incorporate pain
Gordon and Berry (2000) suggest eight steps to
management into the operations of cancer care setimplementing pain practice changes at an organizatings. Georgesen (2000) offers a clinical pathway for
tional level:
outpatient cancer pain management that could be
1. Develop an interdisciplinary workgroup.
adapted in other ambulatory care settings.
2. Analyze current pain management practices.
Help the patient develop and use effective self-advo3. Articulate and implement a standard of practice.
cacy skills. Barriers to appropriate and optimal pain man4. Establish accountability
agement are unlikely to disapfor pain management.
pear in the near future. Pain
Table 1.
5. Provide information
expert C. Stratton Hill suggests
Pain Assessment Parameters
about pharmacologic
“Significant change regarding
and nonpharmacologic
pain control may depend on
1. Physical source of the patient’s pain
interventions.
empowering patients to demand
2. The patient’s mood
6. Promise patients a quick
adequate pain treatment” (1995,
3. The patient’s expectations of pain
response to their reports
p. 1881). Therefore, patients and
4. Available support from family and
of pain.
families must be empowered to
friends
7. Provide staff education.
be effective self-advocates.
5. Alterations in function as a result of
8. Continually evaluate and
Effective self-care and self-advopain
work to improve pain
cacy are especially important, as
management.
much of cancer care occurs in
6. The patient’s perception of severity
Raise the index of suspatients’ homes, outside the
of pain
picion. The prevalence of
purview of the cancer care team.
7. The patient’s fears and anxieties
pain in people with cancer
Establish a partnership
8. The coping strategies the patient
dictates that every cancer
with the patient and family
uses to manage pain, fears, and
care provider presumes that
based on the agreed-upon
anxieties
a person with cancer (or a
goal of achieving a pain-free
9. Perceived response of the family
cancer history) is more likely
state, then work together to
10. Impact of pain on the patient’s
to have pain than not.
reach that goal. A most basic
lifestyle
Patients reluctantly initiate
strategy that any nurse can
pain-related discussions,
employ is to let people at risk
they expect to have pain, and Adapted from Davies and McVicar, 2000a.
for pain problems know that
often assume that cancer pain
they do not need to endure
cannot be relieved without compromising mental clarpain – that cancer doesn’t have to hurt. Helping
ity or risking other debilitating side effects (Corizzo,
patients and families find informational resources
Baker, & Henkelmann, 2000). It’s up to the nurse to
geared to lay readers that explain cancer pain and its
open the discussion and counter patients’ misconcepmanagement is an easy, first step. [Note: the authors’
tions about pain and its management.
book, Cancer Doesn’t Have to Hurt, Haylock & Curtiss,
Learn and apply pain assessment skills. Successful
1997, is one such resource.] The Wisconsin Cancer
pain management depends on accurate and systematic
Pain Initiative, the American Cancer Society, and the
assessment (McMillan, Tittle, Hagan, Laughlin, &
National Institute of Health all offer good resources
Tabler, 2000b). The first element in accurate assessment
developed especially for lay readers.
13
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Conclusion
References
American Association of Critical-Care Nurses. (1999). Role of the
critical-care nurse. Aliso Viejo, CA: American Association
of Critical-Care Nurses.
American Nurses Association. (1991) Promotion of comfort and
relief of pain in dying patients. (Position Statement).
Washington, D.C.: American Nurses Association.
Corizzo, C.C., Baker, M.C., & Henkelmann, G.C. (2000).
Assessment of patient satisfaction with pain management
in small community inpatient and outpatient settings.
Oncology Nursing Forum, 27(8), 1279-1286
Davies, J., & McVicar, A. (2000a). Issues in effective pain control
1: Assessment and education. International Journal of
Palliative Nursing, 6(2), 58-65.
Davies, J., & McVicar A. (2000b). Issues in effective pain control
2: From assessment to management. International Journal
of Palliative Nursing, 6(4), 162-169.
Georgesen, J. (2000). A clinical pathway for outpatient cancer
pain management. Oncology Issues (Suppl.), Oncology
Symptom Management 2000: A Team Approach: Part I, 1316.
Gordon, D.B., & Berry, P.H. (2000). Integrating pain management
into clinical practice. Oncology Issues (Suppl.), Oncology
Symptom Management 2000: A Team Approach: Part I, 912.
Haylock, P.J., & Curtiss, C.P. (1997). Cancer Doesn’t Have to
Hurt. Alameda, CA: Hunter House, Inc.
Hewitt, M., & Simone, J.V. (Eds.). (1999). Institute of Medicine,
National Research Council. Ensuring Quality Cancer Care.
Washington, D.C.: National Academy Press
Hill, C.S. (1995). When will adequate pain treatment be the
norm? JAMA, 274(23), 1881-1882.
Hollen, C.J., Hollen, C.W., & Stolte, K. (2000). Hospice and hospital oncology unit nurses: A comparative survey of knowledge and attitudes about cancer pain. Oncology Nursing
Forum, 27(10), 1593-1599
Howell, D., Butler, L., Vincent, L., Watt-Watson, J., & Stearns, N.
(2000). Influencing nurses’ knowledge, attitudes, and practice in pain management. Cancer Nursing, 23(1), 55-63.
Jacox, A., Carr, D.B., Payne, R., et al. (1994). Management of
Cancer Pain. Clinical Practice Guideline [No. 9 AHCPR
Pub. No. 94-0592]. Rockville, MD: Agency for Health Care
Policy and Research, U.S. Department of Health and
Human Services, Public Health Service, March 1994.
Joranson, D.E., Gildon, A.M., Ryan, K.M., et al. (2000). Achieving
Balance in Federal and State Pain Policy: A Guide to
Evaluation. Madison, WI: The Pain & Policy Studies Group,
University of Wisconsin Comprehensive Cancer Center.
Knoblauch, S.C., & Wilson, C.J. (2000). Clinical outcomes of educating nurses about pediatric pain management. Outcomes
Management for Nursing Practice, 3(2), 87-89.
Maes, S. (2000). Oncology nurses strive to alleviate suffering.
ONS News, 15(10), 1, 4-5.
McMillan, S.C., Tittle, M., Hagan, S., Laughlin, J., & Tabler, R.E.
(2000a). Knowledge and attitudes of nurses in Veterans
Hospitals about pain management in patients with cancer.
Oncology Nursing Forum, 27(9), 1415-1423
McMillan, S.C., Tittle, M., Hagan, S., & Laughlin, J. (2000b).
Management of pain and pain-related symptoms in hospitalized veterans with cancer. Cancer Nursing, 23(5), 327-336.
Miaskowski, C. (2000). Improving pain management: An ongoing journey. Oncology Nursing Forum, 27(6), 938-944.
Oncology Nursing Society. (1998). Position on Cancer Pain
Management. Pittsburgh, PA: Oncology Nursing Society.
There is an increasing acknowledgement that cancer-related pain can and should be managed. On the
other hand, we are a long way from achieving the
desired endpoint where the existence of pain is the
exception rather than the expected.
Optimal management of cancer pain is not dependent on the discovery of new drugs or new technologies. For the most part, cancer-related pain can be easily managed with the armament and skills currently at
hand.
Nurses can and must assume patient advocacy roles
on behalf of individual patients and groups of patients.
There are many expert guides - recognized experts who
are involved in identifying standards of care, and who
give us clear instruction through credible, scientific
publications to helps us address the pain-related issues
more effectively. But what has been missing to date is a
collaboration of nurses from all cancer care settings who
advocate for this most elemental of human needs.
Nurses can wait for grassroots advocacy groups to
demand the care patients deserve - and it will come
eventually - or they can take a proactive position and
work with patients and their advocates to achieve the
goal of complete relief of cancer-related pain.
Yes, we’re a medical and
teaching wonder, but our
most powerful results are
Nurse Manager Ambulatory Services
…at Johns
Hopkins Bayview
Medical Center
our environment
is what you’d
expect from one
of the nation’s
leading
academic
teaching
hospitals. But
the full measure
of our impact is
reflected in the
playgrounds,
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senior centers,
and homes of
the
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• OB/Peds • Urology
Requires BSN (MS preferred) and
3-5 years of ambulatory
management experience. Related
clinical experience is desired.
Discover the Hopkins Bayview
difference – including Competitive
Salary Structures and benefits like
an On-Site Fitness Center and
Tuition Reimbursement. Please
send resumes to: Johns Hopkins
Bayview Medical Center, Attn:
Nurse Recruitment/0101VP, 4940
You’ll
like
Pamela J. Haylock, MA, RN
Oncology Consultant
Medina, TX
(830) 589-7380 • [email protected]
the
January/February - 2001 - Volume 23 Number 1
14
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Best Practices in Nursing
Care to Older Adults
try
Volume 1, Number 3, January 1999
Series Editor: Meredith Wallace RN, MSN, CS, PhD(c)
from The Hartford Institute for Geriatric Nursing
Volume 1, Number 7, January 2000
Series Editor: Meredith Wallace, MSN, RN, CS, PhD(c)
Assessing Pain in
Older Adults
Ellen Flahaerty, MSN, RN, GNP, PhD(c)
impairments. Subjective tools such as the Visual
Analog Scale (VAS) and the Faces Scale are highly
effective in assessing pain in older adults. The VAS is a
straight horizontal 100 mm line anchored with “no
pain” on the left end and “worst possible pain” or
“pain as bad as it could possibly be” on the right. Older
adults are simply asked to choose a position on the line
that represents their pain. The Faces Scale depicts
facial expression on a scale of 0-6, with 0=smile, and
6=crying grimace. Older patients should choose a face
that represents how the pain makes them feel.
Editor’s Note:
The following is an installment of the “Try This” series
published by the John A. Hartford Foundation Institute for
Geriatric Nursing. The content is intended to encourage
nurses to understand the special needs of older adults and
use the highest standards of practice in caring for these
patients. We hope direct care nurses, nurse managers, staff
developers, and nursing faculty who do not consider
TARGET POPULATION: Both the VAS and the
Faces Scale are used with older adults. Studies have
shown that 86% of nursing home residents could complete at least one of these pain scales.
themselves geriatric specialists will gain from this
installment, and from future ones which will be published in
upcoming issues of Viewpoint.
For more information, contact the Hartford Institute
VALIDITY/RELIABILITY: Studies, which have
compared simple pain intensity measures, have
demonstrated high reliability and validity using the
VAS and Faces Scales with older adults.
via e-mail at [email protected] or visit their Web site at
www.nye.edu/education/nursing/hartford.institute/
STRENGTHS AND LIMITATIONS: These simple,
yet effective pain assessment tools are easy to administer and provide a method to evaluate not only the presence of pain, but also the effectiveness of treatment.
However, these assessment tools should not replace
extensive medical history taking and physical exams
which may lead to the determination of etiologies of
pain.
WHY: Studies on pain in older adults (65 years of
age and older) have demonstrated that 25%-45% of
community dwelling older people have chronic pain.
In addition, 45%-85% of nursing home residents also
report pain that is often left untreated. Although there
is minimal research that strictly focuses on pain in
older adults, studies with younger participants have
elucidated associations between pain and depression.
Increased pain has further resulted in decreased
socialization, impaired ambulation, and increased
health care utilization and costs. Older adults are
reluctant to report pain: therefore, nurses need to be
proactive in screening for and assessing pain.
MORE ON THE TOPIC:
American Geriatric Society. (1998). The management of
chronic pain in older persons. Journal of the American
Geriatric Society, 46, 635-651.
Closs, J. (1996). Pain and elderly patients: A survey of nurses’ knowledge and experiences. Journal of Advanced
Nursing, 23, 237-242.
Herr, K.A., & Mobility, P.R. (1993). Comparison of selected
pain assessment tools for use with the elderly. Applied
Nursing Research, 6, 39-46.
BEST TOOL: No objective measure or biological
marker of pain exists. Simply worded questions and
tools which can be easily understood are the most
effective, as older adults frequently encounter numerous factors including sensory deficits and cognitive
15
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Best Practices in Nursing
Care to Older Adults
from The Hartford Institute for Geriatric Nursing
Volume 1, Number 3, January 1999
Series Editor: Meredith Wallace RN, MSN, CS, PhD(c)
INSTRUMENT:
A monthly series provided by The Hartford
Institute for Geriatric Nursing.
Best Practices in Nursing
Care to Older Adults
January/February - 2001 - Volume 23 Number 1
[email protected]
www.nyu.edu/education/nursing/hartford.institute
16
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
with the following goals:
• Apply the clinical knowledge with incorporated
competencies into the nursing and provider roles
• Support the patient with pain as the expert
• Systematically assess pain
• Use combination therapies to balance the pain
management treatment perspective
• Individualize pain treatment and “red flag” negative pain experiences
• Communicate the pain experience across geographic lines
• Identify the barriers to quality pain management
and educate with research-based information
Legally and ethically, higher pain management
standards will drive practice changes.
An important precedent was set in 1999 when
Oregon’s State Medical Board disciplined a doctor for
nonrelief of pain. Oregon has since mandated quality
pain management in patient care.
In 2000, the American Bar Association held a symposium in San Diego, CA, on the legal implications of
unrelieved pain. A jury in North Carolina brought a
$15 million judgment against a long-term care facility
for withholding adequate pain medications (Henry
James v. Hillhaven Corporation, 1999).
Ambulatory nursing must recognize patient rights
and value the person experiencing the pain by providing quality pain care. Specifically, pain must be identified and treated promptly.
In pain management, the standard is the patient’s
self-report, the process is measurement and assessment, and the quality is defined by patient outcomes.
(See related article, “Documenting Pain” on page 5.)
The availability and utilization of ongoing education
for all the players will affect disease state treatment
(American Pain Society Quality of Care Committee,
1995). As they become educated, providers will accept
the defined pain principles. They will also accept that
patients are the pain experts. This is in keeping with
JCAHO’s model that promotes the patient’s right to
pain management. The impact on practice will clearly
change clinical care and improve the “picture of pain.”
New Pain Management Standards
continued from page 1
managing pain in a very different way that will result
in better outcomes for patients. Key nursing associations as well as health care organizations will work
together to develop the tools needed to meet this new
standard of care.
Areas that are affected are:
• Ambulatory care
• Behavioral health care
• Home care
• Healthcare networks
• Hospitals
• Long-term care networks
• Long-term care pharmacies
JCAHO’s standards for pain management will
increase the visibility of this critical component of
patient care and encourage changes in practice. As
pain management standards are applied in ambulatory
settings, the principles of adequate pain management
will prevail. These guidelines have been developed by
the Agency for Healthcare Policy and Research
(AHCPR), the American Society of Pain Management
Nurses (ASPMN), and the World Health Organization
(WHO).
The goal of these new standards is to support:
• The rights of patients to appropriate assessment
and management of pain
• The acknowledgment of pain as a major factor
affecting patient care outcomes
• The need for ongoing pain competencies for clinical providers and staff
• The identification of “red flags” in pain assessment
• The establishment of policies and procedures for
pharmacologic interventions
• The promotion of data collection on the pain management process
• The support of symptom management in discharge
planning (Kowal, 1999)
Ambulatory Care Nurse’s Role
Conclusion
Pain management is dependent on incorporating
ambulatory care nurses as key members of the interdisciplinary team. The organizational structure and standards for the practice of ambulatory care nursing provide a mechanism for monitoring accountability,
establishing communication, and defining quality
patient outcomes (AAACN Administration & Practice
Standards, 2000). As professional nursing seeks to
maximize the patient’s state of health and wellness,
pain management will play a critical role.
Uncontrolled pain costs the public a major toll in
human, economic, and psychosocial terms. All
patients have the right to expert pain diagnosis and
pain management. JCAHO has activated a quality pain
process and created an official mandate to change
practice. The benefits achieved will redefine patient
outcomes in the future.
References
AAACN Nursing Administration and Practice Standards, Fifth
Edition. (2000). Pitman, NJ: The American Academy of
Ambulatory Care Nursing.
American Pain Society Quality of Care Committee. (1995). Quality
improvement guidelines for the treatment of acute pain and
cancer pain. Journal of the American Medical Association, 23,
1874-1880.
Kowal, N. (1999). Report Card for pain management: documentation
standards along the continuum of pain. Analgesia, 10(1), 3-12.
Efforts Intensify
The code of quality pain management was systematically created and refined by experts. Professional
organizations such as ASPMN have written practice
standards for nurses. Currently ASPMN is moving the
vision of quality pain management to a higher level
continued on page 18
17
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
Cleeland, C., Govin, R., Hatfield, A., Edmondson, J., Blum, R.,
Stewarts, & Pandga, K. (1994). Pain and its treatment in outpatients with metastatic disease. The New England Journal of
Medicine, 330, 592-596.
Grant, M., Ferrell, B., Rivera, L., & Lee, J. (1995). Unscheduled readmission’s for uncontrolled symptoms: A healthcare challenge
for nurses. Nursing Clinics of North America, 30, 673-682.
Joint Commission on Accreditation of Healthcare Organizations.
[On-line]. Available: www.jcaho.org.
Shapiro, R. (1996). Healthcare providers liability exposure for inappropriate pain management. The Journal of Health, Law and
Ethics, 24, 360-364.
New Pain Management Standards
continued from page 17
Additional Readings
Bendibba, M., Torgerson, W., & Long, D. (1997). Personality traits,
pain duration and severity, functional impairment, and psychological distress in patients with persistent low back pain. Pain,
72, 115-125.
Bernabei, R., Gambassi, G., Lapane, K., Landi, F., Gatsonis, C.,
Dunlop, R., Lipsitz, L., Steel, K., & Mor, V. (1998). Management
of pain in elderly patients with cancer. Journal of the American
Medical Association, 279, 1877-1882.
Berry, P., & Dahl, J. (2000). The new JCAHO pain standards:
Implications for pain management nurses, l (l), 3-12.
Bonica, J. (1985). Treatment of cancer pain: Current status and future
needs. In H.L. Field, R. Dubner, & F. Cervero (Eds.), Advances
in Pain Research and Therapy, Volume 9. Proceedings of the
Fourth World Congress on Pain (pp. 589-616). New York: Raven
Press.
Bostrom, M. (1997). Summary of the Mayday Fund Survey: Public
attitudes about pain and analgesics. Journal of Pain and
Symptom Management, 13, 166-171.
Nancy R. Kowal, MS, RN,C, NP
President, American Society of Pain Management Nurses
Pain Consultant, University of Massachusetts
Memorial Healthcare System
Worcester, MA
(508) 856-3414
[email protected]
Overview of JCAHO Pain Management Standards
The Joint Commission views pain management
as an integral component of care. To that end, it
has expanded the scope of its pain management
standards, which have been endorsed by the
American Pain Society (APS), to cover all pain scenarios in accredited health care organizations
rather than limiting the scope to end-of-life care.
Patient Education (PF)
Education materials are developed to facilitate
patients’ understanding of pain, involve them in
the treatment plan, and provide them with specific
knowledge and skills to meet their ongoing health
care needs. When assessing patients’ learning
needs, staff should consider such variables as
patients’ beliefs and values; literacy; educational
level and language; barriers to learning and motivations; physical and cognitive limitations; and the
financial implications of care choices.
Continuum of Care (CC)
A collaborative, interdisciplinary team approach
and open lines of communication related to symptom management, pain management strategies
and their effectiveness or barriers, serve to support the continuum of care.
Improving Organization Performance (PI)
The performance improvement plan addresses
the organization’s ongoing measurement priorities, including assessment and measurement of
appropriateness and effectiveness of pain management. Baseline performance indicators for
pain management are measured using patient
interviews, satisfaction surveys and/or medical
record reviews. These indicators are measured at
regular intervals to assess ongoing performance
improvement.
Focal points to consider in complying with the
new Pain Management Standards:
Patient Rights (RI)
Recognize the right of individuals to appropriate
assessment and management of pain in the
patient bill of rights, service standards, and/or
mission of the organization.
Assessment of Patients (PE)
Assess the existence of pain and, if so, the nature
and intensity of pain in all patients according to
the policies/procedures of the organization. The
orientation of patient care providers includes competency assessment and education in pain assessment and management.
Care of Patients (TX)
The organization’s policy assures a uniform interdisciplinary approach to pain assessment and
management across all settings and patient populations. Pain reported by the patient that is not
within the scope of the practice setting will be
referred to an appropriate provider. Standardized
procedures and practice guidelines are adopted to
address patients’ needs and support the appropriate prescribing or ordering of effective pain medication. The effectiveness of referrals and interventions is monitored.
If you have questions, contact Standards
Interpretation at (630) 792-5900 or www.jcaho.org.
Joint Commission on Accreditation of Healthcare Organizations
January/February - 2001 - Volume 23 Number 1
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National Office: (800) AMB-NURS • Web Site: www.aaacn.org
The Parish Nurse
Movement
Sandra W. Reifsteck, MS, RN
Faith Roberts, BSN, RN
Author Sandra Reifsteck conducts a blood pressure test on congregation member Bill Hartz
during a senior citizens’ luncheon at Good Shepherd Lutheran Church in Champaign, IL.
Authors’ Note: Three years ago, we
brought to you the role of the parish nurse
in ambulatory settings and the holistic
approach to delivery of health care
(Viewpoint, March/April, 1998). This past
fall we had the opportunity to represent
the Carle Foundation Hospital, Urbana,
IL, and the University of Illinois College of
Nursing in Champaign-Urbana by attending a 5-day curriculum content program
for coordinators who are delivering or
plan to deliver a Basic Parish Nurse
Preparation Program. It is with this in
mind that we share with you our thoughts
and experiences and invite you to join us
in looking to the future for the role that
nurses in congregational settings can play
in community health care delivery.
History
The literature continues reporting numbers of more than 25,000
to support the health parish nurses.
care industry in Preparation
A core curriculum for parish nurse
producing and using preparation, which is the outcome of the
Third
Invitational
Educational
progressively Colloquium in Parish Nurse Education
held April 27-29, 2000, is now being prosophisticated moted. This ongoing project continues to
be developed through a collaborative
technology, yet facts working arrangement which includes The
International Parish Nurse Resource
prove that most of the Center, Advocate Health Care, Loyola
University, and Marcella Niehoff School of
world’s health problems Nursing (all in Chicago, IL); and Marquette
University College of Nursing in
cannot be totally Milwaukee, WI.
This curriculum shares the philosophy
addressed this way. of parish nursing as a specialty practice
Parish nurse programs are growing nationwide. In the 1970s, Rev.
Granger Westberg began exploring
the link between the church and
medical communities. He believed that conventional
medicine – by overlooking the relationship between
spiritual well-being and physical health – deprived
patients of complete care.
This medical clinic model using physicians
proved too expensive in the congregational setting and
nurses were identified as the “glue between the faith
and medical communities.” The first parish nurse project was piloted by Lutheran General Hospital, Park
Ridge, IL, now the Advocate Health System in
Chicago. This system also supports the International
Parish Nurse Resource Center. Surveys from the center
show that the programs are developing nationwide,
•
•
•
•
•
of
19
and professional model of health ministry.
It is distinguished by the following beliefs:
Parish nursing reclaims the historic roots of health
and healing found in many religious traditions.
Spiritual dimension is central to nursing practice
and holds the belief that all people must be treated
with respect and dignity.
The parish nurse understands health to be a
dynamic process.
The focus of practice is the faith community.
The parish nurse collaborates with the pastoral
staff and congregations as a source of health and
healing.
Curriculum development suggests a specific order
content modules and a required minimum of time
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
allocated for each. Allocated CEs for most basic preparation courses is recommended at 35 contact hours.
Many universities and colleges are also offering parish
nurse preparation programs in both their BSN and
master’s level programs. Partnering with a 4-year institution is important as the parish nurse movement continues to grow in both scope and impact in the community setting.
The strongest model for the delivery of a parish
nurse’s basic preparation course is a collaborative
model between a service provider who sponsors a
parish nurse program and an educational institution.
This builds on the resources of both while encouraging
the college of nursing faculty to be more aware of
parish nursing curricula components. Parish nursing
then becomes a part of the community setting supported by both acute health care providers and community
agencies who provide support services to congregations at the request of the parish nurse.
Currently there is no professional certification for
parish nurses. The American Nurses Association in
Washington, DC, recognizes parish nursing as a specialty. The Health Ministry Association, Hunnington
Beach, CA, has supported standards for parish nursing
as proposed in the Standards for Parish Nursing document. (Scope and Standards of Parish Nursing
Practice [1998], American Nurses Association, and
Health Ministries Association, Inc.)
The Basic Parish Nurse Curriculum offered by the
International Parish Nurse Resource Center in Chicago
uses the term “dimension” to reflect the work of parish
nurses in their congregations and communities. These
dimensions may be expanded or contracted depending
on community needs, resources, and professional
expertise. They are described as:
1. Integrator of Faith and Health
2. Spiritual Caregiver
3. Health Promoter
4. Counselor
5. Advocate
6. Educator
7. Care Coordinator
8. Community Resource Agent
Table 1.
Benefits of Parish Nurse Programs
Institutions
•
Community Service Initiative
•
Hospital + Physicians + Community =
Continuity of Care
•
Good image building for health care organizations
•
Assist in identifying individual’s needs
•
Laboratory of the future for all ages
Communities
•
Healthier and more informed community
population
•
Individuals assuming responsibility for own
health care
•
Involvement of existing community resources
for the good of the whole
•
Prudent use of resources
•
Provide wellness and health information to
community populations
Churches
•
Church mission includes healing
•
Attracts new members
•
Involves current members in stewardship
•
Meets needs of community members whose
needs are not being met (for example, elderly
homebound)
•
Provides gathering place for both churched
and nonchurched
Healthy Goals
The literature continues to support the health care
industry in producing and using progressively sophisticated technology, yet facts prove that most of the
world’s health problems cannot be totally addressed
this way. The mission of a church is health and salvation and interfaces with all ages and socioeconomic
groups from birth to death. As a congregation, people
want to be able to be proud of their ability to improve
the health of their communities. Therefore, they all
have a stake in the future.
Table 1 was developed to show the benefits gained
by each entity when parish nursing is seen as an additional ministry. This diagram was used successfully to
promote an acute care facility’s sponsorship of such a
parish nurse program.
University of Washington SON presents:
PACIFIC NW
AMBULATORY CARE NURSING - 2001
May 9-10, 2001 • 14 contact hours
WA State Convention Center, Seattle
Lessons Learned: One Community Program
A parish nurse program was initiated by Carle
Foundation Hospital in Illinois in the fall of 1997 with
the goal of having 80 nurses complete the 40-hour CE
approved course in 3 years. By fall 2000, 184 nurses
representing 108 congregations (including an Islamic
mosque) have taken the class.
One of the components of the program’s success
has been the unique scheduling of the class itself. As
most nurses work every other weekend, classes are
held over three weekends spread out over several
The conference addresses clinical assessment;
nursing interventions; administration and
management issues; and professional
development with two general sessions and nine
sets of concurrent sessions.
For information call: (206) 543-1047
E-mail: [email protected] or
www.son.washington.edu/cne
January/February - 2001 - Volume 23 Number 1
20
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
get. Other benefactors also come forward to help some
weeks. Participants meet on Friday evenings, all day
of the small churches in rural communities send nurson Saturdays, and both days on the third and final
es to the annual Westburg Symposium in Chicago or
weekend.
they sponsor other program activities.
Since the majority of the nurses will volunteer
their time as parish nurses, they are able to attend
class and still maintain their
Conclusion
work commitments. By meeting
on the weekend the all- important
Who would have thought
bonding or retreat like atmoparish nurses could have such an
sphere is maintained; a necessary
impact on the health of a commuelement for such a course.
nity? Yet that is exactly the stories
Nurses by nature like to “get
that are reported.
things done” and by spreading out
Because parish nursing focusthe weekends, they are able to get
es on wellness and disease prethe course content synthesized
vention; moves from clinicianand the classes completed in a relcentered care to patient-involved
atively short time.
care; and uses a holistic approach
The two quotes from particito health care (body, mind, spirit),
pants most often heard during the
it could spur revolutionary
course are: ”This is what I went
changes in the country’s health.
to nursing school for,” and “I’ve
At the Carle program, combeen doing this for years in my
ments from nurses like “Parish
church. I just never knew there
nursing is the best thing I have
was a name for it.”
done in my 34 years of nursing”
This parish nurse program is
or “Taking this class has been a
truly community based, as the
life changing event for me,” have
nurses come from a variety of Sandra Reifsteck gives a Healthy Eating sparked great excitement for the
health care settings. The largest speech for an “Over 60” church luncheon.
future. In fact, Carle Foundation
group of nurses who have taken
Hospital has made parish nursing
the course come from ambulatory care. The communia priority in their emphasis on community outreach
ty has two large multispecialty physician clinics, one
for rural east central Illinois. Their initiative and ongouniversity supported student health service, and one
ing support, along with similar backing from many
community-funded clinic for the medically underorganizations across the country, is the root of the
served. The dimension of nurse as referral agent is
parish nurse movement, which can only grow and
probably one of the most popular and eye-opening segflourish in the future into a health ministry that proments in the course. Everyone tends to get used to
motes love and healing for all ages.
their own niche or work comfort zone and participants
Sandra Reifsteck, RN, MS, FACMPE
are always amazed to learn about the plethora of serRegional Consultant, Great Plains States
vices available in their own community.
Bayer Institute for Health Care Communication
Champaign, IL
Ongoing Support
(217) 398-3308 • [email protected]
Carle Foundation Hospital supports the parish
Faith Roberts, BSN, RN
nurse program by offering bimonthly sharing sessions,
Program Coordinator
bimonthly CE offerings, and an annual individual
Carle Foundation Hospital Parish Nurse Program
meeting with the program coordinator. In addition, the
(217) 326-2683 • [email protected]
hospital offers liability protection for each parish
Editor’s Note: Sandra Reifsteck is a AAACN past president.
nurse at no cost.
She spent over 28 years at Carle Clinic Association and was
The hospital also publishes a monthly newsletter,
instrumental in bringing the parish nurse program to the
Blessings, which has proven to be a great way to keep
Carle organization where it is currently sponsored and
underwritten by Carle Foundation Hospital. She also serves
in contact with the 184 nurses who have completed
on adjunct faculty at the University of Illinois College of
the program. Each issue includes “Volunteer
Nursing, an educational collaborator for the program.
Opportunities,” “Educational Opportunities,” and
other “Helpful Information” such as a prayer list for
Faith Roberts conducts two training programs annually in
individual nurses, shared programs to use in their own
Illinois. She also conducts continued education for all the
churches, and short stories of sharing and successes.
nurses who are trained in the Carle program. Faith is a frequent speaker at regional and national meetings on the topics
Since the Carle health system also has a managed
of spirituality, parish nursing, and trends in health care.
care product with a senior insurance plan, the parish
nurse program is extremely helpful in reaching many
For more information on parish nursing, visit the Web site
of the members as they deliver preventive care and
www.parishnurse.org.
monitoring of chronic care to the congregation.
The budget for the parish nurse program is approximately 3% of Carle’s total community outreach bud21
January/February - 2001 - Volume 23 Number 1
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
AAACN Election Results
The AAACN Nominating
Committee is pleased to announce
the results of the election for new
officers conducted in December
2000. There were 254 members
(18%) who returned the ballots and
elected the following:
President-Elect (2001-2002)
Candia Baker Laughlin, MS, RN, Cm
Board of Directors (2001-2004)
Deborah Conway, MSN, RN
Regina C. Phillips, MSN, RN
Beth Ann Swan, PhD, CRNP
Nominating Committee (2001-2003)
Karen Griffin, MSN, RN, CNAA
Susan Paschke, MSN, RN, Cm, CNA
Bylaws Approval
Yes: 248
No: 3
No vote: 3
On behalf of the Board of
Directors and the members of
AAACN we congratulate the new
officers and wish them every success as they join the current Board
of Directors, leading our organization into the future.
The overwhelming acceptance
of the bylaws as revised has important implications for AAACN. By
approving these bylaws, the members have ensured that AAACN is in
an advantageous position, able to
create new opportunities for action
as we advance into the new millennium.
The bylaws revision task force
included the members of the
Nominating Committee and three of
AAACN’s past presidents, Jo Ann
Appleyard, PhD, RN, Linda
D’Angelo, MSN, MBA, RNC and
Elizabeth Dickey, MPH, RN.
Marjorie Weber, a Registered
Parliamentarian, served as a consultant.
Nominating Committee (2000-2001)
Chair
Peg Mastal, PhD, RN
(Immediate Past President)
Committee
Cindy Noa, MS, RN, CNAA
(Board Liaison)
Ann Lockhart, MN, RN
Marcia Sheeter, MS, RN
Barbara Tiedemann, BSN, RN, CNA
ANCC Drops BSN as Certification Exam Requirement
Good news for ambulatory care
nurses interested in becoming certified!
The American Nurses Credentialing
Center (ANCC), which administers the
only modular certification examination in
ambulatory care nursing, has announced
that a BSN is no longer required to take this
exam.
In July 2000, the American Academy of
Ambulatory Care Nursing (AAACN), which collaborated with ANCC to develop the exam, requested ANCC
to reconsider the BSN eligibility criterion based on
input received from several members. AAACN is very
pleased with this decision!
When the ambulatory care nursing certification
exam was first developed, ANCC required a BSN for
nurses who did not hold a core certification in another
area. However, nurses who held a core certification,
whether or not they had a BSN, could take the exam.
AAACN felt the BSN eligibility criterion was confusing and sent a conflicting message.
The AAACN Board has discussed the BSN criterion for certification numerous times. While we support
the BSN as the entry level into the profession, we also
realize there are many nurses practicing in ambulatory care who do not hold this degree. Certification is a
practice based credential, not an entry into nursing
credential. Since the ambulatory certification exam is
the only credential that exemplifies expertise in ambulatory care nursing, we believe it is essential that all
January/February - 2001 - Volume 23 Number 1
registered nurses in ambulatory care be eligible to take this exam.
AAACN applauds ANCC’s decision to
drop the BSN requirement. We hope that
now there will be many more ambulatory
care nurses who join the ranks of those nurses who have taken the plunge and become
certified.
For more information about the exam, contact ANCC at (800) 284-CERT(2378) or visit nursingworld.com.
AAACN offers the following excellent resources to
help you study for the exam:
• Certification Review Course, April 2, 2001 – held
in conjunction with the AAACN Annual
Conference in Nashville, TN, March 29-April 1,
2001
• Certification Review Course Syllabus
• Self-Assessment Manual – includes 200 practice
test questions
• Examination Preparation Guide – contains information about the exam and study tips
• AAACN Ambulatory Care Nursing Administration
and Practice Standards
• Core Curriculum for Ambulatory Care Nursing –
this new text will debut at the 2001 AAACN
Conference and will be available for purchase after
the conference.
For more information or to place your order, contact AAACN at (800) AMB-NURS, or visit the Web site
at www.AAACN.org.
22
National Office: (800) AMB-NURS • Web Site: www.aaacn.org
AAACN 2001 Conference
March 29-April 1, 2001 • Nashville, TN
E-Commerce:
From Novice
To Connectivity
Maureen T. Power, RN, MPH
The 2001 AAACN preconference,
E-Commerce: From Novice to
Connectivity, will present both basic
Web technology and information on
assessing today’s telecommunications
systems.
Expert speakers will share their
knowledge about America’s migration
to Web-enhanced services. They will
identify organizational roadblocks
commonly observed in e-commerce
services, describe industry benchmarks, and help participants understand what patients and consumers are
seeking from the health care industry
New-age technology will be
addressed from three perspectives, represented by organizations identified as
leaders in their specialties. E Surg, a
conference sponsor, is a young e-commerce company targeting physician
practices and ambulatory care facilities. Presenter Mike Sweeney, E Surg
vice president of business development, will target Web terminology, evolution of the technology, the impact of
e-commerce in today’s marketplace,
and the need for migration from “brick
and mortar” to the Web.
Robert F. Priddy, director of marketing, and Maurice J. Pitkofsky, product consultant, both of iMcKesson
Access Health Services will discuss the
evolution of nurse triage to expansion
of Web and Internet related services.
The last speaker, Byron Battles, president of Battles Group LLC will provide
a consultant’s perspective on where to
begin, how to identify resources, and
organizational development of e-commerce services.
The Urgency of Keeping Pace
The Internet is the key to maintaining and growing business relationships in today’s virtual marketplace.
Delays in implementing aggressive ecommerce or e-business strategies
could be costly as more customers
want (and expect) goods and services
over the Internet.
This preconference will be
extremely valuable to those who work
for an organization with multiple systems and locations or new mergers
pending. Participants will learn important elements to include in a telecommunications assessment to
help integrate facilities and
systems and expand business
opportunities to Webenhanced services.
Content will be directed
to audience members wishing
to gain a better understanding
of how Web services, e-commerce, and revenue generation affect professionals at all
levels.
This preconference is
appropriate for people who
work for an organization with
a sophisticated or basic call center, for
those relying on operators from another
department to handle customer calls,
and for those at a stand-alone facility
seeking ways to improve operations.
The preconference will also:
•
•
•
Provide information on current
terminology and on the options
available for Web- enhanced call
center services. This will help participants learn how to better communicate with technical support
staff and vendors.
Offer details on what the competition is doing, not just in health
care but also in other businesses.
Identify industry benchmarks
which health care providers need
to match in order to meet customer
expectations for quality service.
Maureen T. Power, MPH, RN
2001 Planning Committee
[email protected]
Conference to Feature Research And Clinical Practice Sessions
Regina C. Phillips, MSN, RN
The 2001 Program Planning Committee is proud to
announce the sessions sponsored by the Practice
Evaluation and Research Committee for the 26th
Annual Conference in Nashville, TN. Continuing the
AAACN tradition of offering sessions highlighting practice evaluation and research data, the 2001 conference
will offer three research-focused sessions:
•
Theatre of Innovation
The first research session will be the Theatre of
Innovation highlighting Telehealth Nursing Practice.
This session will consist of the following three concurrent presentations:
• Use of Protocols and Guidelines by Telephone
Advice Nurses. The speaker for this presentation
will be Ann M. Mayo, DNSc, RN (Kaiser
Permanente). She will explain a study that
describes the availability and types of telephone
protocols and guidelines (P&Gs) for adult patients.
The frequency and comprehensive use of the P&Gs
as well as the relationship between their availability and use to the quality of the nursing process and
selected patient outcomes will be discussed.
Clinical Outcomes of Patients Referred to the ER by
Telephone Triage. The speaker for this presentation
will be Helen P. Leavy, PhD, MSN (University of
New Mexico Health Sciences Call Center). She will
discuss the results of data analyzed for correlation
between triage disposition and ER acuity, triage
diagnosis, and ER diagnosis and for correlation
among frequency of telephone triage and ER usage
and insurance type. Participants will be able to
identify the common clinical endpoints of callers
continued on page 11
23
January/February - 2001 - Volume 23 Number 1
First-Class Mail
U.S. Postage
PAID
Pitman, NJ
Permit # 42
Published by the American Academy of Ambulatory Care Nursing
East Holly Avenue, Box 56
Pitman, NJ 08071-0056
(856) 256-2350
(800) AMB-NURS
(856) 589-7463 FAX
[email protected]
www.AAACN.org
Shirley M. Kedrowski, MSN, RN
President
Cynthia Nowicki, EdD, RN,C
Executive Director
Rebecca Linn Pyle, MS, RN
Editor
Janet Perrella-D'Alesandro
Managing Editor
Liz Van Dzura
Executive Secretary
Bob Taylor
Layout Designer
AAACN Board of Directors
President
Shirley M. Kedrowski, MSN, RN
Project Manager, Ambulatory Care
Stanford Medical Center
153 N San Mateo Drive, #108
San Mateo, CA 94401
(650) 347-5311 (h)
(650) 498-7283 (w)
[email protected]
Mission
President-Elect
E. Mary Johnson, BSN, RN, CNA
Credentialing Consultant
Cleveland Clinic Foundation
9020 Cherokee Run
Macedonia, OH 44056
(330) 467-6224 (h)
[email protected]
Advance the art and science
of ambulatory care nursing
Immediate Past President
Peg Mastal, PhD, MSN, RN
Chief Operating Officer
Health Services for Children
with Special Needs, Inc
1025 Connecticut Avenue NW, Suite 1100
Washington, DC 20036-5405
(202) 466-7460 (w)
[email protected]
Secretary
Cindy Noa, MS, RN, CNAA
Section Chief Immunization Program
Illinois Department of Public Health
2114 Madison Court
Champaign, IL 61820
(217) 785-1455 (w)
[email protected]
Treasurer
Kathleen P. Krone, MS, RN
Consultant
5784 E. Silo Ridge Drive
Ann Arbor, MI 48108
(734) 662-9296 (h)
[email protected]
Directors
Catherine J. Futch, MN, RN, CNAA, CHE
Kaiser Permanente
(404) 354-4707 (w)
[email protected]
Debbie L. Janikowski, MSN, RN, CNA
Department of the Navy, Naval Hospital
(910) 450-4014 (w)
[email protected]
Sandra Dahl, MA, BSN, RN,C
Franklin Square Hospital Center
(443) 777-8175 (w)
[email protected]
Statement
Share Your Passion for Ambulatory Care
Nursing With AAACN
An outstanding professional organization such as AAACN needs volunteers to
help it succeed and provides to those volunteers tremendously enriching opportunities.
Working with your peers to advance and
influence ambulatory care practice is an
investment in your own leadership development, in your expertise in the specialty, and
in your development of a network of peers
that continues to give back to you over time.
The AAACN Board of Directors and the
current leadership of all committees and
Special Interest Groups (SIGs) would like to
invite you to join them. Here are opportunities for you to consider:
• Annual Conference Planning Committee
• Research Committee
• Nominating Committee (elected)
• Web Site Advisory Committee
• Special Interest Group Steering
Committee (chairs of SIGs)
(For more detailed information on these
groups and for names and addresses of chairpersons and members, refer to your
Membership Directory.)
2001 © American Academy of Ambulatory Care Nursing
24
You may also want to consider running
for elected office. You are welcome to contact
any of the current listed members or officers
about their experiences.
Inside this issue of Viewpoint, you will
find a “Willingness to Serve” form. Please complete it, expressing your interests, and return it
to the National Office (see address in box at the
top of this page) at your earliest convenience.
We look forward to hearing from you.
Moderators Needed
Volunteers are needed at the 2001
AAACN Annual Conference in Nashville, TN,
March 29 - April 1, 2001, to moderate concurrent sessions.
If you are planning to attend the conference, this is a great way to get involved and at
the same time help AAACN. Moderating a session is an excellent way to enhance your conference experience.
If you are interested, please contact the
AAACN National Office at (800) AMB-Nurs or
via e-mail at [email protected]