2008 was the 40th anniversary of Margo McCaffery’s writing, "Pain is whatever the experiencing person says it is, existing whenever he or she says it does." It was in an article titled "Nursing Practice Theories Related to Cognition, Bodily Pain, and Man-Environment Interactions." We celebrated this most important event and Margo at the American Society for Pain Management Nursing’s annual meeting in September, and it got me thinking.

In 1969, man first walked on the moon. Those of you who weren’t alive then (or were too young to remember) cannot imagine the excitement and expectation the world felt. Man was going to walk on the moon! When it happened, and Neil Armstrong said "That’s one small step for a man, one giant leap for mankind," it was true. For that one moment, mankind was united in wonder. I was pregnant with my first child then and remember thinking my child will never know a world in which man has not walked on the moon. Unfortunately, that is true. My children don’t understand why it was so exciting, why it was so moving. Man always has walked on the moon in their lifetimes.

Many nurses and other healthcare providers never have known a world without Margo and her advocacy for people in pain. It doesn’t matter that pain management has made strides over the years (and it really has), complacency still exists. Everyone knows that pain is what the patient says it is, but we aren’t where we could be. Many still don’t "buy it." I ask those who are not invested in pain management, has the "amazement" factor been lost? After all, where are the celebrities searching for a cure for pain?
    
I personally remember pre-Margo. In 1959, I was hospitalized for two weeks in the Mercy Children’s Hospital in Sacramento, CA. Although I was only 10 years old at the time, I remember several things vividly to this day. One is the terrible screams of a little girl who was horribly burned and each day had to endure a special bath (I now believe it was likely a whirlpool for debridement). I also remember the nun telling me they were doing all they could to help her pain, though, obviously it wasn’t enough. It was then, during that two week stay, that I decided to become a nurse.

That, of course, was before Margo. I am just overwhelmed by one woman’s courage and the difference it made and continues to make. I just wish nurses and others who never have known a world without the belief that pain is subjective understand the importance of going forward and spreading the word. I pray that they realize the necessity of striving until everyone truly shares that belief (pain is what the person says it is) and that good pain management is recognized by all as a human right.
    
Margo, I thank you, my colleagues thank you, and our patients thank you. What a difference you have made.

Reference

McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.

Patient Satisfaction With Pain Management

Ann Cuvala, RN, MS, OCN^®
Palos Heights, IL
acuvala@aol.com

Pain associated with cancer is a major cause of human suffering. More than two-thirds of patients with cancer will experience pain at some time during the course of their disease. It has been estimated that pain is experienced by 30%–50% of patients with cancer receiving treatment and 70%–90% of those with advanced cancer (Portenoy, 1989). Through the years, many guidelines have been published to manage pain, but unfortunately, we still are living among these statistics.

Reciting the commonly known definition, "Pain is whatever the experiencing person says it is, existing whenever he or she says it does," (McCaffery, 1968) overtly reminds us that it is ultimately the patient’s perception that helps those in research come up with these statistics.

McCaffery and Pasero (1999) published the "Rights of Patients With Pain." They include having the reports of pain accepted and acted on, the pain controlled, and the right to be treated with respect at all times. So what are the barriers to acting on these rights and providing patient satisfaction with pain management? A few of the barriers, among others, continue to be fear of addiction, inadequate knowledge of assessment, drug choices, and dosing.

Zelman et al. (2004) researched the concepts of acceptable, manageable, and tolerable days with regard to management of pain. The results included five key features in which participants identified key components of a day in which they were receiving desirable pain management. These included (1) taking the edge off of the pain, describing that over time patients had decreasing expectations of total pain relief; (2) social engagement is desired, or the ability to want to and look forward to interacting with others; (3) night-time rest in which adequate rest promoted a day of desired pain management; (4) improved function or being able to accomplish important tasks, thus improving quality of life; and (5) improvement in mood or reduction in irritability and agitation.

Improving patient satisfaction also requires patient education. Many institutions use a numeric rating scale to measure pain. When soliciting a pain goal, sometimes a "zero" is not realistic. If this is the case, provide this information to the patient with assurance that everything will be done to provide control. Other themes were identified related to patient education by Bender et al. (2008). These included understanding cancer pain, knowing what to expect, options for pain control, coping with cancer pain, talking with others with cancer pain, finding help managing cancer pain, and describing pain.

Ultimately, improving patient satisfaction with pain management is a multipronged approach, including diligent, attentive pain care, collaboration among healthcare providers, soliciting the patients’ perceptions of attentive pain care, and including the patient in the plan of care.

References

Bender, J.L., Hohenadel, J., Wong, J., Katz, J., Ferris, L.E., Shobbrook, C., et al. (2008). What patients with cancer want to know about pain: A qualitative study. Journal of Pain and Symptom Management, 35(2), 177–187.

McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man-environment interactions. Los Angeles: University of California at Los Angeles Students’ Store.

McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). St. Louis, MO: Mosby.

Portenoy, R.K. (1989). Opioid therapy in the management of chronic back pain. In C.D. Tollison (Ed.), Interdisciplinary rehabilitation of low back pain. Baltimore: Williams and Wilkins.

Sterman, E., Gauker, S., & Krieger, J. (2003). A comprehensive approach to improving cancer pain management and patient satisfaction. Oncology Nursing Forum, 30(5), 857–864.

Zelman, D.C., Smith, M.Y., Hoffman, D., Edwards, L., Reed, P., Levine, E., et al. (2004). Acceptable, manageable, and tolerable days: Patient daily goals for medication management of persistent Pain. Journal of Pain and Symptom Management, 28(5), 474–487.

Ask Ann

Ann Cuvala, RN, MS, OCN^®
Palos Heights, IL
acuvala@aol.com

Question: Which institutions are using end tidal carbon dioxide (ETCO2) or capnography monitoring for patients receiving IV opioids?

Our institution began researching this topic several years ago after several apparent cause analyses regarding opioid-induced respiratory depression in patients with obstructive sleep apnea (OSA) took place. Our initial goal to use ETCO2 monitoring on all patients receiving patient-controlled analgesia (PCA)/epidural and IV (continuous and intermittent) opioids who had a concurrent diagnosis of OSA was lofty. Let me give you a little background on the issue.

We know that opioids have the ability to cause respiratory depression by depressing the brain’s response to CO2. We also know that patients with OSA normally can wake themselves up at night to prevent suffocation. The two, however, can be a deadly combination. The sedation caused by the opioid could render those patients unable to rouse themselves, thus they could slip into respiratory depression. Commonly, we used pulse oximetry for monitoring at-risk patients. Unfortunately, the limitation is that pulse oximetry monitors oxygenation but is not as sensitive as a monitor of hypoventilation, particularly when supplemental oxygen is administered. Capnography monitors how effectively patients’ breathing is removing CO2.

After much consideration, as well as weighing the cost of the machines, we now screen our surgical patients and those receiving PCA/epidural opioids for a history or symptoms of OSA along with their body mass index. Those patients with a positive screen receive the capnography monitoring.

Do you know of any other policies out there?

Letter From the Coordinator

Janice Reynolds, RN, BC, OCN^®, CHPN
Brunswick, ME
jkrrnocn@blazenetme.net

By the time you read this, Congress will have come and gone. I look forward to seeing you all. The Pain Management SIG had several offerings. A Pre-Congress session titled "Pharmacotherapeutics of Pain and Symptom Management" took place on Wednesday, a session titled "Intentional Sedation" took place on Thursday at 3 pm, "Acute Pain and the Oncology Patient" occurred on Friday at 2:30 pm (and was repeated on Sunday at 8 am), and "Pain Management in the Patient With Addictive Disease" was on Saturday at 4:30 pm. I presented on a topic sponsored by the Ethics SIG titled "Oncology Nurses at Risk: Moral Distress," which took place on Friday at 10:30 am (and was repeated at 8 am on Sunday as well). Inadequate or inappropriate pain management can frequently be the source of moral distress in oncology nurses.

I (and others on the team) would like to encourage you to subscribe to the discussion board on our Virtual Community. It would be great to have that be more active. The Chemotherapy SIG has a very active one, and I know it has helped me out. With all of the talented people in our SIG, I would love to see it work for us.

It has been a great two years, and I have enjoyed being coordinator. I wish I could have accomplished more. I know you all will support Ann as she becomes the new coordinator. As she comes in, we are already looking for the next coordinator. Please think about running for the office. Submissions should be coming up shortly (the deadline will be in August).

Co-Editor's Letter

Ann Cuvala, RN, MS, OCN^®
Palos Heights, IL
acuvala@aol.com

Well, this will be my last co-editor’s letter. This period of my life has flown by. I remember seeing the position in the newsletter and just jumping on it. Sometimes I wonder why I do the things I do. I was nervous, and I doubted myself, but for such a small amount of work and effort, I have learned so much and met so many wonderful people.

From what I see our membership doing, our patients are lucky; however, we still have a long way to go. How do you impact pain management in your care settings? No effort is too small—please share them with us—if one person learns from you, isn’t that what matters? Unfortunately, no one in our SIG submitted any information for this newsletter. Don’t forget that with rights (the right to gain information, the right to learn, and the right to implement ideas), come responsibilities. We’re all responsible for providing ideas, thought-provoking questions, and enthusiasm.

Let’s make this the best SIG ever! Well wishes and blessings to all!

Writing Mentorship Program Offers Even More Rewards and Eliminates Application Deadline

Now is the time to start writing for publication. Share your knowledge with colleagues, improve patient care, and reap professional accolades and rewards—all with the help of an experienced nurse author and ONS staff…and all from the comfort of your home or office.

The Clinical Journal of Oncology Nursing (CJON) is dedicated to developing the profession’s next generation of experts and authors through the CJON Writing Mentorship Program. CJON will pair each selected fellow with a previously published author who has knowledge in the area of interest, and ONS will offer the support of a publishing staff member and librarian. The project is completed without travel over a period of nine months, and expenses are reimbursed.

The program recently eliminated its deadline in favor of year-round application, and it now offers even more rewards.

• Get your byline published in a respected peer-reviewed publication that is read by more than 35,000 nursing colleagues, other healthcare personnel, and pharmaceutical professionals.
• Establish yourself as an expert in a specific clinical topic.
• Earn a scholarship to an ONS educational event.
• Receive points toward oncology nursing certification renewal.
• Be recognized in the ONS awards publication, at an ONS Congress reception, and in a letter to your employer.

For more information about the CJON Writing Mentorship Program, including eligibility criteria, visit the ONS Web site or contact ONS Staff Editor Keightley Amen at 412-859-6258 or kamen@ons.org.

ONS Connect Launches New Blog to Continue the Conversation

Join the online conversation as ONS Connect’s new blog, RE:Connect, brings together a diverse group of oncology nurses talking about life at work and at home.

When ONS’s monthly news magazine, ONS Connect, was redesigned in 2007, some of the intent was to address the interests of those new to the field and provide quick news and information to busy professionals. RE:Connect offers an extension of these goals by establishing an online community for readers to talk about issues and share experiences that they deal with on a daily basis. The RE:Connect blog was launched in November in conjunction with ONS’s annual Institutes of Learning and Advanced Practice Nursing Conference.

ONS members have been tapped to initiate the dialogue by posting to the blog on a regular basis.

• Erin Elphee, RN, MN, CON(C), primary clinic nurse for Lymphoma and Malignant Hematology Disease Site Groups at CancerCare Manitoba in Winnipeg, Canada
• Kimberly George, MSN, RN, ACNS-BC, OCN^®, adult health CNS in Wichita Falls, TX
• Jeanine Gordon, RN, MSN, OCN^®, clinical nurse specialist/nurse manager from Brooklyn, NY
• Kari Wujcik, nursing student at Belmont University and a nurse extern in the pediatric intensive care and cardiology units at Monroe Carell Jr. Children’s Hospital at Vanderbilt University

These bloggers will share their thoughts about day-to-day challenges at work, juggling busy lives at home, and keeping up to date with the magnitude of information available for practicing nurses. Readers are encouraged to join in on the conversation and connect with other oncology nurse readers by posting their own stories, tips, ideas, and suggestions in the comments section at the end of each blog post.

Check out RE:Connect today, and share this link with your friends and colleagues!

ONS Social Media Sites of Interest

Do you want up-to-the-minute information about the next conference? Would you like to network with other oncology nurses? Do you want to stay in touch with other ONS members? Now, it’s easier than ever because ONS has joined social media sites that help you do all of this and more. Sign-up is free and easy, and you can always control your privacy settings. Already have an account? Share your story, and make the most of all these sites have to offer. Be sure to invite others to join as well.

ONS is now on Facebook!

• Connect with other oncology nurses, get updates on ONS news, and explore other social media-related sites.

• Oncology Nursing Month is in May and ONS wants you to share your stories. As an oncology nurse, you take on the role of teacher, listener, and shoulder to lean on. You help people through some of the most trying times of their lives. Celebrate and share the work you do.

• ONS Foundation has funded more than 2,022 scholarships, grants, and awards since 1981, and they need your help to continue that support. Join their cause, spread the word, and make a donation.

ONS is now on Twitter!

• Twitter is a free service that lets you keep in touch with people through the exchange of quick, frequent answers to one simple question: What are you doing? Join today to start receiving ONS’s updates.

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Participate in Your SIG’s Virtual Community Discussion Forum

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View past newsletters.

ONS Membership/Leadership Team Contact Information

Angie Stengel, MS, CAE, Director of Membership/Leadership
astengel@ons.org
412-859-6244

Diane Scheuring, MBA, CAE, CMP, Manager of Member Services
dscheuring@ons.org
412-859-6256

Carol DeMarco, Membership/Leadership Specialist
cdemarco@ons.org
412-859-6230

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

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