Manager wants me to force prn pain meds

[Nurse Beth, MSN]

Dear Nurse Beth,

Are we complicit in the opiate crisis? I am 61 years old and decided to take on nursing as a second career after 30 years in an engineering field where I did food production equipment and production plant design and plant management. I finished my BSN and started working on a med surge floor in February of 2019.

I am at odds with my manager when it comes to PRN pain medications. I make a point to ask patients their pain level and if they want their PRN medications when they are available. If they say no, I tell them that I will ask on hourly rounding and to be sure to let me know if they are in pain. I do not wake patients up to administer PRN medications. My manager wants me to not only wake patients up and administer PRN medications, but if they refuse them try to convince them that they should take these medications. I believe that she is doing this to improve our rating.

After discharge the hospital I work for asks all discharged patients "did we do everything we could to manage your pain". Knowing that we have an opioid addiction problem in this country and having seen my son struggle with addiction and spend 6 months in an inpatient rehab program (I am happy to report he has been sober for 10 years now) I feel this is wrong. This leaves me in a conundrum, I have only been a nurse 9 months. Do I just go along to get along, frequently observing patients that are "snowed"?

Do I make a stand and report my concerns to the safety committee or to the FDA, knowing that will probably be the end of my nursing career?

---

Dear Conundrum,

So happy for you and your son that he is 10 yrs sober.

You should never give opiates to a patient who is overly sedated, but let's look at other ways of dealing with this situation aside from ending your career.

You say you observe patients who are "snowed". This is very concerning. Know how to quickly access naloxone on your unit if needed, and what the recommended rescue dose is.

In your own mind, prepare for what you would do if you encounter a patient in respiratory failure from opioids. (Call for help, stay with the patient, BLS if not breathing, administer 0.4 mg naloxone IV, may repeat). Naloxone works immediately. After reversal, monitor the patient closely for re-narcotization, especially in post-op patients.

If you mentally reheorifice what to do in an emergency, you will not panic when the time comes.

Opioid-Related Sedation

Best practice is to prevent respiratory depression. The first sign of opioid-related sedation is change in level of consciousness.

If you are not using an opioid sedation scale before and after administering pain meds, such as the Pasero Opioid Sedation Scale (POSS), talk to your manager. It's a very simple scale that is easy to administer. The POSS measures opioid-related sedation by level of consciousness. If a patient is overly sedated, the pain med is held or the dose is adjusted accordingly.

The Michigan Opioid Sedation Scale (MOSS) is helpful in identifying patients at risk for post-op opioid-related sedation. It's based on several factors, including history of sleep apnea, neck size, and age. These patients require closer monitoring post-op.

Multi-modal

If you are caring for immediate post-op patients, the American Society of Anesthesiologists (ASA) Task Force 2012 recommends that clinicians include an around-the-clock multi-modal medication regimen therapy with combinations of drugs for 24 to 48 hours after surgery.

Multi-modal, for example, could include regional blocks combined with IV acetaminophen and opiates.

Pain Level

A post-op patient's pain should be assessed during the night, and patients who are asleep can experience pain. The key is assessment. You would assess their pain level and sedation level, then give medication accordingly. For example, a pain level of 4 may be treated with hydrocodone, but a pain level of 8 may be treated with Dilaudid.

Most hospitals include asking patients about their pain as the "5th vital sign" and your nursing assistant is going to take vitals during the night, asking the patient their level of pain. If a pain level of 1 or 2 is documented, and the patient's acceptable pain level is 2, then the patient should not be talked into taking medication, but should be regularly assessed for pain control.

If your manager insists you administer prn pain medication when the patient does not need or want it, I would clarify "Are you saying I should give (x) for a pain level of (y)? That is not what is ordered".

Remember to assess and document pain 30 minutes to 1 hour after administering pain medication, based on your hospital's policy.

Respiratory Monitoring

Hopefully your hospital is using pulse oximetry, capnography, or both.

Capnography and pulse ox monitoring both help keep your patients safe. CO2 levels rise faster than O2 levels drop, making capnography the preferred post-op monitoring for respiratory failure secondary to opioid sedation.

Respiratory Assessment

Assess the quality of respirations. This includes regularity and depth. A nursing assistant can count the respiratory rate, but as the RN, you must do the assessment. Remember- rate, rhythm, quality and depth.

Change Agent

You have an interest in this, and I recommend you make yourself a pain expert. Rather than report your manager at this point (unless there is a clear and immediate danger), make it your goal to educate your unit and raise the level of care around pain management of your patients. Research the ASA Guidelines and the American Society for Pain Management Nursing (ASPN).

HCAPPS

The HCAPPS survey does include 3 questions about pain management.

It also asks about overall experience, and a patient who is wakened several times during the night is not likely to give then hospital a high overall rating.

If you are managing a non-surgical patient with pain, I would ask them before they go to sleep if they prefer to be wakened to check on their pain. In that way, patients partner in their own care.

Best wishes,

Nurse Beth

Author, "Your Last Nursing Class: How to Land Your First Nursing Job"...and your next!

[Hoosier_RN, MSN]

I have to agree with the feelings of the poster. We have been taught that pain is what the patient says it is, which can be dangerous, with certain patients. I'm not sure where the middle ground is now that we have this crisis, and the hospitals that have the hotel mentality of approval ratings. Healthcare has painted itself into a corner with this one

[JKL33]

Do not do this. It will take some people skills and finesse, but it's very possible to do the right thing here.

I'd love to ask exactly what kind of trouble this manager is causing for the submitter of the question, but in the event that the person doesn't wish out him/herself here are a few general thoughts:

** If the manager is simply making general declarations directed toward all staff - - just unobtrusively go about your way. Make sure you are on top of patients' pain without resorting to disturbing their sleep or pressuring them to accept a treatment so that you can document something.

Talking with them about it before they attempt sleep is a good idea, as suggested above.

** If the manager states that there is a problem with this individual nurse and that this nurse must change his/her personal practice to the one discussed in the OP, then I would, again, make sure you are having memorable conversations with patients about their pain (while they are awake, not arguing with them while they are trying to sleep). Convey your concern that they not have their pain become severe before addressing it/accepting treatment for it. Reassure them, give them good information, etc., etc. Then continue your practice. Above all else, they are the ones sort of in charge of this; that is the principle of autonomy. They do need appropriate information to make good decisions and fully exercise their autonomy, so make sure they have the info...and convey your caring through that.

Make sure that your hourly rounding documentation includes addressing pain, and make sure that, at reasonable intervals, you include a statement about how pain medication was offered and rationale for PRN medication use before pain becomes severe was discussed. Pt denies need for pain medication at this time. Or something along those lines.

Besides the ethical concerns, it would be folly for you to believe that arguing with hospitalized patients in the middle of the night while they are trying to sleep is going to improve any PG scores, even if doing so does result in a few more doses of pain medication being handed out over the long haul. Your manager is out of ideas and feeling pressured and resorting to nonsense.

** If, by chance, this manager is actually simply looking at eMARS or pulling reports to see who gave what/when in a misguided and blind attempt to improve satisfaction scores and is not addressing an actual problem of under-medicated pain, and if s/he is just going around nitpicking individuals based on how many meds they give out, I would take a more plainly assertive tack because that is 100% unacceptable. Would probably look for a different job and report the one who does this.

[Anonymous865]

HCAPPS has removed the questions about pain management from the survey.

"On July 31, 2018, in the CY 2019 OPPS Proposed Rule, CMS proposed a plan to remove the HCAHPS Survey's Communication About Pain items (questions 12, 13 and 14 on the HCAHPS Survey). The recently released CY 2019 OPPS Final Rule requires that the pain items must be removed from all surveys beginning with patients discharged on October 1, 2019 and forward. This change affects all survey translations and all survey modes."

This is from https://www.hcahpsonline.org/en/whats-new/

You can see the survey here. https://www.hcahpsonline.org/en/survey-instruments/

[Nurse Beth, MSN]

4 hours ago, Anonymous865 said:

HCAPPS has removed the questions about pain management from the survey.

"On July 31, 2018, in the CY 2019 OPPS Proposed Rule, CMS proposed a plan to remove the HCAHPS Survey's Communication About Pain items (questions 12, 13 and 14 on the HCAHPS Survey). The recently released CY 2019 OPPS Final Rule requires that the pain items must be removed from all surveys beginning with patients discharged on October 1, 2019 and forward. This change affects all survey translations and all survey modes."

This is from https://www.hcahpsonline.org/en/whats-new/

You can see the survey here. https://www.hcahpsonline.org/en/survey-instruments/

Thank you!!

[amoLucia]

To OP - I suspect that your family history with addiction may have somewhat skewed your perspective re society's opioid dilemma with accurate individual pts' pain management. I recognize that you're a newbie to the nsg profession. Sometimes it just takes time to develop that fine sense that experienced practitioners acquire of knowing the fine line between assessment & when to intervene. You're getting there.

Let me say that I do understand your hesitancy/reluctance to want to foster drug dependence. And you are addressing pain mgt in a judicious manner.

Your manager may just be overly desirous of improving pain management. Maybe there was some earlier pt PG complaint re not enough pain med, hence your mgr's aggressive focus. Who knows?!?

The PPs all offer different and accurate answers to your issue.

I'm glad to see that CMS and HCAPS are FINALLY catching up to remedy a problem that they most certainly exacerbated. I was just discharged from a hospital last week - I'll let y'all know if I receive an approp survey.

[DowntheRiver]

On 10/13/2019 at 3:25 PM, amoLucia said:

To OP - I suspect that your family history with addiction may have somewhat skewed your perspective re society's opioid dilemma with accurate individual pts' pain management.

This thought crossed my mind as well, so good point to make.

[MSO4foru, ADN]

I am sorry you have had the experience as a parent of addicted child. ( I had a 36 yr old pt who died from OD two weeks ago). As a hospice nurse, I perhaps have a skewed view on pain control. Most education I do with my patient population had to do with " don't wait until you can't stand it anymore to tell me you need pain meds. " and education about pain management, AND education that " 0 pain is not reasonable expectation. [ unless maybe you are imminently dying]". I most often have patients and family members who are terrified of pain meds. I think the psychology and social factors ( and yes, misuse of pain meds) needs more attention and education.

[LovingLife123]

Are you not calling rapids or giving bar an if your patients are snowed? What is your definition of snowed?

While I don’t give out prn medications if the patient is not in pain, I go over pain management with them. We discuss staying ahead of the pain. I have many post op patients that refuse meds and then we spend hours trying to catch up and I’m administering far more opiates than necessary if we had stayed on top of it to begin with.

You have to find that balance. And you have to put aside your personal feelings on pain medications. I currently have a family member addicted. It’s torn people apart and he still is not in recovery. It makes me sad. But that doesn’t interfere with my thoughts on pain control on the job.

We are now hitting a point where we can’t get chronic pain managed, cancer patients are not getting the meds they need, and people are being left to die in horrific pain because nurses and physicians are somehow afraid the actively dying will become addicted.

As long as you are doing proper pain assessing and control you should be fine. The numbers scale is not the only scale you use when assessing pain. If a patient is grimacing and guarding but telling you their pain is fine, there is a problem.