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Speaking Up For the Patient

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David Maxfield 

David Maxfield is coauthor of two New York Times bestsellers, Change Anything and Influencer.

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Q Dear Crucial Skills,

I struggle with the attitude I find in acute care hospitals in regards to pain. Sometimes I hear employees and others discussing a patient’s pain and their need for treatment in a very judgmental, non-mission oriented manner. I am struggling to find the right words to speak up on behalf of that patient and to use words that might resonate to improve acceptance of all patients’ pain reports.

For example, standing outside an ICU room during rounds, the nurse will report the patients’ unrelieved pain. Invariably, the pharmacist or physician will comment about “addiction” or “drug seeking.” By the end of the discussion, almost everyone has made a disparaging comment and dismissed the patient’s pain. I have to speak up. I became a nurse to help end suffering, not to encourage it during one of the most stressful and painful periods in a person’s life. Can you help me find the right words to speak up to physicians who dismiss a patient’s pain?

Pained by Unfair Judgments

A Dear Pained,

Thanks for noticing and caring. All of us are likely to be patients someday, and knowing that caregivers will help to reduce our pain and discomfort is very reassuring. So, what can you do if you aren’t satisfied with your colleague’s attention to pain management?

First, try to avoid feelings of righteous indignation. Try for humility instead. I know this is tough when you don’t think others are showing a caring attitude, but do your best to model a combination of confidence and respect without making accusations.

You described the problem very nicely. You made it clear that this isn’t a problem with a single caregiver or a single kind of pain management issue. Instead, it’s more systemic and involves multiple caregivers and multiple differences of opinion.

Systemic problems require systemic solutions. Since there is too much variance in how caregivers manage pain, the first focus needs to be on the pain-management protocol itself. Then you can more easily improve compliance with the protocol.

Structural Motivation. You might think improving your hospital’s pain-management protocol is too big a job for you to take on, and you’re right. Fixing this problem will require a team approach, but I think you’ll discover you have many willing allies.

Patients’ hospital experiences are now measured using a nation-wide survey called HCAHPS which asks specifically about pain control. Hospital’s scores are public and beginning in March these scores will impact the reimbursement they receive from Medicare and Medicaid. Poor scores can cost a hospital hundreds of thousands of dollars.

This structural incentive has the attention of hospital leaders everywhere. Most are actively seeking ways to improve their hospital’s scores and improving pain management is one of the strategies that has been shown to work. I think you will find hospital leaders very receptive to any improvement ideas you have. In fact, you may discover that your hospital already has a task force working on pain management.

Structural Ability. Your hospital isn’t alone in looking for ways to improve pain management. Many talented organizations, such as the Institute for Healthcare Improvement, are developing and testing strategies that work.

Involve your manager and others in your unit, or enlist a larger team from across the hospital, to develop a formal pain-management plan. Make sure you involve physicians who will help develop and champion this plan as well. Most pain-management systems include the following common elements:

Patient- and family-centered. Involve patients and their families in assessing pain levels and learning what their goals are for pain control.
Documented pain plan. Document pain levels, patient goals, and the pain plan on a white board in the patient’s room where it will be visible to the patient and caregivers.
Track and update. Check in with the patient at least hourly. Update the white board.
Analyze and adjust. Update the pain-management plan at least daily, based on whether the current plan has been working. Record any changes to the plan on the white board.

Make sure every caregiver understands and commits to the new system. Use your manager and physician champions to reach out to every caregiver who needs to understand and employ it.

Personal Ability. Once you have a system in place and have secured verbal buy-in to the system, it is important to cue, remind, and hold others accountable for managing patients’ pain in caring ways. Here are some simple reminders:

“Remember, we need every patient to answer ‘always’ on the HCAHPS survey.”

“I think you forgot to check the white board.”

“Could you help me with this patient? Her pain-management plan hasn’t helped her today. I think she needs you.”

If you get pushback on these simple reminders, you can escalate by explaining the gap between what the person has committed to and what you’re seeing:

“We all agreed to put the patient’s goals at the center of the plan. What you just said about drug-seeking behavior sounds like you disagree with the patient.”

“We all committed to use the white board and to keep it current. Are you changing your mind about that?”

If a caregiver continues to resist following the system, then bring in the manager or physician champion for your unit. I hate to say it, but sometimes the messenger is just as important as the message. Having a senior physician take the person to coffee and discuss the issue in a factual and friendly way will do a lot to get his or her buy-in. Ask the champion to close the loop with you so you can have confidence the person will accept your reminders in the future.

VitalSmarts has done quite a bit of work with hospitals that are working to improve their patient experiences and HCAHPS scores. We have a web seminar coming up on March 8 to discuss this very topic. I encourage you to join.

David

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8 comments

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8 thoughts on “Speaking Up For the Patient

  1. Darrell King says:

    Huge issue. I am an RN who just had an operation, and my doctors and his team are awesome about pain management. I encountered only one nurse who was resistant to delivering my med during my hospital stay, but I have encountered many clinicians during my professional duties. Communicating one’s objections is a tough hurdle to jump in this arena because it can mean standing out from the crowd, not always a good thing anywhere. My own strategy has been to gather facts first and then present them reasonably when advocating: dosing frequency, prescription and orders, vital signs, evidence of discomfort such as guarding or restless movement. Pharmaceutical pain management is not chemical recreational and it is cruel to treat it so.

    D

  2. I as an administrator supervisor RN have found that many pain issues are not fully investigated.I received a call one eve from a recently discharged patient with a complaint. He refused to give me his name but since I cover the whole hospital asking the right questions allowed me to determine what unit he was on. He told me he was a recovering drug and alcohol abuser. he was admitted and though in pain refused pain medications for fear he would start using again. He was a post op patient. He spoke to his Sponsor who said under the circumstances he should be taking something for pain, with his Sponsor’s consent he started accepting pain medications and since he had refused earlier it was assumed by staff that he must be a drug seeker. They called the MD who discontinued all his pain medications and accused him of drug seeking. He left our hospital with angry feelings. I was able to share with him a similar experience we had with my nephew. We talked about how he might handle the situation in the future. I brought this situation back to the post op unit,after hearing all the facts they felt they would have acted differently, gathering all the facts is important.

  3. Dr. Scott Allan Lang says:

    Dear David:
    I thought your reply to ‘Pained’ was thoughtful. Medicine is inherently a hierarchal, competitive, and self-righteous culture. It is difficult for people on the front-lines to trust and respect a system and people in it who do not work hard to ‘walk-their-talk’. I hear you saying that a meaningful cultural-shift can start with each individual within the system by learning how to hold everyone accountable in a respectful manner and by leading-by-example. The problem, as I see it, is a general lack of leadership within medicine as well a general lack of effective communication skills by healthcare providers. Even if someone on the front-lines tries to communicate collaboratively it is very difficult to sustain that effort when positive responses are not garnered, patients continue to suffer, and closed-loop communication does not occur. I empathize with ‘Pained’. I assume that since she/he has articulated their concerns in the manner they have and in this format that they are a believer in good communication skills and personal leadership and are looking for ways to influence others and the profession – Go for it and good luck!

  4. Forever Frustrated says:

    I have to admit that I found this article very painful to read. As the daugher of an alcoholic / addict, I would be relieved if a doctor was to refuse to treat my mother’s so called pain with more medication. For the past 43 years I have known my mother to be an alcoholic/addict. When I was growing up she had a drinking problem and as a result of her alcoholism she now has cirrhosis of the liver. She stopped drinking about 14 years ago but that didn’t stop the addiction. For the past 10 years she has been using, abusing, misusing and/or addicted to some very powerful medications and her family doctor is dishing out the medications liberally. I have witnessed her badgering the family doctor for more medication and he usually gives in. She has also beats, badgers and torments my father until he gives in and will give her his medications (he also takes the same medications regime as my mother). To address this, I wrote a letter to the family doctor explaining my concerns and hand delivered the letter to him personally. He refused to keep the letter on file and he continued to prescribe a regime of narcotics for pain (oxycontin, morphine, dilaudid, etc…) as well as antidepressants, antianxiety medications and sleeping pills. Consequently she has been taken to the hospital several times by ambulance and by me because of over dose. There have been at least two incidents that I am aware of in the past 4 months. I have tried to inform the medical team in the ER about the issues with medication, however the physicians seem resistant to engage in a conversation about addiction. They dance all around the topic and avoid that discussion all together. It is usually down played and it is labelled as a “medication error”. I can assure you that there is no error here. She knows what she wants and is relentless to get it any way she can. My mother is going to die at the hands of the doctor and I can’t do anything because my hands are tied. From my prespective, I would welcome a doctor who is resistant to handing out medication for pain.

  5. Slccom says:

    Forever Frustrated, my heart goes out to you. However, we are talking about people in the Intensive Care Unit. Not too many people who are seeking drugs get themselves admitted to the ICU.

  6. CD says:

    Growing up with an RN for a mom, I heard many stories of physicians who were callous to a patient’s pain. I’ve had surgery a few times and know what it’s like to be in acute pain. I’ve had some nurses who were aware of being on top of pain management and who made sure mine was managed. I’ve also tried to be a hero and suffered when I didn’t want to be “drug seeking”. I don’t think after surgery or during a time of intense physical pain is the time to address a drug problem. I don’t have one but I know people who do and I still think if they have just had surgery, they need pain management. As another poster said, it’s usually not drug addicts in the ICU, though I am sure that happens, too.

  7. Forever Frustrated says:

    Thank you so much for the work that you do in the health care field. It is clear that you care very much about the patient’s pain and suffering. Patients need a voice when they cannot speak for themselves. I agree that there is a time and a place for these medications; for example patients admitted to ICU, palliative care patients and post op patients. I definitely do not want patients to suffer with unnecessary pain but I want health care teams to be cognizant of the highly addictive nature of these types of medications when deciding to start treatment and implement some type of mechanism to assist patients with titrating off of these meds and address any addiction that may follow treatment. My mother was started on pain medications to treat pain following knee replacement surgery 10 years ago and has never stopped taking them. Her problem with prescription medication has snowballed over the last 10 years and has been enabled by her family doctor. My understanding of these meds is that they are really only intended for short term use.

  8. [...] of your motives.  One thing to keep in mind (I learned this thanks to Cathy, who sent me a very interesting journal article): beginning in March 2012, hospitals will receive large amounts of Medicare and Medicaid funding [...]

  9. Linda Doan says:

    This is in response to “Pained”. From a medical professional as well-I thank you & hope that you would be one of my relative’s caregivers at some time!
    Keep on advocating for your employees as this is what the College of Nurses would expect.

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