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