When there is no benchmark: designing a primary care-based chronic pain management program from the scientific basis up.

Managed care has been accused of ignoring the patient with pain. The challenge for a health maintenance organization (HMO) was not just how to deliver state-of-the-art care, but how to deliver it to the 40,000 members who experience chronic pain at a reasonable cost and with enduring outcomes. This article describes how one managed care organization set about improving the care of patients with chronic pain. The article includes the design process, the model implemented, and some suggestions for transfer of this technology to others who might want to explore developing a similar model.

Knowledge and beliefs regarding pain in a sample of nursing faculty.

Pain is a significant problem impacting between 50 per cent and 80 per cent of cancer patients and affecting overall quality of life. Studies have documented that nurses and other health care professionals are inadequately prepared to care for patients in pain. Several reasons have been identified including inadequacies in nursing and medical education, absence of curriculum content related to pain management, and faculty attitudes and beliefs related to pain. This article presents data from a cross-sectional mall survey that consisted of a self-administered knowledge and beliefs questionnaire and a self-reported pain curriculum questionnaire. Faculty from 14 baccalaureate nursing schools in the United States participated in the study. The study suggests that in baccalaureate schools of nursing, faculty knowledge and beliefs about pain and the curriculum content related to pain may be less than optimal.

Acute pain relief.

Pain is a multidimensional psychophysiologic phenomenon. Systematic multidimensional assessment is an essential first component of an effective plan to relieve the pain. Nurses are key to effective pain management because of the close, 24-hour-a-day relationship with the hospitalized patient. It is the nurse who is most critical to the adequate assessment of pain, to the implementation of the treatment plan, and to the evaluation of efficacy. Nurses should continue to develop a better knowledge base about pain and pain therapies and assessment skills, be assertive in obtaining effective treatment for their patients, and perceive themselves as responsible for pain relief.

Psychosocial adjustment to recurrent cancer.

This descriptive study of the perceptions and needs of people with recurrent malignancies asks three questions: How do patients describe the meaning of a recurrence of cancer? Do individuals perceive the diagnosis of recurrence and the initial diagnosis of cancer differently? What are the key psychosocial problems associated with recurrent cancer? The theoretical framework was based on Lazarus and Folkman's theory of stress, appraisal, and coping. Subjects completed the Impact of Event Scale (IES), the Psychosocial Adjustment to Illness Scale--Self-Report (PAIS), and a semistructured qualitative interview. The interview elicited perceptions of the event of recurrence and differences between the diagnosis of recurrence and the initial diagnosis. The convenience sample included 40 patients diagnosed with recurrent cancer within the last 30 days. Many subjects (78%) reported that the recurrence was more upsetting than the initial diagnosis. Scores on both the IES and the PAIS were high when compared to normative samples of patients with cancer suggesting that this sample of patients experienced a lot of psychological distress as well as problems at home, work, and in their social lives. These concerns often were unknown to caregivers. Although more research is needed, the authors propose that, with more accurate assessment, more effective intervention could be implemented and the quality of life improved for patients with recurrent cancer.

Cancer recurrence as a traumatic event.

The authors hypothesized that cancer recurrence can be understood and therefore treated as a traumatic event that places patients at risk for stress response symptoms. To test this, they gave 40 patients with recurrent malignancies of mixed sites the Impact of Event Scale (a measure of response to specific stressors), the Psychosocial Adjustment to Illness Scale-Self-Report version (a measure of general adjustment to illness), and a semi-structured interview in which the patients were asked about their reactions to and experiences surrounding the recurrence, compared with those surrounding their initial diagnosis. In self-report measures and in the interview, patients clearly perceived that adjustment to recurrence is more problematic than adjustment to initial diagnosis. The findings were consistent with an expectation derived from the stress-disorder literature: patients who reported having been completely surprised by the recurrence and those undergoing their first recurrence showed significantly more intrusive and avoidant stress response symptoms. Given the heterogeneity of the patient population and the relatively limited sample size, further study is needed to assess the contribution of other important mediating factors in the development of stress disorders. Because the predictors in this study (extent of surprise and number of previous recurrences) can be identified before or immediately following a recurrence, primary and secondary interventions might help prevent stress disorders in patients who may have had unrealistic expectations.

An historical view of pain management. How we got to where we are!

Over the past 2,000 years the knowledge and theories about pain have evolved through six general stages. Beliefs and practices related to pain from each of these stages continue to influence our contemporary attitudes and practices regarding pain. Optimal pain control demands the integration of all that is known about pain into a holistic approach which benefits the patient experiencing the pain.

The unification model: a collaborative effort.

The Rush unification model unites clinical practice with nursing education. In this system, nursing faculty possess joint responsibilities to the college of nursing and to a specific unit in the medical center. Collaboration among managers, clinical specialists, educators, and researchers leads to achievement of unit, college, and departmental goals. The collaborative process among the leadership group members in the medical intensive care unit, consisting of the unit leader, the assistant unit leader, the clinical nurse specialists, and the practitioner-teachers, is described in detail to show how utilization of the skills and strengths of each team member increases the benefits to the unit and the patient.

Increasing productivity and decreasing costs: the value of RNs.

Are increased nursing personnel or increased levels of preparation of nursing personnel major factors contributing to the sky-rocketing costs of hospital care over the past two decades? The authors discuss a comparison of staffing patterns and staffing costs at a large midwestern medical center and suggest that there is little basis for this belief.