SETTING UP A PAIN CURRICULUM FOR NURSING
Dr Eloise C. J. Carr.

This paper commences by setting the scene in terms of the prevalence of pain and the studies which have identified inadequate knowledge and attitudes as causative factors. This is followed by a brief description of some of the international and UK initiatives which have attempted to address the educational deficeits in pain management. This is then followed by examples of some innovative educational approaches which have been developed at the Institute of Health and Community Studies at Bournemouth University in the UK.

Research documenting the undertreatment of pain with opioid analgesia can be found in the literature dating from over twenty years (Marks & Sachar 1973). Despite the dramatic advances in pain control over the past ten years, many patients in both hospital and the community continue to suffer unrelieved pain and up to three quarters of patients experience moderate to severe pain whilst in hospital (Cohen, 1980 ; Weiss et al, 1983, Bruster 1996 et al). Griepp (1992) reviewed fifteftn pain studies and identified "knowledge deficit" as the most prevalent causative factor, which has been a frequently reported finding in the pain literature (Chapman et al, 1987 ; Allcock 1997). Education is probably the most important tool for improving pain management (Lander, 1990). However, there is a need develop an innovative curriculum so practitioners can facilitate change in their environment, be prepared to develop life-long learning and utilise research based knowledge in their practice.

The International Association for the Study of Pain's (1993) Pain Curriculum for Basic Nurse Education, have provided an excellent start for education in pain management. There is, however, difficulty in ascertaining what is taught within the nursing curricula for pre-registration nurses as it is frequently taught as an integral part of "Cancer Care" rather than as a separate curricula which runs throughout a course. Current knowledge about what is taught in pain curricula in the UK is lacking but an educational sub-committee in the UK has been working to consider what is currently taught about pain management in professional education and what needs to be taught. A further initiative is the Nursing Focus in Pain Management Working Party at the Pain Society in the UK. This group are considering the scope and competency of practice for nurses working in pain management. As part of this work it has used the United Kingdom's Central Council (1999) competencies for Higher Levels of Practice to provide a standards framework. It is hoped these will provide nurses interested in working in pain management with a framework for progression from novice to expert practitioner.

The Instutute of Health and Community Studies at Bournemouth University provides an array of pain education for nurses. These include a pre-registration curriculum which runs throughout a three year programme based upon the IASP Nurse Education Curriculum. For registered nurses there is a six month part-time course at diploma level as well as the opportunity to study a range of open learning modules as part of a BSc Clinical Nursing (Pain Pathway). In 1998 we launched an educational pain video which illuminated common aspects of pain management which could be improved. A teaching guide accompanied the video to provide further discussion and ideas for change.

Education has long been promulgated as the key to improving pain management yet there are few studies which have explicitly linked professional education with improved patient outcomes. We undertook a small pilot project which delivered a series of study days on pain management to a variety of professionals and revealed a small decrease in patients pain. It is essential that research in pain education incorporate patient outcomes as part of the evaluation of its effectiveness. Future curricula also need to take into account the interprofessional nature of pain management and attempt to bring professionals together to learn about pain management. Such initiatives will help them understand their roles and contributions as well as collaborate in the clinical area.

"By any reasonable code, freedom from pain should be a basic human right, limited only by our knowledge to achieve it" (Leibeskind & Melzack, 1987)

References:
Allcock, N. (1996) Factors affecting the assessment of postoperative pain : a literature review. Journal of Advanced Nursing, Vol 24, pll44-1151
Bruster, S, Jarman, ]B, Bosanquet, N., Weston, D., Erens, R., Delbanco, T L. (1994) National survey of hospital patients. British Medical Journal, Vol 309, pl542-1546
Chapman, P. J., Ganendran, A., Scott, R. J. (1987) Attitudes and knowledge of nursing staff in relation to management of postoperative pain.
Australian and New Zealand Journal of Surgery, Vol, p447-450
Cohen, F. (1980) Post-surgical pain relief : patient's status and nurses' medication choice. Pain, Vol 9, p265 - 274
International Association for the Study of Pain (1993) Newsletter, September-October 1993. Technical comer : Pain curriculum for basic nurse education. Edited by C. B. Berde, p4-6
Lander, J. (1990) Clinical judegments in pain management. Pain, Vol 42, pl5-22
Leibeskind, J. C. & Melzack, R. (1987) The International Pain Foundation. Meeting a need for education in pain management. Pain, Vol 30, pl-2
Marks, R. & Sachar, E., 1973. The undertreatment of medical inpatients with narcotic analgesics. Annals of Internal medicine, Vol 78, 173-181.
Oden, R. V. (1989) Acute postoperative pain : incidence, severity, and the aetiology of inadequate treatment. Anaesthetic Clinic of North America, Vol 7, p 1-15
Weiss, D., Sriwatanakul, K., Alloza, J., Weintraub, M. & Lasagna, L., 1983. Attitudes of patients, housestaff and nurses towards postoperative analgesic care. Anesthesia and Analgesia, Vol 62, 70 -74.
United Kingdom Central Council (1999) A Higher Level of Practice-Pilot Standard. Annexe 1. July, London.

A GUIDELINE FOR THE MANAGEMENT OF PHANTOM LIMB PAIN
Dr PD Collins Dept of Pain Management Musgrove Park Hospital Taunton UK
Dr Cathy Stannard Pain clinic Frenchay Hospital Bristol UK
Dr Anne Whyte Dept of Nursing and Midwifery University of Stirling Stirling UK

Guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. Guidelines order and distil the evidence base and may help to reduce inappropriate variation in clinical practice. This is important where the evidence base appears contradictory, or where there is potential for morbidity or mortality from interventions. There are a number of phases in the guideline process; development, dissemmation, implementation and audit of outcome. We decided to develop a national guideline for the management of phantom limb pain. 3 baseline audits were performed, and each showed a substantial variation in practice. These audits are the subject of separate abstracts. A Medline search, with MeSH terms 'phantom,"limb' and 'pain' from 1988 to date revealed 216 papers. Outside the field of pre-emption, there are no randomised controlled trials of any intervention for PLP involving more than 12 patients. We therefore decided to develop a consensus-based guideline. The initial meeting took place over 2 days.

On day 1, a multidisciplinary group of 26 experts reviewed the evidence, and produced a series of position statements.

On day 2, a multidisciplinary group of 140 delegates heard pre-eminent lecturers review the evidence for interventions and were presented with the statements developed on day 1. The delegates voted on the applicability of the statements to clinical practice. A draft guideline was thereafter produced which went to consultation with relevant professional and patient bodies prior to widespread dissemmation. Our presentation will describe the process in detail and present the guideline.

"APPROACH OF THE SUFFERING OF MEDICAL AND PARAMEDIC STAFF IN THE ACCOMPANIMENT OF END OF LIFE. INVENTORY OF FIXTURES IN THE HOSPITAL OF SECLIN"

From 4 til 31 October 1999, we realized an inquiry about "Approach of the suffering of medical and paramedic staff in the accompaniment of end of life. Inventory of fixtures in the hospital of Seclin". Two hundred seventy two persons were included in the study.

Our objectives were to find certain causes of the suffering of medical and paramedic staff in the accompaniment of end of life, to look for a bum out syndrom and to know if medical and paramedic staff had solutions to propose to relieve their own suffering. Globally, causes of the sufferin of medical and paramedic staff have found. Their causes are described in the literature. Our study put in evidence a difference between man's behaviour and woman's behaviour in the accompaniment of end of life: the woman seems to become identified with the patient and the man seems to distance himself from him.

The inquiry also finds a suffering in touch with a lack of communication within teams. The bum out syndrom especially concerns "succession care units" and "emergency-intensive care units".

Medical and paramedic staff express that it is essential to communicate within services. They wish that groups of word be established and that a mobile palliative care team or a palliative care unit be created. They wish a specific training in palliative care and in the accompaniment of end of life.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 309, 353, 361, 362.