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Multidisciplinary Approach

A multidisciplinary approach that includes the physician, registered nurse, physician assistant, advanced practice nurse, and, most important, the family members is imperative in ­providing comprehensive pain management for all infants. Consideration of the role of each team member in mitigating infant pain and providing comfort, as well as promoting communication among members of the team is fundamental to the best interests of the infants. Each member of the team has a unique perspective and bears responsibility for recognizing and providing interventions for recognized pain. Providing techniques for communicating those responsibilities becomes the challenge. First, identification of each individual’s role and responsibility is necessary before communication techniques can be discussed.

MEDICAL APPROACH

Physicians, neonatologists, and pediatricians, including medical residents in pediatric rotation, have an obligation and responsibility for the medical management of the infant, whether in a newborn nursery or a neonatal intensive care unit (NICU). The primary responsibility is the medical management of physiological function and disease management. Directives for physiological management in the form of written or electronic orders directing the interventions are given by the ­physician team. Ideally, the physician should conduct a comprehensive head-to-toe assessment and have a first hand understanding and working knowledge of the physiological condition of the patient. The key role of the physician in mitigating neonatal pain is detection and management of the pain (Boyle & McIntosh, 2004).

Likewise, the roles of the physician assistant and advanced practice nurse are similar to that of the physician. Primary responsibility for the medical management of physiological stability of the infant falls to the physician assistant and advanced practice nurse. Each is also responsible for providing written or electronic orders for interventions that provide physiological stability and direct the support team’s activities and interventions.

NURSING APPROACH

The registered nurse has the primary responsibility of ­assessing physiological systems and the effects of interventions and treatments, administering and monitoring medications, and educating families. Comprehensive head-to-toe assessments are necessary to monitor the effects of interventions. Written or electronic documentation of findings is also a necessary responsibility. The registered nurse’s primary role in mitigating neonatal pain is recognizing, appropriately assessing, reporting the findings, administering and managing nonpharmacological and pharmacological interventions, and assessing the effects of those interventions.

FAMILY APPROACH

The family’s role is to provide support for and advocate for the newborn. Unable to verbalize concerns or needs independently, the neonate is dependent on the family to provide his or her voice. The family has a responsibility to the infant to ensure adequate and safe care is rendered, while providing a voice when further support may be necessary. The family can be key to identifying and reporting pain to health care workers and, as such, are an integral part of the team (Friedrichs, Young, Gallagher, Keller, & Kimura, 1995). The role of the family in mitigating neonatal pain is to understand pain cues of the infant and report and advocate for interventions to treat the pain.

COMMUNICATION IS KEY

A key responsibility in the role of each member of the team is communication. Each member of the team has a responsibility to the neonate to collaborate and communicate, with the infant the primary focus of the interaction. All too often, breakdown in communication between one or more member of the team leads to misunderstanding and, for the purpose of pain ­management, leaves an infant without adequate support. It is fundamentally imperative for each member of the team not only to understand each other’s role, but to find a way to communicate effectively. A recent position statement set forth by pain management task forces formed through neonatal and pediatric organizations suggests a multidisciplinary approach is necessary for all nonverbal patients (Herr et al., 2006). The National Association of Neonatal Nurses provides a guideline for pain assessment and management of neonates and directs health care workers to take a collaborative and interdisciplinary approach to identifying and managing neonatal pain (Walden & Gibbins, 2008; Figure 9.1).

Methods that can promote effective communication include education, case studies, debriefing, and pain committees. Education of both health care workers and family members is essential in management of neonatal pain. Walden and Gibbins (2008) suggest all nurses working in NICUs should receive education and competency validation in pain assessment and management skills upon hire and periodically throughout employment. At a minimum, the education should include the anatomy and physiology of pain transmission, modulation, and perception and the physiological and ­behavioral indicators of pain. Education of pain management for the registered nurse should include nonpharmacological approaches, pharmacological interventions, special procedural techniques, and end-of-life pain management (Walden & Gibbins, 2008). Educational opportunities should also include instruction on how to identify differences in pain for gestational ages and developmental stages. A competent understanding of safe medication administration and adverse effects of pharmaceuticals is necessary. Education should also include the ability to educate the family on pain assessment and management as appropriate for their involvement. The education should include appropriate documentation of pain-assessment findings and intervention responses. Finally, education should include the ability to ­communicate appropriately with the interdisciplinary team regarding the assessment and intervention status of the infant (Walden & Gibbins, 2008).

FIGURE 9.1.  Families should communicate with the health care team members.

HOW TO IMPROVE EDUCATION

Education of the physician team should focus on the physiological and behavioral cues of the infant by gestational and developmental stages. A focus on an understanding of the underlying factors that can alter the infant’s ability to demonstrate pain symptoms should be part of the education as well. A focus on the long-term effects of poor pain management will be useful for physicians in understanding the need for pain management at all gestational ages for all painful interventions (Schultz, Loughran-Fowlds, & Spence, 2009). An educational focus on assessment, appropriate interventions, and postintervention assessment are necessary elements. Communication techniques with the family and interdisciplinary team are a focus for education and annual competency as well.

CASE STUDIES AS LEARNING TOOLS

Case studies are a great tool for interdisciplinary collaboration and learning. Using case studies of current, past, or fictional patients is a nonthreatening, informal method of bringing team members together to review symptoms, interventions, and outcomes of pain management. Case studies promote teamwork and communication skills (Bradshaw & Lowenstein, 2014). The Institute of Medicine (IOM) recommends interdisciplinary systematic reviews of practice guidelines and patient outcomes in an effort to promote quality improvement and improving patient outcomes (Newhouse & Spring, 2010). Case studies promote critical thinking, problem-solving, and decision-making skills of health care workers, which aligns with the IOM recommendation for promoting quality improvement. Systematic review of events presented during a case study can foster communication about what is known about the patient, what is understood about the patient, and where gaps in that knowing and understanding exist.

Elements of a case study for promoting critical thinking, problem-solving, and decision-making skills, as well as communication skills include the problem or situation, the patient scenario, each participant’s contribution, priorities and a solution, implementation of the solution, and results. Presentation of the problem or situation will provide the situation, background, and assessment of the scenario in a neutral format, without consideration of discipline or outcome. It requires simple, straightforward, unbiased accounting of the events and ­circumstances. Next, each discipline’s contribution to the recommendations and outcomes can be presented and reviewed, ideally without opinion or commentary from other disciplines. Remaining neutral when reporting facts will promote collaboration without creating barriers or placing responsibilities on a particular discipline. Keeping information strictly factual is key. Once all salient information is presented and understood by all members present, a group discussion of what each discipline deems a priority can ensue. A word of caution: It may be wise to include a nonbiased, third party to ensure discussions remain productive and not accusatory, as the intent is to promote quality, not point blame, especially when reviewing particularly ­difficult cases. Ideally, to build communication skills, a team new to case study activities should begin with patient outcomes that were positive.

Once priorities from each discipline are determined, a discussion can begin about the rationale for the priority with recommendations for a solution. The recommendations should be supported with evidence-based research and documented proof of outcomes, not simply based on practitioner comfort or ­experience. Using the IOM recommendation of promoting ­outcomes through evidence-based research is key in promoting best practices and establishing consistent standards of care. Comparison of interventions that were implemented to evidence-based research can be the key to overcoming barriers, communication gaps, and advancing practice to the standards supported by evidence. Review of the implemented interventions and the response and outcomes can provide robust conversation for improving processes for future patients. Identifying the gaps in knowledge from any contributing discipline and working collaboratively to overcome those gaps not only improves patient outcomes, but also works to promote teamwork and communication.

Case studies are a useful and productive tool for promoting critical thinking skills and communication retrospectively in a controlled, planned atmosphere. Debriefing allows a similar process to take place in a more abbreviated format in a more real-time manner. Debriefing is a conversation between care providers that includes the sharing and examination of information after a specific event takes place. The Agency for Healthcare Research and Quality (AHRQ) provides comprehensive tools and support to promote health care communication that promotes patient safety in response to the IOM reports of improving patient outcomes. Debriefing is a tool AHRQ provides through the TeamSTEPPS initiative—an evidence-based program with the singular goal of promoting patient safety (AHRQ, n.d.).

DEBRIEFING

The debriefing checklist created by the AHRQ through the TeamSTEPPS initiative covers nine elements of review. This systematic, organized review should include all persons ­intimately involved in the situation for review, including ­parents. The elements of the debriefing tool cover communication concerns, task assistance, resources, and process-improvement elements of what went well and what needs adjustment. Using the debriefing tools when considering managing neonatal pain is a productive way to include all members of the team.

A debriefing session can occur after each episode of neonatal pain, with review of the nine elements to promote a better outcome for future episodes of pain. Include all team members in the review to determine whether communication was clear: Did everyone understand his or her roles and responsibilities in alleviating pain? Were the resources available to alleviate the pain, and, if so, were they successful? Should anything change for the next episode? Debriefing is simple, comprehensive, and timely in promoting patient outcomes. Debriefing can be highly effective in engaging all members of the team, promoting communication skills in an objective manner, and focusing on the patient.

DEBRIEFING CHECKLIST

The team should address the following questions during a debriefing:

___ Was communication clear?

___ Were roles and responsibilities understood?

___ Was situation awareness maintained?

___ Was workload distribution equitable?

___ Was task assistance requested or offered?

___ Were errors made or avoided?

___ Were resources available?

___ What went well?

___ What should improve?

Adapted from the AHRQ website.

PAIN COMMITTEE APPROACH

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