On average, 115 Americans die each day from an opioid overdose (Centers for Disease Control and Prevention, 2018). In 2016, 66% of the total 63,600 overdose deaths involved an opioid. In response to these numbers, national groups along with federal government agencies have implemented strategies to address the concern. In 2016, the Centers for Disease Control and Prevention released guidelines to aid providers to appropriate prescribing practices surrounding the use of opioids for chronic pain (Dowell, Haegerich, & Chou, 2016). In October 2017, President Trump declared the opioid crisis a national public health emergency, setting new initiatives for the state and federal governments to improve opioid prescribing practices (U.S. Department of Health and Human Services, 2017). Now is the time for the nursing profession to act, starting with the education of nurses. In this article, we describe the process used to create a nursing elective course to address pharmacological best practices in pain control, ethical considerations in pain management, and the role of the nurse when caring for patients in pain.
Nursing Education and Pain Management
National associations for health care professionals have made statements and goals for their specific disciplines regarding pain management. The American Nurses Association called for nurses to make an impact in regard to the Opioid Crisis. In their position statement, the American Nurses Association highlighted that RNs are on the front lines of opioid epidemic and play a critical role in the assessing, diagnosing, and managing patients battling addiction (American Nurses Association, 2016a, 2016b).
The initiatives of these national groups are vital; however, it is important to note the lack of education and understanding of comprehensive pain management in both nursing students and practicing nurses. It has long been reported from the early 1990s until now that nurses' knowledge deficit serves as a barrier to effective pain management (Latchman, 2014). A study by Duke, Haas, Yarbrough, and Northam (2013) evaluated 162 junior and senior baccalaureate nursing students and 16 nursing faculty responses to The Knowledge and Attitudes Survey Regarding Pain. The study found a direct correlation between knowledge in pain management and level of education. Graduating seniors and faculty scored 68% and 71%, respectively. The authors recommended that nursing programs reevaluate the way pain assessment and treatment is taught in the curriculum. In 2015, Chow and Chan reiterated the findings of this study stating, “a review of the literatures of pain knowledge and attitudes of nursing students worldwide has revealed that, in general, their pain knowledge is inadequate and attitudes regarding pain management are inappropriate” (p. 371).
Enhancing Pain Management in Nursing Curriculums
Although pain management is identified as an area of opportunity in nursing curriculums, challenges exist regarding how to fit more in-depth pain management content into the already full curriculum. As educators and health care providers, we cannot ignore the benefits of increased education on provider competency and patient outcomes. Brant, Mohr, Coombs, Finn, and Wilmarth (2017) found that having more than 5 years of experience, being a certified nurse, and receiving pain education in the past year were predictive of a higher Knowledge and Attitudes Survey Regarding Pain score. Based on these results, four areas of opportunity for nursing pain education were identified: (a) pharmacological management of pain, specifically opioid potency and duration of action; (b) risks of analgesics including addiction and oversedation; (c) assessment of pain based on the patient's report; and (d) making clinical judgements regarding appropriate opioid administration.
In 2017, the International Association for the Study of Pain developed a curriculum for nursing students that outlines the pain management knowledge and skills necessary for entry-level RNs across the globe (Twycross, Quinn, Leegaard, Salvetti, & Gordon, 2018). One university found that overall pain knowledge scores increased by 20% in students across different medical disciplines that completed an eLearning course taught by an interdisciplinary faculty panel (Watt-Watson et al., 2019). An interdisciplinary approach to course delivery in nursing curriculums allows for different disciplines to share their unique roles, beliefs, and knowledge with students regarding specific content areas. This shared knowledge leads to collaboration and understanding among members of the health care team, which ultimately should lead to improved patient outcomes.
Opioid Crisis and Pain Management: Nursing Elective Course
In the fall of 2016, faculty revised the BSN curriculum to include the requirement of a nursing elective course. Nursing electives allow for a more in-depth examination of ideals that cannot always be included within the traditional curricular courses. Electives can also encourage discussion and dissemination of hot topics related to nursing practice.
With the addition of nursing electives to the curriculum, the pharmacology faculty member, a doctorate of pharmacy (PharmD), proposed an elective focused on effective pain management and the nation's opioid crisis. The proposal was fully supported by the college's administration and curriculum committee based on the current literature and the current legislative agendas and interest in the nation's opioid crisis.
The Course Development Process
The nursing elective courses within the program were approved to be fully online courses in order to allow for scheduling flexibility among interested students. Using the course development process established by the nursing program's curriculum committee, the work of creating the course was initiated by the full-time PharmD faculty. Throughout the development process, the PharmD consulted several other nursing faculties and the coordinator for distance education and instructional design. This interdisciplinary approach ensured that both pharmacological and nursing best practices were addressed within the course.
After a review of the literature, a course description evolved for this two-credit course. The description was concise and specific to identify current gaps and trends in the management of pain in nursing education. Course development began with the collaborative creation of the course description that reads as follows:
This elective will allow the student to explore the current issues surrounding opioid use and abuse while understanding the different sources of pain, appropriate assessment tools, medication choices, and ethical decisions surrounding pain management.
Utilizing the college's coordinator for distance education and instructional design, the course was developed using multiple online teaching strategies to include, but not be limited to, weekly bridge videos, educational media clips, current articles relevant to pain management, discussion boards, and online lectures delivered by faculty. The course was delivered over 10 weeks and divided into three modules (Table 1). Each week the students were assigned specific readings related to the weekly topic. Resources that were used for reading included: International Association for the Study of Pain curriculum, American Nurses Association opioid crisis resources, 2016 Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain, and current articles and news briefs relevant to pain management.
Opioid Crisis Elective Course: Modular Objectives and Weekly Topics
At the completion of the course, the course faculty felt as if the students had significant gains in their pain knowledge, understood the national issues surrounding the opioid crisis, and were able to explore their own personal biases regarding pain management. In the final evaluation of the course, an RN-to-BSN student wrote:
I think my favorite topic this summer has been learning more about the different approaches to pain management. As a labor and delivery nurse, anytime I can learn more about managing pain—especially from different perspectives and different types of pain—I find it helpful in real nursing practice. I enjoy learning things that are applicable to my job, and things that help me be a better nurse, not just in theory a better nurse, but in real situations on my shifts.
A BSN student stated:
This course has opened my eyes to a new perspective and viewpoint on the use of opioids and how I can improve the health care system when it comes to providing effective pain management. I want to become a part of a system where opioids are not used a first line of practice for pain management. I now know that there are other practices out there that are more beneficial for patients as opposed to opioids that I will make it a routine to offer these options and to educate my patients as much as possible on the different routes of treatment that can be provided that can cater specifically to their pain.
Course Evaluation Methods
The course evaluation methods were carefully considered and developed to be consistent with the practices used in other online nursing courses at the college. Because of the type of content, discussion boards were weighed heavily in the total grade (five discussion boards worth 6% each, 30% of the total grade). Having one discussion board every 2 weeks allowed for in-depth conversation of content and appropriate time for peer responses. To support weekly assigned readings and videos, classroom assessment techniques were assigned. Classroom assessment techniques are quick assignments that the students complete online that ask questions related to the topic of the week. The purpose of the classroom assessment technique is to ensure that the students are engaging in the weekly activities related to the content. Fifty-five percent of the students' grade is related to a “Shifting Practice and Perceptions” essay, video, and peer review. This essay allows the students to explore a pain topic of interest to them and address current practice guidelines, ethical issues, applicable laws and legislation, and strategies for future practice. The students then share their essays in an online video summary for their peers' education and analysis. This blend of weekly class activities, discussion boards, and independent projects provided opportunity for ample interaction within the online classroom. Faculty were able to provide simultaneous yet different practice perspectives on pain management to facilitate a deeper understanding of course content, steer discussions to focus on patient outcomes, and encourage students to use their knowledge to immediately apply to real-world scenarios.
An interdisciplinary approach to teaching the course was used in both the development and the delivery of the course material. The course was taught by a PharmD with certification in pain management, and a family nurse practitioner, both of whom are full-time faculty at the college. This approach proved effective within this particular nursing elective as it allowed for interaction and discussion from both a pharmacy and nursing perspective. Each faculty shared their level of expertise related to their scope of practice and the management of pain. Students were given the opportunity to learn the best practices from different disciplines and recognize the role of each discipline in the treatment of those with chronic pain.
Within the 10-week course, the interdisciplinary approach was effective in addressing and discussing key issues in pain management. For example, personal biases of nurses regarding the need for pain medication were discussed openly among the students and course faculty. Traditional nursing students and RN-to-BSN students dialogued about experiences on their units or in their rotations as students. They discussed the “drug seeker” patient and the biases that influence care when pain truly exists. The role of the nurse in assessing and managing pain was discussed by PharmD-certified nurse practitioner, emphasizing proper pharmacological interventions for various populations and needs. Students also had the opportunity to discuss the administration of naloxone by family members and first responders and the ethical considerations that accompany this new approach to combatting the rising number of opioid overdose deaths.
Also of note in this course, was the interaction that occurred between the prelicensure and postlicensure students. The dialog exchanged in the discussion boards containing pharmacist, nurse faculty, RN-to-BSN students, and traditional prelicensure students proved to be robust and supported team-based patient care approaches.
Lessons Learned and Future Possibilities
This 10-week course began in June 2018 and was capped at 25 students with a waiting list. There were 22 BSN and three RN-to-BSN students enrolled. The desired outcome was to have a successful first installment of the course measured by student pass rate and course satisfaction. All students completed the course with a 100% pass rate measured by a cumulative score of ≥ 80%. There was an overall 97% satisfaction rate of the course, with a student response rate of 60%. When asked what worked well for the course, the most common student responses included (a) the expertise of the course faculty; (b) the manner in which the course topics were covered; and (c) the amount of knowledge gained. Many students suggested that the course concepts should be a mandatory educational requirement for all nursing students.
A course report was given to the institution's curriculum committee for comments and directions. Based on student evaluations and the committee's feedback, the faculty and the coordinator for distance education and instructional design met to discuss potential changes for future semesters. Specific changes to be considered included (a) dividing students into groups of five or six for discussion boards for discussion facilitation; (b) having more voiceover lectures provided by faculty; (c) review and editing rubrics for projects; (d) providing more direction in peer responses on discussion boards; and (e) having an interprofessional student cohort. As a single-purpose college within a health system, a plan is in development to introduce course partnership with pharmacy and medical residents. This will not only enhance the learning of each discipline through knowledge sharing, but also strengthen professional communication and collaboration among members of the health care team.
The development of this course served several purposes for our institution. First, it met a need for an elective course for the BSN and RN-to-BSN students' curriculum plan. Second, it met two institutional program outcomes: (a) to engage in communication and collaboration with the interprofessional health care team; and (b) to provide safe, quality care incorporating evidence-based nursing practice. Additionally, it gave the students a platform to explore the current hot topic of the opioid crisis in detail while learning the appropriate pain management tools from experienced faculty. Finally, all allowed collaboration between the institution's two programs and fostered a sense of camaraderie.
- American Nurses Association. (2016a). Nursing's role in addressing the nation's opioid crisis. Retrieved from https://www.nursingworld.org/~4ae212/globalassets/docs/ana/ana_nursings-role-in-opioid-crisis_2016.pdf
- American Nurses Association. (2016b). The opioid epidemic: Addressing the growing drug overdose problem. Retrieved from https://www.nursingworld.org/~4ae212/globalassets/docs/ana/ana_issue-brief-opioids_2016may20.pdf
- Brant, J.M., Mohr, C., Coombs, N.C., Finn, S. & Wilmarth, E. (2017). Nurses' knowledge and attitudes about pain: Personal and professional characteristics and patient reported pain satisfaction. Pain Management Nursing, 18, 214–223. doi:10.1016/j.pmn.2017.04.003 [CrossRef]
- Centers for Disease Control and Prevention. (2018). Opioid overdose: Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html
- Chow, K.M. & Chan, J.C. (2015). Pain knowledge and attitudes of nursing students: A literature review. Nurse Education Today, 35, 366–372. doi:10.1016/j.nedt.2014.10.019 [CrossRef]
- Dowell, D., Haegerich, T.M. & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315, 1624–1645. doi:10.1001/jama.2016.1464 [CrossRef]
- Duke, G., Haas, B.K., Yarbrough, S. & Northam, S. (2013). Pain management knowledge and attitudes of baccalaureate nursing students and faculty. Pain Management Nursing, 14, 11–19. doi:10.1016/j.pmn.2010.03.006 [CrossRef]
- Latchman, J. (2014). Improving pain management at the nursing education level: Evaluating knowledge and attitudes. Journal of the Advanced Practitioner in Oncology, 5, 10–16.
- Twycross, A., Quinn, R., Leegaard, M., Salvetti, M. & Gordon, D. (2018). International Association for the Study of Pain curriculum outline on pain for nursing. Retrieved from http://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2052
- U.S. Department of Health and Human Services. (2017). HHS acting secretary declares public health emergency to address national opioid crisis. Retrieved from https://www.hhs.gov/about/news/2017/10/26/hhs-acting-secretary-declares-public-health-emergency-address-national-opioid-crisis.html
- Watt-Watson, J., McGillion, M., Lax, L., Oskarsson, J., Hunter, J., MacLennan, C. & Victor, J.C. (2019). Evaluating an innovative eLearning pain education interprofessional resource: A pre-post study. Pain Medicine, 20, 37–49. doi:10.1093/pm/pny105 [CrossRef]
Opioid Crisis Elective Course: Modular Objectives and Weekly Topics
|Week 1 to week 4||Module I
Define substance use, abuse, and addiction.
Describe the current opioid crisis within the United States.
Explore the nurse's role within opioid management.
Apply the current standards of practice and tools used when prescribing and monitoring opioid therapy.
Understand the therapeutic use of naloxone and its place in therapy.
Opioid crisis introduction
The nation's struggle with opioid addiction
Nurses' role in the opioid crisis
Centers for Disease Control and Prevention opioid guidelines
|Week 5 to week 6||Module II
Distinguish between different mechanisms involved with pain pathology.
Understand the consequences of unrelieved pain.
Identify individuals who are at risk for undertreatment of their pain.
Use valid and reliable pain assessment tools that are appropriate to the needs of the individual and the demands of the care situation.
Explore how nurses' personal knowledge and attitudes may affect pain management for their patients.
Pain pathology and nurse's attitudes toward treating pain
Appropriate pain assessment
|Week 7 to week 10||Module III
Categorize pharmacokinetic properties, mechanisms of action, and monitoring requirements for non-opioid analgesics.
Identify potential adjuvant medications for nociceptive and neuropathic pain.
Explore the pharmacological use and monitoring of opioids.
Discuss common chronic pain conditions.
Evaluate interdisciplinary and non-pharmacological approaches to pain management.
Traditional pharmacologic management of pain
Alternative, adjunctive, and interdisciplinary approaches to chronic pain management
Chronic pain conditions
Putting it all together