I work within a tertiary pain referral hospital in North London, I have worked in this department for 5 years now and felt that I had a good grasp of how the process of services were set up and also how current guidelines and evidence based medicine helped my practice.

 Since I have started this module I have realised that I probably had only really scratched the surface of a very large iceberg with regards to the above.  The web seminars and reading material have been really helpful in adding further knowledge.  My clinical practice will no doubt improve because of this.

I am currently involved in setting up a new service with one of the pain consultants where we have a former patient, a member of the patient group and other members of staff from the wider Multidisciplinary Team (MDT).  The course so far has helped me to understand the finer details of the process and I feel that I have been able to make more informed contributions to these meetings because of this.

With regards to patients living with pain when I first joined the pain department I was only too aware of the effects that having chronic pain can have on very simple tasks day to day from my own personal experiences especially with mental health wellbeing.  I have always tried to be as empathetic as I can be without it being detrimental to our patient/staff relationship.  Saying that I am not sure I gave full thought into the struggles of specific groups of patients like LGBTQ+ may of went or are currently going through.  

I have always tried to treat everyone with a comforting smile, shoulder to cry on, ear to listen, the odd bad joke and involved them as much as I can in their care.  This will obviously continue, however I feel I am now better informed and will be more aware in future to ensure I am asking the correct questions, signposting people better to ensure a more fully biopsychosocial model care approach.

Pain can be quite necessary and unnecessary experience for our patients.  Pain tells us that we have done too much and that a period of rest is required.  A period of pain can also be a very worrying time for our patients with a multitude of factors that increase its intensity like stress, mental health and cognitive factors.  Then there is the actual injury or disease and all the worries that it brings, will I work again, mobilising, is it curable ….

As health care professional we are here to be the word of reason, informing our patients of what we understand about an injury, disease or trauma, complications of treatment and what treatment options are open to them.

I feel I have a better understanding of the pain process and recently have been able to discuss and describe pain to patients in a way in which they understand, much better than I ever have been able to in the past.  I didn’t fix their pain nor did I reduce it at that point.  But the patients were able to tell me that they felt more relaxed and less concerned about their pain following our discussion.  Following further discussions about medication options and why one drug was more suitable than another due to the type of pain they were describing to me, they felt that they were part of the decision making process and their overall care plan.

Regular follow ups are essential to managing introductions of new analgesics and any changes to them.  This however can be very challenging and frustrating for me at times due to the constraints at work making it near impossible.  More recently I have found myself doing ad hoc telephone clinics to help facilitate quicker follow up appointments to ensure any changes or introductions  of analgesics have been helpful or not, monitoring any adverse side effects and simply giving reassurance and further advise.

I have recently had to relook at my diary and have allocated an hour each day so that I am able to facilitate these types of follow up without it affecting my normal work load.  This time will allow me to communicate with other areas of the patients team including the therapy team and General Practitioner.  Another positive of having this allocated time now means that I am not restricted to a 20min telephone follow up time in my planned telephone clinics.

There will never be a simple 1 size fits all analgesic option for our patients.  What we can promise is by ensuring we communicate better with our patients and changes to analgesics are actioned efficiently and quickly we should be able to ensure good patient recovery.

When there is a break in the nervous system or a noxious stimuli that activates the pain response.  Its initial response when something happens is to try and fix and figure the problem out.  The nervous system sometimes needs help with external factors such as medication, physical therapy, psychological therapy and patient education.

If managed quickly and effectively we can gain an equilibrium and prevent that catastrophic event from happening for our patients.  For some that event does happen due to the nervous system being over stimulated, substance P and Co causing all sorts of mischief.  When this happens it can cause many biopsychosocial problems for our patients, the biggest hurdle being acceptance of their pain and being forced into having to adapt their lifestyle, which can often feel like they have lost themselves and feel unrecognisable. 

We try and help patients to accept that we can help them with coping skills, management plans for flare ups and daily management and also optimisation of analgesics to help them to improve their quality of life for long term management of their pain with the help of a multidisciplinary team.

Acceptance is something that our patients will fall in and out of many times during their life.  But hopefully we are able to help support them with kindness, compassion and empathy and also with co operative work with the multidisciplinary team which includes the patient, hopefully there will be light at the end of the tunnel, we just need to take it day to day.

This course has helped to give me a deeper understanding of the pain process and I have been able to explain and discuss whats going on internally and how the nervous system can become hyper-sensitised in more depth to the patient to help them have a better understanding of their pain in a way in which they would understand.

We also need to be careful of self preservation, keeping open communications with the whole team so that when we are finding it tough to help certain patients and we feel stuck as to what to do we can do so in a safe open environment.

The picture is one that a pain patient painted many years ago now for our team.  For me it captivates and describes chronic pain perfectly.

I learnt that its ok to cry with patients and also behind closed doors but to ensure that you ask for help when you need it, but equally its good to laugh with them and help them celebrate mile stones in their life, birthdays, anniversaries and for some that day when they have been given the all clear.

I learnt lots from the sisters and patients in the hospice, I was taught that taking a family history and what they meant to the patient is key to helping you to understand the patient better.  Having open and honest conversations about their expectations, hopes dreams, how they would like us to help them whilst they were with us and also having that even more difficult discussion abut dying.  This was key to help our patients feel safe throughout their stay, wither that be for respite care or end of life care.

On finishing my nurse training I ended up working in a hospital that helps treat patients with primary bone cancer and cancer metastases.  Helping patients through their surgical treatments and  being mindful of their grief around their cancer diagnosis and continuing treatment plan, but also helping them with the grief of losing a limb or their body not looking the same post surgery and helping them through their rehabilitation with all the ups and downs that comes with that.  

Holding a patients hand when their family members can’t be there with them due to living miles away from the hospital or not having any family.  Sitting with young adults through the night to ease there anxiety and fears as they transition from paediatric care through to being placed on adult wards.   For me this is the most important part of my job when helping patients with or who have had cancer, having just enough empathy with a little bit of tough love to help them get through recovery of surgery and get them home as soon as we are able to.

This course has helped me to understand the mechanism of cancer and treatment options more clearly.  I feel moving forward that this will help benefit discussions and clinical assessments that I will have patients and clinicians.  

 

I run a telephone paediatric follow up clinic as one of our consultants sees children from 11 onwards.  I have to say it’s one of my clinics that I really look forward too.  It can be a challenging clinic as parent and child are often quite anxious, I generally have around 40 minutes per patient as this gives me enough time to discuss any medication changes or Pain management without them feeling rushed.  I feel that the module has helped to build on my current knowledge and I feel more confident in breaking down pain and medications information.

 

Headache and facial pain is a subject quiet close to me, I have been interested in this for some time.  The module has enabled me to look more closely at specific treaHeadtment options and how to help patients moving forward.  From my own experience I feel that some patients aren’t always taken seriously when they talk about their persistent headaches and it can be extremely debilitating for them and I often feel quite helpless and unsure how to help them moving forward. Like most pain clinics referrals can take some time to triaged and accepted.  However, I feel I would be more able to assess and discuss patients with their consultant within our pain team to see if we can help them until they are reviewed by a specific Headache team.

 

However, despite all the negative aspects of living with chronic pain, it is rewarding to help and guide our patients through part of their journey of acceptance and living with pain well, even if the road is rocky from time to time.

 

We have started to receive extra messages on our chronic pain support line that we run, and a lot of patient's are calling us to discuss their flare ups, as due to lockdown their activities and pacing have become better and yet they still have pain which is causing them a great deal of anxiety.  I started to reflected on how I discussed chronic pain and flare ups with my patient's.  I realised that the conversations I have are probably emphasised more on flare ups caused by an increase in activity along with conversations around boom-and-bust cycles.  Whilst this is important it is also important for the patient to understand that pain flare ups can happen without any cause and they should continue with pacing and use their normal flare up plans, or help them to devise a plan that they can use if they don’t have one.

 

Because of this module and the current situation, we find ourselves in, I now find myself discussing flare up plans more regularly with patient's and not just when patients contact us in the middle of a flare up.  I realise, by discussing it more frequently with patient's it may encourage them to have one ready to use and be less fearful of having a flare up of pain.

 

It can be difficult for patients to fully accept the role that psychologist has within the chronic pain team, they understand the role that physiotherapists, occupational therapists and specialist nurses have to help them along their pain journey.  In my experience patients can be distrusting of psychologists, and normally the first thing that patients will say is “I’m not mad” and “what good will come about talking about my pain”.  For some patients it can take a few appointments for them to fully understand the importance of pain psychologists within the pain team and with lots of pain education they can be more willing to see them.

 

But having to work within a multidisciplinary team (MDT) was challenging, yes, I had been part of MDT before when I worked on the ward, but this was different, setting up and managing the psychology MDT, ensuring MRIs were reviewed in the spinal and radiology MDT.  These MDTs are integral to the working of our neuromodulation service, the module emphasised these points well, working within a MDT way helps to ensure the whole patient is cared for in the most appropriate way.

 

The education sessions I carry out, when I first started, I required help from the representatives from the neuromodulation companies and the consultants, as time has passed, I know run these myself.  It is integral that the patient has all the information pertaining to the pre, peri and post of care, complications, contraindications to help them make a fully informed decision about their care.   It’s important the patient is aware that these devises help with pain reduction and not resolution.

 

Pre assessments are carried out for each patient to ensure any pre-existing conditions are managed and optimised before surgery especially anticoagulation therapy and infection prevention, which is something I am fully aware of.

 

The part I most enjoy is helping patients through their journey of Neuromodulation, it’s comforting to see patient's doing well, by having an MDT approach I can work alongside my therapy and psychology colleagues to optimise patient quality of life and patient outcomes.

 

Neuromodulation doesn’t work for everyone and that can be quite hard for our patients a lot of patients have been through so much during their pain journey with what they see as failed surgery and multiple interventions with no benefit, they can often see Neuromodulation as the last try at some relief. 

 

Thankfully we are now starting to see patients referred to us sooner which is good as this helps to reinforce that Neuromodulation is not a last-ditch intervention and can be used in conjunction with our therapy team and psychology team.

 

Intrathecal delivery system section was helpful, as I don’t see many patients with these, it was good to see how patients with cancer pain find these systems helpful for them in reducing pain and maintain better quality of life.

 

I feel this module has helped me to refine my knowledge especially with the mode of action of Neuromodulation, and how pain relief is gained.   I have started to make some changes to my pre assessment of our patients and have started to discuss wither routine bloods including HBa1C are required for every patient, I am reviewing local policy and will discuss this with pain consultants.

Prescribing in the community section was interesting I am not a prescriber however part of my role is to help manage medications wither that is commencement or reduction of analgesics.  It has always been very clear to me that I must be aware of all the side effects of the drugs I am discussing including risk, benefits and contraindications to keep the patient safe.  I often use the leaflets from the pain faculty and NHS website to help with education on analgesics.

I have a clinic specifically for the adolescents I have always enjoyed these clinics speaking them, however I can find managing the parent’s expectations can often be quite difficult.  The lecture we had on this subject was very helpful and I felt I was given some really good information and advice that I can take forward to help me manage the parent’s expectations and also help to encourage the adolescent have a voice.

Chronic pain and Substance misuse patients are a group of patients we do not always see within our service.  I can often find them quite challenging.  I agree that it is key to have a good working relationship and collaboration with all teams involved in their care and having a thorough assessment and management plan is key.

I often suggest non pharmacological treatments to our patients.  I do explain that some of the suggestions do not always have good evidence base behind it due to the difficulty of having placebo etc.  Apart from acupuncture most of our suggestions like tai chi patients would have to find groups local to them, we can often point patients in the right direction but getting the patient to find what’s available in their area also helps with self-management and engagement.

Joint working section was really informative, I often find that when key decisions need to be made the most important people i.e., service users are often not involved.  Patient involvement can be really helpful in showing where services are lacking wither that be in hospital or community environment, we had a focus group about setting up an opioid service and we did involve a previous service user which I found very insightful.

I find third party organisations are very helpful and this is something I get patients to look into with some assistance to see what’s available locally to them, my plan moving forward is to start looking at how I can build relationships with local organisations.