concerns the impact of chronic childhood illness. T h o m p s o n and Gustafson state that the purpose of this section is to discuss the "scope of chronic childhood illness and the impact on individuals and t:amilies." T h e six chapters in this section address epidemiolo~,, classification, psychological adjustment, correlates of psychological adjustment, social adjustment, p e e r relations, school functioning, psychological a d j u s t m e n t of family m e m b e r s (parents and siblings), and adaption models. Chronic childhood illness is viewed as a potential stresSOl-. The authors indicate that children with chronic illness, their parents, and siblings are at increased risk for adjustment difficulties. Section II emphasizes the i m p o r t a n c e of developmental perspectives in understanding and facilitating adjustment to chronic childh o o d illness. T h e three chapters address develo p m e n t a l changes in (a) conceptualizations of health, illness, pain, and death; (b) cognitive processes; and (c) coping. This section is particularly interesting in the authors' integration of their biopsychosocial fi-amework and developmental considerations. Knowledge and u n d e r s t a n d i n g of the i n f o r m a t i o n in these chapters seems imperative for health care providers to foster the adaption of children to chronic illness. Section III tocuses on the implications of the a u t h o r s ' biopsychosocial a p p r o a c h fi)r t r e a t m e n t goals and intervention processes to facilitate adaption to chronic illness by children and their tamilies. T h e three chapters in this section address (a) intervention goals and processes, (b) adherence, and (c) pain mana g e m e n t . T h o m p s o n and Gustafson discuss the treatment literature in terms of the prim a r y goals of e x t e n d i n g the d u r a t i o n a n d quality of life for children with chronic illness. T h e y indicate the i m p o r t a n c e of t a r g e t i n g adaptive processes that minimize the impact of chronic illness on normative life experience. S e c t i o n IV a d d r e s s e s public policy a n d research regarding children with chronic illness based on the implications of their biopsychosocial framework. It is unusual for public policy to be discussed, and the authors should be c o m m e n d e d for their efforts to e n h a n c e the adaption of children with chronic illness in this truly systematic manner. Larger system issues c e r t a i n l y w a r r a n t c o n s i d e r a t i o n as asserted by the family therapy field for m a n y
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years. The suggestions for further research are also noteworthy. T h e b i o p s y c h o s o c i a l f i a m e w o r k used by T h o m p s o n and Gustafson to u n d e r s t a n d and foster adaption to childhood chronic illness seems very interesting and useful. The integration of developmental and family systems perspectives into their f r a m e w o r k a p p e a r s to e n h a n c e the approach. This b o o k is very informative with regard to psychosocial issues associated with adaption to childhood chronic illness. It seems to be of potential interest to social scientists, health care professionals i n c l u d i n g p e d i a t r i c psychologists, and health care professionals in training. T h e b o o k appears to function better as a very accessible authoritative reference on tim subject, r a t h e r than a " h o w to" book. T h e r e is, however, m u c h that can be directly applied to the care of children with chronic illness. Possibly, one could consult individual sections as n e e d e d , a l t h o u g h the b o o k is p o t e n t i a l l y m o s t h e l p f u l w h e n r e a d in its entirety. In all, this b o o k is a valuable resource for health care providers who work with children experiencing chronic illness. Pll S0885-3924(97)00230-3
No Pain, Organizational Gain Paul M. Arnstein, P h D
Building an Institutional Commitment to Pain Management: The Wisconsin Resource M a n u a l for Improvement
By' D e b o r a h D. Gordon, J u n e L. Dahl, and F,aren Knnz Stevenson Published by the Wisconsin Cancer Pain Initiative, Madison, Wisconsin 1996, 239 pages, $;30.00 Despite scientific and professional advances leading to m o r e effective, efficient ways of relieving pain, there remains a great deal of needless pain and suffering a m o n g consumers
Paul M. Arnstein, PhD, RN, CS, is Clinical Nurse Specialist at Concord Hospital, Concord, New Hampshire, USA.
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of health care. Unrelieved pain is not benign; rather, it u n d e r m i n e s goals of health care by i n t e r f e r i n g with h e a l i n g , i m m u n i t y , a n d functioning, l-:~ thus putting patients at high risk to develop complications. If not relieved, pain can affect every body system in a potentially h a r m f u l way, including increasing the extent of cardiac d a m a g e experienced during a h e a r t attack. 4 Pain, allowed to persist, is believed to change the structure and function of the nervous system in a way that increases the intensity, distribution, a n d d u r a t i o n of pain, 5 c o n t r i b u t i n g to the d e v e l o p m e n t of incurable chronic pain syndromes. 6'7 Health care organizations have increasingly recognized a host of problems associated ~ith poorly managed pain, including customer ser~ice problems (for example, patient dissatisfaction), prolonged institutionalization, readmissions, and higher costs. Legal precedents in the form of awards in the millions of dollars a'v reaffirm that organizations are indeed liable for the needless pain and suffering endured by their patients. As the principles of continuous quality improvement are being used by organizations to solve their most complex problems, unrelieved pain is emerging as a suitable target for this type of process improvement. Clinical practice guidelines established by the A g e n c y for H e a l t h (;are Policy a n d Research :<~° have reviewed, critiqued, a n d s u m m a r i z e d an extensive b o d y of research that clearly s u p p o r t that p a i n (acute a n d cancer-related) can be effectively relieved in almost all cases. T h e m e t h o d s of assessing a n d r e l i e v i n g p a i n a r e b a s e d o n a few straightforward principles and easy-toi m p l e m e n t techniques. Merely distributing these guidelines a n d e d u c a t i n g professionals a b o u t these techniques, however, does not by itself i m p r o v e the way pain is m a n a g e d . To be effective, these e d u c a t i o n a l activities m u s t be p a r t of a formalized, institutionally s u p p o r t e d p r o g r a m t h a t f o c u s e s o n the p r o b l e m s of pain a n d attends to the c o m f o r t n e e d s of patients served. T h e clinical practice g u i d e l i n e Q '~° have detailed the important role that organizations have in e n s u r i n g that pain assessment a n d relief is up to par. T h e s e guidelines outline ti)r o r g a n i z a t i o n s what should be d o n e , but not how to do it. B u i l d i n g an I n s t i t u t i o n a l C o m m i t m e n t to P a i n M a n a g e m e n t , is p u b l i s h e d by the a c c l a i m e d
Wisconsin C a n c e r Pain Initiative (Madison, WI) to s u p p o r t i m p r o v e m e n t s in the way pain is assessed a n d m a n a g e d at the organiz a t i o n a l level. With its p u b l i c a t i o n , n o w there is a r e s o u r c e m a n u a l that provides the details of how to plan a n d i m p l e m e n t this type of o r g a n i z a t i o n a l change. In contrast to the clinical practice guidelines, which provide little m o r e t h a n a s t a t e m e n t of what organizations should do (for example, assign responsibility, m o n i t o r quality, a n d p r o m i s e patients attentive care), this m a n u a l devotes entire sections to each o f the recomm e n d a t i o n s . Strategies for g a i n i n g administrative s u p p o r t , e x a m i n i n g p r o b l e m - p r o n e areas, a n d identifying "system b a r r i e r s " that may be a " r o o t c a u s e " of i n a d e q u a t e pain m a n a g e m e n t are detailed. Given the level o f detail, this m a n u a l could be used as a stepby-step guide for activities. It is advisable, however, that this m a n u a l be used to stimulate creative t h i n k i n g of or a m o n g p e o p l e who know the organization, who can m o d e l this v e n t u r e after existing successful prog r a m s while avoiding the pitfalls o f past failures in their setting. T h e r e is a nice balance of specific content a n d o p e n - e n d e d questions that m a k e s this guide flexible e n o u g h to m e e t the needs of a wide variety of organizations, while being suitable tot use by both the novice and expert. O n e section in the b o o k provides a template for submitting a proposal and then describes t h e s t e p s to p r e s e n t it ( t r a n s p a r e n c i e s included) to administration and the b o a r d of trustees. A n o t h e r section is devoted to planning a n d i m p l e m e n t i n g professional education programs. The needs assessment strategies, core curriculum, and teaching plans can be adapted for doctors, nurses, pharmacists, and unlicensed personnel. Excellent resources are listed and tips for success are detailed for a variety of teaching methods, including lectures, case studies, self-directed learning packages, experiential activities, games, and other ways to engage the adult learner. Built on the premise that substandard quality of pain m a n a g e m e n t is related to "process" rather than " p e o p l e " problems, the reader is guided through the quality i m p r o v e m e n t process. T h e P-D-C-A ( P l a n - D o - C h e c k - A c t ) a p p r o a c h is d e s c r i b e d to h e l p the r e a d e r understand b o t h the philosophy and process
of c o n t i n u o u s quality i m p r o v e m e n t (CQI). Unlike the common problem solving approach to try fixing a problem once and for all, from the CQI perspective, there will always be room for improving the way pain is managed. The problem s o M n g a p p r o a c h is the first step of many attempts to improve the way pain is managed. Information from research or standards of practice may be applicable, but primarily this is a process of trial and error to identify what works in the specific setting. While testing ways to positively reinforce successful processes maintaining the gains made and to extinguish problem behaviors, there are c o n t i n u e d efforts to identify f u r t h e r opportunities for improvement. The resource manual lives up to its name. The chapters are short and precise, covering the material with a balance of breadth and depth. More than three quarters of the book is devoted to samples of actual documents, tools, and resources that have been field tested and d e e m e d successful in a variety of settings. These materials include mission and philosophy statements, policies and procedures, standards of practice, chart audits, and a dozen case studies (inpatient and h o m e care) complete with expert analysis to facilitate group discussion and highlight appropriate actions. The tedious process of developing clinical pathways, pain algorithms, clinical competencies, and an interdisciplinary resource team can be facilitated by adopting examples that have b e e n successfully i m p l e m e n t e d elsewhere, with modifications as appropriate. At first glance, the reader may perceive gaps or omissions in this manual. Closer examination may reveal that these represent preconceived notions about existing problems, not s h o r t c o m i n g s of this resource manual. For example, the manual does not address how to get physicians to c h a n g e their prescriptive practices nor how to convince administration that a different staff-to-patient ratio or professional mix is n e e d e d to improve the way pain is managed. By applying the tools proxqded (for example, a Demerol® d r u g utilization evaluation form) and described techniques (for example, estimating resource needs), one can identifT whether these are true root causes of the problem in their environment and then use m e c h a n i s m s or c o m m i t t e e s already in place to suggest and effect change.
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For those ready to embark on a crusade to i m p r o v e the way p a i n is m a n a g e d , this resource manual is a necessary ingredient of their anticipated success, although insufficient standing alone. They ~fill also need courage, fortitude, wisdom, and compassion to overcome a formidable foe, the pain and suffering that is inextricably a part of the h u m a n condition. Given the inherent complexi~" of both pain management and organizational change, such an undertaking is a daunting task. A quote fi-om tbe book seems pertinent for those who feel overwhelmed by the enormity and importance of this endeavoi; "We cannot do everything at once, but we must do something at once." A good starting point for doing something at once to improve the way pain is managed is to get the resource manual, Building an Institutional Commitment to Pain Management. Bargain priced at only $30, it is a must-have reference for any organization that does not already have an established pain management quali~ improvement program. This text is also r e c o m m e n d e d for organizations that have such programs because of the fresh ideas, useful resource materials, and creative approaches applicable in a varie~ of settings to continually improve the way pain is managed. PII S0885-3924(97)00252-2
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7. Portnoy RK, Kanner RM. Pain management: theory and practice. Philadelphia: EA. Davis Compan); 1996. 8. Brider P (news ed). Jury says neglect of pain is worth $15 million award. Am J Nurs 1991;Jan:l10. 9. Shapiro RS. Liabilit)' issues in the management of pain. 1994. J Pain Symptom Manage 9:146-152, 10. Acute Pain
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Acute pain management: operative or medical procedures and trauma. Clinical practice guidelines. Agency for Health Care Policy a n d Research (AHCPR) publication no. 92-0032. Rockville, MD: AHCPR, Public Health Service, 1992. 11. Wallace KG, Graham KM, Ventura MR, Burke R. Lessons learned in the implementation of a staffeducational program in pain management in the acute care setting. J Nurs Staff Dev 13:24-31.