Nursing Leadership

Nursing Leadership 13(4) November 2000 : 5-10.doi:10.12927/cjnl.2000.16288

Leadership through Interdisciplinary Teams: A Case Study of an Acute Pain Service

B. Pesut, S. Baker, B. Elliott and J. Johnson

Abstract

Interdisciplinary teams are rapidly becoming the standard for the organization and delivery of acute care services. Increasingly, research is showing that an interdisciplinary approach has the potential to improve patient care. Implementing a team approach, however, has challenges because of the various perspectives that different disciplines bring. In this paper we present a case study of an Acute Pain Service to illustrate how an interdisciplinary team can work to improve pain management in hospitals. The development of the Acute Pain Service will be described along with a discussion of the challenges that were faced. Key lessons will be presented that may lend direction for the implementation of an Acute Pain Service or for any other interdisciplinary team.

The current health care climate is increasingly calling for interdisciplinary teams to take responsibility for complex clinical problems. While this model has been used for some time in managing chronic illness care, only recently has it become developed within acute care hospitals. Recent efforts to structure patient care using program teams are promising attempts to adopt a standardized approach from an interdisciplinary perspective. Interdisciplinary teams have been shown to improve patient care in a number of complex clinical situations (Abrahm, Callahan, Rossetti, & Pierre, 1996; Gould et al., 1992; Loeb, 1999; Wheatley, Madej, Jackson, & Hunter 1991).

The variety of perspectives that are available in an interdisciplinary team can be a source of strength as well as conflict. Conflicts are common when individuals with differing beliefs, values, attitudes, assumptions and reward structures work together toward a common task (Vinicor, 1995). The leadership challenge is to forge creative, goal-focussed coalitions across a variety of disciplines. Klakovich (1994) argues there is a need for connective leadership for the 21st century. This form of leadership is "leadership which connects individuals creatively to their tasks and visions, to one another, to the immediate group and the larger network, empowering others and instilling confidence" (Lipman-Blumen, 1992, p. 187). Enacting connective leadership, however, can be challenging, and there is a need to document how this vision has been realized in existing interdisciplinary teams. In this paper we use data collected during a program evaluation to explore the strategies used by a group of individuals to realize an interdisciplinary Acute Pain Service. We will first describe how the Acute Pain Service developed, including a description of some of the challenges faced, and then go on to outline key lessons gained from this process that might help others working toward the establishment of an Acute Pain Service or some other interdisciplinary goal.

The Need for Acute Pain Services

Pain is a complex clinical problem that concerns many members of the health care team. Despite advances in the treatment of acute postoperative pain, unrelieved pain remains a significant problem for surgical patients (Cohen, 1980; Donovan, Dillon, & McGuire, 1987; Reid, Evans, Topilko, & Ward, 1992). Some have argued that this clinical problem remains because of the fragmentation of clinical services and lack of accountability (Max, 1990; Von Gunten & Von Roenn, 1994). A potential solution to this problem is the development of interdisciplinary Acute Pain Services in hospitals. An Acute Pain Service was first described in the literature in 1988 by Ready and his colleagues from the University of Washington. They described the goals of an Acute Pain Service as being to improve postoperative analgesia, to educate personnel, to conduct pain research and to institute new analgesic methods. Since this first description there have been descriptions of Acute Pain Services in countries around the world (eg., Macintyre, Runciman & Webb 1990; Rawal & Berggren, 1994; Schug & Haridas, 1993).

A number of Canadian hospitals have also been trying this interdisciplinary approach. The implementation of an Acute Pain Service within the Canadian health care system, however, presents unique challenges from its American counterpart. In the American system the implementation of an Acute Pain Service can be a profit generating mechanism; many patients are willing to pay for sophisticated analgesic techniques such as patient-controlled analgesia. In Canada, however, the money for an Acute Pain Service has to come from other sources within the global health care funding, during a time when concerns about the financing of health care are at the forefront. This means that significant improvements in patient care need to be demonstrated to justify this expense. Not surprisingly, the greatest barrier to establishing an Acute Pain Service within the Canadian health care system has been a lack of resources (Zimmerman & Stewart, 1993).

Development of the Acute Pain Service

Successful programs are built on a strong vision and many years of effort. The development of the interdisciplinary Acute Pain Service that is the focus of this paper, was birthed in the minds of a few, and required 14 years before it was fully realized. The service can be thought of as developing through three stages: the formative years, the patient-controlled analgesia program and finally, the official implementation of the Acute Pain Service. A brief description of each of these stages gives some indication of the patience and effort that was required to see the realization of this program.

The Formative Years

During the 1980s there was a growing recognition of the inadequacy of standard postoperative pain management techniques. Pain management became topical, stimulating interest among health professionals. New treatment techniques such as epidural and patient-controlled analgesia were being lauded within the literature as the answer to pain management problems. Technological advances were producing patient-controlled analgesia pumps that were increasingly safe, dependable and cost effective. Consumers of health care were beginning to demand quality services and more control over their health, and there was a call toward greater accountability within the health care system. All of these factors together influenced a group of anaesthetists and nurses within the hospital to realize a better vision of acute pain management.

In the early 1980s, several anaesthetists had been running an anaesthetic block clinic within the hospital for patients with chronic pain. This clinic proved highly successful and was a strong incentive for providing a similar service for patients in acute pain. During the late 1980s, this same group of anaesthetists and a group of nurses joined forces to implement several progressive analgesic programs. This included introducing epidural and interpleural anaesthesia on several critical care units.

After two years of success with using epidural and interpleural analgesia, two individuals, an anaesthetist and a nurse from the post-anaesthetic care unit, decided to pursue a broader scope of pain management within the hospital and put forth a proposal to administration for a funded Acute Pain Service. This proposal requested hospital operating funds for a director, nurse clinicians and a dedicated resident, fellow or intern. Without rejecting the proposal outright, the administration requested more information and recommended that an interdisciplinary team be established to develop the idea further. In response, the core group of anaesthetists and nurses planned to establish a patient-controlled analgesia program, make it indispensable to the hospital, and then to build an Acute Pain Service around it. A request was put forth to the hospital for funds for patient-controlled analgesia pumps. This request was timely as nurses on the orthopedic and vascular thoracic surgical wards were experiencing significant pain management challenges. Many of their patients experienced the benefits of epidural analgesia in the ICU prior to coming to the surgical ward, but when beds in the ICU were unavailable, they had significant problems. While these pain control problems were not new, the realization that more effective strategies existed created a general dissatisfaction with traditional methods of pain management. This dissatisfaction provided the perfect opportunity for change. The request for patient-controlled analgesia pumps was approved, and the next stage of development began.

Patient Controlled Analgesia Program

The first step taken by the pain management group was to follow the recommendation of administration to establish an interdisciplinary patient-controlled analgesia committee. True interdisciplinary teams were not widely utilized at this time, and so this team was rather unique. An effort was made to include all the key players including medicine, nursing, pharmacy, purchasing, and biomedical engineering. Over the next three years this committee worked to trial and purchase pumps. By 1993, the program had expanded to include 20 pumps operating on six patient care units. During this time there was also further development of the epidural and interpleural program on surgical units.

In 1993, an initiative by the British Columbia Medical Association for a fee schedule for acute pain management finally opened the door for the committee to once again present a proposal to hospital administration for a funded Acute Pain Service. This BCMA initiative meant that anaesthetists would no longer have to volunteer their time for acute pain follow-up, but could be reimbursed by the medical services plan. In December of 1993, a second proposal for an Acute Pain Service was sent to hospital administration. This proposal differed from the first primarily in the amount of resources requested. The request for a full time resident, intern or fellow was deleted and nursing support was reduced to one full time position. The administration approved the proposal with one modification. The full time nursing position was reduced to a half time position, and the person taking the position would also have other educational responsibilities within the hospital.

Acute Pain Service

In September of 1994, fully fourteen years from the establishment of the local anaesthetic block clinic, the Acute Pain Service was officially launched. The patient-controlled analgesia committee was renamed the Acute Pain Service committee. A clinical resource nurse was hired, and staff representation on the committee was increased. Interestingly, this had been such an effective committee that even though the new committee represented the birth of a long awaited goal, several members mourned the transition. All patients receiving epidural, patient-controlled or interpleural analgesia were now followed by a designated Acute Pain Service anaesthetist. The clinical resource nurse was responsible for many of the administrative and educational aspects of the service. The Acute Pain Service was available both for postoperative patients and for patients with other clinical conditions where the management of acute pain was particularly challenging, such as trauma and opioid addiction. Although the demand for management of inpatient chronic pain was growing, the decision was made to keep the program focused on acute pain, primarily due to lack of resources.

Challenges

The challenges to implementing the interdisciplinary Acute Pain Service at times seemed insurmountable. These challenges arose primarily in the areas of workload and control issues. Each new pain modality required the development and introduction of extensive protocols, monitoring tools and preprinted physicians' orders. As these were trialled they required numerous revisions. Nurses and physicians had to be educated about the treatment techniques. Clinical support had to be provided for the frequent problems that arose such as pump malfunctions or inadequate analgesia. This demanded an enormous amount of volunteer time as much of this work was done in addition to pre-existing workloads.

Issues of workload impacted on every part of the interdisciplinary team. For example, the pharmacy department had to take on the task of mixing more epidural and patient-controlled analgesia medications without added personnel. The responsibility for cleaning and tracking the patient-controlled analgesia pumps, and for supporting ward staff as they encountered problems, fell primarily to the staff of the post anaesthetic care unit. Nurses also struggled as they felt some of the new analgesic techniques increased their already heavy workloads. Time saved in not having to deliver intramuscular injections was taken up by responding to pump alarms and monitoring patient parameters.

Even after the program was officially implemented, resources remained tight as the anaesthetists struggled to provide ongoing support during all shifts and weekends, and the nursing support to the Acute Pain Service was limited to less than a half time position. All of these demands accumulated and at times outweighed the resources available to meet them. In turn, the demands placed on the system somewhat diminished staff satisfaction with the program (Pesut, 1997; Pesut & Johnson, 1997).

As the boundaries of accountability for the management of pain began to shift, control issues surfaced in a number of areas. Early on, a decision was made to give as much autonomy as possible to nurses. In other Acute Pain Service models, the team members maintain control of the management of patient-controlled analgesia; however, because of limited resources and a respect for the role of nursing, this interdisciplinary team realized that nursing autonomy was critical to the success of the program. This included transferring some skills, such as the administration of interpleural medications, from medicine to nursing. In being given this autonomy, many nurses struggled with the level of clinical decision making required, and in the case of patient-controlled analgesia, with turning pain control over to the patient. Nurses on the surgical units were used to giving limited amounts of analgesic and so were concerned about the potentially large doses available through patient-controlled analgesia. Nurses in the post-anaesthetic care unit, on the other hand, had been used to giving large amounts of opioid at their discretion. Their concern in giving control to the patient was that patients would not receive sufficient amounts of analgesia.

Control issues also surfaced between surgeons and anaesthetists as to who should have the authority to write patient-controlled analgesia orders. Eventually, the surgeons did not have the necessary time to implement the patient-controlled analgesia program, and one anaesthetist in particular was willing to devote extensive time to its establishment, and so the responsibility fell to the anaesthetists. Frequently, pain management orders by the anaesthetist and the surgeon co-existed on the chart. Some of the surgeons did not like patient-controlled analgesia, believing that their patients recovered quicker with traditional intramuscular analgesia. This sometimes left nurses caught between the desires of the anaesthetist and the surgeon. If the patient had difficulty with patient-controlled analgesia, the nurse was left to choose the physician to call. Often they chose the individual who shared their own preference for delivery technique.

The interdisciplinary team used a number of strategies to face these challenges. In the face of limited resources, there was little they could do about the workload issue; however, they did allow nursing units control over whether or not they would accept a particular analgesic technique. This democratic process, while necessary, did have some drawbacks. The selection of analgesic techniques for a particular patient was driven by which nursing unit the patient would be placed on, rather than by the technique that would optimize pain control. The process also produced some counterproductive stand-offs. At the time of the implementation of patient-controlled analgesia, nurses were not authorized to give direct IV anti-emetics, and they were unwilling to assume responsibility for this skill. One alternative was to deliver the anti-emetics via IV mini-bag; however, the pharmacy staff maintained they were too busy to supply these bags, and nurses were not authorized to mix them. The nurses opted to stay with intramuscular and oral anti-emetics (both less than ideal options) for several years after the implementation of the patient-controlled analgesia program. Not surprisingly, nausea and vomiting was one of the most challenging clinical problems with patient-controlled analgesia.

All innovations were also presented as a trial so nurses would feel that they would not have to commit themselves until they experienced the implications of the change. Pilot sites were selected carefully and were determined primarily by the responsiveness of the nursing staff on the unit to previous change. Each unit has its own "mini-organizational" climate and full advantage was taken of those units that flowed easily with change.

Timing was critical. During this period the hospital was undergoing numerous organizational changes, including a move of nursing units to a recently completed wing of the hospital. Great care was taken to not introduce new analgesic techniques during other significant initiatives. Attention was also paid to staffing levels on a particular unit and to the time of year. Initiatives were not implemented during the summer holidays or during the months surrounding Christmas. While this often required painstaking patience, the benefits were proven in the long run.

Lessons Learned

It has been said that history is a great teacher, and indeed, many lessons have been learned from the development of this particular Acute Pain Service that may help to lend guidance for the development of other interdisciplinary initiatives. Based on our experiences we recommend the following strategies:

  • Keep the patient at the center of the vision. The literature suggests effective interdisciplinary teams "focus their energies and commitment on the patient and on practice in such a way that there is no room for doubts in one group about the professionalism of the other" (Kappeli, 1995, p. 253). With this Acute Pain Service, alliances between medicine and nursing were forged early on in the vision, and their professional boundaries were driven by the needs of the patients rather concerns over who would control the process. Team members were willing to devote extensive volunteer time to improve patient care.
  • Cultivate your champions. The key to success of the program was the ability of the core group of pain management champions to network and generate enthusiasm. They networked with other institutions that were establishing Acute Pain Services. Early on they had the opportunity to present their programs at several pain management conferences, and this generated further enthusiasm. This group was also conscious to network and share their results with their colleagues within the hospital. As one anaesthetist put it, "I made contact in key places recognizing that it was nursing that was going to make this a success.I was not going to be able to force it down anyone's throat". The realization of this interdisciplinary program was largely a product of the extensive volunteer time given by these champions, and while this is laudable, the situation was not ideal. Barr (1997) recognizes the complexity of developing an interdisciplinary team and strongly recommends organizations commit themselves to the time and money required on an organizational, professional and interpersonal level.
  • Make time your friend. Careful consideration should be given to the timing of new initiatives. Particular attention should be paid to staffing levels, to the time of year and to coordinating activities with other initiatives in the hospital. Many times the implementation of a new analgesic technique had to be postponed in deference to other major changes within the hospital. Though this required patience, we are convinced these delays facilitated a smoother and more effective implementation. A longer period of time also enables the interdisciplinary team to network and build a broad base of support. As one author suggests, to maximize the benefits of an interdisciplinary approach it may necessary to go slowly initially, for in doing so, later progress will be more rapid (Vinicor, 1995).
  • Select your pilot sites strategically, and reinforce that nothing is carved in stone. Plan for success by choosing wards that demonstrate the strongest enthusiasm over the proposed change. Also, ensure the change is well suited to the pilot site. For example, we found it was counter productive to implement a new technique that required frequent monitoring on a unit that had pre-existing workload issues. Present all new innovations as a trial and indicate changes can be made in the protocol. Plan for early evaluation and make changes as recommended.
  • Don't be discouraged by resistors. There will always be people who will not approve of the changes, both inside and outside of your interdisciplinary team. Vinicor (1995) suggests that given the widely different perspectives of the interdisciplinary team, some conflict is inevitable, but a simple recognition of these differences is a critical first step in minimizing conflict. Indeed, some would say future leaders must have the ability to thrive on conflict by viewing conflict as a means by which we can embrace the strengthening process of diversity (White, Hodgson, & Crainer, 1996). We have found that once a critical mass of people experience the changes positively, resistance diminishes somewhat. Through the process it is important to share your outcomes, for successes are reinforcing and can be used to generate further enthusiasm for the program.
  • Build a strong network. Ensure that all those who will be involved in the program are aware of the vision and its implementation. Individual professions cannot implement a vision of this magnitude without having each member of the multi-disciplinary team exert influence within their own realm of practice. Whenever possible implement change through a democratic process. We have found that communication is essential to involving staff nurses and that the nurse manager is a critical link between the team and the staff. The presence and support of the nurse manager contributes a great deal to the staffs' comfort with change and risk taking (Klakovich, 1994).

Continuing the Vision

One of the challenges of an interdisciplinary team is to continue to "envision" once a major goal has been reached. The Acute Pain Service has been expanded to a second hospital site within the region, and in future, we will work toward having the Acute Pain Service available to all hospitals within the region. Ideally, this expansion will include an integration of both acute and chronic pain management and will incorporate a broad range of non-pharmaceutical therapies.

Recognizing the importance of even greater interdisciplinary connection, the Acute Pain Service is working with the pre-admission clinic and with the various program teams to ensure pain management is coordinated throughout the patient experience. We are aware, however, that once the vision is realized, and effective pain management is integrated at all levels of care, the need for an Acute Pain Service may be redundant.

About the Author(s)

Barbara Pesut MSN, RN, is Assistant Professor, Department of Nursing, Trinity Western University, Langley, B.C.

Dr. Simon Baker MB, ChB, FRCP( C ) is Director of Acute and Chronic Pain Services, Head of Department of Anaesthesia, Simon Fraser Health Region, Royal Columbian and Eagle Ridge Hospital Sites.

Bonita Elliott BSN, RN, Patient Care Manager, Operating Room and Post Anaesthetic Care Unit, Simon Fraser Health Region, Royal Columbian Hospital Site.

Dr. Joy Johnson PhD, RN, Associate Professor, School of Nursing, University of British Columbia, Vancouver, B.C.

Acknowledgment

The authors would like to acknowledge the Anaesthetic Department of the Royal Columbian Hospital for their funding of this study.

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