Pain Management Nursing

My Specialty

Pain Management Nursing

Keeping patients comfortable during extraordinary pain

By Elizabeth Hanink, RN, BSN, PHN
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According to the American Pain Society, a multidisciplinary organization including nurses, pain is the most common symptom leading to medical care. It involves 50 million lost workdays per year and $100 billion per year in bills and lost wages. Consider, too, that 70 percent of cancer patients experience significant pain during their illness but fewer than half receive adequate treatment for it.

Given these statistics, it’s no wonder that few areas of nursing avoid some form of pain management, be it a school nurse giving Tylenol for a headache or a recovery room nurse medicating a post-knee-replacement patient. But beyond the routine cases, some nurses specialize in extraordinary pain,  the kind that alters every aspect of a patient’s life. You will find them in hospitals and clinics that treat oncology patients, and in pain centers that assist patients with chronic pain. There’s also pediatric pain control, which is a sub-specialty in and of itself because children, like adults, experience all sorts of discomfort, yet they have undeveloped coping skills.

Margo McCaffery, RN, FAAN, has been writing about pain since 1968. And, along with Chris Pasero, RN, FAAN, she has forever established its definition: “It is whatever the person experiencing it says it is, existing whenever he or she says it does.”

Donna Wong, RN, Ph.D., is another nurse in pain management. She is the pediatric nurse who, with her colleague Carol Baker, RN, Ph.D., developed the Wong-Baker Faces Pain Rating Scale. Health professionals worldwide use it to evaluate pain in children and others who aren’t able to describe it.

Choosing This Specialty

So how do nurses get into this specialty? Many are advance practice nurses, either clinical nurse specialists or nurse practitioners, and oftentimes they work independently as contractors or in private practice; in these roles, they can come close to earning what physicians do.

Nurses also find their way into pain management after working in different fields. David Picella, NP, Ph.D. (cand.) began as an ER nurse; then when he moved on to intensive care, he noted that patients who were allowed to rest instead of being awakened for routine care did better. He began to look closely at the issue of pain and palliative care, and in time he became an expert. He earned an advance practice degree as a clinical nurse specialist and another in 1997 from the University of California, Irvine, as a family nurse practitioner.

Now, as a doctoral candidate at the University of Wisconsin, Milwaukee, Mr. Picella works in the Department of Supportive Care at City of Hope in Duarte, California and is an articulate advocate for the distinct contribution nurses make to pain management. He points out what many fail to realize: We spend more time with patients than other professionals and can better assess their pain level.

“The things that nurses can do are just as valuable as, or more valuable than, what doctors can do for pain management,” Mr. Picella says.

Although he has a DEA number and furnishing privileges for schedule 2-5 drugs, he says that pharmacology can only do so much. For a start, many patients, even those in pain, do not take the drugs prescribed for one reason or another. According to Mr. Picella, nursing fills in the blanks. If pharmacological intervention is not chosen or if it does not work, nurses recognize not just the physical but also the social, psychological and spiritual domains in which patients live.

Not an Exact Science

Jeannette Meyer, MSN, RN, of the Palliative Care Program at Santa Monica-UCLA Medical Center and Orthopaedic Hospital, is now pursuing her certification through American Society for Pain Management Nursing. A clinical nurse specialist since 2000, her background is primarily medical-surgical intensive care nursing, an area where many expect definitive cures or relief. In palliative care she uses her expertise with patients who have chronic conditions and not many more treatment options.

These patients, she observes, “May still be pursuing curative treatments for their conditions. They may, for example, if it is a cancer patient, still be receiving chemotherapy. They may still be receiving other active treatments for their conditions. But as the curative treatments run out, then the palliative care aspect of trying to maintain the best pain and symptom control we can and optimizing the quality of life, really starts taking precedence.”

Not all patients, to be sure, have cancer, neither are all dying; some may suffer from congestive heart failure or chronic obstructive pulmonary disease. One area the specialty looks at is the life goals of patients, for whatever length of time they have left, and then gearing the pain and symptom control to help them achieve their goals. Some patients have been on this service for years; unlike hospice, since patients need not be dying, there is no limit to how long service lasts.

Ms. Meyer is in collaborative practice with a palliative care physician team. Her typical day consists of rounding on patients and providing consultative services. Writing policies and procedures is an additional part of her CNS role. She is available to nurses in other areas who need guidance for interventions that might improve patient care. Like Mr. Picella, she recognizes the many things nurses can do, even without physician orders, that can relieve pain and suffering. These include distractive therapy, touch and positioning.

Teaching is a big part of what she does. Ms. Meyer mentions the great need for nurses to have adequate education in pain assessment for different types of patients, especially those with a limited ability to communicate and the need to understand early on how important pain relief is for overall recovery.

“I see nurses very eagerly seeking information to try and give their patients the best pain control that they can,” she says. “Relieving pain is not just a single magic formula.  It may take us a period of time to come up with a good combination of medications that relieve the patient’s discomfort or allow the patient to achieve a tolerable level of discomfort, without side effects… Controlling pain is not an exact science.”

Nurses in this field typically face spiritual distress in themselves and in their patients. They view and participate in painful procedures and they often need to balance priorities, e.g., maintaining blood pressure versus achieving pain relief. Grappling with the contradictions of care, especially care that may be futile, affects all nurses; new graduates especially have difficulty with this aspect of pain management. According to Ms. Meyer, many referrals to the ethics committee at her facility come from nurses who struggle with conflicting goals for patients.


Most nurses do not have the formal education that Mr. Picella and Ms. Meyer have pursued, or Mr. Picella’s advanced research skills and active clinical practice. But there is still a definite role for those with an interest in this area of nursing.

Certification for RN-BC is through the American Nurses Association and the American Society for Pain Management in Nursing. Prerequisites include playing a role in pain assessment and management, pain management education, or related research for at least 2,000 hours in the three years prior to applying for the certification exam. The exam is administered via computer year-round, and the ASPMN website announces regional prep courses. Applicants also complete 30 hours of continuing education within the three years prior to applying, 15 of which must relate to pain management.

Certification is also available from oncology nursing and hospice nursing organizations, however, this certification includes pain management and other aspects of palliative care.

A broad background in nursing is useful and advance practice preparation helps equip nurses for leadership roles. Nevertheless, in-service education and certification also lead to recognition in pain management nursing. If you are interested in this specialty, check out the sites listed nearby or sites of other nursing organizations involved in hospice, palliative and pain management nursing. There is considerable overlap in those three areas, but all the groups offer extensive education.


Statistics from the American Pain Society:

– Arthritis affects 40 million Americans.
– About 26 million Americans between the ages of 20 and 64 have frequent back pain.
– Twenty-five million Americans experience migraine headaches.
– Fibromyalgia affects four million Americans, most of whom are women.
– Around 20 million Americans have jaw and lower facial pain.

Web Resources:

American Society for Pain Management Nursing

American Pain Society

American Academy of Pain Management

Promoting Excellence in End-of-Life Care

Discover Nursing
(Select “Pain Management Nursing” from drop-down box)

Oncology Nursing Certification Corporation

Elizabeth Hanink RN, BSN, PHN, is a freelance writer with extensive hospital and community-based nursing experience.

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