Nurse Practitioner’s Role in Pediatric Intensive Interdisciplinary Pain Treatment
By Mikayla Culpo, MSN, RN, CPNP
Pediatric Pain Rehabilitation Center
Department of Anesthesiology, Critical Care and Pain Medicine
Boston Children’s Hospital
It is well documented that the complex nature of chronic pain is best addressed using a collaborative approach of multiple disciplines utilizing a biopsychosocial model of pain framework. The training and education of nurse practitioners make for valuable members of this collaborative team delivering care to pediatric chronic pain patients in Intensive Interdisciplinary Pain Treatment (IIPT) programs. The role of the nurse practitioner (NP) in an IIPT consists of various aspects that aid in caring for this complex patient population. Three important elements of the NP role in this setting include care coordination, patient and family education, and medication management.
One of the primary responsibilities of nurse practitioners in Intensive Interdisciplinary Pain Treatment programs is care coordination throughout the course of treatment. This process begins when a referral to the program is initiated. A thorough case review is performed by an interdisciplinary team consisting of NPs, a pain physician, a psychologist, a physical therapist, an occupational therapist, and a social worker. The NP’s focus is to ensure a complete diagnostic workup has been performed and that the traditional pain management medications and interventions have been tried without success. The interdisciplinary review team helps to identify any potential barriers to treatment in the program including physical limitations, psychological concerns, or potential barriers in access to care.
Once approved for the program, the patient is added to a waitlist and a pre-admission virtual visit with a nurse practitioner is scheduled to help prepare the family for upcoming admission. During this visit, NPs provide education on the program’s model-of-care, as well as treatment goals, patient, and family expectations, and what to expect while waiting for admission. The waitlist for the program can fluctuate between weeks to months so having the NP as a point-of-contact can help to address any concerns or questions that arise prior to starting.
Once admitted, the nurse practitioner helps to acclimate the patient and family to the program. The admission process includes a thorough initial evaluation and assessment performed by the attending physician and the nurse practitioner. A team discussion is held amongst the various disciplines to relay admission findings and develop an initial treatment plan. The NP then meets daily with patients for continued assessment and evaluation. Any new symptoms or acute concerns are addressed during these visits. The NP contributes to daily interdisciplinary team meetings in which progress in treatment is continually assessed. On average, treatment length is between four and six weeks.
Once patients are ready for discharge, nurse practitioners help to coordinate post-discharge care. This includes relaying treatment recommendations to primary care providers, referring providers and ensuring any recommended consultations are scheduled. Patients are scheduled to meet with the IIPT for three visits over the course of the year post-discharge to assess for continued progress. Nurse practitioners are often the point of the contact if challenges arise between appointments and help to coordinate care with the patient’s primary interdisciplinary treatment team.
Along with care coordination, nurse practitioners help to provide education to patients and families. An important aspect of chronic pain management involves shifting the focus on cure and diagnosis to that of care and rehabilitation. Ideally, this shift begins prior to starting in the program so that time and effort can be focused on rehabilitation; however, at times additional education and even further work-up is needed to support this mindset shift for patients and families. Education is provided by nurse practitioners during daily patient visits, weekly parent/caregiver visits, NP led group treatment consisting of multiple patients, and caregiver education sessions with multiple families. Along with chronic pain education, wellness and healthy balanced lifestyle education is provided on topics such as nutrition, sleep, exercise, and mindfulness.
In addition to care coordination and education, nurse practitioners help many patients achieve their individualized goal of reducing medication use while in the program. It is very common that multiple medications are prescribed to patients prior to admission. Once in the program and upon further evaluation, these medications are noted to be ineffective or to be causing side effects such as cognitive dulling, fatigue, sleep disturbances, etc. In collaboration with pain physicians, NPs help to develop medication tapers to discontinue medications safely and effectively. Close monitoring occurs during the daily visits with patients so that adjustments to the taper schedule can be made if needed. Patients and families often report feelings of relief and satisfaction with decreasing the amount of daily medication. This intervention helps patients to feel more impowered by their own active strategies to manage pain versus relying on the passive approach of ineffective medication. Decreasing medication use also supports the program’s goal of replacing a self-image of disability with one of health and wellness. At times, the NP and pain physician may recommend starting a new medication while in the program but do so while ensuring that this helps to support the patient’s health, overall functioning, and general well-being.
Care coordination, patient and family education and medication management are three important aspects to the nurse practitioner’s role in a pediatric Intensive Interdisciplinary Pain Treatment program, but this is not an exhaustive list. Nurse practitioners have the training and background to help in many other domains of care delivery in this setting, making this role very diverse. Although integral team members, it is important to acknowledge that NPs are only one part of the interdisciplinary team. Progress in treatment cannot occur without the collaborative efforts of the multiple disciplines involved in care, each bringing a different background and focus on treatment, and together working towards the ultimate goal of improving the quality of life for children experiencing chronic pain.