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Anne Federwisch, OTR The four vital signs provide a quick snapshot of a patient’s general condition. But pain management advocates claim this picture isn’t complete without including pain as the fifth vital sign. Nursing organizations are now actively promoting the inclusion of pain assessment in the basic evaluation of every patient. “If you have an idea of the level of pain, then you have a lot of clues as to how you can help that person,” said Marjorie Beyers, PhD, RN, FAAN, executive director of the American Organization of Nurse Executives (AONE). The resolution AONE is part of the Tri-Council for Nursing, the latest group to lobby for pain to be recognized as the fifth vital sign. Other members of the council are the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), and the National League for Nursing (NLN). At its May 6 meeting, the Tri-Council approved a resolution stating that “in order to reduce pain and suffering, healthcare providers should include pain along with temperature, pulse, respiration, and blood pressure as the fifth vital sign.” Since the Tri-Council usually doesn’t address hands-on practice issues, this resolution is unique, said Carol Bradley, MSN, RN, president of AONE. Although the resolution is not directed at anyone in particular, the Tri-Council hopes it will be disseminated to nurses across the country. Bradley said the goal is to raise awareness about the importance of pain assessment and management across the whole spectrum of nursing practice—academics, clinical care, and executive leadership. Routinely assessing pain as the fifth vital sign will help make it more visible to the entire healthcare team, said Geraldine Bednash, PhD, RN, executive director of the AACN. “We should not assume it’s not there because we don’t see it,” she said. By making pain more observable, charting it as the fifth vital sign will likely result in better patient outcomes than by just advocating for pain management in general, Bednash said. “People don’t need to suffer pain,” said Sally Raphel, MSN, RN, director of nursing practice for the ANA. “The days of grin and bear it and you’ll be a better person are gone.” Origins Pain as the fifth vital sign is not a new idea, said Anne Rhome, MPH, RN, deputy executive director for the AACN. It came to the Tri-Council’s attention during a meeting on end-of-life care in December 1998. The idea most likely originated in a 1995 speech by James Campbell, MD, then president of the American Pain Society. But the Tri-Council’s resolution will move the effort forward, Bednash said. By bringing the issue to the attention of the full membership of all four Tri-Council organizations, there’s a greater chance for implementation in a variety of settings nationwide, she said. Bednash foresees nursing professors teaching students to assess pain as the fifth vital sign, nurse executives pushing for facility-wide changes, and clinicians striving for changes at the bedside. Passage of the resolution also reinforces nursing’s contention that pain management is an essential part of nursing care and that it shouldn’t be limited to care at the end of life, said Philip Serghini, spokesperson for the NLN. Putting it into practice The Department of Veterans Affairs understands the importance of pain as a vital sign. It has included pain as the fifth vital sign as part of its new nationwide pain management strategy since March, according to Bonnie Ryan, RN, chief of the VA home and community-based care and co-author of the VA’s resource guide, Pain Assessment: The Fifth Vital Sign. “When you start asking about pain, you can no longer walk away from it. You have to deal with it,” she said. But implementation was no small task, Ryan said. They developed the resource guide to educate clinicians on the practical aspects of including pain as a vital sign. They included information on using the Numeric Pain Rating Scale, a 0-to-10 patient reporting scale used to record pain intensity. The 38-page guide also includes suggestions for patient-education materials and strategies for developing pain assessment procedures. Before clinicians started assessing pain as a vital sign, system-wide changes had to be completed as well. Electronic patient records and paper medical records were revised to include a field for documenting pain. Although it’s too soon to assess the long-term effects of including pain as a vital sign, Ryan said that nurses, physicians, and patients have all reported positive patient outcomes as a result. Members of the Tri-Council said they hope their resolution will help bring pain assessment into routine practice at facilities around the country. “You wouldn’t skip a blood pressure,” Raphel said. “So if pain’s a fifth vital sign, hopefully you won’t skip assessing pain.” |
