Mary Ellen Goldberg
BS, LVT, CVT, SRA, CCRA | Canine Rehabilitation Institute, Wellington, FL
Mary Ellen is a graduate of Harcum College and the University of Pennsylvania. She has been an instructor of anesthesia and pain management for VetMedTeam since 2003. In 2007, she became a surgical research anesthetist certified through the Academy of Surgical Research. In 2008, she became the executive secretary of the International Veterinary Academy of Pain Management. In addition, she is on the Proposed Organizing Committee for the Academy of Physical Rehabilitation Veterinary Technicians for the formation of a NAVTA recognized VTS-physical rehabilitation program.
Mary Ellen has written several books and contributed to numerous chapters regarding anesthesia, pain management, and rehabilitation. She has worked in various aspects of veterinary medicine ranging from small animal to zoo animal medicine.Read Articles Written by Mary Ellen Goldberg
In human medicine, nurses share a common humanity with patients and families that enables them to see patients as unique individuals with rights and needs, which are magnified when the patient is ill and vulnerable.1-3 Because most information about patient advocacy is found in the literature about human medicine, we turn to that to extrapolate patient advocacy to veterinary medicine.
Since the time of Florence Nightingale, leaders in the field of human nursing have envisioned that an integral part of the nursing mission is advocacy for patients and caregivers. Today, the American Nurses Association identifies advocacy for safe, effective practice environments as a responsibility of the professional nurse.4,5 Nurses can fulfill the role of patient advocate by determining the best interests of their patients and by using their own voices to promote those interests.4
Nurses are the healthcare team members who are at patients’ bedsides, monitoring and assessing their responses to treatments. Nurses care for patients after they have received respiratory treatments or physical therapy, after they have received new medications, and during their recovery from injury or illness. As a result, the nurse is often the member of the healthcare team most likely to notice changes that might signal problems or poor responses to treatment. The nurse’s role is to then share this information with the healthcare team. The nurse’s duty is to speak up in a timely and urgent manner when he or she believes—or fears—that the patient’s safety may be at risk.6 The nurse’s role is also to inform the doctor if he or she is concerned about any aspect of a patient’s well-being, including freedom from pain.
When the patient is nonverbal, the role of advocate can be daunting. For pain assessment of nonverbal patients, human medicine recommends use of behavioral and physiologic indicators.7 In human medicine, this nonverbal group includes pediatric, traumatic brain injury, mental disability, geriatric, and Alzheimer’s patients. In veterinary medicine, this group comprises all patients, and behavioral and physiologic indicators are our only indicators.
Veterinary Nurses as Advocates
As a veterinary nurse, you are in the unique position of being responsible for most of a patient’s care and for the quality of that care.8 Veterinary nurses fill a huge role as patient care advocate, often spending more time than the attending veterinarian with patients.3 While veterinarians are in the exam room seeing clients or performing medical and surgical procedures, you are providing moment-to-moment care for hospitalized patients. You must be able to properly assess individual patients, be aware of changes in their medical status, and discuss any concerns with the veterinarian.9
These concerns include pain management. As the healthcare team member who has the most contact with patients, you are in a position to recognize signs of pain and make management recommendations.
Emphasis on Communication
Pain management recommendations depend on your critical thinking, observation, and interpretation skills and ability to communicate with the veterinarian. You can be a source of vital information and suggestions that help the veterinarian determine the most appropriate analgesics. Your discussions with the veterinarian might include concerns about a patient or a general approach to managing different types of pain. On the basis of your interaction with patients, you may suggest adjustments in analgesic regimens, changes or additions to drug protocols, or possible addition of sedatives.10 When reporting to the veterinarian, you must include important criteria, such as an accurate assessment of a patient’s pain and its current physiologic state. Knowledge of the physiology of pain and pharmacology of analgesics is essential. You need to indicate that you can accurately tell how much pain the patient is in while explaining why—or why not—additional analgesics could be beneficial. You are responsible for continually monitoring your patients and often develop a sense of which analgesics seem to work best under various circumstances. It is important that you give the veterinarian as much feedback as possible regarding which analgesic protocols are working well and which need to be improved to increase patient comfort. Pain management issues that you should describe include the appearance and behavior of the patient that prompted the administration of analgesics; the type, dose, and timing of previous analgesic administrations; and the response and any adverse reactions after administration.8
Increasing Your Freedom to Advocate
Although veterinary nurses do not have the freedom to prescribe or initiate therapy, you can gain greater choice and control over pain management if the veterinarians in your practice trust your judgment and experience.8 After the veterinarian has established the orders for a patient, the success of pain management relies on your having the freedom to give analgesics as needed, to adjust dosages when required, to administer adjunctive medications, and to potentially reverse drugs when severe adverse reactions occur. If trust has been established, then your responsibility and freedom to administer agreed-upon analgesics is rewarding for all concerned. When veterinary nurses have a voice in the pain management process, and their thoughts and skills are valued, the team environment is truly positive. In such an environment, patients ultimately receive better care and you can be satisfied that you are doing everything you can to ensure the well-being of patients in your charge.
A Team Approach
A fully integrated approach to pain management comprises pain recognition and systematic assessment, use of pharmacologic and nonpharmacologic methods, and involvement of both the healthcare team members and the client. The veterinary nurse, as advocate, is involved in each of these aspects. An integrated approach ensures that everything possible has been done to relieve a patient’s pain while it is in the practice’s care and after discharge home.
- Curtin LL. The nurse as advocate: a philosophical foundation for nursing. ANS Adv Nurs Sci 1979;1(3):1-10.
- Galuska L. Advocating for patients: honoring professional trust, AORN J 2016 Nov;104(5):410-416.
- Elder CR, Debar LL, Ritenbaugh C, et al. Health care systems support to enhance patient-centered care: lessons from a primary care-based chronic pain management initiative. Perm J 2017;21:16-101.
- Walker DK, Barton-Burke M, Saria MG, et al. Everyday advocates: nursing advocacy is a full-time job. Am J Nurs 2015 Aug;115(8):66-70.
- American Nurses Association. Nursing: Scope and Standards of Practice, 3rd ed. Silver Spring, MD: American Nurses Association; 2015; 4.
- Shannon SE. The nurse as the patient’s advocate: a contrarian view. Hastings Cent Rep 2016 Sep;46:S43-47.
- Arbour C, Gelinas C. Behavioral and physiologic indicators of pain in nonverbal patients with a traumatic brain injury: an integrative review. Pain Management Nursing 2014;15(2):506-518.
- Shaffran N. Pain management: the veterinary technician’s perspective. Vet Clin Small Anim 2008;38:1415–1428.
- Nugent-Deal J. Pain management and becoming a patient advocate. Todays Vet Nurse 2017;2. https://todaysveterinarynurse.com/articles/pain-management-and-becoming-a-patient-advocate. Accessed
- Shaffran N, Grubb T. Pain management: chapter 28. In: Bassert JM, Thomas JA, editors. McCurnin’s Clinical Textbook for Veterinary Technicians, 8th ed. Philadelphia, PA; Elsevier; 2015; 1045-1074.