Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Harnessing Power and Passion:
Lessons from Pain Management Leaders and Literature

Judith A. Spross, PhD, RN, AOCN, FAAN

[Citation: Spross, JA. Harnessing Power and Passion: Lessons from Pain Management Leaders and Literature. Innovations in End-of-Life Care, 2001;3(1), www.edc.org/lastacts]

Introduction

Anyone who has labored in the field of pain management for any length of time knows that the Wisconsin Pain Initiative (WPI, formerly the Wisconsin Cancer Pain Initiative) has been at the leading edge of improving pain management in the United States. Like EF Hutton, when the Wisconsin Pain community speaks, we in the field of pain management listen. The two pieces featured in this issue of Innovations (Improving Pain Management in Long-Term Care Facilities by Dr. Weissman et al., and An Interview with Mary Arata, RN, OCN, Franciscan Woods) illuminate both sides of the intervention experience. Weissman et al. detail the process of designing and implementing an intervention to institutionalize pain management, specifically geared to the needs of long-term care facilities. Ms. Arata, a member of one of the teams in this study, speaks candidly about how staff working in long-term care translate the intervention into practice. As a clinical nurse specialist, I was responsible for improving pain management in acute, rehabilitation, and outpatient oncology settings. As project director of Mayday PainLink (See Resources and Tools), my colleagues and I have been providing technical assistance to teams seeking to improve their institution's methods for assessing and treating pain. Thus, I have had the opportunity to participate in or observe many examples of institutionalizing pain management. One observation that I have made is that institutions that seem to have the same resources and challenges when they start the process of institutional change do not achieve the same results after one or two years of work. Some make great strides, as did the participants from Franciscan Woods. Other institutions get stuck. Over the years, it has become clear to me that improving pain management is not simply a matter of teaching clinicians knowledge and skills, adopting policies and procedures, implementing quality improvement, and empowering nurses. Rather it is a complex, clinical, social and political process, which may explain why we have not seen more progress in relieving pain in the last two decades than we have.

To ensure that all patients have equal access to pain management and relief, it is important to understand the nature of institutional change. By examining the work of our featured innovators, as well as my own experience as a change agent, I explore the process of institutional change, not just what accounts for success, but equally important, what holds clinicians and institutions back. To make the processes and challenges of institutional change more explicit, I first review four dimensions of institutions - strategic, structural, cultural, and technical—that change agents need to address to achieve clinical quality improvement across an organization.¹ I will use the featured improvement efforts to demonstrate what attention to these dimensions entails and discuss factors within each dimension that may influence the success of an initiative. I will then discuss the application of these dimensions to institutional self-assessment and action planning. This framework provides one explanation of the "mechanism of action" of institutional change. Just as pharmacologic mechanisms of action help us to evaluate therapeutic, adverse, and idiosyncratic responses of patients to analgesics, I hope this exploration will help readers evaluate and respond to the responses of staff to institutional efforts to improve pain management.

Dimensions of Institutions: An Overview

The strategic dimension refers to the conditions and processes that are most essential to the organization and provide the greatest opportunity for improvement.¹ The Joint Commission for Accreditation of Healthcare Organizations (JCAHO) pain management standards are, perhaps, the most important incentive clinical settings now have for ensuring that institutions address the strategic dimension. (See Resources and Tools for link to Standards.) The structural dimension refers to the presence or absence of appropriate mechanisms such as committee structures, policies, and procedures, to facilitate adoption of evidence-based practices throughout the organization. The technical dimension refers to the training and information system issues relevant to the institutional change being undertaken.¹ The cultural dimension refers to the beliefs, values, norms and behaviors of individuals within the organization, and the organization as a whole, which can inhibit or facilitate quality improvement work.¹ Adoption of evidence-based practices is influenced by local factors, and so it is critical to study this dimension. Having participated in and observed the process of institutional change, I would add that the cultural dimension also includes the interpersonal factors and emotions that accompany change. Unless all four dimensions are addressed, there will be no long-term organizational impact.

Shortell et al. analyze how the presence and absence of each of these dimensions (strategic, cultural, technical & structural) affects the result of an organization-wide quality improvement effort. They note that absence of attention to the strategic dimension will lead to "no significant results on anything important," no attention to the cultural dimension will lead to "small, temporary effects" but "no lasting impact," the absence of attention to the technical dimension will lead to "frustration and false starts," and that the absence of attention to the structural dimension will lead to an "inability to capture learning and spread it throughout the organization."²

To make institutional self-assessment along these dimensions more straightforward, I have categorized elements of the Medical College of Wisconsin (MCW) pain management in long-term care program according to these dimensions using the program description in Table 1. Note that the table incorporates the objective indicators of institutionalized pain management practices targeted by the MCW program as well as the processes embedded in programs of institutional change. Based on my own experiences and the featured innovation in this issue of Innovations, I now offer a critical analysis of how these elements exemplify each dimension. I hope this analysis, informed as well by my experience as a mentor to teams engaged in improving pain management, can help clinicians understand the "mechanism of action" of institutional change and enable them to identify the areas where they might have the most success, anticipate barriers, and limit frustration.

Table 1.

Dimensions of Change and Strategies for Institutionalizing Pain Management Practices

*numbers in parentheses refer to the indicators targeted by the MCW Program in Figure 2 of Featured Innovation: Part I. My choices here are informed by the following references:^3-14

The Strategic Dimension

Institutional commitment has been recognized as a key element in a number of guidelines^13,15 and publications^{3,4,6,10,14,16-18} but the extent to which institutions have been willing to make this commitment has varied. Institutional commitment can be manifested in a number of ways: administrative support or buy-in, mission statements, policies and procedures, Continuous Quality Improvement (CQI), and resource allocation. Now, I will elaborate on what attention to the strategic dimension means.

The MCW long-term care program and its implementation at Franciscan Woods demonstrate that administrative buy-in is a central element of institutional change. Administrators demonstrated commitment by permitting a facility needs assessment to be done by the MCW staff and by sending facility staff to the MCW program. The MCW staff also anticipated that regulatory barriers might interfere with adoption of better pain management in long-term care facilities (LTCFs), so they involved staff from state regulatory agencies from the beginning. Facilities that followed through on commitments to assess resident/family satisfaction, incorporate pain management as a quality improvement focus, and initiated a program of resident and family education as part of their action plans were publicly stating that their staff would be accountable for managing pain. This is strong evidence of incorporating pain management into the strategic dimension of their organizations. Such accountability is central to pain management initiatives.

Accountability must be established early in an initiative. There are two levels of accountability: individual accountability for integrating good pain management into one's practice and institutional accountability for making institutional changes that spread the learning throughout the organization. If only some individuals adopt better pain management practices, then only some patients will have pain relief. Practically speaking, leaving pain management up to individuals without any institutional change and accountability permits two standards of care to exist—those of the champions who implement evidence-based practices and those who continue to manage pain using knowledge that is 20 or 30 years old. (One could argue that having two [or more] standards of care, one superior and one inferior, is an issue of ethics.) If a champion operates only from his or her own commitment without institutional authority, the initiative and its accomplishments are less likely to survive a change in staffing or workload or the champion will burn out. Accreditation standards that specifically address pain management enhance the champion's ability to enlist administrative support. The JCAHO standards should give facilities a strong incentive to demonstrate their institutional accountability for relieving pain.

The featured innovation demonstrates that embarking on a process of institutional change represents a significant commitment of human and other resources. However, it is not clear from the articles what actual financial and resource commitments are required to improve pain management. In reading, one wants to know what it cost—in staff time, resources such as additional analgesic medications needed in the pharmacy's inventory, or materials for initiating nondrug treatments. Nurses would want to know how Ms. Arata's time as a staff nurse was reallocated so that she could lead the very successful initiative at Franciscan Woods. Not only must administrators think that improving pain management is a good idea and demonstrate verbal support, they must weave it into the process of organizational planning and resource allocation. As LTCFs work to improve pain management, understanding the budget implications will be useful to other change agents.

The Structural Dimension

When one considers the institutional structures needed to improve pain management, committee structures, staffing, and policies and procedures come immediately to mind. One of the first tasks undertaken by the Franciscan Woods staff was developing an interdisciplinary workgroup. I am sure those invited were selected with care. Note that the team included a pharmacist, a key person since many of the new behaviors require more attention to not only prescribing and administering medications, but also to observing the responses of patients. Also, rehabilitation staff were included in the process of change. Since physical and occupational therapies can induce pain and therapy staff make observations of activity-related pain as well as responses to analgesics, they provide important insights into the overall treatment plan. However, it is not enough to establish a team and schedule meetings. Effective committee work depends on qualities associated with the cultural dimension of institutions: good communication, outreach to facility staff and administrators, the recruitment of influential allies, setting priorities, and following through on tasks. One of the laments I have heard from the innovators I have coached is that some key person who could exert influence on potential allies never comes to meetings or does not follow through on commitments made to the team. Since one purpose of an interdisciplinary team is to broaden the base of support for making changes (a cultural intervention), factors such as interest, reliability, and ability to follow through should be considered when assembling a team.

Other LTCFs might start somewhere else. Some teams have found that making pain management a CQI project or developing and disseminating policies is a better first intervention. These structural interventions can build interest in the topic of pain management. Thus, when an institution is ready to address the problems uncovered by a CQI evaluation or the challenges of consistently implementing a pain assessment standard, a core group of committed staff is ready to work together to make change.

The Technical Dimension

For nearly two decades, numerous studies have demonstrated that nurses, physicians and pharmacists lack important pain management knowledge. The initial response to these findings was to develop educational programs. We learned early on that education was insufficient.¹⁹ Pain management is not just a clinical issue but a political and social process that takes place within a societal and institutional context.^4,7,17,20 Any effort to change practice must take this into account. Having said that, the technical dimension—giving staff the knowledge and skills they need—is vital. There is accumulating evidence that the problem of pain undertreatment, well documented in acute care and oncology populations, is also a serious concern for the elderly and for residents of long-term care, in particular.^21-27 As you read this issue and review the tools and resources, you will see that the technical dimension of pain management addresses these important areas: pain assessment and reassessment, pharmacologic management, side effect management, nonpharmacolgic management, communication skills, and institutional assessment and intervention. The evidence-based clinical knowledge and skills needed to relieve pain are well defined and are important, but they are not enough. Concomitant institutional changes must be initiated and maintained, otherwise pain undertreatment will remain an intractable problem. As the MCW program illustrates, clinicians need to be able to communicate effectively, resolve conflicts over pain management productively, and understand the systems in which they work in order to bring about institutional change. Fortunately, a variety of initiatives have led to the development of tools and strategies—essentially, a curriculum for change agents—for institutional assessment and intervention.^{10,12,14,28-31} These resources are indispensable to readers who wish to make change in their own facilities.

The education component is a big part of an initiative—big in terms of content, time, and numbers of staff to reach. Depending on the facility, a team could decide to phase in the education. It could be done by content (e.g., focusing on assessment first) or by role group (e.g., targeting licensed staff first) or by unit. The action plan with regard to education should focus on a realistic goal and a timetable for achieving it. It is important to consider what the "market will bear"— i.e., what staff can handle in terms of content and time commitment. In some settings just getting staff to use the same tool for assessing pain is a tall order. Other settings are eager to embrace new knowledge regarding both assessment and intervention.

Educating staff about pain management and change strategies also begins to address the cultural dimension by challenging the values and myths that are at the heart of pain undertreatment (e.g., opioids are bad, the elderly experience less pain, the elderly can't tolerate opioids, the risk of addiction is high). Innovators need to understand that pain management education is not like teaching staff about a new medication or a new piece of equipment. Pain and pain management have multiple meanings and these meanings often differ, even conflict, depending on the individual.³² Pain management education challenges deeply held convictions about the nature of pain and what constitutes appropriate treatment and, in this sense, efforts to improve pain management are radical. Indeed, educating staff to re-examine their approaches to patients in pain is really a form of proselytizing. one seeks to convert a group to a new way of thinking, not just a new way of doing. The nature of the change will be celebrated and readily adopted by some; others will invest considerable energy in resisting the change; a third group will wait to see which of the first two groups is going to prevail. This understanding of what pain management education means for staff and institutions underscores the importance of addressing the cultural dimension in any institutional change effort.

Cultural Dimension

When one looks at the pain management improvement literature, most of the work has been done on addressing the structural and technical dimension with some attention to the strategic dimension. Although there is considerable evidence that the cultural aspects of organizations have an impact on pain management, with the exception of trying to change clinicians attitudes toward opioids and the risk of addiction, there has been little attention to this dimension of institutions as it relates to improving pain management. Indeed, participants in interventions to improve pain management identify these barriers associated with the cultural dimension: unwillingness to prescribe opioids, regulatory barriers, team communication issues, lack of collaboration between nurses and physicians, and ethical dilemmas.^{4,7,10,11,17,29,33-35} In addition, I believe that the emotions that accompany pain management improvement efforts and the locus of power and decision making are parts of the cultural dimension. Emotions experienced by staff participating in change efforts run the gamut from angry, frustrated, overwhelmed, and helpless to satisfied, successful, supported, and confident. It is important to understand who has the power to make decision. This may be distinct from administrative buy-in. For example, administrators may approve pain as a CQI indicator, but if you cannot get a key physician's or committee's involvement or endorsement, the progress of the initiative will be impeded. Because there is less information on the cultural dimension of institutions in the literature on pain management, I will discuss it here in some detail.

The cultural dimension is not explicitly identified in the fourteen indicators targeted by the MCW program yet many of the indicators can only be successful if the cultural dimension is addressed. To appreciate this dimension, it is important to read between the lines of the two stories and demonstrate the ways in which the MCW program actually addressed the cultural dimension. The most important, perhaps, is recognizing that institutional change is a process that requires support and reinforcement. An implicit goal of scheduling training sessions over the course of a year instead of a one-time meeting was the creation of a mutually supportive, inter-institutional community. I imagine that participants not only consulted with the MCW staff between sessions, but that participants contacted each other for ideas, support, and commiseration. Such support has been an integral part of other change efforts.^10,12,33 Readers who do not have access to the MCW team will want to consider ways of establishing this ongoing support.

Ms. Arata noted that at first they "were a little overwhelmed" by the demands of action planning. As you read, though, you see that they selected specific change targets. She and her colleagues didn't try to do everything at once. The "technical content" provided in the MCW Program helped her and her colleagues see the discrepancy between current practice and recommended practice. Uncovering this discrepancy is one of the most important motivators for changing practice. Staff members want to do a good job, but if they do not know their practices are outdated, they do not have the motivation to change. In some programs and settings, assessing this discrepancy is done by a survey and then sharing the results of the survey with the staff.^10,12,31,33 Thus, one of the key strategies for making staff want to change is to provide evidence of the gap between current practice and recommended practice. Such a gap can be used to persuade administrators that they should make pain management a priority, a strategy for addressing the strategic dimension as well.

Recruiting allies is a key element of enhancing the "cultural" support for changing pain management, enabling one to build a culture of advocacy. It is often difficult to recruit physicians to the change initiative,^31,36 yet the absence of physician support is thought to be a factor in less successful CQI efforts.¹ One primary care physician colleague, who attended a series of pain sessions I taught, came to a session with a testimonial about a cancer survivor who had suffered with pain for years. Having learned the basics of pain management, his patient's quality of life improved dramatically when he finally relieved her pain with opioids. He said, "Now, she is doing great, but I feel like I'm swimming upstream because the neurologist is writing on her chart we have to get her off the opioids." Another primary care physician who participated in the sessions, said, "Once you get into this [good pain management], you want to keep going." Members of all clinical disciplines and role groups, especially nurses, pharmacists, and physicians, have a part to play in improving pain management. However, the best champions may not be the ones that come immediately to mind. In an acute rehabilitation setting, one of my best recruits was a physical therapy assistant whose grandparent had died in pain from cancer. Once recruited, pain champions are usually involved for the long haul and all advocates need nurturing. This can be accomplished by acknowledging and celebrating your team's accomplishments. The storyboard mentioned in the MCW Program is one way to do this. Featuring the team's work or a clinical exemplar in an internal publication or a community newspaper is another strategy. Collecting and publishing testimonials feeds enthusiasm for this labor-intensive effort.

The MCW Program and its participants wisely focused attention on certified nursing assistants (CNAs), the staff members in long-term care with the most direct patient contact. Support staff have not generally been an explicit focus of institutional change initiatives (a notable exception is³⁷), but the innovators recognized that without targeting the involvement of CNAs, any long-term care initiative is doomed to fail. CNAs need to know what to observe, what to report, and what they can do to comfort patients in pain. Indeed, in one report the pain champion told of instructing housekeeping and dietary staff what to observe and report to the nursing staff so the nurses could respond promptly even to nonverbal evidence of pain.³⁸

Ms. Arata's comments highlight some less obvious elements of culture, which change agents would do well to address. If we unpack the idea of nurse empowerment described by Weissman and colleagues in the Featured Innovation, we develop a deep understanding of the cultural change engendered by the pain management initiative. Many of Ms. Arata's comments reveal the challenges and successes inherent in the process of empowering nurses. At first, the initiative was not interdisciplinary. Although an interdisciplinary team is ideal, it may not be realistic or feasible at the beginning. She notes that, "Initially, we were all nurses." Nurses and nursing staff often provide the critical mass of knowledge, commitment, and talent that have contributed to successful initiatives. The MCW program provided the tools of behavioral change. The information and tools Ms. Arata and her colleagues brought back to the facility enabled nurses to start behaving similarly around pain management practices. Specifically, they began to use a common language (the pain scale) when speaking to nursing assistants and physicians. In addition, they applied their knowledge of pharmacologic interventions when making recommendations, and communicated to residents and their families the critical message that pain can be relieved. Her narrative reminded me of a strategy used by a nurse administrator to get people interested in and supportive of change. By getting one group or unit involved in and committed to an institutional change, she created a core group of advocates whose conversations with peers generated some "organizational jealousy."³⁹ Thus, those who might have resisted the change had they been approached first were ready to embrace the change because of the positive perceptions of the "early adopters."⁴⁰

Ms. Arata makes an important point about sustaining practice changes: these new behaviors require reinforcement through ongoing monitoring and coaching. Many reports on improving pain management imply the importance of having an internal coach attending to staff and patient responses to the change effort. Mary Arata's narrative indicates she has served as both consultant and coach. Ms. Arata noted that difficult patients could activate old values, such as believing the patient is drug-seeking or craving attention. Activating old values can "extinguish" the new pain management behaviors if there isn't a coach to help staff apply the new knowledge to more complex patients. The champion/coach must use these teachable moments to link the "difficult" behavior to a likely problem of undertreated pain. Consider these other situations in which staff may need coaching. When scheduled opioids are used instead of prn analgesics, nurses often need reassurance that they can care for their patients safely when they make this change in clinical practice. Or, when staff observe that a particular patient experiences opioid-induced respiratory depression even though they have been told that this is uncommon, someone has to help them not only adjust the particular treatment plan, but also interpret the situation so that staff's fear of causing respiratory depression is not reinforced. In the long-term care setting, concerns about polypharmacy (multiple medications for multiple health problems) in the elderly can conflict/compete with advocating appropriate analgesics. The consultant/coach will need to work with staff to mediate these concerns safely while ensuring patients'pain relief. A coach, recognizing both the institutional and clinical dimensions of improving pain management, supports, debriefs, reinforces, and interprets.

In addition to the cultural aspects of institutions, these innovators' work suggests other aspects that may need to be addressed: the quality of communication, conflict negotiation strategies, and publicizing and celebrating progress. I have addressed only selected cultural aspects of organizational life. As readers consider their own organizations and cultures, you may recognize factors that are more salient in your particular situation than the ones I have addressed here (e.g., the ethnic backgrounds of staff and patients and the impact of these factors on your change initiative). Readers interested in learning more about organizing groups to effect change in their facilities are encouraged to visit the Center for Community Change website to find information about strategies for advocacy and recruiting influential others (See Resources and Tools).

Institutional Self-Assessment, Diagnostic Analysis, and Action Planning

Both the Weissman et al. article and the interview with Mary Arata (Featured Innovation: Parts I & II) make clear that institutional change is essential to achieving the goal of ensuring that residents in long-term care settings have access to appropriate and effective pain management. One may read these pieces and say, "Well, I'm glad it worked for them, but that wouldn't work here." Or one might say, "Wow, this is exactly what would work in my setting." We know that adoption of evidence-based practices is context-dependent.^41-43 That is, one needs to think about specific aspects of the institution as well as clinician practices. So, just as assessment is the first step in managing pain, institutional assessment—an evaluation of a setting's strengths and weaknesses with regard to changing clinical practices—is essential to developing an action plan and optimizing the success of an improvement initiative. Although there are several examples of paper and pencil institutional checklists,^12,28,30 which outline the possibilities for institutional interventions, none are organized with the foregoing understanding of institutional dimensions in mind. The technical and structural dimensions are well addressed in numerous studies. To date, most institutional interventions reported in the literature address the strategic dimension by noting the importance of establishing accountability. Very few reports describe strategies for attending to the cultural dimension of improving pain management, but most provide evidence that the cultural dimension is an issue. Figure 1 lists questions by dimension that staff can ask about their institutions. An affirmative answer indicates an institutional strength; a negative answer identifies a potential focus for intervention.

Figure 1.

Diagnostic Analysis: Questions for Institutional Self-Assessment

Strategic Dimension

• Is there an explicit institutional commitment to improving pain management? Is there evidence of this commitment and is the evidence strong (e.g., dedicated staff member, budgeted resources)?
• Is there sustained, visible support from key clinical and administrative leaders (e.g., CEOs, department directors, senior physicians, nurse administrators and managers?
• Is your setting accredited by organizations that have pain management standards (such as JCAHO)?
• Is pain management recognized as a potential risk management issue?
• Is pain management recognized as a potential financial risk?

Structural Dimension

• Is there an interdisciplinary work group to address pain management?
• Are there policies and procedures for pain assessment and treatment?
• Are there existing committees with clout that can lend support to your pain management improvement effort (e.g., Pharmacy and Therapeutics, Risk Management)?
• Do annual mandatory classes include the topic of pain management (similar to CPR or infection control)?
• Does the formulary include an adequate range (types and routes of administration) of medications for treating pain (e.g., nonopioids/NSAIDS, opioids, co-analgesics)?
• Are there resources for implementing nonpharmacologic interventions (tape players, relaxation and music tapes, hot and cold packs, etc.)?

Technical Dimension

• Has the question of which staff can perform what pain management activities been clearly defined? For example, is there a list of observations CNAs are taught to report? Are there nondrug interventions CNAs can perform under the supervision of nurses?
• Is pain management an emphasis in orientation, inservice education, and continuing education?
• Do staff need to demonstrate their competence in pain management periodically?

• Are physicians (who round less frequently in nursing homes) up to date on the LTC setting's pain management efforts?

Cultural Dimension

• Does the interdisciplinary pain management committee function well? Are communications within the committee, between committee and administrators, between committee and clinician effective and respectful? Is there evidence of commitment, i.e., do committee members show up, follow through on activities?
• Has a "power analysis" been done, i.e., has the team identified the influential others who will support or resist the institutional change?
• Have all staff with patient contact (not just clinical staff, but housekeepers, volunteers) been recruited into the pain improvement effort? Does this group include informal leaders as well as those in positions of influence?
• Is there an "internal marketing" plan for promoting the message that "Pain can be Relieved"?
• Is there a plan to acknowledge and celebrate progress?

It is nearly impossible for any one institution to address all of the issues uncovered by institutional assessment and diagnosis immediately. However, engaging in a diagnostic analysis one can determine what particular strengths exist and in which dimensions. This understanding guides a team's action planning and helps members establish priorities. Strengths can be leveraged to reap short and long-term benefits. For example, one might determine that staff does not have the knowledge to assess and relieve pain (the technical dimension) and that there are only a few pain management champions. Whereas eventually all four dimensions must be addressed for a change effort to "take," the champions may decide that the action plan priority is to widen the base of support for change. When education does occur, the learners are more likely to be receptive. One team with whom I worked spent a year getting the backing of the Ethics Committee, one of the most influential committees in the organization.⁴⁴ Educational efforts were initiated only after the committee's endorsement and activism ensured that pain relief was an institutional priority. Or, the champions could decide that education is the best strategy to widen the base of support. Another team decided to educate nurses about pain management first. Once nurses began "singing from the same sheet of music" with regard to pain management, it became easier to enlist physicians and administrators in the effort. The MCW program faculty emphasized that they did not require participants to use specific tools or policies; they recognized that a successful initiative must take into account the local conditions. There is no "one size fits all" action plan; even with a mandate to meet pain management standards for accreditation, failure to consider the local conditions will undermine any change effort. Ideally, action plans will target activities that are likely to exert influence in multiple dimensions of institutions.

Ms. Arata noted that they had made progress during the first year of participation, but still had "more to do." This comment underscores the nature of change as a long-term process. It takes time to see results and may take two to three years for the accumulated effects of a team's efforts to become visible.³³ Such a sustained effort, particularly considering the vicissitudes of modern health care, requires the interpersonal support that comes from being part of a larger community. To do this requires acknowledging incremental progress and celebrating small victories. Champions have a demanding task: to keep the vision of improved pain management on the front burner while coping with competing clinical and administrative demands, such as complex patient needs and staff turnover.

Conclusions

The MCW program demonstrates that improving pain management requires champions to focus on developing capacity and building community. Developing capacity means giving staff the knowledge, skills, tools, and processes to do the job. This is not a one-shot intervention nor is it sufficient. Providing pain management knowledge and skills and steady attention to integrating them into practice through coaching helps institutions develop capacity. Building community is accomplished by teaching program participants about the change process and socializing staff to become change agents and coaches themselves, enabling them to reproduce these methods in their own settings. Building a community of advocates does not happen overnight--indeed, one needs to be deliberate and strategic in the recruitment effort. I believe the more advocates one has within an institution, the stronger the voice and the less vulnerable a pain management initiative is to the next round of budget cuts or staffing changes.

Every foray into improving pain management is not successful. In fact, many of us who have been involved in this work for more than 20 years, wonder why it has taken so long to make change. As a society, we adopt technology, whether it is Patient Controlled Analgesia (PCA) or cell phones, practically overnight. But when it comes to relatively low-tech strategies, such as the intelligent administration of oral medications advocated by pain management guidelines, as a society (or as a health care system), we drag our feet.

Christine Miaskowski, PhD, RN, nurse researcher and president-elect of the American Pain Society, called for a revolution.⁴⁵ I agree. However, revolution alone, like education alone, will be insufficient. To assume the mantle of pain management advocate is to make a commitment to revolution and transformation. What is needed is a revolution in our collective thinking: we must abandon outdated beliefs and must convince ourselves, our colleagues, residents and their families, that Pain Can Be Relieved. This is a simple message that must be repeated over and over again. Like a mantra, it can sustain us in the most challenging of situations. As hard as it is to abandon old ways of thinking, it can be done more easily now than ever because there is, among many clinical staff members, a sense that we could be doing a better job with pain. However, it is harder (and impractical) to think that we can raze or abandon the systems in which we work. As the work of our authors suggests, we can reinvent and transform our practice environments so that they support evidence-based pain management. To reinvent and transform our practice settings, we must understand the institutional factors that sustain the status quo. With that knowledge we can promote changes that engage the commitment of influential others, redistribute power, and spread evidence-based pain management throughout the organization.

I have tried to illuminate the complexities of institutional change to improve pain management as a clinical, social, and political process. For those who have already undertaken improvement efforts, this analysis may lead to an understanding of why things worked or didn't work, enabling your team to revise your action plan. As the featured articles indicate, an appreciation for this complexity and an action planning process that takes this into account will help patients get pain relief, increase staff's confidence in their ability to relieve pain, and give staff the satisfaction of a job well done. Do we clinicians, administrators, and educators have the passion and will to act knowledgeably, creatively, and radically within our institutions to make this knowledge matter to every one of our patients? This issue of Innovations shows that we can and we must.

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