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Reflections of a ‘Joint Clinical Chair- Advanced Practice Nursing Practitioner’
on Finding Meaning in a Patient’s Story
Allied with Clinical Scholarship
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The significant past history revealed a fall 12 years ago, head injury, right shoul- der and neck injury, and fractured ribs. Neck surgery was for significant neck pain, interscapular pain and tingling and numbness in the middle fingers of the right hand, for which Jamie underwent spinal surgery at C6/7 level 7 years ago. The symptoms in the right arm were relieved following the surgery, but this was followed by an exacerbation of interscapular pain. The longstanding low back pain remains central, usually one episode a week, no specific trigger, no radicular symptoms and no radic- ulopathy. Over the months Jamie also gave a history of sharp pain in the right ear and also pain in the occipital region. Over the last 3 years Jamie has had repeated admissions to hospital with atypical chest pain, thoroughly investigated, not of car- diac origin, last review for this atypical pain was 2 weeks prior to this clinical encounter. He has several risk factors including a high cholesterol, family history of ischaemic heart disease and a cigarette smoker.
On direct questioning by the advanced practice nursing practitioner prior to com- mencing the high-tech pain infusion, it seems that the pain extending all the way down the right arm is ongoing but the intermittent numbness has substantially improved since the cervical spine surgery 7 years ago. The symptoms appear to be present at all times, but deteriorate considerably by the middle of the day and by the end of the day Jamie reports feeling exhausted. In addition, Jamie reports both arms and legs become weak, and sometimes he thinks he does not have the strength to drive the short distance home. He tends to lie down and rest a lot and has had repeated pain interventions [nerve blocks] over the course of the last 3 years with minimal effect and no improvement in quality of life. On examination, Jamie was generally fit and healthy, a smoker of 20–25 nicotine cigarettes a day, and has a high cholesterol. He had normal tone and power in both upper limbs. He is an indepen- dent and ambulatory gentleman. He, however did have an area of tenderness in the interscapular regions, slightly on the right side of the mid-line, directly opposite the T1–T3 spinous processes. A very restricted neck movement was noted on formal assessment, at other times neck movements seemed quite good spontaneously. Well healed neck wound was identified pertinent to the cervical surgery. No motor or sensory loss. No reduction of supinator reflexes. A post-operative MRI scan [7 years ago] showed satisfactory decompression at the operated level, and subsequent MRI [6 months ago] revealed no other evidence of spinal cord or root compression in the adjacent levels. An MRI Brain was within normal limits and a neurology opinion was sought 1 year ago, but nothing focal could be detected. Overall the current symptoms are difficult to explain and correlate with his associated signs. The symp- toms seem to be musculoskeletal in origin and are not explainable by a normal dermatomal pattern of ongoing symptoms.
Chronic pain has been recognized as pain that persists past normal healing time (Bonica 1953) and therefore lacks the acute warning function of physiological nociception. Usually pain is regarded as chronic when it lasts or recurs for more than 3 months (Treede et al. 2015; Merskey and Bogduk 1994). Chronic pain should receive greater attention as a global health priority because adequate pain treatment is a human right, and it is the duty of any health care system to provide it (Goldberg and Summer 2011; Bond et al. 2006). Furthermore, chronic pain is a
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frequent condition, affecting an estimated 20% of the population worldwide (Van Hecke et al. 2013; Goldberg and Summer 2011; IOM 2011; Schopflocker et al.
2011; Gureje et al. 2008; Breivik et al. 2006). Besides, a classification for chronic primary pain has been introduced and defined as pain in one or more anatomical regions that
(1) Persists or recurs for longer than 3 months
(2) Is associated with significant emotional distress (e.g., anxiety, anger, frustra- tion, or depressed mood) and/or significant functional disability (interference in activities of daily life and participation in social roles) and
(3) The symptoms are not better accounted for by another diagnosis (Nicholas et al.
2019, p. 29).
Comorbidity between chronic pain and other conditions, such as psychiatric con- ditions, has been well documented (Kirsh 2010). The presence of comorbid condi- tions is important, as there is evidence that health-care utilisation and health-care costs increase and health-related quality of life diminishes (Dominick et al. 2012).
Specific to pain comorbidities, patients with multiple pain sites or pain syndromes also report higher levels of anxiety and depressive symptoms (Gore et al. 2012;
Gureje et al. 2008). A recent study found that a third of patients reported coexisting chronic pain conditions, but no specific patterns of co-occurrence of pain comorbid- ity were identified (Page et al. 2018). Furthermore, the presence of coexisting pain conditions was found to be significantly associated with lower quality of life, longer pain duration, and older age. In addition, the presence of co-existing chronic pain diagnoses did not seem to have a clinically significant impact on treatment responses (Page et al. 2018).
7.1.2 Exemplar Case and the Role of the Advanced Practice Nursing Practitioner
A Joint Clinical Chair usually refers to a professorial position which is a joint appointment between a university, school, college or faculty and a health service organisation, although there are many different models. In this case, the Joint Clinical Chair involved two major academic medical centres and one large univer- sity. According to Darbyshire (2010) establishing a joint chair position is a signifi- cant, important organisational initiative and investment on the part of the university and hospital. The process should be trusted and the professor left alone to undertake the day-to-day activities. If the selection process has been rigorous and carefully considered, then the successful applicant will be more than capable of being a self- starter, using their creativity, showing imagination rather than always demanding resources, developing the role and their department in exciting and valuable ways, and meeting the aims and goals of the position (Darbyshire 2010). This is why the appointment is at professorial level. This is what the person has been hired to do, not to undertake the minutiae of another’s agenda (Darbyshire 2010, p. 2598).
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In this exemplar case, the role of Joint Clinical Chair enabled each of the five dimensions of scholarship as outlined by Boyer namely, scholarship of teaching, discovery, integration, application and engagement weave through her role as a reg- istered advanced nursing practitioner with prescriptive authority in pain medicine.
The flexible bridges between clinical and academia merged and were filled with opportunities. The visibility of the registered advanced practice nursing practitioner (RANP) with prescriptive authority (RNP) at the bedside doing and thinking pain management with a title ‘clinical professor, RANP, RNP, PhD’ was a game-changer for the clinical staff, the clinical professor and more importantly the patient. The elements of a professional triad of ‘expertise, clinical scholarship and scholarly activity’ were viewed as a valuable resource in the clinical setting. Moreover, the infiltration of this professional triad without pomp or ceremony, respecting the clini- cal knowledge base at the bedside and that of the patient rightly connected the ele- ments of the triad and engineered and implemented a program of research grounded in actual practice.
7.2 Reflection Through the Lens of a ‘Joint Clinical-Chair-