Pain, according to the International Association for the Study of Pain (IASP), is an unpleasant sensory and emotional experience associated (or similar to that associated) with actual or potential tissue damage. However, not all pain experiences have a physical origin; pain has other dimensions or components that play a fundamental role in how pain is perceived and experienced. Based on this, we classify pain into 3 types: physical pain, emotional pain, and psychological pain.

Difference between emotional pain and psychological pain

Emotional pain is a subjective experience in which the person has a wound that no one can see. The causes can be different: unrequited love, a breakup, a change of city, being fired from a job... Regardless of the cause, it originates from not knowing how to manage life changes and not having the necessary resources to cope with the new situation.

Psychic, psychological, or psychogenic pain may seem like emotional pain, but it is not exactly the same. Psychological pain is known as the somatization of pain (or "persistent somatoform pain disorder"), which originates from an emotional state (stress, anxiety, sadness, etc.) and manifests physically or in the form of illness.

Emotional pain of unrequited love

Unrequited love is a clear example of emotional pain, an experience that, although not manifesting in a visible wound, can be just as intense as physical pain. Rejection, loss, and disappointment can activate the same brain regions involved in physical pain, showing that emotional suffering is a legitimate form of pain.

It is important to differentiate between pain and suffering. While pain is a natural response of the body to an assault or threat, suffering is the interpretation we make of that experience. Suffering arises from our resistance to pain, from fighting against what we feel, or from the difficulty in accepting reality as it is. In this sense, while we may not always be able to avoid pain, we can learn to manage suffering, transforming it into an opportunity for growth and resilience.

"Pain is inevitable, suffering is optional" (Siddhartha Gautama)

Facing emotional pain requires recognizing it. It is not a sign of weakness but part of the complex human experience. Learning to deal with emotional pain is key to mental health and well-being, reminding us that, just like physical pain, it can heal over time, with proper support and self-care.

In Spain there is no specific regulation regarding the roles and responsibilities of nursing in the field of Anesthesiology, and the lack of regulation makes it difficult to conceptualize these advanced practice nursing (APN) roles in the same way as in other countries, which is why, at present, they are framed in a paradigm of variable competencies. This is due to the lack of postgraduate specialty content (except for already recognized specialties (e.g., midwifery, mental health nursing...)), budgetary reasons and because the polyvalence of nursing has been promoted to the detriment of its specific training.

A FIGURE THAT HAS BEEN “MATURING”

However, although over the years there has been no normative evolution and we find ourselves in the same situation, progress has been made in improving the visibility and empowerment of the important role of nursing in society:

1. In the early 2000s, and coinciding with an increase in healthcare demand and the super-specialization and scope of anesthesiology, postgraduate training programs in anesthesia for nurses began to emerge and, at present, different Spanish universities offer postgraduate training with a master's degree in the field of Anesthesia, Resuscitation and Pain Therapeutics. We at Sedalux, aware of the importance of formal training, also created our own Expert Course in Nurse Anesthesia.

2. As of 2012, the competencies and functions in Spain of anesthesia nurses were defined by the Spanish Association of Anesthesia, Resuscitation and Pain Therapy Nursing (ASEEDAR-TD), in tune with those defined by the International Federation of Nurse Anesthetists (IFNA) because there are a large number of nurses working in the field of anesthesia coinciding with the role of a specialist nurse or EPA.

3. The conceptual change from Anesthesiology to Perioperative Medicine has led to the emergence of new opportunities for anesthesia nursing in Spain, which not only represent an aid to the anesthesiologist, but also entail an advanced practice of the profession that allows differentiating these roles from those of surgical nursing.
4. Morbidity and mortality, the aging of the population, the increase in life expectancy, the increase in the demand for care, as well as the development of technology and the expansion of the areas of work of anesthesiologists, among other factors, have resulted in an increase in the demand for anesthetic procedures and have led to an overload of work for the medical specialist. With training in line with existing needs and aimed at complementing the role of the anesthesiologist, the nurse anesthetist becomes an integral part of a team that manages to improve patient safety. The Minessota study in the USA compared outcomes and costs between anesthesia performed by nurse anesthetists alone or by anesthesiologists. This study found higher mortality when anesthesia was performed by nurses, but the best results were obtained when anesthesiologists worked as a team with nurses. These data were later confirmed and have encouraged the use of the term Anesthesia Team, a way of working that is being implemented in the USA and has advocates in Europe, based on the fact that “four eyes see more than two”, a popular saying that alludes to the fact that teamwork between doctor and EPA provides safer care and optimizes assistance by providing greater effectiveness in the diagnosis of irregular situations, adverse events or complications during anesthesia and thus providing greater safety to the patient.

SPECIALTY WITHOUT RECOGNITION, BUT WITH LEGAL COVERAGE

However, the nurse anesthetist, a role that has existed in our country for years but lacks legal recognition and accredited training, provides collaborative assistance in different areas to the anesthesiologist, which is not exempt from legal coverage.

According to the Law for the Regulation of Health Professions (LOPS) (BOE Law 44/2003 of November 21), in its article 9 “Interprofessional Relations and Teamwork” comes to give legal coverage to the “anesthesia team” and says in its points 3 and 4: 

3.- CWhen a healthcare action is carried out by a team of professionals, it shall be articulated in a hierarchical or collegiate manner, as the case may be, taking into account the criteria of knowledge and competence, and where appropriate the qualifications, of the professionals that make up the team, depending on the specific activity to be performed, the trust and reciprocal knowledge of the capabilities of its members and the principles of accessibility and continuity of care for the persons being attended. 

4.- Within a team of professionals, it will be possible to delegate actions, provided that the conditions under which such delegation or distribution of actions may take place are previously established within the team. A necessary condition for the delegation is the capacity to carry it out on the part of the person receiving the delegation, a capacity that must be objectifiable, whenever possible, with the appropriate accreditation.

Therefore, in accordance with the provisions of the aforementioned LOPS, it can be deduced that the performance of nurses in the field of anesthesiology should be governed by the following principles: 


1. Its performance will never be autonomous, always working under the delegation and supervision of functions by an anesthesiologist.
2. They should have specific training for the tasks entrusted to them, which should be objectifiable and with the consequent accreditation. This training should provide knowledge and training in airway management (the main cause of complications in sedation outside the operating room), in respiratory and cardiovascular physiology, in monitoring and in pharmacology, without entering into the disquisitions of which drugs should be used and which should not, as long as the staff is trained in their use. The debate should be limited to guaranteeing safety, regardless of the drug and who uses it.

Thus, there is an adequate legal framework to promote the change towards standardization and empowerment of multidisciplinary work teams, essential to develop the “new anesthesia” called Perioperative Medicine, at the same time that we have the positive experience in other countries that endorse the operation of this duality.

It is up to us to strive to further define competencies, to work every day for adequate training and to develop a plan to share tasks, creating a situation of mutual interest between nurse and anesthesiologist in order to take anesthesia to the next level.

Anesthesiology today is very different from 40 years ago, as is the nursing profession, but the organizational model has not changed much since then. New fronts have opened up in the work of anesthesiologists: the universalization of major outpatient surgery programs, the pre-anesthetic assessment of all patients, the Acute Pain Units (inpatient care of postoperative pain) and the Chronic Pain Units, the increasingly complex Post-Anesthesia Recovery Units due to the type of patients and which incorporate in their objective faster postoperative recovery (fast track), the greater proliferation of diagnostic-therapeutic procedures requiring anesthetic sedation, obstetric epidural analgesia for all women, the role of the anesthesiologist in local anesthetics with monitored surveillance, etc.

The socio-sanitary reality in which we live pushes us to propose new forms of internal organization of the anesthesiologists' teams and also of the nursing staff who share with us the tasks of clinical care of patients with respect to the total of anesthetic procedures and services.

THE NEED FOR CHANGE

Anesthesiologists must lead this change and propose solutions that adapt to a workload with different intensities and complexities attended by a team with different competencies that is not based on the structure of one anesthesiologist for each anesthesia. In some cases two anesthesiologists may be necessary and, in others, part of the process may be delegated. The proposal of an “anesthesia team ” that includes anesthesiologists, specialized nurses and/or trained assistants, directed by the head of the Anesthesiology Department who assigns the different tasks according to the different levels of training and skills seems the most reasonable; and training, in this case, is one of the keys for anesthesiologists to be able to delegate part of our current tasks to nurses.

A TRAINING PROGRAM TO AROUSE INTEREST

With the aim of making visible and enhancing the expert help that Nurse Anesthesia can provide to the field of Anesthesiology and the illusion of contributing to the change of the current paradigm, this Expert Course in Nurse Anesthesia is born, which aims to bring to all graduates in nursing a discipline, often even unknown to them, in order to establish some basic knowledge and arouse interest in an expanded postgraduate training in the field of Anesthesia, Resuscitation and Pain Therapy.

For years there has been a belief that newborns perceive pain less and tolerate it better due to their biological immaturity. It was also thought that the inability of infants to verbalize their feelings and express their pain was synonymous with an inability to experience and remember it.

To this must be added that in children the response to pain often does not differ from other responses, such as fear and stress, to other non-painful situations.

Therefore, it was not uncommon to hear from many health professionals phrases such as: “Less pain is experienced in infancy”, “Neonates do not remember the experience of pain”, “Children cannot locate or describe their pain” or even “Pain helps to build character”.

BUT THE OPPOSITE WAS TRUE.

ARE MORE SENSITIVE TO PAIN THE SMALLER THEY ARE

There is currently sufficient data to affirm that the neonate is capable of feeling pain. From before 28 weeks of gestation, the fetus has developed the anatomical, neurophysiological and hormonal components necessary for the perception of pain, but with a drawback that makes them even more vulnerable; and that is that many inhibitory mechanisms (with which we manage to “tolerate pain” or mitigate it physiologically) will not develop until several weeks or months after birth, which implies that newborns have a more intense pain response to the same painful stimulus than older children and adults, and that is because there is a lower pain threshold at a lower gestational age.

It is also possible that they have a higher concentration of substance P receptors. They have a lower threshold of excitation and sensitization, which leads to greater central effects with nociceptive stimuli. These factors seem to be responsible for the fact that the painful sensation is more severe in children than in adults.

CONSEQUENCES OF UNTREATED PAIN IN THE NEWBORN

The prevention of pain in these children is important not only for ethical reasons, but also because of its short- and long-term consequences.

In the short term, they experience increased catabolism (and oxygen consumption), blood pressure, intracranial pressure and stress hormones (catecholamines, cortisol, glucagon); which together with the decrease in oxygen saturation and insulin secretion (which lead to an increase in glucose levels that can be harmful to the immature brain) lead to an increased risk of neurological damage and an increased susceptibility to infections, due to the depression of the immune system resulting from stress.

In the long term, studies suggest that early painful experiences may trigger exaggerated affective-functional responses to later painful experiences, and contribute to neurodevelopmental disturbances (sleep, behavioral, cognitive and learning development).

TREATMENT OF NEONATAL PAIN

There are many acute painful stimuli, often recurrent, that are performed during the care of the NB for diagnostic or therapeutic purposes (blood extraction, cannulation of IVs,…), care procedures (placement of probes, postural changes, removal of adhesive tapes) or explorations. Neonates in the incubator, in addition to the ability to perceive pain, are able to recognize suffering, anxiety and fear. Therefore, we must be clear that their treatment is absolutely necessary.

There are a series of non-pharmacological measures (preventive, environmental and behavioral) that can provide adequate analgesia in mild pain, and even when used together with analgesics, they enhance its efficacy. However, there are occasions when these resources are insufficient and we have to resort to pharmacological measures. The most commonly used drugs are local anesthetics, opioids and non-steroidal anti-inflammatory analgesics. On the other hand, there are stressful situations that are not painful for the neonate, in which the appropriate treatment is sedation and not analgesia.

“MAKE PAIN VISIBLE AND MAKE PAIN MATTER”

Although in recent years there has been increased interest in pain in the neonatal period, measures to prevent pain in the newborn are applied in only a small percentage of cases. As in other aspects of newborn care, there continues to be a wide gap between what is known and what is done. Raising awareness, both in the national health system and in society, is essential to ensure that strategies for the prevention and treatment of pain in the newborn are integrated into daily clinical routines.

From Sedalux we want to make the problem of infant pain visible and make it matter. But not only that: we are going to fight it and act in a proactive, integrated and global way, in order to achieve a better approach to pain in all its different aspects: prevention, detection and treatment; in order to improve its care at all levels.

Although “anesthetist” and “anesthesiologist” are used interchangeably in many contexts and even the Dictionary of the Royal Spanish Academy of the language considers it valid to use both nouns as synonyms, in medical language and among specialists in Anesthesiology and Resuscitation a distinction is preferred between the two terms.

According to the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), an anesthesiologist is one who has completed a career in general medicine and has subsequently specialized in this branch by completing a period of specialized M.I.R. training in anesthesiology, pain management and perioperative intensive care (or “resuscitation”). In some countries, such as Spain, the term anesthesiologist is also used to refer to a physician specializing in anesthesiology; however, in many other Spanish-speaking areas (America and Latin America) this term is used to refer to other types of healthcare personnel (nurse anesthetist, technician or anesthesiologist assistant) who practice anesthesia without medical qualifications, usually under the supervision of anesthesiologists.

So, although it may seem somewhat confusing, in these areas anesthesiologists usually work under the supervision of an anesthesiologist and that is why our professional society, SEDAR, prefers the term anesthesiologist to be used to refer to specialized physicians.

On the other hand, it should be added that the term anesthesiologist, used in the 19th century and until the first half of the 20th century, which referred to those who administered anesthesia during surgical procedures, usually practitioners, medical students or self-taught physicians, is now considered to be in disuse.