Core Curriculum for the European Diploma in Pain Nursing (EDPN)

Section 1. Pain science and knowledge

3 sub-sections · 18 learning objectives

Pain has a devastating impact on individuals, their families, health and social care, and wider society. Pain nurses need a detailed understanding of the mechanisms of pain in order to manage it effectively, and to work in partnership with people, their families, and other healthcare professionals to prevent pain or minimise its impact and long-term consequences.

• 1.1 Multidimensional impact and nature of pain. Pain from a biopsychosocial perspective, including its cognitive, sensory, and affective dimensions; the individual nature of pain and the factors shaping how it is understood, experienced, and expressed; the influence of social roles, school or work, occupational factors, finances, housing, and recreation; pain management as a basic human right; partnership working and advocacy that promotes independence and self-management; and the prevalence of acute, chronic/persistent, and cancer-related pain and its impact on healthcare and society.
• 1.2 Pain mechanisms. The characteristics and mechanisms of nociceptive, inflammatory, neuropathic, referred, and phantom limb pain, and nociplastic pain syndromes; the distinction between nociception and pain; transduction, transmission, perception, and modulation in nociceptive pathways, including the somatosensory and autonomic nervous systems, somatic and visceral peripheral nerves, spinal level processing, and midbrain, brainstem, thalamic, cortical, and limbic processing; peripheral and central sensitisation and primary/secondary hyperalgesia; the transition from acute to chronic/persistent pain and how effective management can reduce this risk; brain changes in chronic/persistent pain and their impact on cognition, memory, and mood, including fear-avoidance; the overlap between chronic/persistent pain and common comorbidities such as stress, sleep, mood, depression, and anxiety; the mechanisms underlying placebo and nocebo responses; and the role of genetics and epigenetics in the risk of developing chronic/persistent pain and in pharmacotherapy.
• 1.3 IASP's definitions of pain and related phenomena. Pain and pain-related terminology according to the IASP taxonomy, including acute, chronic/persistent, cancer-related, neuropathic, nociplastic, spontaneous, evoked, breakthrough, incident-related, visceral, and somatic pain; terms used in pain-oriented sensory testing, including sensory and pain threshold, pain tolerance, and punctate mechanical, dynamic, and static allodynia; and the importance of the World Health Organisation's International Classification of Diseases for pain-related diagnoses.

Section 2. Interprofessional working and learning

9 learning objectives

Assessment and management of pain is the result of the skills and expertise of various professionals working in an interprofessional team and adhering to a biopsychosocial perspective. An effective interprofessional team recognises the interdependence of its members and shares a mission, vision, and goals with patients, in contrast to multidisciplinary working, where each profession acts separately.

The objectives cover the importance of interprofessional working and its barriers and facilitators; working respectfully and in partnership with patients, families, carers, and other team members and agencies; creating and engaging in regular opportunities for interprofessional education and supervision; critically reflecting on one's own contribution to the team and continually improving interpersonal and team skills such as communication, negotiation, problem solving, and decision-making; understanding the perspectives, skills, goals, and priorities of all team members; negotiating overlapping and shared responsibilities for episodic or ongoing care; respecting professional differences and acknowledging misunderstandings or limitations that contribute to interprofessional tension; and reflecting, negotiating, and working with others to resolve conflict and implement strategies that improve team-based care.

Section 3. Principles of assessment and measurement

2 sub-sections · 15 learning objectives

Pain assessment and measurement can be a complex procedure. It requires effective interpersonal skills to build a trusting relationship with the patient, evaluation of the wide range of factors affecting the pain experienced, and selection of valid and reliable measures for that individual patient, with observational skills and nurse-led ratings used where self-report is not possible.

• 3.1 Assessment. Obtaining a comprehensive pain history and assessing the patient across the lifespan, considering social, psychological, and biological components; a person-centred approach that accounts for social and cultural factors, language, psychological factors, physical activity, age, health literacy, values and beliefs, traditional medical practices, and the patient's and family's wishes, motivations, goals, and strengths; patients' and families' affective, cognitive, and behavioural responses to pain and illness; the rationale for self-report and for nurse-led ratings where self-report is not possible; recognising individuals at risk of under-treatment, such as those unable to self-report, neonates, or people who are cognitively impaired; selecting assessment tools appropriately for different situations; using valid, reliable, and sensitive tools to assess pain at rest and on movement; ensuring culturally sensitive assessment for patients who speak a different language to the healthcare team; understanding the rationale behind basic investigations in relation to serious pathology; understanding specialist assessment by other medical and allied health professionals and when to refer; the importance of accurately documenting pain assessments; assessing the patient's coping behaviour and skills; and evaluating the assessment process and the impact of interventions on pain and function.
• 3.2 Outcome measures. Critical selection of appropriate, valid, and reliable assessment and outcome measures, and shared decision-making with patients in setting goals relating to physical activity, function in daily life, and sleep.

Section 4. Principles of treatment

5 sub-sections · 32 learning objectives

Nurses support and empower people experiencing pain by promoting independence and self-management wherever possible, and play a key role across the full range of pharmacological, non-pharmacological, and interventional approaches, including medication administration, safety, patient education, and the management of side effects.

• 4.1 Promoting self-management. The importance and implementation of health promotion and self-management; the limitations of medication alone and the value of combining pharmacotherapeutic approaches with other multimodal, non-pharmacological strategies; assessing and adapting to patients' preferences and values in setting pain-related goals and priorities; facilitating return-to-work strategies in collaboration with the pain team and employers, including work adaptation and removal of barriers; and promoting active self-management through effective interpersonal skills, education, and motivational techniques.
• 4.2 Non-pharmacological interventions. The use, evidence, efficacy, and potential interactions and adverse effects of complementary and alternative medicine; initiating and educating patients and families about physical strategies such as exercise, stretching and pacing, comfort and positioning, massage and manual therapies, heat or cold, and hydrotherapy; psychological strategies including distraction, relaxation, stress management, patient and family education, and counselling; evidence-based behavioural therapies including cognitive behavioural therapy, mindfulness-based approaches and Acceptance and Commitment Therapy, systemic therapy, hypnosis and guided imagery, biofeedback and progressive muscle relaxation, and graded exposure; and alternative strategies such as acupuncture, electrotherapies including TENS and spinal cord stimulation, and palliative radiation.
• 4.3 Pharmacological interventions. The different types of analgesics and potential combinations, including non-opioids, opioids, atypical analgesics, and local anaesthetics; mechanism and site of action, appropriate routes of administration, adverse effects, indications, precautions, and contraindications, and interactions across nociceptive, nociplastic, and neuropathic pain; principles of safe prescribing and administration; prevention and management of common side effects and adverse events; the long-term effects of opioids and the evidence for these; the distinction between physical dependence, tolerance, withdrawal, pseudo-addiction, and addiction/dependence syndrome; reasons for non-adherence and strategies to address it; monitoring treatment effectiveness and side effects; the evidence for acute pain management and enhanced recovery in preventing chronic/persistent pain; ongoing pain management after discharge, including ambulatory surgery; and pharmacological and non-pharmacological options to reduce procedure-related pain.
• 4.4 Interventional therapies. The risks, benefits, and safety considerations of intravenous, sublingual, or oral patient-controlled analgesia, epidural and intrathecal analgesia, and major peripheral, plexus, paravertebral, and plane nerve blocks; potential complications of neuraxial and other regional analgesia; and the indications, efficacy, complications, management, and follow-up for procedural treatment modalities including peripheral and neuraxial injections, electrical stimulation, electroacupuncture, ablative techniques, neuromodulation, epiduroscopy, and surgical interventions.
• 4.5 Comorbidities. The problems faced by patients with comorbidities such as cardiovascular disease and stroke, diabetes, renal or liver failure, cancer, and trauma; clinical practice guidelines addressing pain management in these patients; developing, implementing, and progressing tailored multidimensional assessment; clinical reasoning in developing a tailored interprofessional treatment plan; the evidence base for pharmacological, surgical/interventional, and non-pharmacological management; ongoing pain management issues; and the essential role of close collaboration between medical specialists, nurses, psychologists, social workers, the workplace, and family.

Section 5. Pain subgroups / special patient populations

8 sub-sections · 62 learning objectives

Pain nurses work in a variety of healthcare settings and may not be directly involved in providing services to all special or vulnerable patient populations, but all need an understanding of the nursing interventions in these areas. An individual may also have more than one vulnerability, for example a child receiving critical care.

• 5.1 Infants, children and adolescents. The long-term biopsychosocial consequences of pain in infancy, childhood, and adolescence; age-related behavioural and physiological changes; assessment using validated tools, both for those unable to self-report and for those who can; partnership working and realistic functional goal-setting with children and families; the evidence base for pharmacological pain management across procedural, acute, complex, and cancer-related conditions; non-pharmacological approaches such as breastfeeding, touch, heat/cold, play, and distraction; parent coaching and interprofessional team management; and identifying children at risk and implementing safeguarding procedures.
• 5.2 People with intellectual disabilities. The emotional response to pain and coping in people with intellectual disabilities; a flexible approach to assessment, recognising that not everyone can or will generate a pain score on demand; the use of behavioural indicators; the nature, strengths, and limitations of multidimensional pain scales such as the EDAAP; and the importance of collaboration with families and formal carers, and of the closeness of the relationship to the therapeutic and pain management process.
• 5.3 People with cognitive impairment. The impact of cognitive impairment on pain experience and expression; typical non-verbal cues such as facial expression and muscle tension; comorbidities that influence pain perception and processing; assessing communication patterns and gathering information from family and informal carers; critical evaluation of self-report and observational assessment tools and their suitability by level of cognitive ability; detecting behaviour changes that may indicate pain; developing an appropriate care plan using pharmacological and non-pharmacological strategies; the role of formal and informal carers as cognitive decline develops; and the consequences of poor pain management, including for family and informal carers.
• 5.4 Older people. The impact of ageing on pain mechanisms and experience, including the effect of cognitive impairment; how comorbidities that arise with age, such as falls, influence pain perception and processing; critical appraisal of assessment tools appropriate to level of cognitive ability; developing an appropriate care plan; the risks associated with pharmacological interventions in this population; adapting self-management approaches; and the role of older adults in pain research.
• 5.5 People experiencing substance dependence. Distinguishing inappropriate prescriber behaviour from unsanctioned user behaviour; stratifying patients by risk when considering opioid prescription; recognising forms of substance dependence that may be comorbid with pain across all ages; appraising tools for assessing suitability for, and monitoring of, opioid prescription in chronic/persistent non-cancer pain; quantifying medication use, including cumulative effects of multiple substances; strategies to reduce opioid diversion; managing substance dependence in the context of acute and chronic/persistent pain, including monitoring, drug therapy, and rehabilitation; advising patients, families, carers, and colleagues on withdrawal of opioids and benzodiazepines; working ethically with general practitioners, addiction services, families, and employers; and assisting in the management of healthcare professionals with dependence syndrome.
• 5.6 Cancer survivors. The problems faced by cancer survivors with persistent pain; comparing and contrasting their assessment and management with acute pain, cancer pain, or chronic/persistent non-cancer pain; the choice of analgesics and adjuvants and the evidence base; prevention and management of common adverse effects; the role and impact of pain for survivors and their social network; and the essential role of collaboration between the pain specialist, oncologist, surgeon, family physicians, physiotherapists, and psychologists.
• 5.7 Torture survivors. The need for a sensitive and detailed pain and torture history, and awareness of current risks to health such as ongoing conditions, housing, money, and uncertain immigration status; assessing beliefs around pain and cognitive ability, and designing a culturally sensitive assessment using tools in the person's own language wherever possible; helping patients and families understand the nature of their pain and realistic expectations of management; and developing, in partnership with the individual, carer, and interprofessional team, a biopsychosocial, multimodal rehabilitation plan with realistic pain and function goals.
• 5.8 Critical care and trauma patients. Clinical reasoning in developing a tailored assessment and treatment plan of acute pain for critically ill patients; differential diagnosis and therapeutic interventions for acute pain, agitation, and delirium; the nature, advantages, and limitations of observational pain scales such as the BPS and CPOT; the adverse physiological and psychological effects of pain and its treatment in severe traumatic brain injury, polytrauma, burns, and sepsis; comparing protocol-based approaches such as individual therapy goals, assessment-driven protocols, and treatment/weaning protocols; the impact of pain as a post-traumatic stress factor; and the barriers to pain assessment in the intensive care unit and interprofessional team.

Section 6. Pain education

2 sub-sections · 22 learning objectives

Nurses play a central role in providing education for patients, their families, and other healthcare professionals in the interprofessional team. Assessing health literacy and educational needs, designing and using learning resources, and evaluating the impact of education are important competencies for pain nurses.

• 6.1 Patient and family education. Empathetic, compassionate, and effective communication with patients, family caregivers, and the interprofessional team; teaching patients and relatives about their condition and pain mechanisms; a range of educational delivery modes, including online, group, face-to-face, motivational interviewing, and coaching; explaining how chronic/persistent pain differs from acute pain and the rationale for self-management; identifying and modifying barriers to effective self-management; the use of health behaviour change theories and strategies, and their strengths and limitations; building on patients' existing skills, coping strategies, and strengths; incorporating patient education into goal-setting, coping, pacing, and motivation; setting appropriate learning objectives across different levels of learning; selecting appropriate teaching techniques; and evaluating education provided against predetermined goals.
• 6.2 Educating other professionals. Identifying situations where other professionals should be educated about pain management; assessing prior knowledge and skills using valid and reliable methods; understanding learning needs and setting realistic educational goals; implementing effective teaching strategies on pain mechanisms, assessment, and treatment; a range of active learning methods; variables that may impact on knowledge, attitudes, and skills, such as beliefs, culture, and comorbidities; evaluating education provided against predetermined goals; and providing and inviting constructive feedback to evaluate teaching effectiveness.

Section 7. Quality of care

4 sub-sections · 32 learning objectives

Effective pain management is a basic human right and an indicator of healthcare quality. Pain nurses need to understand the barriers to pain relief at patient, staff, and organisational level, and their central position in the team and leadership skills mean they can evaluate pain across organisations, conduct audits, contribute to research, and benchmark care against evidence-based practice.

• 7.1 Addressing barriers to pain management. Patient and family-related barriers and how these can be reduced or removed; how the attitudes and experiences of practitioners can affect effective pain management; evaluating barriers for healthcare practitioners by reflecting on local working practices and co-creating solutions with colleagues; and the requirements for safe and effective delivery of pain management techniques in hospital, community, or outpatient settings, including staff education, monitoring, equipment, and audit.
• 7.2 Leadership and improving pain management. Developing coordinated care plans and referring appropriately within the interprofessional team; acting as a role model and mentor on the biopsychosocial/spiritual approach to pain management; supporting the advancement of nursing practice by mentoring others; making ethically based decisions in the absence of previous experience or protocols; ensuring services follow best practice across patient groups; developing and evaluating policies and guidelines; documenting and escalating quality, safety, or service delivery issues; developing, implementing, and evaluating strategic plans and service improvements; presenting evidence-based recommendations to the wider team; applying bioethical principles including justice, autonomy, beneficence, and non-maleficence; reflecting on and addressing gaps in one's own knowledge and competencies; collaborating with regional, national, and international networks; disseminating innovations in nursing practice; and lobbying for resources to support and develop pain services.
• 7.3 Evidence-based pain management. Principles of assessing scientific pain-related evidence, including grades of evidence, systematic reviews and meta-analyses, relevant databases, and sources of bias; critically interpreting and summarising advanced evidence-based knowledge with patients and the interprofessional team; supporting the advancement of nursing practice; generating new solutions through lateral thinking and evidence; participating in and critically discussing research, including the involvement of patients; understanding and upholding the ethical principles guiding research in humans; and accurately documenting, communicating, and disseminating data and service developments locally, nationally, and internationally.
• 7.4 Audit and data management. The rationale for data collection around pain management and the distinction between audit and research; using data on pain and pain management, including internal and external benchmarks, as part of internal quality assurance; the possibilities of external audit for quality management, such as pain-related certification; and designing audit and research activities to measure, evaluate, and feed back to managers.