Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses

BACKGROUND

Pain management of sedated and ventilated patients in intensive care units lacks consistency.

OBJECTIVES

To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives.

METHODS

A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to.

OUTCOME MEASURES

Demographics, training, governance, clinical practice, knowledge, and attitudes.

RESULTS/FINDINGS

108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness."

CONCLUSION

The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management.

IMPLICATIONS FOR CLINICAL PRACTICE

Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.

Conceptualising personhood in nursing care for people with altered consciousness, cognition and behaviours: A discussion paper

The aim of this discussion paper is to explore factors and contexts that influence how nurses might conceptualise and assign personhood for people with altered consciousness, cognition and behaviours. While a biomedical framing is founded upon a dichotomy between the body and self, such that the body can be subjected to a medical and objectifying gaze, relational theories of self, multiculturalism and technological advances for life-sustaining interventions present new dilemmas which necessitate discussion about what constitutes personhood. The concept of personhood is dynamic and evolving: where historical constructs of rationality, agency, autonomy and a conscious mind once formed the basis for personhood, these ideas have been challenged to encompass embodied, relational, social and cultural paradigms of selfhood. Themes in this discussion include: the right to personhood, mind-body dualism versus the embodied self; personhood as consciousness, rationality and narratives of self; social relational contexts of personhood and cultural contexts of personhood. Patricia Benner's and Christine Tanner's clinical judgement model is then applied to consider the implications for nursing care that seeks to reflexively incorporate personhood. Nurse clinicians are able to move between conceptions of personhood and act to support the body, as well as presumed autonomy and relational, social and cultural personhood. In doing so, they use analytical, intuitive and narrative reasoning which prioritises autonomous constructions of self. They also incorporate relational and social contexts of the person receiving care within the possibilities of technological advances and constraints of contextual resources.

Person-Centred Pain Measurement in the ICU: A Multicentre Clinimetric Comparison Study of Pain Behaviour Observation Scales in Critically Ill Adult Patients with Burns

Pain in critically ill adults with burns should be assessed using structured pain behavioural observation measures. This study tested the clinimetric qualities and usability of the behaviour pain scale (BPS) and the critical-care pain observation tool (CPOT) in this population. This prospective observational cohort study included 132 nurses who rated pain behaviour in 75 patients. The majority of nurses indicated that BPS and CPOT reflect background and procedural pain-specific features (63-72 and 87-80%, respectively). All BPS and CPOT items loaded on one latent variable (≥0.70), except for compliance ventilator and vocalisation for CPOT (0.69 and 0.64, respectively). Internal consistency also met the criterion of ≥0.70 in ventilated and non-ventilated patients for both scales, except for non-ventilated patients observed by BPS (0.67). Intraclass correlation coefficients (ICCs) of total scores were sufficient (≥0.70), but decreased when patients had facial burns. In general, the scales were fast to administer and easy to understand. Cut-off scores for BPS and CPOT were 4 and 1, respectively. In conclusion, both scales seem valid, reliable, and useful for the measurement of acute pain in ICU patients with burns, including patients with facial burns. Cut-off scores associated with BPS and CPOT for the burn population allow professionals to connect total scores to person-centred treatment protocols.

An Appraisal of Pharmacotherapy-Pertinent Literature Published in 2021 and 2022 for Clinicians Caring for Patients With Thermal or Inhalation Injury

Studies focusing on pharmacotherapy interventions to aid patients after thermal injury are a minor focus in burn injury-centered studies and published across a wide array of journals, which challenges those with limited resources to keep their knowledge current. This review is a renewal of previous years' work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Twenty-three geographically dispersed, board-certified pharmacists participated in the review. A Medical Subject Heading-based, filtered search returned 2336 manuscripts over the previous 2-year period. After manual review, 98 (4%) manuscripts were determined to have a potential impact on current pharmacotherapy practice. The top 10 scored manuscripts are discussed. Only 17% of those reviewed were assessed to likely have little effect on current practice. The overall impact of the current cohort was higher than previous editions of this review, which is encouraging. There remains a need for investment in well-designed, high-impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.

Facial Expressions Based Automatic Pain Assessment System

Pain assessment is used to improve patients’ treatment outcomes. Human observers may be influenced by personal factors, such as inexperience and medical organizations are facing a shortage of experts. In this study, we developed a facial expressions-based automatic pain assessment system (FEAPAS) to notify medical staff when a patient suffers pain by activating an alarm and recording the incident and pain level with the date and time. The model consists of two identical concurrent subsystems, each of which takes one of the two inputs of the model, i.e., “full face” and “the upper half of the same face”. The subsystems extract the relevant input features via two pre-trained convolutional neural networks (CNNs), using either VGG16, InceptionV3, ResNet50, or ResNeXt50, while freezing all convolutional blocks and replacing the classifier layer with a shallow CNN. The concatenated outputs in this stage is then sent to the model’s classifier. This approach mimics the human observer method and gives more importance to the upper part of the face, which is similar to the Prkachin and Soloman pain intensity (PSPI). Additionally, we further optimized our models by applying four optimizers (SGD/ADAM/RMSprop/RAdam) to each model and testing them on the UNBC-McMaster shoulder pain expression archive dataset to find the optimal combination, InceptionV3-SGD. The optimal model showed an accuracy of 99.10% on 10-fold cross-validation, thus outperforming the state-of-the-art model on the UNBC-McMaster database. It also scored 90.56% on unseen subject data. To speed up the system response time and reduce unnecessary alarms associated with temporary facial expressions, a select but effective subset of frames was inspected and classified. Two frame-selection criteria were reported. Classifying only two frames at the middle of 30-frame sequence was optimal, with an average reaction time of at most 6.49 s and the ability to avoid unnecessary alarms.

Experience of Pain and Satisfaction with Pain Management in Patients After a Lumbar Disc Herniation Surgery

PURPOSE

The descriptive study was performed to assess patients' pain experienced in the early postoperative period of a lumbar disc herniation surgery and their satisfaction with the pain management administered.

DESIGN

This was a descriptive and cross-sectional study conducted from May 8 to November 8, 2017.

METHODS

Data collection was performed during interviews through the Patient Information Form (20 questions), Turkish version of clinical quality indicators in the Postoperative Pain Management questionnaire (19 questions). The questionnaire included 14 items and 3 subdimensions named nursing interventions, pain management, and the environment. The remaining 5 questions were related to pain management satisfaction and pain severity. Questionnaire items scored on a 1 to 5 Likert scale. The higher the total score obtained from the questionnaire is the satisfaction with pain management increases.

FINDINGS

The mean score obtained from the total questionnaire was 51.4 (standard deviation: 6.6).Characteristics of patients with lumbar disc herniation did not influence the total score obtained from the instrument and its sub-dimensions (P > .05). Overall satisfaction with pain management was high (mean: 8.3; standard deviation: 1.6) on the 0 to 10 visual analog scale. There was a statistically significant difference between the length of hospital stay, the type of anesthesia used, having more pain than expected, and the satisfaction score of patients (P < .05). As the length of procedure increases, the average and current pain scores increase as well (P < .05).

CONCLUSIONS

Results of this study indicate that despite pain experienced after the lumbar disc herniation surgery, patients' satisfaction with pain management was high. Encouraging nurses to implement systematic and evidence-based practices in pain management may help alleviate patients' pain after surgery and reduce variety of pain management practices among nurses.