Individual nurse and organizational context considerations for better Knowledge Use in Pain Care

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Online Learning to Improve Nurses' Knowledge, Attitudes, and Self-Efficacy About Managing Postoperative Pain in Older Adults

BACKGROUND

Older adults undergoing total knee arthroplasty may develop chronic pain without effective postoperative pain management. Increasing nurses' knowledge, changing their attitudes, and developing their pain management self-efficacy could improve the effectiveness of pain management.

AIM

To determine the effectiveness of an online learning program to help registered nurses to manage postoperative pain in older adults undergoing total knee arthroplasty.

DESIGN

A quasi-experimental pre-test-post-test design with intervention and control groups.

METHOD

Six inpatient units were randomly selected at a large tertiary care medical center. Sixty nurses were evenly divided between intervention and control groups to participate in online learning about postoperative pain management in patients undergoing total knee arthroplasty. The content was based on Kolb's experiential learning theory. Data were collected on nurses' knowledge and attitudes toward pain management and pain management self-efficacy at baseline and after completion. Data were analyzed using descriptive statistics, chi-square tests, paired t-tests, and independent t-tests.

RESULTS

The knowledge and attitudes about pain management and pain management self-efficacy toward older adults undergoing total knee arthroplasty of nurses in the intervention group significantly improved compared to the baseline and were also significantly higher than in the control group.

CONCLUSIONS

An online learning program improves nurses' understanding and ability to manage pain in older adults undergoing total knee arthroplasty. This was therefore an effective learning method.

Organisational challenges of pain management in neonatal intensive care unit: a qualitative study

OBJECTIVES

Despite credible evidence, optimal neonates' pain management in the neonatal intensive care unit (NICU) is a challenging issue. In this regard, the organisational context is an essential factor. The existing challenges vary depending on the context, and investigating them can help to improve the quality of care. The study aimed to explore organisational challenges to neonates' pain management in the NICU.

METHODS

This qualitative study included 31 nurses and physicians in the NICU of Children's Hospital, Tabriz, Iran. Data collection was done through individual and focus group interviews. For data analysis, we used conventional content analysis.

RESULTS

The identified challenges included organisational culture (poor interprofessional collaboration and low parental participation), organisational structure (lack of unified approach in relieving pain and limited supervision for pain management) and organisational resources (lack of time due to high workload and inadequate educational programmes).

CONCLUSIONS

Many organisational factors consistently affect neonatal pain management. Adopting some approaches to enhance the cooperation of treatment team members, holding educational programmes, proper organisational supervision and implementing a unified neonatal-based pain management programme could improve neonatal pain management.

A cross-sectional study of factors associated with nurses' postoperative pain management practices for older patients

AIM

The aim of the study was to identify factors associated with nurses' pain management practices in older patients undergoing surgery.

DESIGN

A cross-sectional study.

METHODS

The study sample was 85 Registered nurses working in inpatient surgical units in a tertiary care hospital, Thailand. Data were analysed using descriptive statistics, Pearson's and point biserial correlation coefficients, and stepwise multiple regression analysis.

RESULTS

A positive correlation was found between practices and (a) pain management training and (b) perceptions related to collaboration with physicians. However, practices were negatively related to (a) the nurses' perception of their workload and (b) the number of years of nursing experience. The recent pain management training, the nurses' perceptions of both collaboration with physicians and their workload explained 24.40% of the variance in practices. Appropriate nursing workloads, regular pain management training and promoting collaboration among the healthcare team could all improve the quality of nurses' postoperative pain management.

Nurse and Provider Pain Management Education Priorities and Barriers

BACKGROUND

The purpose of this research was to describe health care nurse and providers' pain management education priorities and barriers for pediatric cardio-thoracic surgical (CTS) patients and their caregivers.

DESIGN

This was a qualitative-descriptive study design using survey methodology.

METHODS

A convenience sample of 206 (CTS) health care professionals including 172 nurses, 11 advanced practice providers, and 23 physicians were invited to participate in this study. The survey was distributed through a work e-mail within a 145-bed tertiary pediatric hospital and focused on collaborative pain management educational priorities and barriers.

RESULTS

Of the 206 cardio-thoracic service health care nurses/providers surveyed, 45.6 % (N = 94) responded to the survey. The top pain management education priority for these nurses/providers included immediate postoperative pain management knowledge for the caregiver and pediatric CTS patient. The lowest priority 13.8% (N = 13) included education related to pain management needs after discharge. Of the 94 nurses/providers who responded, 31.9% (n = 30) identified the presence of timing and communication barriers in providing pain management education with caregivers and pediatric CTS patients.

AIMS

The aim of this research was to describe health care providers pain management education priorities and barriers for cardio-thoracic surgical (CTS) pediatric patients and their caregivers.

SETTING

145-bed tertiary pediatric hospital.

PARTICIPANTS/SUBJECTS

Nurses, advanced practice providers [APP's], and physicians.

CONCLUSIONS

Nurses and providers prioritize immediate postoperative pain management education; however, there remains a need to focus more on the outcomes of pain management education for caregivers and pediatric CTS patients after discharge.

Context, complexity and process in the implementation of evidence-based innovation: a realist informed review

Background

This review of scholarly work in health care knowledge translation advances understanding of implementation components that support the complete and timely integration of new knowledge. We adopt a realist approach to investigate what is known from the current literature about the impact of, and the potential relationships between, context, complexity and implementation process.

Methods

Informed by two distinct pathways, knowledge utilization and knowledge translation, we utilize Rogers’ Diffusion of Innovations theory (DOI) and Harvey and Kitson’s integrated- Promoting Action on Research Implementation in Health Service framework (PARIHS) to ground this review. Articles from 5 databases; Medline, Scopus, PsycInfo, Web of Science, and Google Scholar and a search of authors were retrieved. Themes and patterns related to these implementation components were extracted. Literature was selected for inclusion by consensus. Data extraction was iterative and was moderated by the authors.

Results

A total of 67 articles were included in the review. Context was a central component to implementation. It was not clear how and to what extent context impacted implementation. Complexity was found to be a characteristic of context, implementation process, innovations and a product of the relationship between these three elements. Social processes in particular were reported as influential however; descriptions of how these social process impact were limited. Multiple theoretical and operational models were found to ground implementation processes. We offer an emerging conceptual model to illustrate the key discoveries.

Conclusions

The review findings indicate there are dynamic relationship between context, complexity and implementation process for enhancing uptake of evidence-based knowledge in hospital settings. These are represented in a conceptual model. Limited empiric evidence was found to explain the nature of the relationships.

Exploration of nurses' pediatric pain management experiences in rural hospitals: A qualitative descriptive study

BACKGROUND

Hospitalized children continue to experience inadequate pain management. Children in the rural hospital setting may be at risk due to unique challenges experienced by Registered Nurses (RNs) in this context.

OBJECTIVES

To understand the experience of pain care from RNs who work in rural hospitals with inpatient pediatric patients.

DESIGN

Qualitative description that used semi-structured interviews to explore RNs' inpatient pediatric pain care experiences.

PARTICIPANTS

RNs who: 1) worked directly with pediatric in-patients; 2) spoke English; 3) and who worked in rural Northern Ontario. Hospital sites were selected based on population density, from one province in Canada. To reduce heterogeneity, only sites with dedicated pediatric beds were eligible (n = 9).

METHODS

This qualitative descriptive study used semi-structured interviews over Skype and telephone. Data were analyzed using inductive content analysis.

RESULTS

Ten participants were recruited from seven sites. Five main categories were identified, with one category that influenced all other categories. Rural RNs needed to practice as generalists as they care for many types of patients. Resource challenges included a lack of specialist expertise and educational opportunities. Pediatric pain was not perceived as a priority within their organizations. Most participants perceived there were no explicit standards for pain care. Moving forward the adoption of built in assessments in electronic documentation was suggested as a solution to standard pain care.

CONCLUSIONS

Opportunity exists to improve pediatric pain management, however, without a systematic approach that considers the rural context, pain care for children will continue to be based on individual's beliefs and knowledge.

Factors affecting Korean neonatal nurses' pain care: Psychometric evaluation of three instruments

AIM

The purpose of this study was to evaluate the psychometric properties of the Korean-language versions of Pain Knowledge and Use (PKU-K), Collaboration and Satisfaction About Care Decisions (CSACD-K), and Environmental Complexity Scale (ECS-K).

METHODS

A cross-sectional design was used with a convenience sample of 159 Korean nurses in seven neonatal intensive care units (NICUs). The data were collected by surveying the nurses with the PKU-K, CSACD-K, and ECS-K. Internal consistency reliability was assessed and Horn's parallel analysis, a confirmatory factor analysis, and a convergent construct validity test were conducted in order to evaluate the psychometric properties of the instruments.

RESULTS

The PKU-K, CSACD-K, and ECS-K exhibited strong internal consistency reliability. Horn's parallel analysis showed four factor structures for the PKU-K, one for the CSACD-K, and three for the ECS-K. The confirmatory factor analysis showed a good model fit for the PKU-K and CSACD-K, but the ECS-K model showed a poor fit. Most factor loadings were statistically significant. The CSACD-K's convergent validity was supported by significant correlations for collegial nurse-physician relations with a validated instrument.

CONCLUSION

The findings support the reliability and validity of the PKU-K, CSACD-K, and ECS-K for measuring nurses' knowledge about neonatal pain care, nurse-physician collaboration, and the work environment in NICUs. However, the ECS-K needs further refinement before it is applied to Korean NICU nurses.

Factors Affecting Korean Neonatal Infant Pain Care: Translation and Validation of Three Instruments

This study aimed to translate three English-language instruments-Pain Knowledge and Use (PKU), Collaboration and Satisfaction About Care Decisions (CSACD), and Environmental Complexity Scale (ECS)-into Korean and evaluate the equivalence of the instrument versions. Three Korean translators and two senior reviewers translated the instruments' 56 items using a committee approach. Eight Korean experts evaluated the cultural relevance of the translated instruments using a content validity index (CVI), and 12 Korean neonatal nurses were interviewed to assess their understanding of items. In an expert panel review, the item-CVI was less than 0.78 for 14 items. Based on cognitive interviews, four items were found to be unsuitable in Korea. Based on expert panel review and cognitive interviews, unsuitable items were modified or deleted. In another expert panel review, the scale-CVI was 1.00 for the final instruments. The findings support the validity of the Korean-language PKU, CSACD, and ECS for research application.

Nurses' Beliefs Regarding Pain in Critically Ill Children: A Mixed-Methods Study

The purpose of this study was to provide a current and comprehensive evaluation of nurses' beliefs regarding pain in critically ill children.

DESIGN AND METHODS

A convergent parallel mixed-methods design was used. Nurse beliefs were captured via questionnaire and interview and then compared.

RESULTS

Forty nurses participated. Most beliefs reported via questionnaire were consistent with effective pain management practices. Common inaccurate beliefs included the need to verify pain reports with physical indicators and the pharmacokinetics of intravenous opioids. Beliefs commonly shared during interviews concerned the need to verify pain reports with observed behavior, the accuracy of pain reports, the need to respond to pain, concerns regarding opioid analgesics, and the need to "start low" with interventions. Convergent beliefs between the questionnaire and interview included the use of physical indicators to verify pain, the need to take the child's word when pain is described, and concerns regarding negative effects of analgesics. Divergent and conflicting findings were most often regarding the legitimacy of a child's pain report.

CONCLUSIONS

Findings from this study regarding the accuracy of nurses' pain beliefs for critically ill children are consistent with past research. The presence of divergent and conflicting responses suggests that nurses' pain beliefs are not static and may vary with patient characteristics.

PRACTICE IMPLICATIONS

While most nurses appreciate the risks of unrelieved pain in children, many are concerned about the potential adverse effects of opioid administration. Interventions are needed to guide nurses in minimizing both of these risks.

Staff Nurse Utilization of Kangaroo Care as an Intervention for Procedural Pain in Preterm Infants

BACKGROUND

Skin-to-skin contact between mother and infant, commonly referred to as Kangaroo Care (KC), has demonstrated efficacy as a pain-relieving strategy for infants, yet, it remains underutilized in clinical practice.

PURPOSE

To evaluate changes in neonatal intensive care unit staff nurse beliefs, utilization, and challenges related to practice change in implementing KC as an intervention for management of procedural pain in preterm infants between 2 time points.

METHODS

Nurses who participated in a larger clinical trial examining the sustained efficacy of KC were asked to complete a questionnaire at 2 time points: 1- and 6 month(s) following study initiation. Identified benefits, expectations, frequency of use, and challenges related to practice change uptake were described using frequencies and percentages. Data from the 2 different time points were compared using χ analysis.

RESULTS

Of the 40 nurses approached, all completed the questionnaire (19 at the 1-month and 21 at the 6-month time point). Of the sample (n = 40), 97% of participants indicated that they expected KC to provide good pain relief or better. Staff nurses reported significantly improved preconceived ideas (χ = 22.68, P < .01) and significantly fewer concerns (χ = 22.10, P = .01) related to using KC as a pain-relieving intervention between the 2 time points. No significant differences were seen in the frequency of using KC as an intervention between time points.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Despite increasingly positive preconceived ideas and reduced concerns, the frequency of using KC for procedural pain relief remained unchanged. Further research addressing ways to overcome barriers to utilizing KC as an intervention for procedural pain is warranted.

PICU Nurses' Pain Assessments and Intervention Choices for Virtual Human and Written Vignettes

The purpose of this concurrent mixed-methods study was to 1) examine the factors pediatric intensive care unit nurses consider when assessing and intervening for children who report severe pain and to 2) determine the effect of child behavior and diagnosis on the nurses' pain ratings and intervention choices for written and virtual human vignettes. Quantitative and qualitative results substantiated that despite recommendations to use self-report, many PICU nurses use behavior as the primary indicator to assess and treat pain, even when a child is old enough to articulate pain intensity and there is sufficient cause for pain to be present.

A systematic review of implementation frameworks of innovations in healthcare and resulting generic implementation framework

BACKGROUND

Implementation science and knowledge translation have developed across multiple disciplines with the common aim of bringing innovations to practice. Numerous implementation frameworks, models, and theories have been developed to target a diverse array of innovations. As such, it is plausible that not all frameworks include the full range of concepts now thought to be involved in implementation. Users face the decision of selecting a single or combining multiple implementation frameworks. To aid this decision, the aim of this review was to assess the comprehensiveness of existing frameworks.

METHODS

A systematic search was undertaken in PubMed to identify implementation frameworks of innovations in healthcare published from 2004 to May 2013. Additionally, titles and abstracts from Implementation Science journal and references from identified papers were reviewed. The orientation, type, and presence of stages and domains, along with the degree of inclusion and depth of analysis of factors, strategies, and evaluations of implementation of included frameworks were analysed.

RESULTS

Frameworks were assessed individually and grouped according to their targeted innovation. Frameworks for particular innovations had similar settings, end-users, and 'type' (descriptive, prescriptive, explanatory, or predictive). On the whole, frameworks were descriptive and explanatory more often than prescriptive and predictive. A small number of the reviewed frameworks covered an implementation concept(s) in detail, however, overall, there was limited degree and depth of analysis of implementation concepts. The core implementation concepts across the frameworks were collated to form a Generic Implementation Framework, which includes the process of implementation (often portrayed as a series of stages and/or steps), the innovation to be implemented, the context in which the implementation is to occur (divided into a range of domains), and influencing factors, strategies, and evaluations.

CONCLUSIONS

The selection of implementation framework(s) should be based not solely on the healthcare innovation to be implemented, but include other aspects of the framework's orientation, e.g., the setting and end-user, as well as the degree of inclusion and depth of analysis of the implementation concepts. The resulting generic structure provides researchers, policy-makers, health administrators, and practitioners a base that can be used as guidance for their implementation efforts.

Influences shaping nurses' use of distraction for children's procedural pain

PURPOSE

This study explored pediatric nurses' choices to use distraction for managing painful procedures.

DESIGN AND METHODS

Using interpretive description approaches, interviews with pediatric nurses provided descriptions of choices to manage procedural pain.

RESULTS

Nurses' distress influenced distraction use to mitigate the suffering of children and themselves. Newer nurses described task mastery as influencing distraction choices. Nurses' accounts of performing painful procedures on children mirrored children's descriptions of pain from the literature.

PRACTICE IMPLICATIONS

Nurses' distress and competency performing painful procedures on children influenced practice. Future qualitative studies could extend understanding of pain management choices by pediatric nurses and the impact on undermanaged pain.

Translational research: a concept analysis

BACKGROUND/CONCEPTUAL FRAMEWORK: Little is known about which approaches facilitate adoption and sustainment of evidence-based practice change in the highly complex care environments that constitute clinical practice today. The purpose of this article was to complete a concept analysis of translational research using a modified Walker and Avant approach. DESIGN/DATA COLLECTION: Using a rigorous and thorough review of the recent health care literature generated by a deep electronic search from 2004-2011, 85 appropriate documents were retrieved. Close reading of the articles by three coresearchers yielded an analysis of the emerging concept of translational research.

DATA ANALYSIS

Using the iterative process described by Walker and Avant, a tentative definition of the concept of translational research, along with antecedents and consequences were identified. Implications for health care professionals in education, practice, and research are offered. Further research is needed to determine the adequacy of the definition, to identify empirical referents, and to guide theory development.

RESULTS

The study resulted in a theoretical definition of the concept of translational research, along with identification of antecedents and consequences and a description of an ideal or model case to illustrate the definition.

IMPLICATIONS/CONCLUSIONS

Implications for practice and education include the importance of focusing on translational research approaches that may reduce the research-practice gap in health care, thereby improving patient care delivery. Research is needed to determine the usefulness of the definition in health care clinical practice.

Nonpharmacological management of pain during common needle puncture procedures in infants: current research evidence and practical considerations

All infants undergo painful procedures involving skin puncture as part of routine medical care. Pain from needle puncture procedures is suboptimally managed. Numerous nonpharmacologic interventions are available for these painful procedures, including swaddling, holding, skin-to-skin care, pacifier, sweet-tasting solutions, and breast-feeding. Adoption of nonpharmacologic pain-relieving interventions into routine clinical practice is feasible and should be a standard of care in the delivery of quality health care for infants. This review summarizes current knowledge about the epidemiology of pain from common needle puncture procedures in infants, the effectiveness of nonpharmacologic interventions, implementation considerations, and unanswered questions for future research.