Refusing analgesics: using continuous improvement to improve pain management on a surgical ward

A multinational study of pain management among Hispanics

A multinational project involving pain research teams from three countries examined pain management outcomes in Hispanics. The limited research on pain management outcomes in Hispanics are primarily from the USA, lacking the distinct multinational cultural influences. This article compares the descriptive analysis of the post-operative pain experience of Hispanics in the USA, Puerto Rico and Mexico and tests the reliability of a new Spanish language instrument, the Cuestionario de Houston Sobre el Dolor (Houston Pain Outcome Instrument, HPOI).

There were similarities in expectations related to pain relief, proportion of patients reporting worst pain, usual pain and pain-related interference with function. Significant differences were found on adequacy of pain management. Participants reported high use of non-pharmacologic approaches, particularly prayer and family support. The newly developed instrument indicated acceptable reliability in all settings, Chronbach’s Alpha > 0.75, with some variability by study site. Further cross-ethnic and multinational research are needed to provide culturally relevant evidence-based practice models to overcome barriers and reduce disparity.

Seeking empowerment to comfort patients in severe pain: a grounded theory study of the nurse's perspective

BACKGROUND

Hospital patients experience significant pain, which can delay healing and increase the risk of developing chronic pain. Nurses are affected by patients' ongoing pain and may cope with consequent anxiety and helplessness by distancing themselves from such patients. Understanding nurses' responses to patients in severe pain will inform strategies to support their coping, their patients and, ultimately, their retention in the nursing workforce.

OBJECTIVES

The aim of the study was to develop a substantive theory explaining the hospital nurse's perspective of caring for patients in severe pain.

DESIGN

The study used grounded theory method.

SETTINGS

Data were collected on four acute care wards in a 610 bed Australian hospital.

PARTICIPANTS

The sample included 33 nurse participants and 11 patient participants. Selection criteria for nurse participants were those who worked in the four study wards, cared for patients who experienced severe pain, and consented to be included. Selection criteria for patient participants were those who self-reported pain at intensity of seven or more on a scale of 0-10, were aged 18 years or older, could speak and read English, and consented to be included.

METHODS

Theoretical sampling directed the collection of data using semi-structured interviews with nurses and participant observation, including structured observations of nurses who cared for patients in pain. Data were analysed using constant comparison method.

RESULTS

Nurse participants encountered a basic psychosocial problem of feelings of disempowerment when their patients experienced persisting severe pain. In response, they used a basic psychosocial process of seeking empowerment to provide comfort in order to resolve distress and exhaustion associated with disempowerment. This coping process comprised three stages: building connections; finding alternative ways to comfort; and quelling emotional turmoil.

CONCLUSIONS

The substantive theory proposed a link between the stress of nurses' disempowerment and a coping response that provides direction to support nurses' practice. Strategies indicated include enhanced communication protocols, access to advanced practice nurses, use of nonpharmacological comfort measures, utilization of ward-based pain resource nurses, and unit-specific pain management education. Further research to verify and extend the substantive theory to other settings and nursing populations is warranted.

The Ghanaian surgical nurse and postoperative pain management: a clinical ethnographic insight

Nurses form an indispensable part of the clinical team that manages postoperative pain (POP). Within a particular clinical context, nurses perceive and respond to pain based on specific factors. This study aimed at illuminating the perceptions and responses of Ghanaian surgical nurses regarding their patients' POP. It also identified the factors that influenced nurses' pain responses. A focused ethnography was used, and data were collected through individual interviews. Sampling was performed purposively to include junior, senior, day, and night nurses who cared for surgical patients. Concurrent data analysis was performed and data were saturated with 12 individual interviews. The findings indicated that nurses perceived POP as an individual phenomenon, and nurses responded to patients' pain by administering analgesics and by using nonpharmacologic measures. Factors that influenced the nurses' response were individual factors, such as commitment, discretion, fear of addiction, and organizational factors, such as organizational laxity and challenges of teamwork. The study recommended that nurses should be educated, supported, and encouraged to ensure pain relief after surgery and that they should see pain relief as a priority postoperative care to avert the negative repercussions of poorly managed POP.

Reasons for under-use of prescribed opioid medications by patients in pain

BACKGROUND

With the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do not take their medications as prescribed and find nonadherence rates of approximately 25%.

OBJECTIVE

To identify the prevalence of under-use of opioid medications and the reasons and implications of under-use.

DESIGN

As part of a variety of structured assessments, subjects were asked detailed questions about how they used their opioid medication in their daily lives.

PARTICIPANTS

One hundred ninety-one veterans who received an opioid prescription for any pain problem within the 12 months before the interview.

MEASURES

We defined a patient who under-used his/her medication as one who took less than their prescribed dose of medication and reported that pain impaired their ability to engage in normal daily activities.

RESULTS

Under-use of opioids (20%) was more common than over-use (9%), consistent with research on medication adherence. Patients who under-used their opioids offered the same reasons for under-use that patients report for other medications. However, while under-users reported more pain than other opioid users they filled only slightly fewer opioid prescriptions. Communication problems between patients and providers about opioids were common.

CONCLUSIONS

Improved communication between patients and providers and shared decision-making regarding opioid prescriptions may improve pain management and minimize the problems associated with over-prescription of opioids (i.e., diversion).

The challenge of caring for patients in pain: from the nurse's perspective

AIM

To increase understanding of what it is like for nurses to care for patients in pain.

BACKGROUND

Hospitalised patients are still suffering from pain despite increased knowledge, new technology and a wealth of research. Since nurses are key figures in successful pain management and research findings indicate that caring for suffering patients is a stressful and demanding experience where conflict often arises in nurses' relations with patients and doctors, it may be fruitful to study nurses' experience of caring for patients in pain to increase understanding of the above problem.

DESIGN

A phenomenological study involved 20 dialogues with 10 experienced nurses.

RESULTS

The findings indicate that caring for a patient in pain is a 'challenging journey' for the nurse. The nurse seems to have a 'strong motivation to ease the pain' through moral obligation, knowledge, personal experience and conviction. The main challenges that face the nurse are 'reading the patient', 'dealing with inner conflict of moral dilemmas', 'dealing with gatekeepers' (physicians) and 'organisational hindrances'. Depending upon the outcome, pain management can have positive or negative effects on the patient and the nurse.

CONCLUSIONS

Nurses need various coexisting patterns of knowledge, as well as a favourable organisational environment, if they are to be capable of performing in accord with their moral and professional obligations regarding pain relief. Nurses' knowledge in this respect may hitherto have been too narrowly defined.

RELEVANCE TO CLINICAL PRACTICE

The findings can stimulate nurses to reflect critically on their current pain management practice. By identifying their strengths as well as their limitations, they can improve their knowledge and performance on their own, or else request more education, training and support. Since nurses' clinical decisions are constantly moulded and stimulated by multiple patterns of knowledge, educators in pain management should focus not only on theoretical but also on personal and ethical knowledge.

How military nurses rationalize their postoperative pain assessment decisions

AIM

This paper is a report of a study to explore how military nurses rationalize their postoperative pain assessment decisions, particularly when these differ from patients' pain self-reports.

BACKGROUND

Postoperative pain is a complex phenomenon influenced by many factors that make assessment difficult. Nurses are taught to believe what patients say about their pain. However, their attitudes to pain are influenced by their cultural background and they may disagree with patients' self-reports. Military nurses belong to a military culture with different pain attitudes that may also influence their postoperative pain assessment.

METHOD

An ethnomethodological ethnography study was carried out in 2003. A purposive sample of 29 British military surgical/orthopaedic Registered Nurses were interviewed to identify their taken-for-granted assumptions and commonsense cultural knowledge surrounding postoperative pain assessment. The data were analysed using a systematic process of inductive reasoning aided by Non-numerical, Unstructured Data for Indexing, Searching and Theorizing (QSR N6, NUD*IST).

FINDINGS

Participants told two distinct stories in their postoperative pain narratives. The first, the cultural story, described how military nurses normally assess postoperative pain and revealed taken-for-granted assumptions surrounding this assessment. However, when military nurses believe that patients over- or under-report their pain, the cultural story was challenged through a collective story in which nurses used their commonsense knowledge to account for these differences.

CONCLUSION

Postoperative pain assessment within a military culture is complex, but all nurses need to be aware that their socialization into different nursing cultures may influence their attitudes to postoperative pain assessment.

Postoperative pain in older people: a review of the literature

AIMS AND OBJECTIVES

The literature review was conducted to explore those factors which complicate pain management in older people to inform future research, education and nursing practice in this area.

BACKGROUND

Acute pain management in hospitalized older people is complex because of the physiological changes of ageing, pharmacological factors and under-representation of this patient group in reported research about assessing acute pain.

METHODS

A review of the literature was undertaken using electronic databases and specified search terms, some hand searching was also used and included the grey literature, textbooks and conference proceedings. A computerized literature search was carried out using CINAHL, Bandolier, Cochrane, Medline, the British Nursing Index and the International Association for the Study of Pain website for the period 1992-2004. The search terms were acute pain, older people, elder care, pain assessment and acute pain services. Thirty-seven research-based reviews and published studies and 17 policy documents were included.

CONCLUSIONS

Managing acute pain well in older adults involves understanding the influence of a series of integrated factors: attitudes and beliefs, physiological ageing processes, pharmacological factors and the social construction of the older person in healthcare contexts.

RELEVANCE TO CLINICAL PRACTICE

This review offers new insight into those factors which, taken together, add complexity to managing acute pain in older people well. Moreover, nurses are the professional group mainly responsible for assessing pain, administering and now prescribing analgesia and evaluating the quality of pain relief in older people. On this basis, they are also the group most likely to effect improved patient outcomes.

Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study

AIM

The aim of this project was to examine pain management practices with older people admitted to the colorectal unit of an acute hospital trust.

BACKGROUND

Although pain assessment and management are judged to be a priority, little research has examined the care older people receive in the acute surgical setting. Thus, pain in older people (65 years and over) can be under recognized and unrelieved. With the number of older people requiring surgery increasing, it is important to identify factors in the practice context that enhance or inhibit effective pain management.

DESIGN

The project drew upon an in-depth ethnographic approach.

METHOD

Sixty-two hours of around the clock, non-participant observation of nursing practice was completed. Thirty-nine (78%) nurses and forty-six (42%) patients were observed. Seven (6%) additional patients participated in pre- and postoperative interviews and 35 (90%) nurses completed the Nursing Work Index--Revised Questionnaire.

FINDINGS

Holistic pain assessment for older people was found to be deficient in the acute surgical setting. Nurses appeared unaware of the importance of addressing the particular pain needs of older patients. Inflexible analgesic prescriptions provided the mainstay treatment of pain, with minimal consideration given to non-pharmacological strategies. Older people wanted to be active participants in their care. However, existing pain management practices disempowered older patients, making them reluctant or unable to discuss their pain with ward staff.

CONCLUSION

Comprehensive pain assessment, improved documentation and proficient communication, inclusive of older patients, are necessary to improve pain management practices. It is imperative that patients, nurses, doctors and Acute Pain Service work in collaboration to challenge pain management practices and implement change.

RELEVANCE TO CLINICAL PRACTICE

The project demonstrated some of the multiple and complex factors that affect the older persons' pain experience and identified three action research cycles for further development work.

Nurses' opportunistic interventions with patients in relation to smoking

AIM

This paper reports a study exploring nurses' provision of opportunistic health education on smoking for hospital patients.

BACKGROUND

Smoking cessation guidelines recommend assessment of patients' smoking habits and provision of smoking cessation advice when possible, and highlight the importance of the role of nurses in health promotion and health education. In the past, nurses have been criticized for lack of knowledge, skills and confidence in relation to health education and the perception that it is additional to, rather than integrated with, nursing care.

METHODS

A qualitative case study design was selected to explore the health education practice of 12 nurses working in acute wards in three general hospitals in Scotland. Data were collected in 2000 through non-participant observation, semi-structured interviews and the use of a radio-microphone to record nurse-patient interactions. The data analysis was guided by four key elements of health education practice: 'the teachable moment', 'readiness to learn', 'the provision of health information' and 'oral communication'.

FINDINGS

Smoking was part of the nurses' agenda, as most recognized opportunities to introduce health education on smoking during nursing care, suggesting a tentative move towards the integration of health education with nursing care. Evidence from patients' interactions indicated ample opportunity for nurses to provide smoking-related health information. However, the content of nurses' interactions on smoking was variable, with some limited by poor communication skills and inadequate knowledge of smoking and smoking cessation. The context of the interactions was also important in understanding some of the restrictions on conversational progress.

CONCLUSIONS

Nurses require the knowledge and skills to perform a health education role, and the inclusion of smoking cessation guidelines in nursing curricula would contribute to this. Where patients are in hospitals for short periods of time, opportunistic health education on smoking needs to be introduced as the basis for more specialist intervention.

Patients' decision-making strategies for managing postoperative pain

Despite technological advances, many postoperative patients continue to suffer unrelieved pain. The aim of this study was to identify the strategies used by postoperative patients to bring about pain management decisions. A single-group noncomparative study design was chosen using observations as the means of examining pain activities in 2 surgical units of a metropolitan teaching hospital in Melbourne, Australia. A total of 52 nurses and 312 patients participated in the study, and 316 pain activities were observed. The most common strategy used was patients acting as a passive recipient for pain relief (60%), whereas problem solving (23%) and active negotiation (17%) were less commonly used. Patients in this study were admitted for surgical treatment of a particular condition, and their subsequent pain was specifically related to this acute event. Therefore, the lack of familiarity of the situation and the severity of pain experienced may have encouraged passivity. Patients may have also felt uncertain about how to approach the pain decision, preferring to defer to nurses. Because increased pain levels can be associated with fear, patients could have been unwilling to speak with nurses to discuss their need for pain relief.

PERSPECTIVE

This paper shows that patient decision making for postoperative pain relief largely involves the use of passive requests, compared with problem solving and active negotiation. Effective communication must be supported between health professionals and patients if shared understandings about treatment options are to become a reality.

Improving assessment of postoperative pain in surgical wards by education and training

PROBLEM

There is a need to improve postoperative pain organisation and management in hospitals. One of the most important factors in achieving this is to improve active assessment of pain in the postoperative phase.

DESIGN

Repeated audits on an annual basis over a 3 year period. Ward nurses, appointed as "pain control representatives", performed the data collection.

SETTING

Departments of general surgery and orthopaedics in a university hospital with 1200 beds. KEY MEASURE FOR IMPROVEMENT: Assessment of postoperative pain intensity using a numerical rating scale.

STRATEGIES FOR CHANGE

On the basis of the first audit in 1999 the team decided to introduce a mandatory training programme in postoperative pain management for all involved staff, including surgeons and ward nurses. Guidelines for postoperative care were upgraded and made accessible through the intranet. Regular staff meetings in the surgical wards with representatives from the acute pain service team were introduced.

EFFECTS OF CHANGE

The assessment of pain according to protocols increased from 71% to 91% in the surgical wards and from 60% to 88% in the orthopaedic wards between 1999 and 2001/2.

LESSONS LEARNT

To increase the awareness of pain and improve pain assessment, the importance of mandatory training, regular staff meetings and regular audits must be emphasised. It is also imperative to give feedback on the regular audits to the ward and staff members involved.

Pain Management

Nursing students often have fear and anxiety about managing pain. The most common misconceptions include fear that patients in acute pain are easily addicted to pain medication, persons who are alert experience side effects from medication such as respiratory depression, and pain is inevitable and cannot completely be relieved. Cognitive restructuring is a method of changing behavior that focuses on identifying misconceptions, influencing distorted thinking, and thereby diminishing anxiety and promoting reasoned practice.

A literature review exploring how healthcare professionals contribute to the assessment and control of postoperative pain in older people

Little research has examined the care older people receive in the acute surgical setting. Although pain assessment and management are judged to be a priority in nursing, often pain, in older people, is undermanaged for a variety of reasons. Factors such as stoicism, communication and ageism can shape both the patients' and nurses' attitude towards the perception of pain which subsequently affects pain management. Through a review of the literature, this paper aims to: (i) identify how healthcare professionals contribute to the assessment and control of postoperative pain in older people and (ii) explore potential barriers to achieving more advantageous pain control in this group. It is suggested that to improve pain management there is a need to individualize pain assessment for older people and to assist clinicians with enhancing their education and decision-making abilities in this field. This may best be achieved by supporting a programme of change to develop the skills of staff and encouraging learning through reflective practice. There is however a need for further research in this area.