PD effluent specimen collection: Your questions answered

When a patient on peritoneal dialysis (PD) presents with suspected PD-related peritonitis (e.g. cloudy PD fluid and abdominal pain), one of the most important initial aspects of management is for the nephrology nurse/home dialysis nurse to collect PD effluent specimens for white blood cells count, Gram stain, culture and sensitivity for inspection and to send for laboratory testing before antibiotics are started. A review by seven members of the International Society for Peritoneal Dialysis (ISPD) Nursing Committee of all 133 questions posted to the ISPD website 'Questions about PD' over the last 4 years (January 2018-December 2021), revealed 97 posted by nephrology nurses from around the world. Of these 97 questions, 10 were noted to be related to best practices for PD effluent specimen collection. For our review, we focused on these 10 questions along with their responses by the members of the ISPD 'Ask The Experts Team', whereby existing best practice recommendations were considered, if available, relevant literature was cited and differences in international practice discussed. We revised the original responses for clarity and updated the references. We found that these 10 questions were quite varied but could be organised into four categories: how to collect PD effluent safely; how to proceed with PD effluent collection; how to collect PD effluent for assessment; and how to proceed with follow-up PD effluent collection after intraperitoneal antibiotics have been started. In general, we found that there was limited evidence in the PD literature to answer several of these 10 questions posted to the ISPD website 'Questions about PD' by nephrology nurses from around the world on this important clinical topic of best practices for PD effluent specimen collection. Some of these questions were also not addressed in the latest ISPD Peritonitis Guidelines. Moreover, when polling members of our ISPD Nursing Committee we found when answering a few of these questions, nursing practice varied within and among countries. We encourage PD nurses to conduct their own research on this important topic, focusing on areas where research evidence is lacking.

Scope and heterogeneity of outcomes reported in randomized trials in patients receiving peritoneal dialysis

BACKGROUND

Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD).

METHODS

We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics.

RESULTS

From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13-37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once.

CONCLUSIONS

Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance.

Meaning of empowerment in peritoneal dialysis: focus groups with patients and caregivers

BACKGROUND

While peritoneal dialysis (PD) can offer patients more independence and flexibility compared with in-center hemodialysis, managing the ongoing and technically demanding regimen can impose a burden on patients and caregivers. Patient empowerment can strengthen capacity for self-management and improve treatment outcomes. We aimed to describe patients' and caregivers' perspectives on the meaning and role of patient empowerment in PD.

METHODS

Adult patients receiving PD (n = 81) and their caregivers (n = 45), purposively sampled from nine dialysis units in Australia, Hong Kong and the USA, participated in 14 focus groups. Transcripts were thematically analyzed.

RESULTS

We identified six themes: lacking clarity for self-management (limited understanding of rationale behind necessary restrictions, muddled by conflicting information); PD regimen restricting flexibility and freedom (burden in budgeting time, confined to be close to home); strength with supportive relationships (gaining reassurance with practical assistance, comforted by considerate health professionals, supported by family and friends); defying constraints (reclaiming the day, undeterred by treatment, refusing to be defined by illness); regaining lost vitality (enabling physical functioning, restoring energy for life participation); and personal growth through adjustment (building resilience and enabling positive outlook, accepting the dialysis regimen).

CONCLUSIONS

Understanding the rationale behind lifestyle restrictions, practical assistance and family support in managing PD promoted patient empowerment, whereas being constrained in time and capacity for life participation outside the home undermined it. Education, counseling and strategies to minimize the disruption and burden of PD may enhance satisfaction and outcomes in patients requiring PD.

The Use of Community Nurses for Home Peritoneal Dialysis: Is it Cost -Effective?

In the late 1970s, continuous ambulatory peritoneal dialysis was first introduced as a mode of treatment for patients with end-stage renal disease. Since that time many patients, themselves or with the help of family members, have routinely performed the therapy at home. There are now 2935 home peritoneal dialysis patients in Canada (36% of the total dialysis population}. Today, however, the average patient on dialysis is likely to be older and have other complicating illnesses; moreover, patients may live alone, or have family members who are working.

Over the past three years, through the use of innovative assistive devices and strong educational links with community nursing agencies, we have been able to manage peritoneal dialysis patients with complex needs in the home. We performed a retrospective analysis of 18 patients, with severe comorbid conditions, who were managed in the home with the help of community nurses. We will show that this is an economic, efficient, and effective method of caring for home dialysis patients with severe disabilities. Home care agencies need our support so that they can continue to help us manage the complex peritoneal dialysis patient in the 1990s.

Establishing a Core Outcome Set for Peritoneal Dialysis: Report of the SONG-PD (Standardized Outcomes in Nephrology-Peritoneal Dialysis) Consensus Workshop

Outcomes reported in randomized controlled trials in peritoneal dialysis (PD) are diverse, are measured inconsistently, and may not be important to patients, families, and clinicians. The Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative aims to establish a core outcome set for trials in PD based on the shared priorities of all stakeholders. We convened an international SONG-PD stakeholder consensus workshop in May 2018 in Vancouver, Canada. Nineteen patients/caregivers and 51 health professionals attended. Participants discussed core outcome domains and implementation in trials in PD. Four themes relating to the formation of core outcome domains were identified: life participation as a main goal of PD, impact of fatigue, empowerment for preparation and planning, and separation of contributing factors from core factors. Considerations for implementation were identified: standardizing patient-reported outcomes, requiring a validated and feasible measure, simplicity of binary outcomes, responsiveness to interventions, and using positive terminology. All stakeholders supported inclusion of PD-related infection, cardiovascular disease, mortality, technique survival, and life participation as the core outcome domains for PD.

“Can I go to Glasgow?” Learnings from patient involvement at the 17th Congress of the International Society for Peritoneal Dialysis (ISPD)

Background:

Recognition of the discrepancy between the research priorities of patients and health professionals has prompted efforts to involve patients as active contributors in research activities, including scientific conferences. However, there is limited evidence about the experience, challenges, and impacts of patient involvement to inform best practice. This study aims to describe patient and health professional perspectives on patient involvement at the Congress of the International Society for Peritoneal Dialysis (ISPD).

Methods:

Semi-structured interviews were conducted with 14 patients/caregivers and 15 health professionals from six countries who attended ISPD. Interviews were recorded and transcribed verbatim, and transcripts were analyzed thematically.

Results:

We identified four themes: protecting and enhancing scientific learning (grounding science in stories, sharing and inspiring new perspectives, distilling the key messages of research presentations, striking a balance between accommodating patients and presenting the science); democratizing access to research (redistributing power, challenging the traditional ownership of knowledge, cultivating self-management through demystifying research); inadequate support for patient/caregiver delegates (lacking purposeful inclusion, challenges in interpreting research findings, soliciting medical advice, difficulty negotiating venue and program, limited financial assistance in attending); and amplifying impact beyond the room (sparking innovation in practice, giving patients and families hope for the future).

Conclusions:

Patient involvement at the ISPD Congress clarified the applicability of research to patient care and self-management, democratized science, and strengthened the potential impact of research. More structured support for patients to help them purposefully articulate their experience in relation to session objectives may enhance their contribution and their own learning experience.

An international Delphi survey helped develop consensus-based core outcome domains for trials in peritoneal dialysis

Shared decision-making about clinical care options in end-stage kidney disease is limited by inconsistencies in the reporting of outcomes and the omission of patient-important outcomes in trials. Here we generated a consensus-based prioritized list of outcomes to be reported during trials in peritoneal dialysis (PD). In an international, online, three-round Delphi survey, patients/caregivers and health professionals rated the importance of outcomes using a 9-point Likert scale (with 7-9 indicating critical importance) and provided comments. Using a Best-Worst Scale (BWS), the relative importance of outcomes was estimated. Comments were analyzed thematically. In total, 873 participants (207 patients/caregivers and 666 health professionals) from 68 countries completed round one, 629 completed round two and 530 completed round three. The top outcomes were PD-related infection, membrane function, peritoneal dialysis failure, cardiovascular disease, death, catheter complications, and the ability to do usual activities. Compared with health professionals, patients/caregivers gave higher priority to six outcomes: blood pressure (mean difference, 0.4), fatigue (0.3), membrane function (0.3), impact on family/friends (0.1), peritoneal thickening (0.1) and usual activities (0.1). Four themes were identified that underpinned the reasons for ratings: contributing to treatment longevity, preserving quality of life, escalating morbidity, and irrelevant and futile information and treatment. Patients/caregivers and health professionals gave highest priority to clinical outcomes. In contrast to health professionals, patients/caregivers gave higher priority to lifestyle-related outcomes including the impact on family/friends and usual activities. Thus, prioritization will inform a core outcome set to improve the consistency and relevance of outcomes for trials in PD.

Patient and Caregiver Priorities for Outcomes in Peritoneal Dialysis: Multinational Nominal Group Technique Study

BACKGROUND AND OBJECTIVES

The absence of accepted patient-centered outcomes in research can limit shared decision-making in peritoneal dialysis (PD), particularly because PD-related treatments can be associated with mortality, technique failure, and complications that can impair quality of life. We aimed to identify patient and caregiver priorities for outcomes in PD, and to describe the reasons for their choices.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients on PD and their caregivers were purposively sampled from nine dialysis units across Australia, the United States, and Hong Kong. Using nominal group technique, participants identified and ranked outcomes, and discussed the reasons for their choices. An importance score (scale 0-1) was calculated for each outcome. Qualitative data were analyzed thematically.

RESULTS

Across 14 groups, 126 participants (81 patients, 45 caregivers), aged 18-84 (mean 54, SD 15) years, identified 56 outcomes. The ten highest ranked outcomes were PD infection (importance score, 0.27), mortality (0.25), fatigue (0.25), flexibility with time (0.18), BP (0.17), PD failure (0.16), ability to travel (0.15), sleep (0.14), ability to work (0.14), and effect on family (0.12). Mortality was ranked first in Australia, second in Hong Kong, and 15th in the United States. The five themes were serious and cascading consequences on health, current and impending relevance, maintaining role and social functioning, requiring constant vigilance, and beyond control and responsibility.

CONCLUSIONS

For patients on PD and their caregivers, PD-related infection, mortality, and fatigue were of highest priority, and were focused on health, maintaining lifestyle, and self-management. Reporting these patient-centered outcomes may enhance the relevance of research to inform shared decision-making.

Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD): Study Protocol for Establishing a Core Outcome Set in PD

BACKGROUND

Worldwide, approximately 11% of patients on dialysis receive peritoneal dialysis (PD). Whilst PD may offer more autonomy to patients compared with hemodialysis, patient and caregiver burnout, technique failure, and peritonitis remain major challenges to the success of PD. Improvements in care and outcomes are likely to be mediated by randomized trials of innovative therapies, but will be limited if the outcomes measured and reported are not important for patients and clinicians. The aim of the Standardised Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) study is to establish a set of core outcomes for trials in patients on PD based on the shared priorities of all stakeholders, so that outcomes of most relevance for decision-making can be evaluated, and that interventions can be compared reliably.

METHODS

The 5 phases in the SONG-PD project are: a systematic review to identify outcomes and outcome measures that have been reported in randomized trials involving patients on PD; focus groups using nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choice of outcomes; semi-structured key informant interviews with health professionals; a 3-round international Delphi survey involving a multi-stakeholder panel; and a consensus workshop to review and endorse the proposed set of core outcome domains for PD trials.

DISCUSSION

The establishment of 3 to 5 high-priority core outcomes, to be measured and reported consistently in all trials in PD, will enable patients and clinicians to make informed decisions about the relative effectiveness of interventions, based upon outcomes of common importance.

ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part II - Management of Various Cardiovascular Complications

Cardiovascular mortality has remained high in patients on peritoneal dialysis (PD) due to the high prevalence of various cardiovascular complications including coronary artery disease, left ventricular hypertrophy and dysfunction, heart failure, arrhythmia (especially atrial fibrillation), cerebrovascular disease, and peripheral arterial disease. In addition, nearly a quarter of PD patients develop sudden cardiac death as the terminal life event. Thus, it is essential to identify effective treatment that may lower cardiovascular mortality and improve survival of PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendation statements regarding lifestyle modification, assessment and management of various cardiovascular risk factors, and management of the various cardiovascular complications to be published in 2 guideline documents. This publication forms the second part of the guideline documents and includes recommendation statements on the management of various cardiovascular complications in adult chronic PD patients. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. We also define areas where evidence is clearly deficient and make suggestions for future research in each specific area.

A Syllabus for Teaching Peritoneal Dialysis to Patients and Caregivers

Being aware of controversies and lack of evidence in peritoneal dialysis (PD) training, the Nursing Liaison Committee of the International Society for Peritoneal Dialysis (ISPD) has undertaken a review of PD training programs around the world in order to develop a syllabus for PD training. This syllabus has been developed to help PD nurses train patients and caregivers based on a consensus of training program reviews, utilizing current theories and principles of adult education. It is designed as a 5-day program of about 3 hours per day, but both duration and content may be adjusted based on the learner. After completion of our proposed PD training syllabus, the PD nurse will have provided education to a patient and/or caregiver such that the patient/caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively. The course may also be modified to move some topics to additional training times in the early weeks after the initial sessions. Extra time may be needed to introduce other concepts, such as the renal diet or healthy lifestyle, or to arrange meetings with other healthcare professionals. The syllabus includes a checklist for PD patient assessment and another for PD training. Further research will be needed to evaluate the effect of training using this syllabus, based on patient and nurse satisfaction as well as on infection rates and longevity of PD as a treatment.

ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part I - Assessment and Management of Various Cardiovascular Risk Factors

Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.

A change to radiological peritoneal dialysis catheter insertion: three-month outcomes

BACKGROUND

Best practices for peritoneal dialysis (PD) catheter insertion call for timely placement of catheters to reduce complications and increase the likelihood of a successful initiation of PD. The purpose of our study was to assess if a change in approach to PD catheter insertion, including a switch to radiological insertion of PD catheters and introduction of a dialysis access nurse to coordinate all patient care, was associated with more outpatient procedures and achievement of guideline-based outcomes, including timelier PD starts. ♢

METHODS

We conducted a single-center retrospective chart review of all patients that had their first PD catheter inserted at our center over a 7-year period ending in 2007. ♢

RESULTS

PD catheters were placed in 88 patients by interventional radiology and in 125 patients by surgical insertion during an earlier period. Insertion of PD catheters by interventional radiology was significantly associated with a higher rate of outpatient procedures (70% vs 32%, p < 0.0001) than surgical placement. At PD start, 82% of patients that underwent radiological insertions had an estimated glomerular filtration rate of over 8 mL/minute/1.73 m(2) and their mean serum albumin level was 38.2 g/L. ♢

CONCLUSIONS

The new procedure of radiological insertion of PD catheters, coordinated by a dedicated dialysis access nurse, was associated with more outpatient procedures than the earlier surgical method and allowed patients to receive a PD catheter with timing consistent with clinical practice recommendations.

A systematic review of factors influencing decision-making in adults living with chronic kidney disease

OBJECTIVE

To identify factors influencing patient involvement in decision-making in the context of chronic kidney disease (CKD) and effective interventions to support their decision-making needs.

METHODS

A systematic review included studies and decision support tools that involved: (1) adults with CKD, (2) studies published from 1998-2008; and (3) a focus on patient decision-making needs, and/or barriers and facilitators to shared decision-making. Studies were quality appraised.

RESULTS

Forty studies were appraised. These studies mainly focused on the decisions patients with CKD faced around the choice of renal replacement therapy and withholding/withdrawing dialysis. Moreover, studies typically focused on health care professional's provision of information about the decision rather than identifying decisional conflict and supporting patients in decision-making. No studies were found that identified the patient's point of view about factors that might influence or inhibit quality decision-making. Factors influencing CKD patient's participation in decision included: (1) interpersonal relationships; (2) preservation of current well being, normality and quality of life; (3) need for control; and (4) personal importance on benefits and risks. Of the four patient decision aids identified, none had been evaluated for effectiveness.

CONCLUSION

Patients with CKD face decisions that are likely to cause decisional conflict. Most studies focused on information needs related to renal replacement therapy and withdrawing or withholding dialysis. There was less focus on other decision-making needs in the context of those choices and across the trajectory of CKD. Although patient decision aids and implementation of shared decision-making have been evaluated in patients with other medical conditions, little is known about interventions to support patients with CKD making quality decisions.

PRACTICE IMPLICATIONS

Patients with CKD have decision-making needs across the trajectory of their illness. Although little is known about supporting patients with CKD decision-making, support could be provided with protocols and tools that have been developed for other chronic illness situations. Development of CKD-specific clinical practice guidelines that include decision support best practices could benefit CKD patients. Research priorities include development and evaluation of CKD focused decision support tools and processes.

Meeting the guidelines for end-of-life care

The number of patients initiating dialysis in most countries continues to increase, with the greatest increase being in the oldest age group. Clinical practice guidelines have been developed to help the nephrology team with end-of-life carefor patients on dialysis. The aim of the project reported here was to assess if we were meeting the guidelines. We conducted a retrospective cohort study of all patients 80 years of age and older who had started dialysis at our center Our cohort included 105 patients (50% men; median age: 84.5 years; age range: 80-95 years), of whom 55% were on hemodialysis and 45% were on peritoneal dialysis (PD). Overall life expectancy was 2.1 years. Among the 59 patients who died while still part of our program, 92% had a do not resuscitate order in place, and 46% had withdrawn from dialysis. Palliative care was consulted in 46% of cases. Dyspnea and pain were the two most common symptoms in the last 24 hours of life. Of these 59 patients, 71% died in hospital. Only 6 patients died at home, all of these being on home PD. End-of-life care for this elderly cohort of dialysis patients could be improved on several measures to meet clinical practice guidelines, especially with greater access to palliative care units and community palliative care programs.

The psychological well-being of renal peer support volunteers

AIM OF THE STUDY

The purpose of this study was to describe the characteristics of renal peer support volunteers (PSVs) and explore the effects on their psychological well-being from helping others.

BACKGROUND

Dialysis patients, transplant patients and family members who become renal PSVs receive special training in empathy, listening, self-awareness and problem solving. The trained renal PSVs offer a unique service to others struggling to learn to live with renal failure because they have faced the same struggles.

METHODS

This exploratory study utilized a longitudinal design. The first time for data collection was immediately after the volunteers had completed a Kidney Foundation of Canada training programme. Subsequent interviews were at time intervals of 4, 8 and 12 months after the first interview. Information on the psychological well-being of the volunteers was collected at each interview in two different ways: the 38-item Mental Health Inventory (MHI) and open-ended questions.

FINDINGS

Thirty-one PSVs completed all four interviews. The average age of the volunteers was 45 years and almost half had a university level of education. They identified themselves as belonging to 12 different ethno-cultural groups. Analysis of the quantitative data from the MHI indicated that the mental health of the PSVs stayed remarkably stable over time. Analysis of the qualitative data from the open-ended questions revealed four major themes which, taken together, showed notable increases in personal growth and well-being for the PSVs over time.

CONCLUSION

After participating in a training programme, renal PSVs maintained, and possibly improved, their own well-being by helping others with chronic renal failure.

A writing workshop for the CANNT Journal

Writing for publication requires special skills and understanding. The aim of this workshop held by the co-editors of the CANNT Journal was to help participants identify the first steps needed to initiate the process of writing for publication. During the workshop, the attendees were invited to join small groups with a facilitator for each group. The individual groups identified what they considered to be their first five steps to writing for publication. This information from each group was shared with all the attendees. At the end of the session, helpful tools to aid potential authors were identified and thoughts on future writing workshops were discussed.

Care of the hemodialysis patient with a new permanent vascular access: review of assessment and teaching

Problems related to vascular access are the main reasons for admission to hospitals for hemodialysis patients today. Some patients develop vascular access problems prior to use and many require repeated surgery. This article addresses some of the key aspects of patient assessment and monitoring in the immediate preoperative/postoperative period. The focus is on the prevention of early vascular access failure. Approaches for patient teaching are included, as are strategies that should be part of a vascular access management program.

A comparison of two methods of measuring fatigue in patients on chronic haemodialysis: visual analogue vs Likert scale

The study compared level of fatigue measured by two self-report instruments in 43 patients on chronic haemodialysis. The two fatigue measures were the multi-item fatigue subscale of the Profile of Mood States (POMS) and a single-item visual analogue scale (VAS). There was a significant relationship between the two measures (r = 0.80); however, the shared variance was only 64%. Males and females, as well as subjects of different ages, responded to the two scales in different ways. Nurses need to know that different tools may give different results, even when the same concept, that is fatigue, is being measured in the same subjects at the same time.

Peritonitis in patients on peritoneal dialysis: a review of pathophysiology and treatment

The incidence of peritonitis has decreased in peritoneal dialysis patients because of new delivery systems and connecting devices; however, peritonitis is still of major concern. Peritonitis remains the most common reason for admission to hospitals and is still a primary reason for failure of this method of dialysis. Nephrology nurses need a clear understanding of peritonitis etiology, recommended treatment regimens, side effects of treatment, and complications. This should enable nephrology nurses to provide a higher level of care, and, thus, improve patient well-being.

What do nurses know and believe about patients with pain? Results of a hospital survey

Nurses in every area of clinical practice are confronted with the challenge of caring for patients in pain. The purpose of this study was to determine nurses' knowledge and attitudes regarding pain in the acute and long-term care settings of a large Canadian teaching hospital. This paper reports the results of a pain survey completed by 514 nurses using the Nurses' Knowledge and Attitudes Survey (Ferrell and Leek, 1990). The mean percent score was 41. Nurses with a university education scored significantly higher (P < 0.0001) than those nurses who were not university prepared. Nurses who had attended educational sessions on pain management within the last year also scored significantly higher (P < 0.0001) than those who had not attended. Results indicated that nurses lacked knowledge and understanding of basic pain management principles, opioid usage, and acute and chronic pain. These results supported the value of advanced educational preparation and continuing education sessions for nurses, and the need and direction for pain management programs at this hospital.