Exploring how bedside nurses care for patients with chronic pain: a grounded theory study

Concept Analysis of Moral Distress in Pain Management

OBJECTIVE

Managing pain continues to be a difficult issue worldwide. Pain management has ethical connotations, with the potential to result in moral distress in nurses. The aim of this concept analysis is to analyze moral distress in pain management.

DESIGN

Walker and Avant's method of concept analysis was utilized to determine attributes, antecedents, and consequences of moral distress in pain management.

METHODS

Literature searches in The Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, Web of Science, and Pub Med were performed. The search identified and utilized 16 articles in the concept analysis.

RESULTS

Four major attributes of moral distress in pain management are discussed: (1) feeling of ownership of patient pain, (2) perceived powerlessness, (3) frustration, and (4) feelings of conflict between pain management situation, personal values, and professional values of nursing. Antecedents were patients experiencing pain, barriers, and having knowledge of the right thing to do. Consequences included nurse burnout, turnover and exit from the profession, compromised patient care, emotional withdrawal from patients, depersonalization of patients, and feelings of complicity and wrongdoing.

CONCLUSIONS

This concept analysis provides a foundation for future research examining moral distress in pain management.

Effects of Education on Nurses' Knowledge and Attitudes of Pain Management in a Postoperative Cardiovascular Unit

BACKGROUND

This project explores the impact of an educational in-service on nurses' knowledge and attitudes toward pain on a postoperative cardiovascular unit.

METHOD

A convenience sample of nurses employed on the postoperative cardiovascular intensive care unit (n = 82) were asked to participate in this project, with 74 nurses attending the in-service training. Surveys that were 70% complete were used for analysis (preeducation, n = 22; posteducation, n = 24).

RESULTS

The results from this project demonstrated that the use of a brief educational in-service is effective and efficient in increasing nurses' knowledge and attitudes related to pain management in this group of nurses. Posteducation survey scores were significantly higher than preeducation survey scores (p < .001).

CONCLUSION

These findings suggest that a brief educational in-service on pain management can improve nurses' knowledge and attitudes on pain management in this postoperative cardiovascular unit. [J Contin Educ Nurs. 2020;51(8):377-383.].

Postoperative Pain Management: A Bedside Perspective

PURPOSE

Postoperative pain management is an ongoing challenge in surgical care, during which inadequate relief can contribute to postoperative complications, and nurses are key figures in this process. The aim of the present study was to gain knowledge of how nurses provide postoperative pain management for women undergoing major surgery for endometriosis.

DESIGN

An ethnographic field study, consisting of semi-structured interviews and participant observations, was conducted in a setting of 2 gynecological units within a large Scandinavian university hospital.

METHOD

The participants were mainly nurses and patients. The overall focus for the field observations and interviews was on how the participants interacted and made care decisions concerning pain. The analysis focused on nurse-patient interaction in postoperative bedside care. A principal theme, pain-related nursing practice emerged, together with the sub-themes nurse-patient interaction, interpretation and assessment of pain and pain management, which represented a circular process, identified in bedside practice.

CONCLUSIONS

To some extend the postoperative pain management was influenced by unexpressed health beliefs and routine actions, and patient involvement was not prominent. Furthermore, the existing guidelines for pain management did not seem useful to the nurses.

CLINICAL IMPLICATIONS

There is a need to develop a new and more practice-oriented postoperative pain management, in ways that also integrate the patient experience.

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Background

People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.

Objectives

(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.

Design

We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.

Data sources

We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.

Results

We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.

Limitations

There are no agreed methods for determining confidence in QESs.

Conclusions

We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.

Future work

Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain

OBJECTIVES

We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care.

DESIGN

Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high.

CONCLUSIONS

This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.

A qualitative evidence synthesis to explore healthcare professionals' experience of prescribing opioids to adults with chronic non-malignant pain

Background

Despite recent guidelines suggesting that patients with chronic non-malignant pain might not benefit, there has been a significant rise in opioid prescription for chronic non-malignant pain. This topic is important because an increasing number of HCPs are prescribing opioids despite very limited evidence for long-term opioid therapy for chronic non-malignant pain outside of end-of-life care. To better understand the challenges of providing effective treatment, we conducted the first qualitative evidence synthesis to explore healthcare professionals’ experience of treating people with chronic non-malignant pain. We report findings that explore healthcare professionals’ experience of prescribing opioids to this group of patients.

Methods

We searched five electronic bibliographic databases (Medline, Embase, CINAHL, PsychINFO, AMED) from inception to November 2015 and screened titles, abstracts and full texts of potential studies. We included studies in English that explored healthcare professionals’ experience of treating adults with chronic non-malignant pain. Two reviewers quality appraised each paper. We used the methods of meta-ethnography developed and refined for large reviews, and the GRADE-CERQual framework to rate confidence in review findings.

Results

We screened 954 abstracts and 184 full texts, and included 77 studies in the full review. 17 of these 77 studies included concepts that explored the experience of prescribing opioids. We abstracted these concepts into 6 overarching themes: (1) Should I, shouldn’t I? (2) Pain is Pain; (3) Walking a fine line; (4) Social guardianship; (5) Moral boundary work; (6) Regulations and guidelines. We used the GRADE-CERQual framework to evaluate confidence in findings. A new overarching concept of ‘ambiguity’ explains the balancing required around the factors taken into account when prescribing opioids. Managing this ambiguity is challenging and these findings can inform healthcare professionals dealing with these decisions.

Conclusions

This conceptual model demonstrates the complexity of making a decision to prescribe opioids to someone with chronic non-malignant pain. Although opioid prescription is underpinned by the therapeutic aim of alleviating pain, this aim may be misplaced. This has implications for education in light of the new regulations for opioid prescription. Findings also demonstrate that the decision is influenced by intra- and interpersonal factors and broader external concerns.

POSTOPERATIVE PAIN: MANAGEMENT AND DOCUMENTATION BY IRANIAN NURSES

Background:

Pain is one of the most common symptoms experienced by patients after surgeries. Inadequate postoperative pain management is an international problem and the need to improve its management is well documented. The aim of the study was to assess nursing reports related to the patients’ pain intensity and quality, concomitant symptoms, use of scales in pain assessment, and compliance with the national guideline after surgery.

Methods:

This study was a retrospective cohort; samples were nurse records of patients who had elective surgery.

Result:

Only 6% of the patients’ pain records included pain intensity which was not measured with standard scales. More than half of all injections were opioid analgesic which is in contrast to the guidelines of the Iranian Ministry of Health. Pain assessment was higher in women and by nurses with more than 15 years of working experience.

Conclusion:

to conclude, the patients’ pain was not assessed properly in terms of intensity, quality, and associated symptoms. Therefore, training and motivating nurses is very important in this context and should be incorporated in nurses’ academic and continuous educational courses.

Knowledge and Beliefs about Chronic Non Cancer Pain Management for Family Medicine Group Nurses

To provide effective care for chronic pain sufferers, nurses must have a knowledge of chronic pain management. In Quebec, nurses working in Family Medicine Groups (FMGs) could play a major role in helping patients with chronic noncancer pain (CNCP); however, the extent of their knowledge about CNCP management is unknown. The primary goal of this study was to explore the knowledge and beliefs of FMG nurses about CNCP management. The secondary goal was to explore the obstacles seen by these nurses as preventing them from performing CNCP management. We used a mixed-methods design with quantitative preponderance. Fifty-three FMG nurses answered a self-administered mail-in questionnaire. A rigorous data collection method was used. FMG nurses have suboptimal knowledge about CNCP management. They identify their lack of training and lack of knowledge as major obstacles to conducting pain management interventions. There is a need for pain management training specifically designed around the realities of FMG nursing.

Nurses Managing Patients’ Pain May Experience Moral Distress

Bedside nurses care for patients with pain every day but the task is often challenging. A previous qualitative study that investigated nurses’ experiences as they treated patients with pain suggested that nurses may suffer from moral distress if they are unsuccessful in providing adequate pain relief. As 20 of the original 48 nurses interviewed described frustration and distress when constrained from doing the right thing to provide pain relief for their patients, the purpose of this secondary qualitative analysis was to answer new research questions on nurse moral distress related to managing pain. Findings indicated that difficulties in nurse/physician communication and lack of pain education were contributors to nurses’ frustrations and provided barriers to optimal pain management. Many participants indicated a need for interprofessional pain management education. Further investigation is needed to clarify the impact of moral distress on nurses managing hospitalized patients’ pain.