Helplessness and powerlessness: caring for clients in pain

Exploratory study of "real world" implementation of a clinical poverty tool in diverse family medicine and pediatric care settings

Background

Poverty is associated with increased morbidity related to multiple child and adult health conditions and increased risk of premature death. Despite robust evidence linking income and health, and some recommendations for universal screening, poverty screening is not routinely conducted in clinical care.

Methods

We conducted an exploratory study of implementing universal poverty screening and intervention in family medicine and a range of pediatric care settings (primary through tertiary). After attending a training session, health care providers (HCPs) were instructed to perform universal screening using a clinical poverty tool with the question “Do you ever have difficulty making ends meet at the end of the month?” for the three-month implementation period. HCPs tracked the number of patients screened and a convenience sample of their patients were surveyed regarding the acceptability of being screened for poverty in a healthcare setting. HCPs participated in semi-structured focus groups to explore barriers to and facilitators of universal implementation of the tool.

Results

Twenty-two HCPs (10 pediatricians, 9 family physicians, 3 nurse practitioners) participated and 150 patients completed surveys. Eighteen HCPs participated in focus groups. Despite the self-described motivation of the HCPs, screening rates were low (9% according to self-reported numbers). The majority of patients either supported (72%) or were neutral (22%) about the appropriateness of HCPs screening for and intervening on poverty. HCPs viewed poverty as relevant to clinical care but identified time constraints, physician discomfort, lack of expertise and habitual factors as barriers to implementation of universal screening.

Conclusions

Poverty screening is important and acceptable to clinicians and patients. However, multiple barriers need to be addressed to allow for successful implementation of poverty screening and intervention in health care settings.

Protection against perceptions of powerlessness and helplessness during palliative care: The family members' perspective

Objective:

Resilience in relation to coping with stress, loss, and bereavement has recently received increased attention. The aim of the current study was to describe aspects that are experienced as a protection against powerlessness and/or helplessness during advanced palliative home care (APHC) or as a help when coping with such perceptions.

Method:

Both family members during ongoing APHC and family members 3–9 months after the patient's death responded (in total, N = 233; response rate 72%) to a postal questionnaire with mainly open-ended questions. The text responses were analyzed using Manifest Content Analysis.

Results:

Protection against powerlessness and helplessness had been facilitated by a stable patient condition, the patient coping well, a trusting relationship with the patient, practical and emotional support from family and friends, access to palliative expertise, and staff support that was both individually-focused and cooperative. Other aspects that had helped or protected family members against powerlessness and helplessness were a belief that they had their own reliable knowledge to manage the difficult situation, talking to someone, doing good for the patient, distracting activities, acceptance, meaning and hope, and an inner feeling of security.

Significance of results:

The findings are discussed in relation to existential psychology, the dual process model of coping with bereavement, and repressive coping. Clinical implications are suggested.

Nurses' Reassessment of Postoperative Pain After Analgesic Administration

OBJECTIVES

To identify when and how nurses reassess patients' pain after analgesic administration in the postoperative context.

METHODS

Fifty-two nurses were observed caring for postoperative patients (N=364) in 2 surgical settings in a major metropolitan hospital. Seventy-four observation periods of 2 hours duration were studied. The research assistant observed nurses' activities in caring for the allocated patients', detailing behavioral and verbal responses onto audiotape.

RESULTS

Of the 316 pain activities that occurred in 74 observation periods, 14 (4.4%) were reassessments after analgesic administration. Four themes were evident from the 14 reassessments: opportunistic reassessment, the use of simple questioning, a focus on surgical wound pain not procedural pain, and nurse-initiated reassessment.

CONCLUSIONS

Despite the focus on meeting standards of care in the area of pain management, there was an extraordinary lack of patient reassessment by nurses after the administration of analgesics. Given the raised awareness internationally on assessment generally and a lack of evidence focused on reassessment after an intervention, this may explain why research is failing to identify shifts in pain severity scores and indeed patient pain.

Temperament and character personality dimensions in patients with nonspecific musculoskeletal disorders

OBJECTIVE

The aim of this study was to investigate temperament and character dimensions in a group of patients with nonspecific musculoskeletal disorders and to show how personality is related to pain and psychologic distress in pain patients.

METHOD

A total of 78 patients with musculoskeletal disorders were compared with a matched control group of 118 nonpatients. The Temperament and Character Inventory, the Symptom Check List, and the Multidimensional Pain Inventory were used.

RESULTS

The pain patients differed significantly from the controls and exhibited a personality profile with high harm avoidance and low self-directness, which indicate that patients with nonspecific musculoskeletal pain disorders can be characterized as being cautious, insecure, and pessimistic. In addition, they can be described as having difficulties in accepting responsibility, lack of long-term goals, chronically low self-esteem, and struggle with identity. This is probably a salient characteristic of patients with chronic pain. The results also showed that personality dimensions had a stronger correlation to psychologic distress than to pain. The result indicated that harm avoidance probably is an important personality trait in anxiety states.

CONCLUSIONS

The results underline the importance of using instruments assessing personality and psychologic symptoms in patients with nonspecific musculoskeletal disorders both as diagnostic tools and in treatment planning.

Acute pain management: implications of scientific evidence for nursing practice in the postoperative context

Unrelieved acute pain remains prevalent in hospitalized patients despite advances in pain management. A decade after the Australian National Health and Medical Research Council called for improved pain management practices by health professionals, it released clinical guidelines to provide clinicians with current scientific evidence to augment their clinical decision-making. This paper examines the implications of national guidelines on nursing practice and highlights the inadequacies of current implementation policies. Pain management guidelines have failed to decrease patients' postoperative pain because organizations and researchers have ignored the impact of contextual influences on clinicians' decision-making. It is recommended that for successful implementation of national guidelines to occur at the local level of practice, organizations must assist clinicians to identify local influences on their decision-making, to address the issues specific to their own work environment and to evaluate any changes in practice.

Pain and the administration of analgesia: what nurses say

Pain of moderate to severe intensity continues to be an important problem for many hospitalized patients. Nurses spend more time with patients than any other health professional group and have a key role to play in the management of patients' pain. This paper reports the findings from a series of focus group interviews which were undertaken to explore nurses' perceptions regarding pain and the administration of narcotic analgesia. Themes identified from participants' comments related to (1) the pivotal role of nurses in pain management; (2) nursing assessment and pain management decisions (3) individual factors influencing nurses' pain management decisions and (4) the influence of others on nurses' pain management decisions.

Feelings of powerlessness in relation to pain: ascribed causes and reported strategies. A qualitative study among Dutch community nurses caring for cancer patients with pain

This qualitative study focused on the causes for the feelings of powerlessness experienced by dutch community nurses in caring for cancer patients with pain. In addition, the study focused on the strategies community nurses employed to cope with feelings of powerlessness. Semistructured interviews revealed the following ascribed causes for feelings of powerlessness: problems in communication between community nurses and patients and between community nurses and personal physicians, dilemmas concerning physical care and opiates, and discrepancies between community nurses' pain management goals and what can realistically be achieved. The main strategies for reducing feelings of powerlessness were sharing feelings with the patient and colleagues, increasing knowledge and skills, and standing back from the situation.

Qualitative Needs Assessment Prior to a Continuing Education Program

The usefulness of qualitative research is illustrated by the presentation of a needs assessment among Dutch surgical cancer nurses and patients. Participant observations and qualitative interviews showed that nurses usually did not assess pain systematically, gave insufficient pain medication, were unaware of the effectiveness of some nonpharmacological techniques, and often felt powerless in giving psychosocial support. Patients appeared inhibited in expressing pain and inhibition was reinforced by ineffective interactions with nurses. using these findings, a continuing education program on pain assessment and management was developed.