Patients' experiences and actions when describing pain after surgery--a critical incident technique analysis

The Use and Perceptions of the Defense and Veterans Pain Rating Scale by Nursing Personnel

BACKGROUND

In 2010, the Office of the US Army Surgeon General recommended the Veterans Administration (VA) assess pain using the Defense and Veterans Pain Rating Scale (DVPRS). One item in the DVPRS is for measuring pain intensity. This item contains a combination of five response metrics: categories, faces, colors, numbers, and functional descriptors. A few studies have supported patients' and health care providers' preferences for the DVPRS and its psychometric properties. However, they also left uncertainties about its usability and validity.

AIMS

To advance our understanding of the DVPRS, this study examined the use and perceptions of the DVPRS' pain intensity item by nursing personnel during multi-modal care.

DESIGN

A cross-sectional survey design was used.

SETTING

VA Community Living Center.

PARTICIPANTS

Nursing personnel.

METHODS

Nursing personnel answered closed- and open-ended survey questions during a single session.

RESULTS

Nursing personnel reported sufficient training before implementing the measure and that patients primarily used the numeric metric. When patients used a non-numeric metric, the nursing personnel responded in variable ways. In addition, the nursing personnel interpreted the functional descriptors differently. The nursing personnel also noted the need to supplement the pain intensity item with patients' pain duration and pain location.

CONCLUSIONS

Results from this study inform the nursing community about the DVPRS' pain intensity item, which combines multiple response metrics. The results support the need for nursing units to generate and standardize procedures for using the item to measure multi-site pain and for interpreting and documenting patients' non-numeric responses. The effects of such procedures on the measure's usability and psychometric properties warrants additional investigation.

Perioperative Comfort and Discomfort: Transitioning From Epidural to Oral Pain Treatment After Pancreas Surgery: A Qualitative Study

PURPOSE

To explore patients' experiences of pain treatment in the perioperative period after surgery for pancreatic cancer.

DESIGN

A qualitative descriptive design using semi-structured interviews.

METHODS

This study was a qualitative study based on 12 interviews. Participants were patients that had undergone surgery for pancreatic cancer. The interviews were conducted 1 to 2 days after the epidural was turned off, in a surgical department in Sweden. The interviews were analysed with qualitative content analysis. The Standard for Reporting Qualitative Research checklist was used for reporting the qualitative research study.

FINDINGS

The analysis of the transcribed interviews, generated one theme: Maintaining a sense of control in the perioperative phase, and two subthemes: (i) Sense of vulnerability and safety, and (ii) Sense of comfort and discomfort, were found.

CONCLUSIONS

The participants experienced comfort after pancreas surgery if they maintained a sense of control in the perioperative phase and when the epidural pain treatment provided pain relief without any side effects. The transition from epidural pain treatment to oral pain treatment with opioid tablets was experienced individually, from an almost unnoticed transition to the experience of severe pain, nausea, and fatigue. The sense of vulnerability and safety among the participants were affected by nursing care relationship and the environment on the ward.

A qualitative study exploring the lived experiences of patients living with mild, moderate and severe frailty, following hip fracture surgery and hospitalisation

It is well recognised that hip fracture surgery is associated with a negative impact on short and long-term post-operative physical health and emotional well-being for patients. Furthermore, these patients are known to be frail with multiple co-morbidities. This study explores how frailty shapes the lived experiences of rehabilitation and recovery for patients who have undergone hip fracture surgery. Semi-structured interviews were conducted with sixteen participants, recently discharged from hospital following hip fracture surgery. Interpretative phenomenological analysis was applied to explore the lived experiences of frail patients and ascertain important themes. Patient experiences were captured in seven overarching themes: 1) the hospital as a place of "safety", 2) placing trust in others, 3) the slow recovery journey impeded by attitude and support, 4) maintaining autonomy and dignity whilst feeling vulnerable, 5) seeking a new normal, 6) loneliness and social isolation and 7) the ageing body. Based on our study findings, we have been able to suggest a number of opportunities to improve support for frailer patients in finding a new routine to their everyday lives, these include on-going physical and psychological support, information and education and a robust pathway for transition of care into the community. A conceptual thematic diagram is presented which helps to understand the experience and the complex needs of frail older people undergoing hip fracture surgery.

The patient's "story": an examination of patient-reported safety incidents in general practice

BACKGROUND

Patient safety incidents (PSIs) are typically studied through engagement with healthcare providers, without input from patients despite their privileged viewpoint of care experiences.

OBJECTIVES

To examine the potential of the patient viewpoint as a lens for future safety improvement initiatives, by: (i) collecting and analysing patients' accounts of PSIs; and (ii) comparing patient and clinician perceptions of PSIs.

METHODS

Firstly, Critical Incident Technique (CIT) interviews were used to obtain rich descriptions of PSIs, which were then condensed into patient stories. Deductive content analysis was used to code the safety deficiencies described in patient stories using patient-derived safety categories. Secondly, General Practitioners (GPs) and patients individually rated the perceived severity and likelihood of each story.

RESULTS

A total of 32 eligible patient stories were obtained from 25 interviews. Stories commonly described deficiencies related to communication, staff performance, and compassion/dignity/respect. There were significant differences in GP (n = 14) and patient (n = 11) severity and likelihood ratings. GPs were significantly more likely to consider stories to be a lower severity, and occurring with a lower frequency than patients.

CONCLUSION

Elicitation of the patient perspective using the CIT allowed for the rich description of safety deficiencies that occur in general practice. Given that patients bring a unique and important viewpoint on safety, there is a need to make greater efforts to include the patient perspective of safety in healthcare.

Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis

Background

Health care workers (HCWs) are at high risk of occupational injuries and approximately 10–15% of patients are affected by an adverse event during their hospital stay. There is scarce scientific literature about how HCWs manage these risks in practice and what support they need. This knowledge is needed to improve safety for patients and HCWs. This study explores HCWs’ experiences of workplace incidents that led to injury or posed a risk of patient and worker injury, with focus on HCWs’ emotions and actions.

Methods

This study employed a qualitative design using the critical incident technique. Semi-structured individual interviews were held with 34 HCWs from three regions in Sweden. Data were analysed using inductive category development.

Results

Altogether 71 workplace incidents were reported. The analysis of two dimensions – the emotions HCWs feel and the actions team members and managers take when a workplace incident occurs – yielded two categories each: Anxiety during the incident, Persistent distress after the incident, Team interplay for safety actions and Support and ratification from managers and colleagues. Health care workers risked their own safety and health to provide patient safety. Teamwork and trustful relationships were critical for patient and worker safety. Support and validation from colleagues and managers were important for closure; unsatisfactory manager response and insufficient opportunities to debrief the incident could lead to persistent negative emotions. Participants described insecurity and fear, sadness over being injured at work, and shame and self-regret when the patient or themselves were injured. When the workplace had not taken the expected action, they felt anger and resignation, often turning into long-term distress.

Conclusions

Work situations leading to injury or risk of patient and worker injury are emotionally distressing for HCWs. Team interplay may facilitate safe and dynamic practices and help HCWs overcome negative emotions. Organizational support is imperative for individual closure. For safety in health care, employers need to develop strategies for active management of risks, avoiding injuries and providing support after an injury.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06517-x.

In the eye of a quiet storm: A critical incident study on the quarantine experience during the coronavirus pandemic

OBJECTIVE

In 2020, the COVID-19 appeared in Italy with an exponential transmission capacity and serious consequences for the whole population. To counter the spread of the virus, the Italian government has adopted an extensive lockdown, forcing citizens to stay at home and avoid social contact. The COVID-19 quarantine represents a unique phenomenon in the recent centuries, and its long-term consequences on people's lives and mental health are still to be understood. This study aimed to explore significant experiences of people who did not contract the virus, yet experienced the quarantine as a potentially stressful condition.

METHODS

Italians who did not contract the COVID-19 were invited to participate in semi-structured interviews employing the Critical Incident Technique. Interviews were designed to capture the significant experiences related to the lockdown period in Italy. Participants were asked to describe the most significant (1) negative and (2) positive critical events that they personally experienced during the ongoing quarantine. Such events were meant to provide information on their experience of the quarantine as a whole. The audio-taped interviews were transcribed verbatim and analyzed following Critical Incident Technique's indications.

RESULTS

Twenty two participants described a total of 43 critical events, including 22 negative episodes and 21 positive events experienced during the COVID-19 quarantine. Three categories emerged from the negative episodes and four categories emerged from the positive events described by the participants. Relevant themes both positive and negative concerned mostly relationships (with partners, family, and friends), and the alteration of everyday activities, Also a specific "sensation of emergency" that the participants felt during the pandemic emerged, as an emotionally-charged response to quarantine-related external stimuli.

CONCLUSIONS

To our knowledge this is the first in-depth qualitative study investigating the significant negative and positive events that people experienced during the COVID-19 quarantine. Future research could employ analogous event recollection methods but focus on other populations (e.g., fragile subjects or on other national contests), in order to extend the information on the quarantine experience and its possible long-lasting effects.

What narrative devices do people with systemic sclerosis use to describe the experience of pain from digital ulcers: a multicentre focus group study at UK scleroderma centres

OBJECTIVES

Digital ulcers (DUs) are a common complication in systemic sclerosis (SSc). No existing studies have specifically reported on the qualitative patient experience of DU pain, and our current patient-reported outcome measure (PROM) does not capture the multifaceted painful experience of SSc-DU. Our aim was to examine the patient experience of SSc-DU pain.

DESIGN

Focus groups with people diagnosed with SSc who had experienced DUs were conducted using a topic guide developed by people with SSc, experts in SSc and experienced qualitative researchers. Focus groups were continued until data saturation had been reached. The focus groups were audio recorded, transcribed verbatim, anonymised and analysed using inductive thematic analysis. Our current study is an integration of the data from these focus groups to specifically examine the patient experience of DU pain.

SETTING

Three specialist scleroderma units across the UK (Bath, Manchester and London).

PARTICIPANTS

Four focus groups were undertaken; 29 adults (20 women, 9 men) with SSc and a spectrum of historical DUs participated. We included participants with a diverse demographic (including ethnic) background and disease-related characteristics.

RESULTS

Five narrative devices were identified, which encompass how people describe the pain from SSc-DUs: 'Words to express DU-associated pain', 'Descriptions of physical and psychological reactions to pain', 'Comparisons with other painful events', 'Descriptions of factors that exacerbate pain' and 'Descriptions of strategies for coping with the pain'.

CONCLUSION

The experience of SSc-DU pain leads to the use of graphic language and rich description by participants in the focus group setting. Existing SSc-DU outcomes do not adequately capture the patient experiences of SSc-DU pain. Our findings further highlight the multifaceted nature of SSc-DUs and will hopefully support the development of a novel PROM to assess the severity and impact of SSc-DUs.

Violence and aggression in psychiatric inpatient care in Sweden: a critical incident technique analysis of staff descriptions

BACKGROUND

Violence towards staff working in psychiatric inpatient care is a serious problem. The aim of the present study was to explore staff perspectives of serious violent incidents involving psychiatric inpatients through the following research questions: Which factors contributed to violent incidents, according to staff? How do staff describe their actions and experiences during and after violent incidents?

METHODS

We collected data via a questionnaire with open-ended questions, and captured 283 incidents reported by 181 staff members from 10 inpatient psychiatric wards in four different regions. We used the Critical Incident Technique to analyse the material. Our structural analysis started by structuring extracts from the critical incidents into descriptions, which were grouped into three chronological units of analyses: before the incident, during the incident and after the incident. Thereafter, we categorised all descriptions into subcategories, categories and main areas.

RESULTS

Staff members often attributed aggression and violence to internal patient factors rather than situational/relational or organisational factors. The descriptions of violent acts included verbal threats, serious assault and death threats. In addition to coercive measures and removal of patients from the ward, staff often dealt with these incidents using other active measures rather than passive defence or de-escalation. The main effects of violent incidents on staff were psychological and emotional. After violent incidents, staff had to continue caring for patients, and colleagues provided support. Support from managers was reported more rarely and staff expressed some dissatisfaction with the management.

CONCLUSIONS

As a primary prevention effort, it is important to raise awareness that external factors (organisational, situational and relational) are important causes of violence and may be easier to modify than internal patient factors. A secondary prevention approach could be to improve staff competence in the use of de-escalation techniques. An important tertiary prevention measure would be for management to follow up with staff regularly after violent incidents and to increase psychological support in such situations.

Engagement and availability in shaping nurses' management of postoperative pain: a qualitative study

Background

Studies reporting inadequate nursing care for patients indicate that nurses are negatively affected in such situations, and research is needed to study nursing care in postoperative situations.

Objective

To describe situations of postoperative pain management in a surgical ward in Thailand.

Methods

A qualitative approach using the Critical Incident Technique was chosen to investigate situations of postoperative pain management from the perspective of surgical nurses in Thailand. Data were collected through multiple semi-structured interviews with nine nurses over a five-week period.

Results

The situations of surgical nurses described three elements that heavily influenced the quality of postoperative pain management: engagement in a trustful nurse-patient relationship, availability of pain medication and nursing care when needed, and imbalance between meeting the patient’s needs and completing routine nursing duties.

Conclusion

The results help to expand our understanding of how Thai nurses manage pain in postoperative situations and indicate areas that could be improved in terms of how nurses respond to patients’ pain. Nurses challenge existing guidelines and facilitate development of new nursing guidelines and/or policies in pain management.

"It breaks your soul": An in-depth exploration of workplace injustice in nursing

AIM(S)

To understand nurses' experiences of injustice in the workplace and to identify the impact of injustice on well-being.

BACKGROUND

Little is known about how nurses view injustice or its effects on their well-being, although research indicates that such perceptions are central to workplace practices such as performance management and outcomes such as employee well-being.

METHOD(S)

A qualitative study was conducted with semi-structured interviews for nurses employed in Australian public hospitals. Data were analysed using content analysis.

RESULTS

Experiences of injustice and unfairness negatively impacted on performance and the personal health of nurses. Unfair treatment was met with reduced effort and commitment.

CONCLUSION(S)

This study provides valuable insights into how nurses perceive and experience injustice at work and supports the link between injustice and nurses' decreased well-being and effectiveness.

IMPLICATIONS FOR NURSING MANAGEMENT

Implications for nurse managers include the need for managers to engage in regular conversations regarding systemic barriers to performance and implementing performance management as an ongoing dialogue designed for employee voice and relationship management. This process also suggests a need for leadership development in nursing management. Using such steps and strategies would significantly enhance best practice in nursing management.

Nursing actions that create a sense of good nursing care in patients with wet age-related macular degeneration

AIMS AND OBJECTIVES

To identify and describe nursing actions performed by nurses that create a sense of good nursing care in patients with wet age-related macular degeneration.

BACKGROUND

People who suffer from wet age-related macular degeneration risk central vision loss. Treatment with antivascular endothelial growth factor is the only available option at present that preserves vision and no definitive cure currently exists. Patients feel that they are compelled to accept this treatment because they might otherwise become blind.

DESIGN

An explorative and descriptive design based on the critical incident technique was used.

METHOD

Interviews with 16 Swedish patients who all had received intravitreal treatment for wet age-related macular degeneration.

RESULTS

Two main areas of good nursing care were identified: 'Being perceived as an individual' and 'Being empowered'. The first area was divided into two categories: being respectful and being engaged. Being respectful was observed when nurses had a benevolent attitude towards their patients and answered questions kindly and politely. Patients saw themselves as individuals when nurses were available for conversation and focused on them. The second area was divided into two categories: encouraging participation and creating confidence. Encouraging participation refers to when nurses provided information continuously. Nurses instilled confidence and trust in their patients by keeping promises and by being honest.

CONCLUSIONS

A respectful interaction between patients and caregivers is necessary for patients to obtain beneficial health care.

RELEVANCE TO CLINICAL PRACTICE

Patient interviews revealed important information about nursing actions that created a sense of good nursing care in patients with wet age-related macular degeneration. Nurses acknowledged people as individuals and created trust by building partnerships and sharing decision-making. To address each patient's concerns, nurses need to prioritise each patient's narrative and participation by documenting agreements in their medical record.