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The Importance of Education for Effective Pain ManagementErica Rene LewisOur Lady of the Lake College December 3, 2013Keeley DupuyNURS: 4915Capstone AbstractThe purpose of this paper is to investigate the effectiveness of post licensure pain management education, through the use of continuing education for nurses, working in a clinical care setting. “Pain management is an important component of postoperative care in patients of all ages” CITATION Smi12 \p 1 \l 1033 (Smith, 2012, p. 1) and providing comfort for the patient both physically and emotionally is the job of the nurse. However, patient’s pain is going untreated due to the nurses’ inadequate knowledge of pain assessment and management. A quasi-experimental design (in the form of a questionnaire) was completed by six nurses working on the Trauma-Neuro Critical Care Unit (TNCC) of Our Lady of the Lake Regional Medical Center to determine if a continuing educational program focusing on pain assessment would improve the nurse’ ability to manage the pain level of the patients in their care. Of the six participants, two representing 22% scored below an 80% on the questionnaire. Based on the results, there is a clear need for the establishment of clinical pain management guidelines and pharmacological/non-pharmacological training. This training would improve the nurses’ ability to effectively assess pain levels and to proficiently provide effective pain management care to all patients. Table of Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc247607890 \h 4Literature Review PAGEREF _Toc247607891 \h 5Methods PAGEREF _Toc247607892 \h 10Design PAGEREF _Toc247607893 \h 10Subjects and settings PAGEREF _Toc247607894 \h 11Limitations PAGEREF _Toc247607895 \h 12Data evaluation and analysis PAGEREF _Toc247607896 \h 12Ethical considerations PAGEREF _Toc247607897 \h 12Results PAGEREF _Toc247607898 \h 13Conclusion PAGEREF _Toc247607899 \h 13References PAGEREF _Toc247607900 \h 15Appendix PAGEREF _Toc247607901 \h 17The Importance of Education and Pain ManagementIntroduction“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage”, and is one of the major reasons people are seeking medical care assistance (International Association for the Study of Pain: Pain Definition, 2011). “Pain is a subjective phenomenon and is triggered by a number of factors such as: age, sex, culture, and previous experiences with pain” CITATION Owa08 \l 1033 (Oware-Gyekye, 2008). However, an important factor to note is that pain tolerance and sensitivity is different for men, women and children. Each individual’s experience with pain should be addressed through effective pain management and control. For example, children possess limited capability of pain expression because of its unfamiliarity, and this can hinder them from communicating what they are experiencing. Whereas, as adults we adapt the necessary skills to either suppress or seek health care assistance when pain becomes unbearable. There is no evidence that our reaction to pain differ based on gender, however, “cultural influence on gender may produce different expressions of pain”CITATION Owa08 \p 51 \l 1033 (Oware-Gyekye, 2008, p. 51). In addition, a communication barrier, such as language, can also affect how health care providers manage pain in their patients. Pain can be a debilitating experience and its existence can hinder a person from performing their basic life skills, such as walking, bathing, or caring for themselves, thus affecting their quality of life. As a result, pain management should be held to the highest regard for all nurses in order to ensure that their patients are comfortable while under their care. Many nurses do not trust the judgment of their patient’s self- reported pain level when asked to rate their pain on a scale of 1-10 (10 being the most severe). Consequently, there has been a consistent theme in the literature for a lack of knowledge concerning pain assessment and management CITATION AlS11 \l 1033 (Al-Shaer, Hill, & Anderson, 2011). Therefore, due to nurse’s inadequate knowledge of assessment and management of pain, the patient’s pain is going untreated. Al-Shaer et al. (2011) mentions, “Nurses need current knowledge and appropriate attitudes regarding pain assessment and management regardless of patient age and origin of clinical practice” (p. 7). Patients enter into the care of hospitals for various reasons, and each department caters specifically to the patients’ needs, including pain management. Although the severity of patient’s pain levels differs from unit to unit, the nurse’s knowledge of pain management and assessment should be consistent.This paper will discuss the lack of knowledge regarding pain management among nurses from varying units. In addition, the purpose of this paper is to review literature that investigates the effectiveness of post licensure pain management education, in the form of continuing education, for nurses working in ta clinical setting. I hypothesize that establishing clinical pain management guidelines and pharmacological/non-pharmacological training will enable nurses to adequately assess pain levels and proficiently provide effective pain control. Literature ReviewAllcock et al. (2011) states “today’s critical care nurses are faced with the challenge of providing effective and efficient pain management while trying to sustain the lives of their patients.” Allcock et al. (2011) conducted a study in order to explore the challenges of a nurse in the critical care unit in regards to providing pain management. The findings from this qualitative study, which are similar to those found in McNamara, Harmon & Saunders (2012) study, shows that the problem in regards to pain management is due to the lack of the critical care nurses’ ability to recognize and promptly provide treatment for patients in pain. To manage patient’s pain successfully, nurses need to know the physiology of pain, myths and misconceptions about pain, how to assess pain, patients’ behaviors when in pain, pharmacological and non-pharmacological pain-management techniques and ethical issues in pain management (Ferrell et al.1993, Wang & Tsai, 2009 pg. 3189).The participants from McNamara et al. (2012) mixed method experimental study stated, “pain assessment should be carried out every 24 hours, as opposed to one to two hourly” (p.962). However, contrary to their beliefs, pain assessment should be carried out every four hours. If pharmacological interventions are utilized, its effectiveness should be evaluated 30 minutes after the patient takes the medication. Medication follow-up is an important task that nurses are required to perform in order to evaluate the effectiveness of the pain control measures being taken. In addition, pain management is an interdisciplinary intervention that requires the collaboration of nurses, health care professionals, the patient as well as family members. The nurses in Allcock et al. (2011) study relied heavily on the opinions of pain expert’s, which included the anesthetist, intensivist and acute pain team when providing pain management interventions, because they felt they lacked similar expertise. Recent studies on the issue of pain management suggest that there are limitations in the area of nursing knowledge related to pain management practice and there is a need for standardized pain management to guide nurses in decision making (McCaffery et al. 2000, Jacobi et al. 2002, Puntillo et al. 2002, Aslan et al. 2003, Shannon & Bucknall 2003, Allcock et al. 2011 p.1258). The nurses expressed the need for clinical guidelines in order to guide their clinical practice and reduce the under treatment of patient’s pain (Allcock et al. 2011). Wang et al. (2010) states that the under treatment of the patients pain on the ICU unit is due to the improper documentation of the patients stated pain level. “ICU nurses have consistently rated their patients pain lower than the patient’s self-reported pain” (Puntillo et al. 1997, Shannon & Bucknall 2003, Wang et al. 2009 p.3194).The limitations of the nurses knowledge of pain management due to their lack of clinical education and training impedes their clinical judgment when collaborating with healthcare team members, the patient and family. Wang et al. (2009) found within their cross-sectional study that the lack of knowledge of ICU nurses was related to their educational level, nursing clinical position, type of ICU and hospital accreditation category. “Nurses need to be equipped with adequate knowledge of pain management in making accurate and relevant clinical judgments” (Allcock et al. 2011, pg. 1259). Therefore, non-verbal and verbal cues should be viewed during the assessment and evaluation of pain management. It is imperative that nurses not only be knowledgeable, but trained on how to properly intervene for their patients when they’re experiencing a pain level outside of their acceptable range. Education alone may not change clinical nursing practice. Health care organizations need to institutionalize pain management practices by incorporating basic principles of pain assessment and management into daily practice (Berry &Dahl, 2000; Al-Shaer et al. 2011, pg. 10)As stated, education alone does not make a nurse competent in providing pain control. However, nurses must be equipped with the necessary skills in order to adequately identity and meet the needs of all patients’ pain levels. “The participants felt that when training was provided, nurses’ knowledge was retained and they felt more confident in caring for their patients” (Allcock et al. 2011, pg. 1258). Information is retained when one is able to skillfully apply what one has been taught. Although knowledge about pain management is a necessity in order to practice as a nurse, training and clinical experience is also a factor in the continuing development of a nurse’s practice. 20.3% admitted that they lacked the ability to assess pain and 23.8% thought that they did not have adequate knowledge about dealing with pain. Showing a gap between ICU nurses’ actual knowledge and their perceived knowledge CITATION Wan09 \p 3194 \l 1033 (Wang & Tsai, 2009, p. 3194). NcNamare et al. (2012) & Machira, Kariuki & Martindale (2013) both found within their studies that there was an improvement in the attitudes and knowledge of those nurses who participated in educational programs. As stated in Machira et al. (2013) there is a “need for continuous professional development (CPD), as professional development ensures that nurses’ knowledge and skills are kept up to date and remains relevant (Quinn & Hughes, 2007), improving patient care” (pg. 345). In order to make sure a nurse remains competent post licensure, pain management experience should not stop in the classroom but should continue in the clinical environment. According to Wilson (2007), though educational programs contribute to the increase in knowledge regarding pain, “it is the clinical environment that has a significant influence on the development and application of knowledge on pain management” (McNamara et al. 2012, p. 958). Pain management education and training should be consistent across all nursing academia since pain is a sensation that is universally pain. Nurses on different units tend to possess varying degrees of knowledge toward pain management due to the different levels of experience and education. The nurses understanding and actions to control pain in the patient are essential for the well-being of the patient. The registered nurses (RNs) of Al-Shaer et al. (2011) study were competent in their understanding of pain management and assessment. However, they lacked knowledge of pharmacological intervention. In regards to pharmacological intervention a discrepancy exited in the nurses’ knowledge of side effects to medication, medication dosage and duration of action (Al-Shaer et al. 2011). However, analgesics use isn’t the only way to suppress painful stimuli. “Some studies have shown that relaxation therapy is effective in decreasing pre-operative anxiety in surgical patients, in decreasing postoperative pain and in speeding postoperative recovery” (DeMarco-Sinatra 2000, Schaffer &Yucha 2004, Lin, Chiang, Chiang &Chen 2008, p. 2033). Lin et al. (2008) conducted a quasi-experimental study showing that after nurses completed courses on relaxation therapy, they were more inclined to include this pain management method into their practice. In the study conducted by Al-Shaer et al. (2011) there were no significant differences noted between nurses based on educational level. The veteran and oncology nurses were considerably more knowledgeable about pain as opposed to nurses on a different unit. In addition, the oncology nurses advanced knowledge of assessment and pain management is due to their “holistic and palliative approach, which are central to orientation and continuing education for oncology nurses” (Al-Shaer et al. 2011, pg. 10). Although Dalton et al. (1996) was unsuccessful in his attempt to conduct a continuing educational program on the knowledge of pain management in cancer patients, palliative care is essential to the quality of life of those with terminal illnesses and should be included in nurses’ health training (Machira et al. 2013).Health policies are rules set in place within a society using decision making, planning, and utilizing actions to achieve specific health care goal. Humana is a health care insurance company whose pain management services for their members are provided through OrthoNet. OrthoNet evaluates the medical necessity of the services and request any needed medical records. The following services are provided through OrthoNet: pain infusion pumps (back and neck pain only), spinal fusions, Epidural injections (outpatient only) etc.… CITATION Hum13 \l 1033 (Humana , 2013). “Patients and health professionals continue to report that pain in often inadequately managed in hospitals and community settings” (Godfrey, 2005, Ogston-Tuck 2012, p. 514). When caring for the older adult in a community the nurses must possess better assessment skills in order to better detect pain in this populationMethodsDesign A quasi-experimental pre and posttest approach was taken in order to assess the effects of an educational program on the nurse’s knowledge of pain assessment and management. A seven-item pretest consisting of 5 assessment and 2 non-pharmacological questions (figure1) was administered to evaluate the participant’s baseline knowledge of pain management. A posttest would be administered following an online course. Information on how to develop a training course was gathered from the Manager of Clinical Experiences in the training and development department of the Our Lady of the Lake Regional Medical Center. In following the Institutional Review Board (IRB) process certification would be obtained and a proposal would be composed before conducting the study. The proposal would include the purpose of the research, plans on how the research would be carried out and all the materials used to conduct the research. However, before submitting a proposal an IRB application would be completed. A PowerPoint presentation documenting pain management would be composed based on low scores achieved in particular content areas regarding pain. The PowerPoint presentation would be reviewed and evaluated by the Clinical Educator for flaws and redundancy. After evaluation and approval by the Clinical Educator, the Training Specialist would upload it as a computer-based module onto to the Decision Critical Application. Next, the modules would be assigned to each nurse based their recorded score on the pre-test. Scores lower that 80% would require enrollment into the online course. In order to gain access to their modules the nurses would enter their employee login on a work based computer. The participants would be given six to eight weeks to complete the online-based course. There would be three modules in this online course: assessment, pharmacological and non-pharmacological pain interventions. If the participants do not complete the modules within the allotted time frame they will be suspended without pay until it is completed. In order to keep the nurses compliant with completing their course, the nurse manager will be contacted electronically by email the fourth week after the modules have been assigned to remind them of the nurses who are required to complete the modules. Subjects and settings The study would be conducted at Our Lady of the Lake Regional Medical Center. The sample size would consist of six registered nurses (RNs) on the Trauma-Neuro Critical Care (TNCC) unit. This is a 10-bed unit with two patients assigned to each nurse. Inclusion would be based on having at least three years of clinical experience on the TNCC unit, hold a BSN degree, providing direct patient care during the study and being an employee of the hospital where the study is being conducted. Nurses were excluded if they had less than one-year experience on the TNCC unit or a new nurse orientee.Limitations There were limitations to this study due to sample size and demographics of the nursing staff. The participants were all female and only one unit was considered for this study. There was a lack of randomization when selecting the participants. The pretest used in this study showed no validity and reliability due to its lack of the evaluation of the nurses’ pharmacological background and minute consideration of non-pharmacological itemsData evaluation and analysisData was collected using a pretest to evaluate the nurse beginning level of knowledge in regards to pain management. All six nurses participated in completed the pretest. The instruments used in this study were the Decision Critical Application and Microsoft Office (Excel, PowerPoint &Word). The participant’s knowledge of the content presented in the modules would be evaluated using a posttest to which they will have to make an 80% or higher to be consider competent. The nurses’ were evaluated on a 7-point grading scale. The participants would be given the same test in order to evaluate the effectiveness of the online training. Ethical considerationsBefore conducting this study approval from the IRB of the research institute would first have to be obtained. Permission to distribute the pre-test to the nurses on the unit was obtained from the nurse manager. Participants were informed that entry into the study was completely voluntary and that they could withdraw at anytime during the study period. It was explained that consent would be implied if they choose to complete the pre-test. Before administering the pre-test the purpose, both the benefits and penalization and selection criteria of the study were also clearly explained. No identifying information was asked of potential participants. The nurses were told that their results to both the pre and posttest would be made available to them and the confidentially would be maintained through the use of codes, rather than names. Results One hundred per cent of the sample completed the pre test (n=6). Of the six participants only two participants (22%) scored below an 80%. Table 1 shows how the nurses scored on the pretest. Majority of the nurses on this unit was knowledgeable about how to assess their patients for pain as represented by the test. The most frequently missed question pertained to non- pharmacological interventions for pain, however some assessment questions were missed (Table. 2). Items 5 and 6 of the pre test explored non-pharmacological intervention for pain and 22% of the participants answered correctly. The effect of the pain management education program on the nurses’ knowledge could not be evaluated because a posttest was not administered. Due to the lack of reliability of the pre/posttest and the fact that only one unit was considered this study would not contributed nor helped resolve the issue of the nurses’ lack of knowledge of pain management. ConclusionIn the closing of this paper it has been discovered that patients pain have been undertreated due to the lack of pain management knowledge on behalf of the nurse. Improvement in the pain management skills of the nurses is imperative because they are involved in direct care of their patients. Nurses are responsible for providing both pharmacological and non-pharmacological pain relieving interventions in order to increase their patient’s outcomes. Although the test lack reliability the results of this study indicates majority of the nurses were knowledgeable about pain management. With advancement in professional knowledge and skills of the nurse, improvement can be made in the quality of care of the patient and shorten their stay in the hospital. Because nurses in different departments deal with varying degrees of pain, and most come in contact with it more often than others. Some nurses’ lack the clinical experience needed to maintain the knowledge they once obtained. However, with the incorporation of continuing educational programs nurses’ knowledge of pain management and assessment has said to be improved. References1. BIBLIOGRAPHY Allcock, N., James, V., & Lathlean, J. (2011). Challenges faced by nurses in managing pain in critical care setting. Journal of Clinical Nursing , 1254-1260.2. Al-Shaer, D., Hill, P. D., & Anderson, M. A. (2011). Nurses' Knowledge and Attitudes Regarding Pain Assessment and Intervention. MedSurg Nursing , 1-10.3. American Nurses Credentialing Center. (2013). ANNC. Retrieved November 25, 2013, from ANNC: Pain Management Nurse Exam Sample Questions: . Aslan FE, Badir A & Selimen D (2003) How do intensive care nurses assess patients’ pain? Nursing in Critical Care 8, 62–675. Berry, P.H., & Dahl, J.L. (2000). The new JCAHO pain standards: Implications for pain management nurses. Pain Management Nursing, 1(1), 3-12.6. DeMarco-Sinatra J (2000) Relaxation training as a holistic nursing intervention. Holistic Nursing Practice 14, 30–39.7. Ferrell BR, Grant M, Ritchey KJ, Ropchan R & Rivera LM (1993) The pain resource nurse training program: a unique approach to pain management. Journal of Pain & Symptom Management 8, 549–556.8. Flanagan J (1954) The critical incident techniques. Psychological Bulletin 51, 327–358.9. Godfrey H (2005) Understanding pain, part 1: physiology of pain. Br J Nurs14(16):846-5210. Humana . (2013). Humana: Pain Management . Retrieved November 30, 2013, from Humana : . International Association for the Study of Pain: Pain Definitions [Retrieved 10 Sep 2011]. "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage" Derived from Bonica JJ. The need of a taxonomy. Pain. 1979;6(3):247–8. doi:10.1016/0304-3959(79)90046-0. PMID 460931.12. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D & Wittbrodt ET (2002) Clinical practice guidelines for the sus- tained use of sedatives and analgesics in the critically ill adult. Critical Care Medicine 30, 119–141.13. Lin, P.-C., Chiang, H. W., Chiang, T.-T., & Chen, C.-S. (2008). Pain management:evaluating the effectiveness of an efucational programme for surgical nursing staff. Journal of Clinical Nursing , 2032-2040.14. Machira, G., Kariuki, H., & Martindale, L. (2013). Impact of an educational pain management programme on nurses' pain knowledge and attitudes in Kenya . International Journal of Palliative Nursing , 341-345.15. McNamare, M. C., Harmon, D., & Saunders, J. (2012). Effects of education on knowledge, skill and attitutdes around pain . Bristish Journal of Nursing , 958-963. 16. Oware-Gyekye, F. (2008). Pain managemnent: The role of the Nurse . West African Journal of Nursing , 50-54.17. Puntillo KA, Kehrle K, Gleeson S & Nye P (1997) Relationship between behavioral and physiological indicators of pain, critical care patients’ self-reports of pain and opioid administration. Critical Care Medicine 25, 1159–1166.18. Puntillo K, Stannard D, Miaskowski C, Kehrle K & Gleeson S (2002) Use of a pain assessment and intervention nota- tion (P.A.I.N.) tool in critical care nursing practice: nurses’ evaluations. Heart and Lung 31, 303–314.19. Quinn FM, Hughes SJ (2007) Quinn’s Principles and Practice of Nurse Education. 5th edn. Nelson Thornes Limited, UK20. Schaffer SD & Yucha CB (2004) Relaxation and pain management: the relaxation response can play a role in managing chronic and acute pain. American Journal of Nursing 104, 75–76, 78–79, 81–82.21. Shannon K & Bucknall T (2003) Pain assessment in critical care: what have we learnt from research. Intensive and Critical Care Nursing 19, 154–162.22. Smith, N. (2012, December 7). Pain Management in Adults, Posteroperative. Nursing Practice & Skills , pp. 1-4.23. Wang, H.-L., & Tsai, Y.-F. (2009). Nurses' knowledge and barriers regarding pain management in intensive care units . Journal of Clinical Nursing , 3188-3195.AppendixFigure 1.By completing the survey you are implying informed consent.? There is no risk to completing this competency test Which statement indicates the development of opioid tolerance?Larger doses of opioids are needed to control pain compared to several weeks earlier.Stimulants are needed to counteract the sedating effects of opioids.The patient becomes anxious about knowing the exact time of the next dose of opioid.The patient no longer experiences constipation from the usual dose of opioid.When assessing a patient's cultural beliefs about pain, the pain management nurse asks about:A family history of pain.Home remedies used to treat pain.The frequency of visits to health care facilities.The patient's dietary preferences.When assessing a patient for possible side effects related to acetaminophen (Tylenol), the pain management nurse asks the patient about the use of:Alcohol.Marijuana.Opioids.Tobacco. A 45-year-old male patient reports pain in his foot that moves up along his calf. The patient states, "My right foot feels like it is on fire." The patient further describes that he has no previous history of injuries or falls, and that his pain started yesterday. Which components of pain assessment has the patient reported?Aggravating and alleviating factorsExacerbation, and associated signs and symptomsIntensity, temporal characteristics, and functional impactLocation, quality, and onsetWhich behavioral therapy works best to relieve pain with muscle tension and spasms in patients who are anxious about their pain?DistractionHypnosisRelaxationStress managementWhich non-pharmacologic intervention is difficult to use with older adults who are cognitively impaired?AromatherapyDistractionGuided imageryHeat applicationThe pain management nurse notices a male patient grimacing as he moves from the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse's response is to:Clarify the patient's report by reviewing the patient's nonverbal behavior.Confronting the patient's denial of pain.Obtaining an order for pain medication.Supporting the patient's stoic behaviorCITATION Ame131 \l 1033 (American Nurses Credentialing Center, 2013)Table 1. Distribution of Letter Grades for the Pain Management Knowledge Pretest(N=6)GradesPercent CorrectN (%)A94-1000B87-930C80-864 (66. 7)D77-791 (16.7)F≤741 (16.6)Table 2. Most Frequently Missed ItemsIncorrect Which behavioral therapy works best to relieve pain with muscle tension and spasms in patients who are anxious about their pain 66.7%The pain management nurse notices a male patient grimacing as he moves form the bed to a chair. The patient tells the nurse that he is not experiencing any pain. The nurse’s response is to:33.3% ................
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