Pathophysiology - Poor Pain Management in Hospitals - Nursing Care Assessment Answer

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Case Scenario

Background

Acute pain is commonly experienced throughout the world and forms an important aspect of surgery, childbirth, acute medical illness and injury. It also accounts for a majority of emergency department visits in Australia and across the globe (Finnerup et al 2015). Inadequate pain control and management in hospital settings has been linked with various severe consequences. It serves to increase hospital stay, deteriorates quality of life and is an added financial burden (Yuxiang et al 2012). Further, it also acts as an added stressor for nursing professionals tending to the patient and trying to manage pain effectively (Rawlinson et al 2012).

Despite several advances in pain research and an increased focused on effective pain control, management in hospital settings remains suboptimal. A part of the problem lies in improper identification of all barriers which might impact pain management (Duke et al 2013). Although various studies have been conducted to identify barriers which prevent professionals from adequately managing pain in hospital settings, findings are diverse and unclear (Kozlowski et al 2014).

This outlines the need for undertaking a comprehensive review of literature and identifying main causes of poor pain management in hospitals.

Assignment Task

Why is pain poorly managed in a hospital setting?

Introduction

Trauma is considered as the major reason behind maximum mortalities all over the world. Science has also made major advances in the field of managing pain in trauma patients. The advancement in the management of pain in trauma patient has reduced mortality and enhanced the functioning of the management techniques (Cohen, Christo & Moroz, 2004; Hogan & Perron, 2011). Improvement in the pain management technique has increased comfort for the trauma patients and also reduced the long term adverse effects of trauma. However, there might be some barriers in administering pain management in trauma patients. The article “Facilitators and barriers in pain management for trauma patients in the chain of emergency care” is selected to identify the barriers and facilitators in the pain management in trauma patient. The study also finds facilitators as well as barriers in the chain of emergency services, which display the organizational aspects of pain management.

Literature Review

The author provided the relevant literature review and started with stating that how acute pain is related to trauma. The author justified his statement of linking acute pain with trauma by stating the substantial impact of trauma on the patient’s nociceptor pathway. According to the author the main complaint of pain is seen in the patient’s seeking emergency care (Zempsky & Cravero, 2004). The author also provides the evidence for the major barrio in pain management is seen in the pre-hospital ambulance EMS (emergency medical services) as well as in the Emergency Department (ED) (Todd et al, 2007). Author further lists the negative aspects of these services, which increases unnecessary pain. These services are unable to manage pain in the patient also give negative impact on the psychological and physiological condition of patient that makes the pain management difficult (Maintyre et al, 2010). According to the literature offered by the author, such patients suffer from acute pain even after a year of trauma. By this author justifies the research question of acute pain management requirement in the professional and organizational level, and how it is a facilitator as well as a barrier for the pain management in the trauma patients? In the very starting author made it very clear that evidence based study is provided for identifying the facilitator and barriers in managing pain during emergency care. Thus, author also explained that they are going to include two EMS (emergency medical services) ambulance services and three EDs (emergency departments) from Netherlands, for their study. The author also explained that they are going to focus of five services and 10 personal interviews. The selection of the focus group was done on the basis of their availability and general characteristics. The author also validated their study by stating that there is no prior research done or no systematic approach is used for acute pain management in trauma patients in Netherlands. Thus, for preparing the clinical guidelines for the acute pain management in emergency care, they have reviewed the literature stating about facilitators and barriers in pain management in emergency care.

According to the study of literature, author finds that there a various barriers for providing effective pain management. They have studied the literature focusing on the barriers related to patients perspectives, such as race & ethnicity (Shavers, Bakos, & Sheppard, 2010), reluctance to report pain (Wilsey et al, 2008), and refusal of the patient for pharmacological treatment (Singer et al, 2008). In spite of identifying the negative attitudes of the patients that becomes the major barrier in acute pain management; author also identifies the negative attitude of the emergency physicians and lack of knowledge in them as the barriers in providing comprehensive acute pain management in emergency care. Author also identified the facilitating factors for the pain management in trauma patient, these factors are implementation of the pain protocol (Zohar et al, 2002), emergency medical quality control program (Ricard-Hibon et al, 2004), appropriate knowledge of the emergency professionals (nurses) (Decosterd et al, 2007), and high triage score in the emergency department (Singer et al, 2008). The study identifies various facilitators and barriers in the pain management in emergency care; however the specific barriers and facilitators for the pain management in ‘trauma patient’ could not clearly understood through literature. Thus, author provides the insight of the barriers and facilitators for pain management in trauma patient, who come under emergency care in Netherlands. The study is particularly relevant because there has not been any research or study done for identifying the different factors associated with pain management in trauma patients in Emergency medical services and emergency department. The literature selected by the author is relevant to the study.

Methodology

The author has used the quantitative approach for determining the results associated with pain management in emergency care. The author used the 2 emergency medical services and 3 emergency departments, which also constitutes 10 interviews of the focus groups. The author stated that bringing changes in the clinical practice could not be self-implementing. Thus, author suggests that improvement in the implementation efforts in the emergency care are required to improve pain management. For the purpose of the study, author used the step 2 from the model of Grol et al (2005).The implementation model of change by Grol et al, includes five main steps. The second step of this model is “analyses the target group and setting – both current practice and the barriers and facilitators” (Grol et al, 2005). Thus, the methodology used by the author is appropriate for the study design of focusing on the perspectives of the organization and professionals. The study included the participants from 2 EMSs and 3 ED. For the purpose of the interview, four to six people were invited and people who were interested responded to the invitation mail. This process increases the validity of the study. The professionals were selected on the basis of different variable like gender, years of experience and professional background. The questioner of the study was based on the past study (Krueger & Casey, 2014) that explains the reliability of the interview. The interviews were conducted by the help of independent moderators, who had received training in moderating skills, in order to justify the quality of the interview. The interviews taken considered the attitude of the nurses and professionals related to pain management, assessment of pain, treatment of pain, and facilitators and barriers in pain management. The methodology described in the article is clearly laid, which ensures that it could be clearly understood.

Ethics Consideration

The major ethical consideration in preparing the research design is that all the professionals and interviewers were protected and informed before the commencement of the study. The interview of the managers was taken separately from the interview of other nurses, because the perspective of the nurses could be affected in front of their managers. Thus, complete consideration was given to protection of information. The audio recording and transcripts of the interview were prepared with complete knowledge of the participants. The author has also provided a short note about the ethical consideration that the study is based on the study protocol and regional Committee on Research Involving Human Subjects waived the need for a review of the study.

Significant Results

The significant results of the study including interviews of the 10 participants from EMSs and ED identified the five main concepts in the chain of the emergency care. These five concepts among which facilitators and barriers are identified for each are knowledge, attitude, professional communication, organizational aspects and patient input. Except attitude every concept had facilitators and barriers. Attitudes were found to be the barrier in providing acute pain management to the trauma patients. All the respondents reported that pain was not considered as the life threatening aspect and patient were first treated with other life threatening problems. The author also identified, whether these concepts and themes occur in chain in emergency care. Thus, according to the results knowledge, attitude and patient input shared the themes in the chain of care.

Discussion/reflective critique

The overall research showed that attitude of the professionals is among the major barrier in the pain management in trauma patients. The study identified the barriers and facilitators within the concepts of knowledge, attitude and patient input (Gunnarsdottir, Serlin, & Ward, 2005). However, it was not clear that these themes have been identified in EMSs and ED, as these strategies for pain management have not been used in professional and organizational level. The organizational aspects presented in the study are based on the previous literature, which states that implementation of the change plan in the clinical practice and organizational structure of Emergency Medical Services and Emergency Department (Fosnocht, Swanson & Barton, 2005).

Recommendations

The limitation of the study is that it is only based on the theoretical model of Grol et al (2005). The qualitative approach provides the insight in the facilitators and barriers of the pain management, but no quantitative approach was addressed. Another limitation of the study was the limited selection of the samples and interview question, which question the complete saturation of the research.