Pain assessment in critical care: what have we learnt from research.

Despite an ongoing acknowledgement in the literature that pain is a significant problem within the critical care environment, this issue has not been adequately addressed by critical care nurses. This paper examines strategies for changing pain management practices in critical care, including reviewing documentation practices, the utilisation of guidelines and algorithms to augment clinical decision making, and increasing educational opportunities available to critical care nurses. It is recommended that pain assessment be given a higher priority within the clinical context, particularly as inadequate pain assessment and management has been linked to increased morbidity and mortality within critical care. Importantly, critical care nurses need to not only be aware of research-based pain management practices, but also lead the way in implementation and continuous evaluation as a measure of decreasing patient pain in the future.     

Physical assessment skills: a developing dimension of clinical nursing practice.

This paper proposes that the current use of physical assessment skills within critical care nursing practice is part of a on-going nursing role development process. A review of the critical care nursing role highlights how nurses in this setting have always been responsive to patient management needs. In exploring one recent nursing role development, the critical care outreach nurse, it is suggested that enhanced assessment skills enable these practitioners to safely and competently assess critically ill patients out of the intensive care environment. The use of patient case studies in this paper, demonstrate how the theory of a more intensive physical assessment knowledge base can be applied in the everyday practice of an critical care outreach nurse. Through such systematic patient review, patient management plans can be agreed and ward based practitioners can be supported in the on-going treatment of sick ward patients. The use of the cases presented also highlights the complexity of the outreach nurse's practice in addressing clinical management and team management issues.     

Using nurse-sensitive outcomes to improve clinical practice.

With the many uncertainties in the current health care milieu and continuing movement from general guidelines to ensure an optimal practice approach, it is especially vital that critical care nurses facilitate a research culture in their workplace and strive to improve clinical practice through understanding and evaluating research. Outcomes research helps to identify discipline-specific accountability in patient care. Through understanding the basic aspects of outcomes research and the issues that influence nurse-sensitive outcomes, the critical care nurse is informed and can make clearer and appropriate choices in patient care. Outcomes research continues to be instrumental in defining a base for nursing practice. Although it is not necessary or even desirable that all nurses conduct research, nurses are accountable for providing scientific and appropriate care to ensure the optimal outcome for the patient.     

How do intensive care nurses assess patients’ pain?

Identification and evaluation of pain in critical care patients may be difficult because of communication problems. Moreover, at present there are very few nursing studies that examine the attitudes of critical care nurses towards the assessment of patients' pain. This study was designed to determine the approach of critical care nurses towards assessing patients' pain levels, and to evaluate the problems in nursing diagnosis of those having difficulty in articulating their pain symptoms. We used a questionnaire to assess nurses attitudes to patients' pain. The study sample consisted of 91 critical care nurses who were recruited between January and February 2002. The results suggest that patient pain was considered undesirable by 44% of nurses. About 70-3% of the nurses reported resorting to administering analgesics to relieve their patients' pain. Some 57.1 % of nurses stated that they would have investigated whether the patients had really been experiencing pain, prior to administering the prescribed analgesics to patients. Some 85.7% of the sample indicated that the patients themselves would make the most accurate evaluation of their pain. The data suggested that 39.6% of nurses did not know how to evaluate pain symptoms in critical care patients suffering from complicated problems, and that 37.4% evaluated pain by monitoring the patients' behaviours. The study demonstrated that most of the critical care nurses did not know how to evaluate pain in patients having communication problems. The paper concludes by suggesting that there is a clear need to address nursing education and training with regard to evaluation and management of patients' pain whilst in critical care environment.     

Structural empowerment and patient safety culture among registered nurses working in adult critical care units

armellino d. , Quinn Griffin m.t. & Fitzpatrick j.j. (2010) Journal of Nursing Management 18, 796–803
Structural empowerment and patient safety culture among registered nurses working in adult critical care units Aim The aim of the present study was to examine the relationship between structural empowerment and patient safety culture among staff level Registered Nurses (RNs) within adult critical care units (ACCU). Background There is literature to support the value of RNs’ structurally empowered work environments and emerging literature towards patient safety culture; the link between empowerment and patient safety culture is being discovered. Methods A sample of 257 RNs, working within adult critical care of a tertiary hospital in the United States, was surveyed. Instruments included a background data sheet, the Conditions of Workplace Effectiveness and the Hospital Survey on Patient Safety Culture. Results Structural empowerment and patient safety culture were significantly correlated. As structural empowerment increased so did the RNs’ perception of patient safety culture. Conclusion To foster patient safety culture, nurse leaders should consider providing structurally empowering work environments for RNs. Implications for nursing management This study contributes to the body of knowledge linking structural empowerment and patient safety culture. Results link structurally empowered RNs and increased patient safety culture, essential elements in delivering efficient, competent, quality care. They inform nursing management of key factors in the nurses’ environment that promote safe patient care environments.     

The emerging role of advanced nursing practice in acute pain management throughout Canada

The purpose of this study was to describe the role qualifications and responsibilities related to advanced nursing practice in acute pain management across Canada. The Canadian Nurses Association national framework on advanced nursing practice was used as a guide to identify role components for nurses within this specialty. A self-administered questionnaire of fixed choice and open-ended questions was mailed to nurses in acute pain management throughout Canada. Respondents identified their primary role responsibilities as clinical, educational, and administrative. Role challenges included lack of administrative/colleague support, complexity of pain problems, role definition, and acceptance. Key areas of positive outcomes involved the patient as well as interdisciplinary and nursing teams. Nurses described the ability to provide continuity of care, patient and staff education, and leadership in pain management as important and rewarding. The role of advanced nursing practice in acute pain management throughout Canada is evolving. The affect of this role promises to enhance the quality of pain management for healthcare professionals and their patients.     

Analysis of strategies in the management of coronary patients' pain

This exploratory clinical investigation identified clinical practice strategies used by expert critical care nurses in the assessment and management of pain. The investigator found that nurses use short, effective questions and observations for cardiac pain assessment.     

The role of the outpatient clinic nurse in monitoring opioid therapy

Outpatient clinical nurses specialize in patient care in a particular area of nursing practice. Typically, the registered nurse also holds a professional certification in that specialty or subspecialty. The only nursing certification related to pain and symptom management is the Hospice and Palliative Care certification. Managing the patient with chronic pain is a common clinical challenge, especially when opioid therapy is indicated. Chronic pain often is undertreated in patients with cancer and in those with non-malignant conditions. Because chronic pain can be complex, successful long-term treatment is more difficult for providers. Professional nurses are the primary team members who assess, coordinate, direct, and evaluate patient care needs during times of illness. A nurse is one of the first contacts in the health care system that the patient encounters. Nurses must possess unique qualifications and be able to deal compassionately with a demanding and sometimes hostile group of patients. How the patients are accepted into a pain medicine practice and managed is discussed in this article.     

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.     

Nursing responsibility levels for cardiac surgical procedures

Nursing liability is an issue discussed regularly by both critical care staff nurses and nursing managers. Questions frequently arise regarding practice within the "gray area" of critical care. The high level of patient acuity often necessitates an expanded nursing role. Specific practice issues within the controversial areas of cardiac surgical nursing are addressed in this article, with a discussion of the implications of performing care that may be outside the accepted standard of practice.     

Critical caring. Promoting good end-of-life care in the intensive care unit.

Changing the culture in the ICU to include palliative care interventions along with curative interventions is already underway. Further work is needed, however. This is a role for the critical care nurse. Critical care nurses can be involved in research and education to enhance their future practice in end-of-life care. Research to establish evidence-based protocols for use in patients who require palliative care in the ICU needs to be done. Critical care nurses can prepare themselves for carrying or dying patients by attending palliative care seminars and continuing education courses or by taking a short clinical sabbatical or internship in a local hospice to observe and help give end-of-life care. Hospice nurses can be invited to the ICU to give inservice sessions and to help nurses and other staff understand the transition to dying, including the services that need to be offered to the patient and the family. Nurses from the hospital palliative care team can consult and be available for follow-up. Promoting good end-of-life care should be a goal for all intensive care nurses and critical care units. This goal is reached one patient at a time.     

Australian hospital generalist and critical care nurses' perceptions of doctor-nurse collaboration

Abstract Previous researchers have indicated that collaborative practice between doctors and nurses results in positive effects on patient care, health-care costs and provider satisfaction. Despite these benefits, collaborative practice appears to be the exception, rather than the dominant pattern, within health care. A collaborative relationship cannot evolve if individuals do not value and respect others' competencies. This study, a mailed survey, used the Collaboration with Medical Staff Scale to compare the perceptions of doctor–nurse collaboration held by critical care nurses and generalist hospital nurses. The hypothesis that critical care nurses perceive there to be greater collaboration with doctors than their generalist nurse colleagues was supported even after taking into consideration education and experience. These results suggest that critical care is an area that might be useful when trying to understand the dimensions and implications of collaboration among health professionals.     

Hospice care and patients' pain: communication between patients,relatives, nurses and doctors

This article describes a study that sought to assess how patients, relatives, doctors and nurses in a palliative care unit viewed pain and pain management, and how standards and expectations for pain relief can be raised by upholding statements of care and agreed partnership values. The results showed that research-based pain management enables the provision of pain control that is acceptable to patients, relatives, doctors and nurses. By valuing patient-centred care, where assessment tools assist communication and information sharing, a partnership of care is established in which patient and professional autonomy are recognized and respected, international recommendations for pain relief are practised and professional codes of conduct upheld. Good pain management requires accurate assessment that is best achieved by open and honest discussion in a supportive environment. Hospices provide specialist symptom control aimed at improving quality of life for patients with advanced disease. They are not only an ideal setting to provide evidence for practice, but also a learning environment for specialist understanding of symptom control and a resource base for other professionals.     

Nursing’s Role in Cancer Pain Management

Nurses have advanced practice, research, and education in the field of cancer pain management. This paper highlights the contributions nurses have made to pain science and practice through literature published in the past 3 years. Work accomplished by nurses is examined in the areas of pain assessment, pain management, intervention-based research, evidence-based practice, patient education, and palliative care. Nurses serve as advocates for empowering patients to engage in self-management of their pain, and offer education and support to patients and families at their most vulnerable times. Nurse researchers have been at the forefront of work to develop and test new instruments and approaches to measure pain, elucidate pain experiences through quantitative and qualitative methodologies, and gauge the quality of pain care for patients and its impact on their caregivers. This research has uncovered many patient, health care professional, and systemic barriers to effective pain control, and has offered feasible solutions to overcoming these barriers.     

Acute pain and the critically ill trauma patient

Pain is a frequent experience throughout our lifetime, and each person responds in a different manner to every pain experience. Critically ill trauma patients are obviously more likely to experience pain due to their injuries or iatrogenic causes. To optimize pain management for trauma patients, critical care nurses must continually be aware of the potential for pain. However, pain assessment for critically ill patients is usually complicated by their inability to express the subjective component of their pain experience. Understanding the pathophysiology of pain facilitates the assessment of the objective components of pain. It is imperative for the critical care nurse to function as the patient advocate especially regarding pain management issues.     

Back to basics—Essential nursing care in the ED: Part One

Emergency nurses are expected to work under pressure to many standards, guidelines and protocols related to patient care, and often in an advanced practice role. These expectations can sometimes take priority over basic nursing care once emergency/resuscitative intervention has occurred. However, posing the question ‘How would I want this patient to be cared for if they were my grandmother/father/child’ sets a benchmark for nursing practice [Fulbrook P, Grealy B. Essential nursing care of the critically ill patient. In: Elliot D, Aitken L, Cheboyer W, editors. ACCCN critical care nursing. Sydney: Elsevier; 2006]. How well patients are cared for has a direct effect on their sense of well-being and their recovery. Effective communication is essential to good nursing care and patient outcomes. The length of stay of the patient in the ED may be extended, and the use of “holding” wards while waiting for investigation results of patients for probable discharge necessitates the ED nurse to consider basic but essential aspects of nursing care that will be discussed. Other essential aspects of care such as psychosocial; including culture, pain management and infection control are beyond the scope of this paper.     

Creating an advanced practice nurse-friendly culture: a marathon, not a sprint

Advanced practice nurses (APNs) have extraordinary opportunities in acute and critical care settings. However, new obstacles accompany these opportunities and these obstacles can needlessly hamper APN practice and reduce the APN's contributions to patient care. Contributions by APNs can be maximized by deliberately and thoughtfully creating a practice culture that is APN-friendly. This article analyzes eight characteristics important to creating the APN-friendly culture: clarity of vision and values, commitment, communication, collaboration, credibility, contributions, confidence, and complexity. Creating an APN-friendly culture is a worthwhile organizational investment in order to enhance optimal APN practice and to benefit patients and families.     

Caring for the patient who has undergone female circumcision

Home health and hospice nurses are increasingly called to care for patients the world over. The provision of culturally competent and culturally sensitive care is critical to patient care planning. Viewing the patient holistically and within the context of family and culture provides the basis of most effective care. While nurses may not be providing skilled care directly related to female circumcision, it is important to include all of the patient's concerns within the framework of a comprehensive plan of care.