Barriers to nurse-led pain management for adult patients in intensive care units: An integrative review

ObjectiveThis integrative review sought to identify and synthesise quantitative and qualitative evidence on barriers to pain management in adult intensive care units (ICUs).BackgroundPain is experienced by 58% of adult ICU patients, which leads to consequences such as decreased healing and delirium. Managing pain effectively is an integral part of the critical care nurse's role.MethodsAn integrative review was conducted based on Whittemore and Knafl's approach. Peer-reviewed research articles were sourced from five databases. Included articles were limited to those published in English and Arabic. The quality of included papers was evaluated using the Mixed Methods Appraisal Tool (MMAT). Identified barriers to pain management in adult ICUs were mapped onto the components of the COM-B model. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsNine hundred and ninety-one papers were identified; 19 studies met the inclusion criteria. Seventeen studies focused on pain management from the perspective of nurses, whereas the remaining two focused on the perspectives of patients and nurses. Using the MMAT, two studies were rated 5 stars (out of 5), nine studies were rated 4 stars, seven studies were rated 3 stars, and one study was rated 2 stars. Lack of knowledge and skills was found to be psychological capability barriers, while nurse dependency on following doctor's orders, poor staffing levels, lack of pain assessment skills, and lack of education were barriers mapped to physical capability. Opportunity was represented by three barriers: inadequate documentation of pain and shortage of nurses were mapped to the physical opportunity, and poor communication to the social opportunity. Nurses' beliefs towards pain assessment were mapped to reflective motivation.ConclusionsThe findings of this study suggest that knowledge, nursing beliefs, insufficient numbers of nursing staff, lack of documentation, and lack of communication commonly affect pain management in adult ICUs.Prospero registrationCRD42020179913     

Parents' Participation in Managing Their Children's Postoperative Pain at Home: An Integrative Literature Review

ObjectivesThis integrative review aimed to synthesize and critically evaluate the methodological quality of the evidence on parent's participation in managing their children's postoperative pain at home.DesignIntegrative review.Data SourcesTo locate relevant articles, two reviewers independently searched four electronic databases systematically using predefined inclusion and exclusion criteria.Review/Analysis MethodsThe methodological quality of 23 eligible studies was critically appraised using published evaluation criteria. A qualitative content analysis was then conducted to synthesize findings of the studies to identify thematic trends and factors on the nature of parents' participation and ability to effectively manage their children's pain at home.ResultsMethodological quality of most of the 15 surveys was adequate, whereas shortcomings were identified in 6 of the 7 clinical trials and the 1 qualitative study that were included in this review. The three themes identified pertained to parent use of informational sources, postoperative pain medications, and nonpharmacologic pain treatment approaches. Results indicate parents lack the information they need to effectively make use of pharmacologic and nonpharmacologic pain treatment approaches.ConclusionsThere is need to improve communication between parents and health professionals before and after the child's surgery and to provide parents with specific verbal and written instructions and strategies on how to assess and manage their children's pain.     

Does Education Improve Nurses’ Knowledge,Attitudes, Skills,and Practice in Relation to Pain Management? An Integrative Review

BackgroundPain is undertreated in both adults and children and a major factor linked to this is nurses’ lack of knowledge as evidenced by studies undertaken globally.ObjectiveThis review sought to explore the effects educational interventions can have on nurses’ knowledge, attitudes, skills, and practice regarding pain management.DesignAn integrative reviewData sourcesSystematic search of CINAHL, MEDLINE, AMED, EMBASE, and Psych INFO.Review/Analysis MethodsFive major databases were systematically searched from the year 2000-December 2019 with a total of 33 studies included in the final review.ResultsThe literature revealed that many nurses had inadequate knowledge and a poor attitude towards pain at baseline, which may be improved through educational intervention. However, misconceptions remained at post-intervention, particularly regarding pharmacological pain management.ConclusionsEducation is a possible means to enhance nurses’ knowledge and improve attitudes and practices in pain management. However, there was some evidence that this may decline over time, and continuous professional updates are likely required.     

Psychometric Evaluation of the Nurses' Cancer Pain Management Competency Scale

BackgroundThere is lack of instruments for assessing nurses' comprehensive pain management competency.AimThis study aimed to assess the psychometric properties of the Nurses' Cancer Pain Management Competency Scale and to conduct a cursory survey of the pain management educational needs/resources of nurses caring for patients with cancer pain.MethodA convenience sample of 230 Korean nurses who met the eligibility criteria completed the researcher developed the Nurses' Cancer Pain Management Competency Scale and a pain management educational needs/resources survey. The Nurses' Cancer Pain Management Competency Scale was based on the pain management core competencies identified by Fishman et al (2013). Internal consistency was assessed using Cronbach's alpha, and construct validity was examined using exploratory factor analysis with varimax rotation.ResultsCronbach's alpha of the scale was 0.89. Nurse cancer pain management competency includes four factors, which accounted for 68.44% of the variance: the context of pain management, pain assessment and measurement, management of pain, and multidimensional nature of pain. Approximately 42% of nurses had no available protocols related to cancer pain management. Nurses preferred multi-component educational modalities, including simulation-based learning.ConclusionsFindings support internal consistency reliability and content and construct validity of the Nurses' Cancer Pain Management Competency Scale that can help examine pain management competency of nurses. Adopting an evidence-based clinical cancer pain management-related protocol and multi-component training programs are needed to achieve optimal cancer pain management competency in nurses.     

Understanding Nurses’ Knowledge and Attitudes Toward Pain Assessment in Dementia: A Literature Review

BackgroundPain is underrecognized and undertreated in patients with dementia. It has been suggested that nurses’ attitudinal barriers may contribute to the challenges surrounding pain assessment and management in dementia.AimsThis integrative literature review aims to identify and explore nurses’ knowledge and attitudes towards pain assessment in older people with dementia and how it may affect pain management in this patient group.MethodElectronic searches were conducted in Web of Science, MEDLINE, Scopus, ProQuest, PubMed, and EBSCOhost from January 2008 to December 2018 for articles specifically focusing on nurses’ knowledge and attitudes towards pain assessment in older patients with dementia.ResultsTen studies were included in the review after meeting the inclusion criteria. Data extracted from each study included study design, aims and objectives, setting/sample, findings, and limitations. Patients with dementia are at greater risk of experiencing underassessment, undertreatment, and delayed treatment of pain due to nurses’ knowledge deficits and uncertainty in the decision-making process. Nurses see providing comfort and reducing pain as ethical obligation. However, they find pain assessment a challenge due to the complexity of recognizing painful behaviors, and difficulty differentiating between pain and behavioral disturbances in dementia. Poor multidisciplinary communication, time constraints, and workload pressure, as well as uncertainty about opioid use, are important barriers to effective pain assessment and management among patients with dementia.ConclusionIt is essential that nurses gain confidence in distinguishing signs and symptoms of pain from behavioral changes in dementia. It is important to improve interdisciplinary communication and to get physicians to listen and prioritize pain assessment and management.     

A Nonrandomized Pretest Posttest Study on the Impact of an Educational Pain Management Program on Nurses’ Knowledge and Attitudes Regarding Pain in a Middle Eastern Country

BackgroundAlthough nurse's knowledge and attitudes regarding pain management has been sufficiently studied worldwide, the impact of an educational intervention program in improving such attitudes and knowledge has not been likewise researched, especially in Middle Eastern countries.AimsTo examine nurses’ knowledge and attitudes regarding pain at a university hospital in Lebanon before and after the introduction of a pain management educational program. And to assess the relationship between the characteristic of nurses and their pain knowledge.MethodsDesign; A nonrandomized pretest posttest study design was used. Setting; A university hospital in Lebanon. Participants; Included 183 nurses using the Nurses' Knowledge and Attitudes Survey Regarding Pain questionnaire. The pain educational intervention was based on the principles of Ajzen's theory of planned behavior.ResultsA significant difference between the pre and post test scores was noted (p = .016). Questions answered correctly by 80% of participants were related to questions about pain, pain assessment and management, and questions related to medications, such as correct dosages and opioid side effects were not answered correctly by the majority of nurses. There were significant associations between test scores and the nurses’ educational level, their age, and their years of experience. Nurses who worked in critical care units, the emergency department and oncology had higher scores than nurses who worked on general units.ConclusionsDespite the intensive pain education provided at our institution, the pain knowledge of nurses remains below that recommended level which indicates a dire need for more intensive and continuous education in order to provide a pain free environment.     

Pediatric Nurses' Cognitive Representations of Children's Pain

The aim of this mixed methods exploratory study was to describe pediatric nurses' cognitive representations (CRs) of the assessment and management of children's pain and to determine the relationships between their CRs and their choices about pain assessment and morphine administration. We recruited a convenience sample of 87 nurses caring for hospitalized children at 4 institutions. We measured the CRs with the Conceptual Content Cognitive Map (3CM) technique and pain assessment and morphine administration with smiling and grimacing child vignettes. We used content analyses for the 3CM data and fit logistic regression models to predict participants' analgesic choice for each vignette. Nearly all (91%) participants identified the child's behavior as an assessment approach; 48% indicated it as most important. Participants (92%) identified pharmacologic as a management approach; 47% indicated it as most important. Participants' CRs did not predict assessment or morphine administration choices. Significantly more participants chose the appropriate analgesic response for the grimacing child than they did for the smiling child. Nurses with more years of pediatric experience were less likely to select administration of the appropriate morphine dose. The 3CM method provided insights into nurses' thinking about pain that are indicative of gaps, which may be amenable to interventions.PerspectiveFindings are from an innovative, unique measure of nurses' knowledge and beliefs about the complex phenomenon of children's pain management. Extensive details about the thought processes of pediatric nurses regarding pain assessment and management surfaced through this analysis, which provide excellent information for direction of future research and practice innovations.     

Effects of Nonpharmacologic Distraction Methods on Children's Postoperative Pain—A Nonmatched Case-Control Study

PurposeTo investigate whether nonpharmacologic distraction as a supplement to conventional pain management can reduce children's assessment of pain in the postanesthesia care unit (PACU), and if parental assessment is a reliable proxy in assessing children's postoperative pain.DesignA nonmatched case-control study.MethodsThe sample included 241 children aged 2 to 7 years assigned to one of five intervention groups or a control group. Children's and parents' assessments of pain were registered on arrival to PACU and repeated after 15, 30, and 45 minutes using the Wong-Baker FACES Pain Rating Scale.FindingsPositive effects of interventions were found in both children's and parental assessments. Results indicate a positive correlation between children's and parental assessments in children older than 3 years (P < .001).ConclusionsNonpharmacologic distraction is recommended as a supplement to conventional postoperative pain management. Parental assessment is a reliable proxy in assessing postoperative pain in children younger than 5 years.     

Understanding Nurse Characteristics that Influence Assessment and Intention to Treat Pain in Postoperative Patients: An Integrative Literature Review

ObjectivesAn understanding of nurse characteristics that influence pain management, which are potentially amenable to change, can help to refine and improve nurse education and practice, resulting in better patient outcomes. The purpose of this review was to identify nurse characteristics that influence their assessment of and intention to treat postoperative pain.DesignIntegrative literature review.Data sourcesA systematic search of electronic databases (CINAHL, Scopus, PsycINFO, Medline, and Embase), using these constructs “pain assessment”, “pain management”, “postoperative pain”, “nurses”, “cultural beliefs” and “nurses’ perceptions” was conducted for the period 2000 to October 2020.Review/Analysis methodsFollowing a systematic screening process, the included articles were analyzed and synthesized to identify themes and subthemes.ResultsA total of 40 articles were included with three main themes identified: nurse knowledge; nurse sociocultural factors, personal beliefs and attitudes, and other characteristics; and believing or doubting the patient. There was evidence that targeted education interventions can improve nurse knowledge and nurses’ clinical practice in relation to pain management. What was less clear was which nurse attitudes and biases influenced their pain management practice or how these could be changed.ConclusionsMore studies are needed to investigate the influence of cultural characteristics on pain assessment and management. There is a need for further quantitative studies that explore the relationship between nurse characteristics and their pain management practice. Intervention studies using innovative educational approaches that change attitudes and biases, and improve practice are needed.     

Development of an Evidence-Based Pediatric Preoperative Risk Assessment Checklist

PurposeTo describe how a pediatric preoperative risk assessment (PPRA) checklist was developed to inform perianesthesia nurses of potential postanesthesia care unit (PACU) respiratory complications.DesignEvidence-based practice approach.MethodsA systematic search was conducted using PubMed, CINAHL and Cochrane Library databases for this project. In addition, an integrative review process was conducted to develop an assessment checklist of evidence-based pediatric preoperative risk factor criteria associated with PACU respiratory complications. Evidence-based review focused on summarizing and appraising current research for quality levels for each of the individual pediatric preoperative risk factor that comprised the assessment checklist.FindingsEleven risk categories were established: Age, American Society of Anesthesiologists Physical Status, gender, general anesthesia, airway comorbidities, syndromes/congenital anomalies, pulmonary comorbidities, African American ethnicity, obesity, neurologic comorbidities, and cardiac comorbidities. Multidisciplinary experts came to consensus on content and face validity as well as reliability of the PPRA checklist.ConclusionsThe PPRA checklist presents a rapid way to communicate through handoff the preoperative “big picture” to interpret children's acuity and comprehensive risk for significant pediatric respiratory adverse events in the PACU.     

Impact of a pain management program on nurses' knowledge and attitude toward pain in United Arab Emirates: Experimental-four Solomon group design

BackgroundLack of knowledge about pain is a common barrier to effective pain management. Educational pain management programs directed to health care professionals can improve knowledge and attitudes about pain. However, changing practice is more challenging, but can be achieved with more targeted educational interventions within the clinical setting.ObjectivesThe main objective of this study was to examine which of four separate pain management educational designs improved nurses' knowledge and attitudes toward pain over time. Secondary objectives were to compare and contrast nurse's knowledge and attitudes toward pain before and after the educational intervention.DesignThis randomized controlled trial using a four Solomon group design.SettingThis study took place in Dubai Hospital, Dubai Health Authority, in United Arab Emirates between January 2019–April 2019.ParticipantsThe sample consisted of 200 registered nurses who were randomly selected and assigned into four separate educational groups. Participants had at least one year of experience in Dubai hospital prior to data collection.Resultspaired t-test has shown the experimental group scored significantly higher than the control group (p < 0.01). One-way ANOVA revealed significant post-test score differences between groups p < 0.001. A repeated measures ANOVA with a Greenhouse-Geisser correction determined that mean scores over three months was not statistically significant. Indicating that the level of knowledge did not change over time within any of the groups.Conclusion and recommendationsThe most important findings were the relatively low pre-test knowledge scores among staff nurses, and the significant improvement in knowledge for most test items following the educational intervention. Moreover, the level of knowledge and attitudes were maintained over three months. The pain management program proved to be effective in improving nurses' pain knowledge, attitudes, and assessment practices. Nurses in the experimental group increased their pain score significantly after the pain management program.Registration number: NETUBR.     

Nurses’ experiences in voluntary error reporting: An integrative literature review

ObjectiveThis integrative review aimed to examine and understand nurses’ experiences of voluntary error reporting (VER) and elucidate factors underlying their decision to engage in VER.MethodThis is an integrative review based on Whittemore & Knafl five-stage framework. A systematic search guided by the PRISMA 2020 approach was performed on four electronic databases: CINAHL, Medline (PubMed), Scopus, and Embase. Peer-reviewed articles published in the English language from January 2010 to December 2020 were retrieved and screened for relevancy.ResultsTotally 31 papers were included in this review following the quality appraisal. A constant comparative approach was used to synthesize findings of eligible studies to report nurses' experiences of VER represented by three major themes: nurses' beliefs, behavior, and sentiments towards VER; nurses' perceived enabling factors of VER and nurses' perceived inhibiting factors of VER. Findings of this review revealed that nurses’ experiences of VER were less than ideal. Firstly, these negative experiences were accounted for by the interplays of factors that influenced their attitudes, perceptions, emotions, and practices. Additionally, their negative experiences were underpinned by a spectrum of system, administrative and organizational factors that focuses on attributing the error to human failure characterized by an unsupportive, blaming, and punitive approach to error management.ConclusionFindings of this review add to the body of knowledge to inform on the areas of focus to guide nursing management perspectives to strengthen institutional efforts to improve nurses' recognition, reception, and contribution towards VER. It is recommended that nursing leaders prioritize and invest in strategies to enhance existing institutional error management approaches to establish a just and open patient safety culture that would promote positivity in nurses’ overall experiences towards VER.     

Perspectives on Cancer Pain Assessment and Management in Children

ObjectiveTo report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.Data SourcesPublished research and clinical guidelines.ConclusionChildren and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.Implications for Nursing PracticePediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.     

A Scoping Review of Nursing's Contribution to the Management of Patients with Pain and Opioid Misuse

BackgroundNursing brings a unique lens to care of patients with pain and opioid misuse.AimsThis scoping review describes nursing's contribution to the literature on the management of patients with pain and opioid misuse, generating evidence to guide clinical care.DesignThe scoping review was conducted according to Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews guideline.Data SourcesUsing combined key terms (“opioid misuse,” “pain,” “nursing”) in systematic searches in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases, snowball technique, and personal knowledge resulted in 108 relevant articles, reports, and websites.Analysis MethodSummative approach to content analysis was used to quantify and describe nursing's contribution to the literature.ResultsContributions of nurses emerged in the areas of research, clinical practice, policy, and education. The highest number of publications addressed research (50%, 54 of 108), whereas the fewest number of publications involved education (7%, 8 of 108).ConclusionResults provide a picture of the breadth of expertise and crucial leadership that nurses contribute to influence management of patients with pain and opioid misuse.Implications for NursingThis scoping review indicates the importance of continued support from key stakeholders, including training and interprofessional collaboration opportunities supported by the National Institutes of Health, to sustain nursing's contribution to quality care of patients with pain and opioid misuse. Ultimately, all health care professionals must collaborate to conduct rigorous research and construct evidence-based guidelines to inform policy initiatives and education strategies to solve the complex co-occurring epidemics of pain and opioid misuse.     

Challenges of conducting of online educational programs for family caregivers of people with dementia living at home: An integrative review

ObjectivesThis integrative review aimed to understand the challenges of conducting online educational programs for family caregivers of people with dementia by focusing on the components and design of them.MethodsFollowing Whittemore & Knafl’s five-step method, seven databases were systematically searched. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies.ResultsOf the 25,256 articles identified, 49 studies were included. Limitations in components (including useless or repetitive information, incomplete access to dementia-related information, the impact of components related to culture or ethnicity or gender) and in the format of delivered information (including less interaction, time schedule limitations and preference for traditional forms of delivery of information) make it more challenging to conduct online educational programs. Additionally, implementation constraints such as technical problems, poor computer literacy, and fidelity assessment are challenges that cannot be ignored.ConclusionsInsight into the challenges of online educational programs for family caregivers of people with dementia can help guide researchers in constructing the optimal online educational program. Incorporating cultural specificity, considering structured construction strategies, optimizing interaction design, and increasing fidelity assessment may contribute to the conduct of online educational programs.