Quality of care in postoperative pain management: what is realistic in clinical practice?

This paper presents a study describing nurses' assessment of whether it was realistic to carry out good quality of care in postoperative pain management. Further, the study compared their assessment with the quality of care actually performed in clinical practice as assessed by both patients and nurses. Three questionnaires were used; one for patients (n = 198) and two for nurses (n = 63). Nurses and patients responded to similar questions; the patients assessed the quality of care they had received, and the nurses assessed the quality of care they had delivered. The nurses also responded to questions concerning whether the different aspects of good quality of care were realistic to carry out in practice. The results show that in several important aspects of postoperative pain management, both patients and nurses assessed the quality of care to be lower than the nurses' assessment of what was actually possible to effectuate in clinical practice, e.g. pain assessment and information. This finding highlights the problem of applying evidence-based care in actual clinical practice.     

What is the evidence on evidence‐based nursing? An epistemological concern

AIM: This paper adopts an epistemological perspective in order to support the assertion that there is very little evidence to support the existence of evidence-based nursing as a distinct construct or process. RATIONALE: This analysis of concept meaning is based on the theory of symbolic interactionism. By adopting this theory the commonalities and inconsistencies in the use of evidence-based symbolism by nurses and other health care professionals can be used to evaluate the perceived meaning of the term. METHODS: A frequency analysis of relevant key words in one publications data-base demonstrates the increasing use of evidence-based terminology and its euphemistic status visa vi research. An epistemological analysis is conducted on a sample of concept clarification statements taken from the popular literature, defining the nature of 'evidence' and 'evidence-based practice'. FINDINGS: The results of the frequency analysis show that the keywords 'evidence-based medicine' revealed 5612 papers, evidence-based practice (EBP) 432 papers, evidence-based nursing 47 papers, evidence-based health care 60 papers, and evidence-based decision making 43. Almost all of these papers have been published since 1995 and the earliest use of the symbol 'evidence-based' is 1992. There is also an increase in papers adopting 'evidence-based' symbolism along with a commensurate decrease in the use of the term 'research' in the nursing context. CONCLUSION: 'Evidence-based practice' is commonly a euphemism for information management, clinical judgement, professional practice development or managed care. There is insufficient evidence to demonstrate that evidence-based nursing is a single construct or process that can be distinguished from its concomitants. The term adds little more to the existing long standing traditions of quality assurance and research-based practice. Nurses must avoid the inefficiency brought about by the 'intense enthusiasm followed by sad disenchantment' that has been associated with other attempts to introduce innovation in health care delivery (Fienstein & Horowitz 1997).     

What is the research question? A case study in the early stages of design of a randomised controlled trial for a complementary therapy

Randomised controlled trials (RCTs) can be used to evaluate aspects of the effectiveness of complementary therapies. Given the individualised and non-blindable nature of many treatments, the design of such studies is often not trivial. One decision to be made is what specific research question is to be asked, of the many potential questions that could be asked. This paper describes discussions that took place during the design of a trial to evaluate the effectiveness of herbal practitioners for menopausal women, and illustrates the tribulations associated with such a process. Specifically, it discusses implications of the choice of control group. It is critically important that a relevant and answerable research question is posed.     

What is it that matters most in the practice of nursing children?

This article discusses the results of a workshop designed as an action research cycle to ascertain what matters most in the practice of nursing children in South Africa today. The workshop was convened at the University of Cape Town (UCT), in order to guide and direct the newly established post-basic, children's nursing pathway in the Bachelor of Nursing for Registered nurses [BN(RN)] programme. The participants were eight experienced paediatric nurses, currently practising in a variety of settings in the Western Cape. The results show that the participants move from their original task- and procedure-based perspective to a more processive one in which the focus of the learning is relational, emphasising the family and culture of the child.     

Reflexivity in nursing: where is the patient? Where is the nurse?

Drawing upon forty years of nursing experience, in this paper we are reflexive about four issues relative to nursing clinical practices: seeking technological solutions to health and ill-health; moving from the nurse-patient relationship to the patient-healer relationship; utilising critical pathways; and, supporting evidence-based nursing. We examine current nursing practices and ask probing questions to generate debate. Most of all, we encourage nurses to engage in reflexivity and not to lose sight of their selves (knowledge, expertise and skills), and their patients' voices and subjectivity, in their contribution to health care.     

Pacemaker‐mediated tachycardia in a dual‐lead CRT‐D: What is the mechanism?

A 73‐year‐old gentleman with dilated cardiomyopathy, left bundle branch block and a left ventricular (LV) ejection fraction of 20% was implanted with two LV leads in a tri‐ventricular cardiac resynchronisation therapy defibrillator (CRT‐D) trial. As a part of the trial he was programmed with fusion‐based CRT therapy with dual LV lead only pacing. The patient presented to local heart failure service 12 years after implant, after a positive response to CRT therapy, with increase in fatigue, shortness of breath and bilateral pitting oedema. The patient sent a remote monitoring transmission that suggested loss of capture on one of the LV leads. This coupled with atrial ectopics was producing a high burden of pacemaker‐mediated tachycardia (PMT) that was not seen when both LV leads had been capturing. What is the mechanism for this? Dual LV‐lead tri‐ventricular leads have been shown to have variable improvements in CRT response but with an increased complexity of implant procedure. This is the first case report of PMT‐induced heart failure exacerbation in a tri‐ventricular device following loss of LV capture of one lead.     

Kinesio Taping? is not better than placebo in reducing pain and disability in patients with chronic non-specific low back pain: a randomized controlled trial

Background:

Kinesio Taping ^® has been widely used in clinical practice. However, it is unknown whether this type of tape is more effective than placebo taping in patients with chronic lower back pain.

Objective:

To compare the effectiveness of Kinesio Taping ^® in patients with chronic non-specific low back pain against a placebo tape and a control group.

Method:

This is a 3-arm, randomized controlled trial with a blinded assessor. Sixty patients with chronic non-specific low back pain were randomized into one of the three groups: Kinesio Taping ^® group (n=20), Micropore^® (placebo) group (n=20) and control group (n=20). Patients allocated to both the Kinesio Taping ^® group and the placebo group used the different types of tape for a period of 48 hours. The control group did not receive any intervention. The outcomes measured were pain intensity (measured by an 11-point numerical rating scale) and disability (measured by the 24-item Roland Morris Disability Questionnaire). A blinded assessor measured the outcomes at baseline, 48 hours and 7 days after randomization.

Results:

After 48 hours, there was a statistically significant difference between the Kinesio Taping ^® group versus the control group (mean between-group difference = -3.1 points, 95% CI=-5.2 to -1.1, p=0.003), but no difference when compared to the placebo group (mean between-group difference= 1.9 points, 95% CI=-0.2 to 3.9, p=0.08). For the other outcomes no differences were observed.

Conclusions:

The Kinesio Taping ^® is not better than placebo (Micropore^®) in patients with chronic low back pain.     

Cancer pain in palliative care: why is management so difficult?

Pain is the major source of anxiety and distress at the end of life, particularly in cases of end-stage cancer. However, pain management is not always effective or effectively implemented. This article identifies several barriers to effective pain relief in terminal cancer--the complexity of pain; difficulties in physical, emotional and spiritual assessment; difficulties in the delivery of medication--that challenge the skills of all professionals involved in palliative care. There are no simple answers, but awareness of the breadth of the issues may help focus nurses' minds on the patient in every encounter.     

Psychological factors in chronic pain: a worthwhile undertaking for nursing?

Chronic pain is one of the clearest examples of the complex relationship between the mind, body, spirit, and environment. After decades of research, a growing body of evidence supports the importance of certain psychological factors in the chronic pain experience. This article reviews research related to evaluating the role of depression, personality factors, pain-related beliefs, trauma, and coping style in the chronic pain experience. Understanding and using the findings of this research can improve nursing care of persons with chronic pain.     

Contemporary therapy: aromatherapy in the management of acute pain?

Recent surveys indicate that people are increasingly using complementary therapies as an adjunct or alternative to conventional treatment options as well as for general health and well being. Whilst complementary therapies such as aromatherapy have been utilised in clinical settings as diverse as long term care facilities and palliative care, its application to the acute care setting has not been explored in depth. The changes in contemporary health care practices such as post-operative pain management and length of hospital admissions have provided nurses with the challenge of examining the range of therapeutic interventions that can be applied to their practice. The purpose of this paper is to examine critically the potential uses of aromatherapy in the management of acute post-operative pain. The concept of aromatherapy will be explored in relation to its effects on the pain pathways, methods of administration and therapeutic effects. Specific reference will be made to Lavender (Lavandula angustifolia) and its use in aromatherapy. A review of the literature points to gaps in the knowledge related to the clinical application of aromatherapy in relation to issues of dosage, methods of administration and therapeutic effects. The relatively small number of studies that have looked at aromatherapy in the acute care setting supports the literature reviewed. Issues such as small sample sizes and the difficulty in replicating these studies make it difficult to generalize the findings. In order to achieve best practice, further research is necessary to explore the use of aromatherapy in the management of acute post-operative pain.     

Complementary and alternative therapies: what is their place in the management of chronic pain?

Nurses have used complementary therapies for many years to relieve anxiety, promote comfort, and reduce or alleviate pain. The therapies described in this article are examples of the many therapies available for nurses to consider when planning care for patients with chronic pain. The increasing body of scientific knowledge is providing more guidance about the efficacy of specific therapies. As with all interventions, ongoing evaluation about the effectiveness of a therapy for each patient is an important component of quality nursing care. Complementary therapies provide an avenue for nurses to be autonomous in furthering the relief of chronic pain, as many of these therapies fall within the domain of nursing. Incorporating selected therapies into the plan of care provides multiple opportunities for nurses to demonstrate caring, a premier characteristic of nursing. A number of the complementary therapies, such as journaling, hand massage, and imagery, can be taught to patients and their families, thus promoting self-care. Anecdotal evidence and findings from numerous smaller studies provide some support for the use of many complementary therapies to manage chronic pain or their use as adjuncts in the treatment regimen. Still, the nurse must weigh the risks and benefits before suggesting a therapy to a patient. Evaluating the effectiveness of the complementary therapy to promote comfort in patients with chronic pain is essential. Obtaining this information is not only critical to the care of a particular patient, but these data will assist nurses in learning more about specific therapies. Most importantly, nurses need to pursue research to further the scientific basis for many of the complementary therapies.