AHCPR clinical practice guideline on surgical pain management: adoption and outcomes

Pain management practices and short-term patient outcomes in nine acute care hospitals in Milwaukee, Wisconsin, were studied at two points in time. One-and-a-half years after the Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline on Acute Pain Management was published, data from 330 adult surgical patients were collected (Time I). These data were contrasted with data from 373 adult surgical patients collected 2 years later (Time II). There were significant increases in the percentage of patients who reported being taught how to report pain using a pain rating scale and about setting a pain goal preoperatively; in the percentage of patient hospital records with at least one documented numeric pain rating; and in the percentage of patients who received analgesics by intravenous administration. However, pain management practices continued to differ from recommendations in the AHCPR guideline. No significant improvement was noted in the short-term outcomes of patient-rated pain or patient satisfaction with pain management. Availability of well-published guidelines alone may be insufficient to ensure comprehensive adoption of guidelines that are multidimensional in nature and to obtain improvements in patient outcome.     

Organizational factors that support the implementation of a nursing best practice guideline

BACKGROUND: The context of the healthcare setting may play a crucial role in influencing the implementation of best practice guidelines in nursing. Further study is required to understand these organizational factors. Two variables, organizational culture and leadership, are thought to influence the adoption of best practice guidelines. AIM: A discussion of organizational factors that influence best practice guideline adoption is presented. A small pilot study is provided as an example of methods for further research. METHODS: A quantitative survey of nursing staff was conducted. RESULTS: Results from the pilot study reveal variability in best practice guideline implementation despite the presence of a culture of organizational learning and transformational leadership. CONCLUSIONS: There is beginning evidence in the literature that culture and leadership are key elements influencing guideline implementation. In this pilot work on two inpatient units where a nursing best practice guideline was implemented, a supportive organizational culture and key people leading change were present. Implications for further studies are offered. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leaders interested in promoting the use of best practice guidelines must pay attention to the organizational context in which nursing care occurs. A supportive culture where learning is valued coupled with transformational leadership may be key factors in the implementation and the sustainability of best practice guidelines.     

Effects of the implementation of a breastfeeding best practice guideline in a Canadian public health agency

Several strategies were used to implement a breastfeeding best practice guideline (BPG) in a Canadian public health agency. Nurses surveyed before and 1 year after implementation reported increased BPG‐related knowledge and stronger beliefs regarding breastfeeding duration beyond 1 year. Telephone surveys also were conducted with mothers; 90 before BPG implementation and another cohort of 141 mothers following implementation. Post‐implementation mothers were more knowledgeable about sources of breastfeeding help, obtained more help from public health nurses, and reported more breastfeeding‐related discussion with healthcare providers. Compared to the pre‐implementation cohort, mothers in the post‐implementation cohort who were still breastfeeding at 6 months intended to continue breastfeeding longer. Implementing a breastfeeding BPG can affect breastfeeding‐related experiences at a population level. © 2012 Wiley Periodicals, Inc. Res Nurs Health 35:435–449, 2012     

Effectiveness of an acute pain service in surgical patients — a hospital comparison study

The implementation of an acute pain service (APS) has been advocated as the cornerstone of effective pain management. However, convincing evidence demonstrating the effectiveness of an APS in controlled studies is scarce. In this study we compared both subjective and objective variables of surgical patients in two similar hospitals, one of which had established an APS. During the study period of two years 498 patients were prospectively enrolled. Pain and other related variables (appetite, mobility, need for sleep, fatigue, and general satisfaction) were assessed pre- and postoperatively by means of 10 cm VAS scales printed on two identical questionnaires. Additional data were retrieved from the patients' records. Those patients who were cared for by an APS suffered less pain (25 mm VAS at rest), sleepiness (13 mm VAS), mobility restriction, and loss of appetite. For most measures the beneficial effects of the APS were present pre- and postoperatively. However, hospital stay was similar in both hospitals (13.7 vs 14.3 days; A vs B). Our data indicate large and patient-relevant benefits of an APS, but our study design was vulnerable to various kinds of bias.     

Nurses' willingness to manage the pain of specific groups of patients

Effective pain management remains a challenge for the nursing profession. While nurses' knowledge of appropriate pain strategies has improved considerably, additional research needs to be conducted into the influence of factors other than knowledge on the management of pain. This study examined the willingness of nurses (n = 157) and nursing students (n = 265) to spend time and energy managing the pain of different groups of patients, when told that all patients had the same degree of pain. The willingness of nurses to spend time and energy in managing patients' pain was used as a proxy for preconceived notions relative to particular groups of patients. A pattern emerged that suggested that nurses' and nursing students' willingness to spend time and energy managing patients' pain in influenced by their perceptions of different groups of patients.     

The development of best practice in breaking bad news to patients

There can be few tasks that a health care practitioner has to undertake that impact more upon patients and their relatives, than that of breaking bad news. Consideration needs to be given to the people involved, the communication process, and the environment. This article highlights the issues that make for best practice in this important area of care--including who gives the information, how it is presented, and the nature of the environment where it is given.     

Parents' awareness and use of nonpharmacological methods to manage their baby's procedural pain in a surgical neonatal intensive care unit

Parents whose babies had undergone major surgery and were admitted to the surgical neonatal intensive care unit for more than five days, and who could communicate in English were surveyed to explore their use of nonpharmacological methods to manage their baby's procedural pain in the post-operative period. Eighty-one parents, including 48 mothers, completed a 4-part questionnaire. Parents most frequently used physical and comforting touch methods to comfort their babies. Skin-to-skin care, sucrose, breastmilk-scented pads, and breastfeeding were least frequently used. While the majority of parents were aware of most unit practices regarding their baby's pain management, some practices needing greater awareness were identified. These findings highlight the need to promote a range of parent-led nonpharmacological pain management methods. This could be achieved by educating clinicians to collaboratively support and encourage parents' involvement in managing their baby's pain.     

How to manage type 2 diabetes in medical and surgical patients in the hospital

Many patients admitted to the hospital have diabetes mellitus-diagnosed or undiagnosed-and others develop hyperglycemia from the stress of hospitalization. This paper discusses the prevalence, outcomes, and evidence for best management of hyperglycemia and diabetes in hospitalized patients outside the critical care setting.