Examination of Factors Affecting Therapeutic Attitude and Empowerment of Perianesthesia Nurses Who Care for Patients With Opioid Use Disorder

PurposePatients with opioid use disorder (OUD) and associated complexities are presenting to hospitals in increasing numbers. Preparation of perianesthesia nurses caring for this patient population has lagged, with noted deficits in continuing education, resources, and role support. Previous research found education without considering therapeutic attitude (TA), empowerment and factors that influence nursing practice does not translate into feelings of competence in nursing care. The purpose of this study was to identify correlates and predictors that affect TA and empowerment among perianesthesia nurses caring for patients with OUD.DesignA cross-sectional, correlation design was used to identify correlates and predictors of TA and empowerment in a national sample of perianesthesia nurses (N = 215)MethodsA national survey collected data from perianesthesia nurses. The Perianesthesia Nurse Empowerment and Therapeutic Attitude Model was the guiding framework. Pearson product-moment correlation and hierarchical multiple regression analyses were used to examine relationships between personal factors, the professional practice environment and societal factors of perianesthesia nurses.FindingsThe standardized regression coefficients indicated the professional practice environment (β = -0.28), drug user stigma (β = 0.27), access to a pain specialist (β = 0.25), and exposure to drug users (β = 0.25) were the strongest predictors of TA. Access to a pain specialist (β = -0.15) and the professional practice environment (β = 0.72) were the strongest predictors of empowerment.ConclusionsThe professional practice environment directly influenced the degree of empowerment and TA reported by perianesthesia nurses. Exposure to persons with OUD and personal stigmatization of persons who misuse drugs decreased TA but had no association with empowerment. Access to a pain specialist was moderately predictive of empowerment and negatively associated with TA suggesting a lack of role legitimacy and the need for further research into perianesthesia nurses’ perceptions of their role when caring for this population.     

A Competency-Based Orientation (CBO) Protocol Enhances Competency Among Newly Hired Perianesthesia Nurses

PurposeThe purpose of this quality improvement project was to develop a competency-based orientation (CBO) protocol based on the American Society of PeriAnesthesia Nurses Nursing Standards and CBO for perianesthesia nurses.DesignFeasibility study with pre–post survey design.MethodsA CBO protocol that included nursing care workflows for 11 common surgical cases was developed and used in orienting newly hired perianesthesia nurses. Newly hired nurses completed a pre–post self-assessment on their level of competency in caring for surgical patients.FindingsUsing Wilcoxon signed rank test, improved competency was found in all service areas except for pediatric care.ConclusionsNursing competency in the perianesthesia area is critical in fulfilling one's role as a nurse. A robust CBO protocol for the perianesthesia nurse is important when integrating an employee into the organization and preparing the nurse for success.     

Safety Climate and Organizational Communication Satisfaction Among Korean Perianesthesia Care Unit Nurses

PurposeThis study investigated organizational communication satisfaction and safety climate among perianesthesia care unit (PACU) nurses and factors affecting safety climate.DesignA cross-sectional study of 103 registered nurses currently working in PACUs in Korea.MethodsOrganizational communication satisfaction was measured using the Communication Satisfaction Questionnaire, and safety climate was assessed using the Safety Attitudes Questionnaire-Korean version 2. Additional questions covered the demographics of the respondents and the characteristics of the hospital where they worked.FindingsFactors affecting teamwork climate included communication climate and horizontal informal communication. Safety climate was affected by media quality and organizational integration; job satisfaction by working in secondary hospitals, communication climate, and media quality; perception of management by working in public hospitals, media quality, and personal feedback; and working conditions by working in public hospitals, media quality, and personal feedback.ConclusionsThe results show that Korean PACU nurses experience poorer safety climate compared with other countries. One suggestion is to enhance nurses’ satisfaction using organizational communication (eg, by developing effective communication media that satisfy users) and to promote communication at an organizational level so that individual health care professionals are aware of their organizations’ vision and policies.     

Nurses’ use of the clinically aligned pain assessment tool: A mixed methods study

BackgroundAssessment of pain in the hospital has often relied on intensity rating alone. To address the gap in meeting patients' pain management expectations, a Midwestern medical center implemented the CAPA (Clinical Aligned Pain Assessment) tool for more comprehensive nursing pain assessments.AimsThis research described nurses' experience using CAPA on an adult general medicine unit and their documentation of the tool in the electronic health record (EHR) more than 5 years after CAPA implementation.DesignMixed methods exploratory sequential design.MethodsA convenience sample of nurses (N = 8) participated in 2 focus groups to describe how they used CAPA, how well it assessed pain, how it determined pain interventions, and the challenges and advantages of using CAPA. Patient EHR data (N = 373) for a 6-month period from the same unit were analyzed to evaluate CAPA documentation.ResultsQualitative themes included: benefits of using CAPA, CAPA leads to a more comprehensive picture, variation in how CAPA is used, and challenges. Quantitative findings demonstrated most frequent documentation in the comfort domain and earlier, though still delayed, reassessment when a higher level of pain was noted. Mixed methods analysis revealed variation in knowledge and practice regarding which domains to document each shift and during reassessment.ConclusionsAs patient advocates, nurses are integral to thorough assessment and treatment of pain. Findings identified the need for methodological research of CAPA. As with any assessment tool, when using CAPA, ongoing monitoring is needed to address how it is administered, coded, and used for decision-making about pain management.     

妇科腹腔镜术后患者主诉疼痛与护理评估结果的比较

目的比较妇科手术后患者主诉疼痛情况与护理人员评估的差异,以期为临床护理中疼痛照顾提供参考依据。方法采用便利抽样法选取2010年6-10月在宁波市妇儿医院妇科行腹腔镜手术治疗的200例患者为研究对象,所有患者于术后第1天采用数字疼痛评估量表(numeric rating scale,NRS)测量其疼痛情况,并与护理人员评估结果相比较。结果患者主诉疼痛强度分布于0～10分,而护士评估介于0～6分之间;差值为1～8分。护士低估患者疼痛者占54%,高估者占34%。结论与患者主诉相比,护理人员低估了患者的术后疼痛,应加强临床护理工作中疼痛评估及疼痛沟通的训练。     

Nursing documentation of postoperative pain management

Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.     

Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children

Background: The National Association of Emergency Medical Services Physicians’ (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed. Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations. Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record. Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02). Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.     

The Effect of Educational Strategies Targeted for Nurses on Pain Assessment and Management in Children: An Integrative Review

BackgroundNurses play an important role in children's pain assessment and management because they spend the majority of the time with them and provide care on a 24-hour basis. However, research studies continue to report on nurses' inadequate assessment and management of children's pain, which may be partly attributed to their insufficient education in this area.ObjectivesThis integrative review sought to examine the effect of strategies used in educating nurses on pediatric pain assessment and management.DesignAn integrative review.Data SourcesCumulative Index to Nursing and Allied Health Literature, Cochrane, PubMed/ Medline and Scopus.Review/Analysis MethodsFour databases were searched up to February 2018 based on a prescribed eligibility criteria. The review included 37 studies with varied methodologic quality.ResultsOur findings revealed that various types of educational strategies improve nurses’ knowledge, attitudes, and practice of pain assessment, management, and/or documentation.ConclusionsDeveloping a responsive program that includes expectations of beneficiaries, integrating it into existing facility training systems and delivering it through multidisciplinary collaboration, offers the benefit of securing sustainability of the educational gains.     

Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013

Introduction: Pain is the most common symptom in patients presenting for prehospital (PH) care. Research in civilian emergency medical systems has shown wide variability in PH pain assessment and analgesic practices, yet a minimal amount is known about pain assessment and analgesic intervention practices in the military, particularly when PH care is delivered in a combat zone. Objective: To describe prehospital (PH) pain care practices for U.S. military personnel injured in Iraq and Afghanistan 2010–2013 and explore potential relationships to explain variation. Methods: An exploratory retrospective, cross-sectional study of Department of Defense Trauma Registry data from 2010 to 2013 was performed. Demographic, clinical, or health system variables for associations with three outcomes: 1) pain assessment documentation; 2) pain severity (0–10 scale); and 3) analgesic administration (yes/no). Including only variables with significant associations, backward stepwise regression was used to develop explanatory models for each outcome. Results: Patient records (n = 3,317) were evaluated for documentation of PH pain assessment and analgesic administration. The prevalence of PH pain score documentation was 37.8% (n = 1,253). Overall, the proportion of records with PH pain scores increased over time: 19.8% (2010), 35.1% (2011), 58.2% (2012), and 62.2% (2013). Severity of pain scores ranged 0–10; mean = 5.5 (SD = 3.1); median = 6 (IQR = 3–8). Analgesics were reported for 50.8% (n = 1,684), of whom 38.3% had a pain severity score documented. The pain assessment documentation model included any documented vital signs, injury year, and mechanism of injury and explained 19.3% of the variance in documentation. The pain severity model included vital signs and injury severity score (ISS) and explained 5.0% of the variance in severity. The analgesic model included any vital signs, pain severity, trauma type, mechanism of injury, ISS, and year. Conclusions: Pain assessment and treatment documentation improved each year, but remain suboptimal. Available data yielded poor prediction of the outcomes of interest, emphasizing the importance of individual assessment. Analgesic effectiveness could not be evaluated.     

Partnership Through Integration: Perianesthesia Policy Standardization

PurposeTo develop system-wide perianesthesia policies, through partnerships, across 11 acute care hospitals and 1 ambulatory surgery center.DesignA partnership culture was created and maintained throughout the development and integration of multiple site-based policies into system policies.MethodsPolicies were built using evidence-based practice and professional organizational standards with an emphasis on quality, safety, and standardization of patient care. Early and ongoing partnerships with key stakeholders were maintained in order to effectively develop the policies.FindingsMore than 50 independent policies across 11 acute care hospitals and 1 ambulatory surgery center were integrated and updated into 4 main perianesthesia nursing policies.ConclusionsFlexibility and partnership with key stakeholders throughout the policy process was instrumental for early detection of barriers and the successful development of perianesthesia nursing policies.     

Perianesthesia applied research.

Research is important for perianesthesia nursing to validate and to advance patient care. Evidence-based nursing practice is discussed as one method of advancing PACU nursing practice. PACU nurses are encouraged to submit pain study reviews as a beginning to evidence-based nursing practice. Resources are given for research method techniques.     

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

BackgroundOver 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception.AimsTo investigate nurses’ perception of pain management in HF patients.MethodsMembers of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.ResultsA total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.ConclusionsThe impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.     

An Exploration of Pain Documentation for People Living with Dementia in Aged Care Services

BackgroundPain in people with dementia is a common occurrence. Providing evidence-based pain management for people with dementia in residential aged care services is imperative to providing quality care. However, it remains unclear from current research how various aged care staff (Registered Nurses (RNs), Enrolled Nurses (ENs), Personal Care Assistants (PCAs)) engage at specific points of the pain management pathway. With structural changes to the residential aged care workforce over the past two decades, understanding the relative contributions of these aged care staff to pain management practices is crucial for future practice development.AimTo investigate the quality and completeness of pain documentation for people living with dementia, and assess the extent to aged care staff are engaged in documentation processes.DesignA three-month retrospective documentation audit.Setting and ParticipantsThe audit was conducted on the files of 114 residents with moderate to very severe dementia, across four Australian residential aged care facilities.MethodsData was collected on each resident’s pain profile (n=114). One hundred and sixty-nine (169) pain episodes were audited for quality and completeness of pain documentation and the extent to which aged care staff (RNs/ENs and PCAs) were engaged in the documentation of pain management.ResultsTwenty-nine percent of pain episodes had no documentation about how resident pain was identified and only 22% of the episodes contained an evidence-based (E-B) assessment. At least one intervention was documented for 89% of the pain episodes, the majority (68%) being non-pharmacological. Only 8% of pain episodes had an E-B evaluation reported. Thirteen percent (13%) of episodes contained information across all four pain management domains (Identification/ problems, assessment, intervention and evaluation). Documentation by PCAs was evident at all points in the pain management pathway. PCAs were responsible for considerately more episodes of assessment (50% vs 18%) compared to nursing staff.Conclusion and Clinical ImplicationsDespite the high prevalence of pain in people with dementia in aged care settings, current pain management documentation does not reflect best practice standards. Future capacity building initiatives must engage PCAs, as key stakeholders in pain management, with support and clinical leadership of nursing staff.     

Survey of Nurses’ Use of the Clinically Aligned Pain Assessment (CAPA) Tool

BackgroundLimited research is available on tools for assessing pain and its effect on function in the acute care setting.AimThis research's purpose is to describe nurses’ use of the Clinically Aligned Pain Assessment (CAPA) tool and their beliefs about its utility for assessing pain compared to the numeric rating scale (NRS) in a hospital where CAPA had been used for 6 years.DesignA cross-sectional self-report survey.MethodsNurses (N = 110) from 13 adult inpatient units in an academic center participated in this survey describing frequency of CAPA and NRS use, CAPA domains documented, and how nurses asked about pain and distinguished between categories when coding for documentation. Beliefs about the tools’ effectiveness were also reported.ResultsMost nurses used CAPA routinely for assessments; almost half used the NRS at times. They believed both tools were effective for assessment, but CAPA was more effective to determine what intervention was needed. They also believed patient report using CAPA was more likely to match the nurse's assessment; a majority reported incorporating their observations into CAPA documentation. Most asked the patient about pain without using CAPA words, although many used the specific words. Practice varied in how nurses determined which category to select in the comfort domain and which domains were assessed routinely.ConclusionsAlthough many nurses believed CAPA was effective, variation existed in how it was used to assess and document pain, increasing potential for inconsistent assessments and interpretations of pain and pain management.     

Effect of a QI Intervention on Nursing Assistants’ Pain Knowledge and Reporting Behavior

BackgroundPain among long-term care residents is often underdiagnosed and inadequately treated. We examined the effect of a multimodal intervention on certified nursing assistants’ pain recognition knowledge and verbal reporting behavior. Secondarily, we examined pain documentation in a newly established pain log compared with pain verbally reported to nurses and documented in the electronic health record (EHR).DesignQuality improvement project using a pretest–posttest design.SettingA skilled nursing and rehabilitation facility in Southwestern Pennsylvania including two long-term care units and one transitional rehabilitation unit.Participants/SubjectsFifty-six nursing assistants.MethodsThe intervention was a face-to-face educational session with a training video and introduction of a new pain log used to document residents' pain. Pain knowledge was measured before and after the educational intervention. Multiple measures were used to examine nursing assistants’ pain reporting.ResultsNursing assistants’ pain knowledge improved (p < .001). There was no change in verbal pain reporting behaviors. The percent of pain episodes documented in the electronic health record that were reported to nurses varied by unit type (45% on the long-term care units vs. 100% on the rehabilitation unit) but remained unchanged postintervention. Pain logs were used more often on the rehabilitation than the long-term care units; use was low overall. Nursing assistant reports that nurses provided feedback on their reports of resident pain increased from 45% in week 1 to 75% in week 4.ConclusionsAlthough the multimodal intervention improved nursing assistants’ pain knowledge and their perceptions of the feedback they received from nurses when they reported pain, it had no effect on certified nursing assistants reporting of pain to nurses (per nurse report).