How Nurses Know if the Patient is in Pain - Essay Example

? Research Design NURS60018 78837160 Word count: 3660 Postoperative pain in Patients in a Kuwait Hospital: A Study of How Nurses Know if the Patient is in Pain 1. Question Formulation and Theoretical Perspectives Background The Kuwait health care network is deemed to be the best in the entire gulf region and even amongst the finest in the world often comparable to those of the health care systems offered in European countries (WHO 2011). Despite this positive reality, it is still undeniable that there is still much to be improved with the way general health care services are provided in Kuwait. According to Mourshed, Hediger and Lambert (2006), the Cooperation Council for the Arab States of the Gulf which includes Kuwait, will face a skyrocketing increase in the demand for better health care services over the next two decades. All over the world it has been acknowledged by researchers that a significant exists in the field of pain management. (Ebert, 2010, p.438). Researchers also agree that the cornerstone to quality care in this area is pain assessment. (Ebert, 2010, p.438). A study of hospitalized patients in Kuwait’, in 1993, found that the pain estimates made by nurses who participated in the study were lower than that of the corresponding patients (Harrison,1993). There are also a number of studies carried out in other nations that suggest that usually health professionals underestimate pain in health care situations (Solomon, 2001; Remington and Footrell, 2005, p.269; Amery, 2009, p.103). Hence it is assumed that one specific aspect of health care service that needs improvement is pain assessment and management and also from working in Kuwait health care setting for many years, this researcher personally has an anecdotal impression that pain assessment is poor in Kuwait hospitals. In this context, this study envisages finding out, how nurses know whether the post operative patient is in pain, by carrying out an investigation in a Kuwait hospital Pain being a subjective experience,“self-report is the single most reliable indicator of pain” (Ebert, 2010, p.5). Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (International Association for the Study of Pain, 2011). Pain may be classified into either acute or chronic (Ebert, 2010, p.6). The difference between the two can be understood by the following definitions. The definition of acute pain proposes that it “is associated with strains, sprains, fractures, surgery, diagnostic procedures, or trauma, and has a short time course as it gradually diminishes as healing occurs” (Ebert, 2010, p.6). Chronic pain is on the other hand, “continuous or intermittent pain and is arbitrarily defined as pain that pasts longer than 3-6 months” (Ebert, 2010, p.6). For the purpose of this study, it is acute pain that is dealt with just because it is that post operative pain (that comes under the category of acute pain), that is discussed. There are several health care professionals who are directly involved in pain management but no other health-related profession comes as close to the pain experience of the patient as the nurse. Various studies have also suggested this because basically it is the nurses’ duty to give care and show compassion to their patients who are in pain. (Ebert, 2010; Solomon, 2001, Ball, 2000). No other health care profession has more interaction with the many facets of patient care than the nursing profession (Ball 2000). At the centre of the duty towards better pain management is the improvement in nursing. This is because pain management is now considered to be a natural component of the duties of nurses while different nursing organisations acknowledge the need for prompt, safe and effective pain management (CAPRCE 2011). Post operative pain, which is an acute pain, is an “expected phenomenon” in health care field and which should be assessed and documented (Coll et al, 2004, p.124). This is an important issue because post-operative pain may cause many adverse effects (Al-Khayat et al, 2008). Charlton (1997) relates that prolonged pain can reduce physical activity which can lead to venous stasis and risk developing deep vein thrombosis and pulmonary embolism. The harmful effects of inadequate management of pain include worsening of pain that impairs the patient’s quality of life and social determinants (for example, affecting relationships and employment capacity); continuous pain that lead to depression, anxiety and suicidal tendencies; and, constant pain that prolongs the body’s stress responses and oftentimes lead to health complications (such as suppressed immune functions, increased cardiac risk, increase susceptibility of hormonal imbalance) (Wells, Pasero & McCaffery, 2008). Evidence suggests there are many reports of inadequate pain management over the years that consequently lead to harmful complications to patients (Brunner et al., 2009; Carr et al., 2010), including increased length of hospital stay, progression to chronic post-surgical pain, and even death (Wood, 2010; Marmo & Fowler, 2010) Brunner et al (2009) has revealed that “inadequate pain management” is an outcome of “misconceptions and insufficient knowledge about pain assessment and pharmacologic interventions on the part of patients, families, and healthcare providers (p.380). But Brunner et al (2009) by giving equal importance to the inadequacies in the pain assessment of patients, families and health care professionals, have not specifically addressed the lacuna in the pain assessment carried out by health care professionals. But by pointing out how “inadequate pain management” eventually results in a “diminished quality of life characterized by suffering, anxiety, fear, immobility, isolation and depression”, these authors (Brunner et al., 2009) have shown how important is pain management for the total well-being and recovery of the patient (p.380). Carr et al (2010) have extensively dealth with the topic of “pain control” by compiling several studies done on the topic and come to the conclusion that “uncontrolled pain” can lead to many bad health consequences including death (p.12). This book is very elaborate in dealing with the possible consequences of improper pain assessment and control (Carr et al. 2010). It is in relation with pain physiology that Wood (2010) has tried to find out the lacunae in pain management. But as this study focuses on the physiological aspects of pain alone, it has discarded the importance of patient self-report (Wood, 2010). But the strength of this study is in that it has extensively dealt with the knowledge base available on the physiological aspects of pain and stressed the need for imparting this knowledge to nurses (Wood, 2010). While examining and comparing the pain assessment process and its methodologies and tools, Marmo and Fowler (2010) have carried out a “descriptive repeated-measures study (that) compared three pain assessment tools in nonverbal critically ill patients in a cardiac postanesthesia care unit”. By using pictures of patients’ bodily expressions, and assessing them as against three pain assessment tools, this study has provided highly reliable evidence to show that the use of pain assessment tools can crucially change the quality of pain assessment and management (Marmo and Fowler, 2010). But again this study has ignored the primary source for pain assessment, that is, patient self-report (Marmo anf Fowler, 2010). As a result, appropriate recognition, assessment and management of pain are essential in the nursing practice (Brunner et al., 2009; Carr et al., 2010). The Report of the Working Party on Pain After Surgery in 1990 found out that it was during the “first 24 hours after surgery” that the patient was recorded as having a pain level that is 60% of the maximum pain level. This report has also pointed out that “the median interval between the return of pain and a further injection of analgesic was 2 hours” (The Report of the Working Party on Pain After Surgery, 1990). Most importantly, this report also showed that “only half of the medical and nursing staff questioned thought that post-operative analgesia should relieve pain completely [...] [and] drugs were prescribed and administered with too little attention to the patient’s response” (The Report of the Working Party on Pain After Surgery, 1990). This report (A Report of the Working Party on Pain After Surgery, 1990) has thus suggested that all post-operative pain is unnecessary and only a problem that arises from inadequate assessment and management. While examining the relevance of this finding to nursing profession, the role of nurse in his/her profession has to be defined first. According to established research, the surgical nurses have the following responsibilities in the surgical ward: a) monitoring patients’ postoperative status; b) assessing patients’ postoperative pain; c) believing the patient’s pain and documenting the pain; d) identifying the source of the pain; e) planning appropriate care plan; f) administering prescribed analgesia; g) monitoring and evaluating efficacy of pain relief; and, h) ensuring good pain control and individualised treatment (Buckley, 2000; Ubino, 2003; Mahfudh, 2011) Buckley (2000) had arrived at a conclusion on the responsibilities of nurses in the post operative unit of a surgical ward, by carrying out a review of literature. Hence this study can be considered only as a secondary source that draws from research findings of others and does not put forth any empirical or direct evidence (Buckley, 2000). But by compiling the available research findings on the topic, this study can be taken as a starting point to assess the roles and responsibilities of nurses in a post surgical scenario and also to find out the inadequacies involved (Buckley, 2000). Ubino (2003) has contributed to preparing the list of roles given above by exploring the general scenario involved rather than carrying out a methodical study. Hence, this study can be utilized only to gather a general impression of the problems involved and to identify the possible variables for the future studies (Ubino, 2003). Mahfudh (2011) while addressing the role of nurses in relation with cancer pain control has provided a comprehensive analysis of the same, though from a literature review angle. It is the detailing that goes into this study that has made it useful for the preparation of a comprehensive list of responsibilities of surgical nurses, in this paper as well (Mahfudh, 2011). The primary assessment of pain thus becomes the sole responsibility of the nurse. Also, it is evident from the above list that the management of pain is the responsibility of the nurse once the treatment has been prescribed. Therefore, it is argued that the nurses have a role in providing the post operative patients, adequate pain assessment and efficient pain management. This research seeks to provide a clear view of how nurses assess pain, that is, how they know if their patients are in pain so that better pain assessment can be offered in health care. This research will also be focused in one specific aspect of pain, that is, pain assessment for post-operative pain among patients in a surgical unit in a Kuwait Hospital. At present, no specific research study was found about postoperative pain assessment or management that is conducted locally in Kuwait Hospital. Thus, it is deduced that a knowledge gap exists about postoperative pain nursing practice in Kuwait hospitals. Moreover, the researcher’s experience indicates that there is a lack of adequate pain assessment. Purpose of the Study The purpose of this study is to provide accurate and useful information regarding how nurses assess pain in post operative patients. This will include finding out what is the beliefs of nurses about pain, what are their perceptions of pain and what are their attitudes towards patients who are in post operative pain in general, and specifically towards, patient self-reports, pain symptoms, and the physical manifestations of pain in post operative patients. To find out how nurses make pain assessment in post operative patients, this study will also explore whether the nurses in the specific hospital in which the study is being carried out, make use of any medically approved pain assessment tools and also whether there are any culture-specific aspects to the assessment being made. This will help find out the level to which the nurses in this study have been skilled in using advanced technologies in their profession (medically approved pain assessment tools) and also whether the results can be generalised (cultural aspects), respectively. Aims and Objectives This qualitative research study aims to find out how nurses make pain assessment in post operative patients by finding out: 1. What are the nurses’ beliefs and perceptions about post operative pain; 2. What are the nurses’ attitudes towards post operative pain; 3. Through which methods and symptoms, do the nurses know that the post operative patient is in pain 4. To what extent, the nurses believe the post operative patients’ self-report of pain 5. Which are the perceived facial, verbal and physical expressions of post operative pain by nurses? Theoretical Perspective This research will seek to observe, describe, interpret and understand how surgical nurses know that their patients are in pain. There will be no controlling of the environment in order to extract information from the surgical nurses. As qualitative research is closely intertwined with the naturalistic paradigm, this study will be grounded on the naturalistic paradigm (Keele, 2011, p.35). A naturalistic paradigm requires an emergent research design that involves observation, description, interpretation and understanding of how events take place in the real world rather than in a controlled environment (Keele 2011, p.35). In opposition to the positivistic paradigm that “believes that a single reality exists that can be measured”, the naturalistic paradigm puts forth the proposition that “there are multiple realities that are continuously changing” (Keele 2011, p.35). Given this changing nature of reality as proposed by the naturalistic paradigm, a holistic approach needs to be adopted, the “findings cannot be generalized beyond the study sample”, and the“research is subjective and value bound” (Keele 2011, p,37). But the advantage of using naturalistic paradigm in research is that an issue is understood in its context and not in isolation, the methodology accounts for the subjective biases that are inevitably present in any kind of research setting, and the purposive sampling enabled by this paradigm allows certain amount of control even as keeping away from imposing an artificial controlled setting (Keele, 2011, p.44-45). Research Questions 1. What are the nurses’ beliefs and perceptions about post operative pain; 2. What are the nurses’ attitudes towards post operative pain; 3. Through which methods and symptoms, do the nurses know that the post operative patient is in pain 4. Which are the perceived facial, verbal and physical expressions of post operative pain by nurses? 5. To what extent, do the nurses believe the post operative patients’ self-report of pain 2. Methods to be used This qualitative research will select its methods based on the notions of grounded theory research (Glaser and Strauss, 1967; Holloway and Todres, 2010). Holloway and Todres (2010) relate that the findings of a Grounded Theory (hitherto referred to also as GT), research in nursing will generally have implications for practice as they identify how participants make sense of their experiences. The concept of grounded theory research focuses on the developing social and psychological aspects that characterise an experience (Glaser and Strauss, 1967). This implies that interviewing surgical nurses will help the evaluation of not only the objective aspect of their experiences but also the subjective aspect as they relate their own professional or personal views and opinions about relieving pain or experiencing pain ( Glaser and Strauss, 1967). A vital part of the grounded theory is the discovery of a core variable that is fundamental in explaining the experience (Glaser and Strauss, 1967, p.143). This means that in collecting data via semi-structured interviews, the researchers seek to discover a common factor present in the responses of surgical nurses. This may be in the form of common perceptions, fears or worries about their patients for nurses. This coincides with the fact that pure qualitative research is focused in obtaining opinions, experiences and feelings of people which produce subjective data (Hancock 1998). Grounded theory is both inductive and deductive because it seeks the widest possible range of experience about the phenomenon being studied (Milliken and Schreiber 2001). This means that data collected will come from a wide range of experiences. Sometimes even conflicting experiences of surgical nurses will become the basis for theories that will help the researchers understand how surgical nurses assess pain. Theories generated from the data will also pave way for the formulation of better parameters for assessment and interventions ultimately improving post-operative pain management in the surgical unit. 2.1 Sampling Principles and Procedures Purposive sampling is going to be used in this study. In purposive sampling, the “elements” suitable for the research in terms of helping the “investigation” are decided by the researcher making use of one’s own “judgment” (Adler and Clark, 2010, p.123). The advantage of this method is that the researcher can include any particular “element” that is according to his/her “judgment”, very crucial for the investigation, into the research schemata (Alder and Clark, 2010, p.123). Hence, the research will select nurses who work in surgical units because they are the best subjects to be interviewed. Those nurses are knowledgeable about pain for post-operative, so they are considered to be an ideal group to deal with in this study. Only those nurses who are currently assigned in the surgical unit of the Kuwait Hospital become eligible to participate in the study. Only registered nurses will be included. Doctors, midwives, pharmacists, nursing aides or nursing students will not be allowed to form part of the sample population. All those that cannot be included are deemed excluded and shall form part of the exclusion criteria. Typically the recommended sample for a semi-structured interview is about 20 to 30 (Editorial Consulting Services, 1998). Determining the sample size depend on the quality and richness of the data. This research will have 20 nurses for a high-quality start and , a guiding principle in sampling will be data saturation: which mean to continue sampling until no new information is obtained and redundancy is accomplished. Prior to conducting the study, the researchers will first provide a formal letter to the hospital administration and to the surgical unit supervisor or manager requesting that they be granted to pursue a nursing research (Alder and Clark, 2010, p.45). Once the approval is attained, the researchers will then proceed to place a notice in the surgical ward which will invite volunteers from among surgical nurses who are willing to take part in the research or those who are readily available to become participants of the research. Confidentiality will be maintained throughout the study by ensuring that no other persons than the researcher and his instructor will have access to the data collected from the participants (Alder and Clark, 2010, p.57-58). Nurses’ professional views and opinions will be shared to the researcher will not be traced back to them. Their identities will be kept anonymous. A simple numbering system will be used to identify participants without having the need to divulge their true identities (Alder and Clark, 2010, p.57-58).. Under this numbering system, each participant will be given a number which will serve as his or her identity throughout the research. This numbering system will also help increase recruitment because possible participants know that their identities will be concealed. 2.2 Data Collection Methods In-depth interview, which is the most familiarized data source in grounded theory studies, will be used (Alder and Clark, 2010, p.252). Moreover, in-depth interview allows intensive exploration of a topic with someone who has had related experiences and allows the participants “structure and control” a great amount of the information thereby making their insights a valuable value-addition to the research (Alder and Clark, 2010, p.252). Data will be collected through a one on one semi-structured interview of nurses. This is only fitting considering that Hancock (1998) relates that data collection in a qualitative research involves direct encounters with individuals through one to one interviews. The reason for using a semi-structured interview instead of a formally structured interview is to give leeway for the researchers to get as much details as possible in the answers of the participants and ask sub-questions that may arise out of the participants’ responses (Alder and Clark, 2010, p.279). It will not limit the opportunity for the researchers to ask more questions and clarify situations. The questions for nurses will cover mainly areas of interest such as how do you know that your patients are in pain?, what parameters or cues do patients use to signal that they are in pain?, what are the most common reactions of patients when it comes to experiencing pain?, do patients sometimes fake their pain?, and do all patients complain about their pain?. Open-ended questions will be used during the interview. This is in contrast with close-ended questions which limit further exploration of the participants’ experiences. One practical consideration is the veracity of what the participants will say. Considering that the data will mostly be subjective, it is within the participants control to withhold information or not tell the truth about their experiences possibly because they are shy or fear that what they say may negatively affect them. It is estimated that each interview will take 30-45 minutes (Alder and Clark, 2010, p.236). All interviews will be tape recorded after taking the consent of the nurse. The researcher will seek help in transcribing all the interviews using word processor (Microsoft Word), and then they will be read thoroughly and repeatedly. 3. Data Analysis Data analysis begins by discovering patterns and themes hidden in the individual responses of the participants (Polit and Beck 2009). Similar to other qualitative research methods, the sequential distinction between data collection and data analysis is unclear, with analysis starting much earlier in the research process than in quantitative studies, with no clear end point (Rennie and Fergus 2000). However, the basic principle is that data are examined initially at a descriptive level, and as the analysis progresses and the data structured into smaller categories, the organising models become more and more theoretical and expounding, until they can be interpreted as a conceptual framework (Giles 2002). Inasmuch as the data are in narrative form comprising of sentences, and statements from the participants, the researchers will have to individually scrutinise the data, compare and contrast them according to several groups. Strauss and Corbin’s (1998) GT method will be used which involves three types of coding: open, axial and selective coding (p.217). Open coding relies on the comparison of the differences and similarities. It tags portions of data depending on their content (Strauss and Corbin, 1998, p.217). In axial coding, the researcher sub-categorizes the data under broader headings by seeking the relationship between the codes (Strauss and Corbin, 1998, p.217). Selective coding focuses on incorporating and filtering the findings (Strauss and Corbin, 1998, p.217). It concentrates its attention on just the core codes, which are the codes emerged from open and axial coding (Strauss and Corbin, 1998, p.217). Other groups may come to light during analysis such as grouping nurse participants’ responses by their number of years in service as nurse. It will be under data analysis that generalisations in the form of theories will be created that will become basis for the formulation of practical yet effective interventions for acute post-operative pain management. Furthermore, there are numerous techniques which researchers need to carry out in order to deal with issues of reliability and validity (Giles 2002). These entail comprehensive documentation of the whole research process through memos, methods for organising the data into consequential categories, for example, saturation, and various means of evaluating the strength of the analysis, such as theoretical sampling (Giles 2002). The fundamental understanding of data analysis in grounded theory is the continuous comparative analysis, which gives the researcher with general instructions on how to move forward analytically with the data (Bryant and Charmaz 2010). The analytical procedures described above led to a new understanding of the studied process (Charmaz 2003). By constantly defining and redefining categories, researchers become theoretically receptive and gain a better understanding of what participants view as being significant and important (Charmaz 2006). Thus, a complete understanding of the underlying processes leads to confident intervention of professional to help resolve different societal problems (Glaser 1978). 4. Deliverables This research hopes to provide information that will help improve knowledge about how nurses assess pain in post operative setting. A possible impact of the findings of this study is that it will create a solid awareness that proper pain assessment is an indispensable part of nursing practice and help find out which are the specific areas in which there are inadequacies in pain assessment carried out by nurses in post operative setting; hence, it must continuously be studied to improve the way nurses care for their patients who are in pain. 5. Estimation of the Resources Required to Complete the Study This research is economic just because the sample size is small and it will be demanding only on the side of the researchers’ time spend, in order to make the semi-structured interviews as detailed as possible and thus ensure the best quality data. Snacks or other forms of token of gratitude for having participated in the study will have to be given to the participants; hence, this will require extra cost. Finally, hours of staff time will also be included as part of resources and though this cannot be equated with money, the time given by the participants to answer questions will be much appreciated. For the equipment, computers and printers will be used for the questionnaires for the semi-structured interview. 6. Scheduling of the Study Activity May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Preparation of proposal  20-30                   First meeting    6                 Obtain consent from hospital administration     5-9               Submission of the proposal        2           Data collection          1-31  1-31 1-31       Data analysis            1-31       Writing up the final result of the study                1-30  1-31   Feedback from the supervisor                    1-30 Evaluation, final draft                     1-23 Submission of the dissertation 222 7. Ethical Issues There are a number of ethical issues apparent in this study. One issue is the possibility of breach of confidentiality but this can easily be avoided through the use of the numbering system previously described. Study participants will have the right to expect that any data they provide will be kept in the strictest confidence (Polit and Beck 2009). Naturally, nurses who will participate in the study will want to maintain their confidentiality. Their professional views and opinions towards their patients who are in pain and with their colleagues may not always be positive; hence, it is crucial that their statements will not be traced back to them. Another ethical issue involved is that in case of a nurse quoting a specific patient, the confidentiality of that patient will also become a matter of concern. To address this issue, the participants will be cautioned not to mention any specific names or identifiable details of the patients they are referring to, if any. Another ethical issue might be the impact of the presence of the researchers will have on the patients’ mental state in a post operative setting and also the problems that it may present to the perfect fulfilment of the duty by the nurses. This possibility is there, owing to the sensitive nature of the setting and the human situation involved. To avoid this, a pre-determined physical distance will be kept by the researchers from the patients and the nurses so as not to obstruct the clinical activities going on. 8. Reflection on the Study Using grounded theory approach opens the door for creativity and originality; almost all the data analyzed are going to be new. No pre-assumptions are going to be made about the nursing pain assessment.. The semi-structured interviews will yield rich and in depth information that can cover the multiple dimensions of a complicated phenomenon such as post operative pain, perceptions of nurses about post operative pain and the importance of such perceptions in pain assessment and subsequently the management of it. On the other hand, a possible weakness of this study is the validity of the data because the information will be gathered from human beings and humans are sensitive, emotional, and fallible. And the flexibility of qualitative research design that gets evolved at each step in the process of research work, puts forth a challenge of ensuring the validity at each step (Maxwell, 2005, p.3). Validity is also an element of research that is influenced by the research method, research question, existing theoretical framework, pilot research, and preliminary data gathered (Maxwell, 2005, p.6). Another potential weakness involves the generalizability of the findings. It is not necessary that two researchers studying the same phenomenon in the same setting will get the same results. In qualitative research, generalizability is ensured by making the study in a large canvas and also by having a representative sample about which a solid sampling logic exists (Maxwell, 2005, p.71). Though this particular study has ensured a minimum level of representation through purposive sampling, the small sample size restricts its generalizability. In Addition, the lack of time to interview nurses might be an issue because they are busy and maybe they would hurry through it to save time. Lastly, a possible limitation also would be hallo effect which is how an individual generally think about their badness or goodness. This can lead to inaccurate result based on the assumption they make. The subjectivity of the researcher and the participants is yet another influence that can make the final results biased and away from the truth (Maxwell, 2005, 20). But subjectivity can be turned into the strength of qualitative research by drawing from it “insights, hypotheses, and validity checks” (Maxwell, 2005, p.38). In this study, the researchers will ensure the “quality” of this research by adhering to “basic principles of rigour” (Swanwick, 2011). Rigour pertains to the strength of the research design in terms of ensuring that all procedures have been strictly followed that all possible confounding factors have been eliminated and that the users of the research are confident that the conclusions and recommendations are dependable (Lacey 2010). For this study, rigour is achieved by ensuring that the right people are sampled, the sample size is adequate to provide sufficient understanding of the problem; the researcher’s relationship with the participants is taken into account for assessing the level of subjectivity; by using field notes and semi-structured interviews, triangulation of data is made possible; and all possible validity checking measures are adopted as the study progresses (Swanwick, 2011). Also, a detailed timetable as part of the schedule of the study has been formulated (Refer to Schedule of Study) with the purpose of ensuring that everything is in order and in schedule and that in case delays are incurred, activities can easily be adjusted. 9. References Alder, E.S. and Clark, R (2010) An invitation to social research: how it’ done, Cengage Learning, Connecticut. Al-Khayat HS, Patwari A, El-Khatib MS, Osman H, Naguib K. (2008). 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