Non-pharmacological and pharmacological methods - Essay Example

Cardiff BSc Nursing Studies Overseas In patients with burn injuries; does non-pharmacological method in comparison with pharmacological method, result in reducing the level of pain Introduction It is axiomatic to squabble that most nurses are often faced with a challenge of identifying the best method to reduce pain amongst patients. Nurses need to play an active role in decision-making to achieve a high standard of knowledge and to provide high quality care. Therefore, Evidence-Based Practice (EBP) presents practical tool, to answer questions in health care settings. EBP collects the latest or recent evidence from research and guides the improvement in healthcare by presenting the best possible outcome for patients (Saba and McCormick 2011). Fain (2009) declares that evidence-based practice counts the variability from the study and the examination findings because we all are unable to adjust one common process or even add new facts without powerful evidence. Similarly, EBP had been described by Rees (2011, p.3) as “a problem -solving and decision-making system, based on collection, evaluation and synthesis of sound evidence, which ensures best practice by health professionals”. This definition highlighted that EBP is about using different studies and comparing them by people who are expert on clinical judgment to produce quality and value practice for the patients (Rees 2011). Both authors agreed that evidence is dependent generally with the kind of the research and the method it had been conducted (Holland and Rees 2010). Locally, ‘professional knowledge and competence’ is one element of Oman Nursing and Midwifery Council Code of Professional Conduct (2011:9). According to ethical key principles, nurses should conform to good, effective and safe practice, such as beneficence and non-malfeasance, when caring for patients. Gastmans et al. (1997) mentions that ethical consideration is synonymous with good care and the relationship between EBP and nursing ethical codes is to provide good quality care with one goal direction. It is relevant to nursing as it shows a caring behaviour through virtue and expert activity by ensuring that the most up to date clinical practice is recommended and used in practice. According to Renee and Judith (2008 p.138), beneficence is “the obligation to do good” while non-malfeasance is “the obligation to do no harm”. Assignment Topic The number of patients with burn injuries admitted, annually, in the National Burn Unit (NBU) in Oman increased steadily between 1986 and 2011 (Al Shaqsi et al. 2013). For instance, in 2010 the number of admitted patients in NBU was 884; 23% of these were considered severe, and received tertiary care (MOH 2010). The increasing numbers of patients with burn injuries need close attention from MOH to facilitate pain management practices because first and second burn injuries cause severe pain during dressing, despite the frontline analgesia. The administered patient will therefore need additional methods to decrease the pain (Summer, Puntillo etal. 2007). In contrast, third degree burn considered less or absent of pain because the nerve ending is damaged or burnt. Furthermore, in burn patients, dressing changes are considered as a routine procedure. Some of these procedures are, washing the wound; debridement and application of new dressing once, twice or three times daily to decrease the inflammation access due to the open size of the burned area in the body which is called Total Body Surface Area (TBSA)(Appendix 1). This process requires cautious dealing with burn patients, as they are going through a lot of psychological and physiological disturbance such as anxiety, fears and depression sometimes due to change in body surface. Nurses’ role in burn dressing is to reduce the pain encountered during the dressing procedure. Acknowledging clients coping mechanism is importance to have the maximum effect of non-pharmacological methods. This review will analyse integrated practice evidence on use of non-pharmacological methods such as, jaw relaxation, relaxation breathing and music identified within studies reviewed. Aim The aim of this assignment is to; Compare the use of non-pharmacological pain management with pharmacological pain management; To reduce the level of pain by patients with burn injuries during wound dressing To avoid second dose of analgesia. The PICO format is the first step in developing clinical questions (Melnyk and Fineout-Overholt 2005). According to Holland and Rees (2010) it concentrates entirely on the significant issues that need to be researched and an evaluation is declared. The review PICO statement is: In patients with burn injuries; does non-pharmacological method in comparison with pharmacological method, result in reducing the level of pain.? The element tips: The populations = patients with burnt injuries. Intervention= non-pharmacological treatment intervention (jaw-relaxation, breathing exercise and music). Comparison= compared to the patients who were treated though the pharmacological treatment. The outcome = reduction in the level of pain. The next section will critically analyze the literature review of the subject. Review of Literature Review of literature is a collection of vital conclusion or overview gathered from the best literary works about certain topic (Fain 2009). Most of the collected evidence was obtained from Cardiff University’s e-database. Other search engine used includes: Pub med, CINAHL, Ovid SP and Google Scholar. Different key words, synonyms and phrases; written for answering the PICO question such as burn, pain, non-pharmacological and afterward articles keywords are also studied. Initially, in Pub med search engine, keyword burn came-up with 89535 hits (Appendix 2), after which the hits reduced to five articles as some of them were excluded given that their methodology did not fit the criteria. The focus was to include articles with the most recent and the strongest evidence. According to Holland and Rees (2010), randomized controlled clinical trial (RCT) and systematic reviews with well-designed RCT, have high quality evidence. Most studies were obtained from a high hierarchy of evidence (see Appendix 3). The research was limited to a ten-year period ranging from 2004 to 2014 in English language journals and without geographical limit. Some of the key themes include pain anxiety, relaxation, and burns among others. Use of non-pharmacological methods Fakhar et al. (2013) examined the effect of jaw relaxation (JR) method, based on the Gate Control Theory of pain. According to Ferguson and Voll (2004), in certain points, the transmission of the pain in the nervous system can be stopped through practicing relaxation process as pain is sensory and cognitive experience. Fakhar et al. examined the effectiveness of Jaw relaxation technique in reducing pain from several study to ensure its reliability as pilot study. Fakhar et al. (2013) aimed to measure the pain anxiety related to change of dressing in admitted burn patients with age ranging from 18 to 60 years. The inclusion was only of 2nd degree burns (9-35% Total Body Surface Area-TBSA) and other burn degrees were excluded. Inclusion criteria meant people who are representative of the study and exclusion criteria meant people who may cause bias or hurt themselves. It is an experimental randomized clinical trial (RCT) with two groups. RCT is on the second top of hierarchy besides RCT can affect the decision-making if the sample size is calculated appropriately. RCTs are the useful trials that could admit the generalization of cause and affect relationships between intervention introduced and outcome measure. Sample size was estimated using power analysis to have a representative group. This power analysis helps to estimate the sample needed in experimental and control groups to support the findings as outlined by Burns and Grove (2009). The experimental group used jaw relaxation technique while the control group used usual medication care only without specifying it as this counted a weakness against the study. Randomization of allocation is done to ensure similarities in groups with a six months’ time period. Experimental group was taught to master jaw relaxation for 20 minutes and then asked to rate their pain anxiety level before dressing and again 15-20 minutes after the dressing. The study’s strengths focused on severity of baseline pain and anxiety before and after the burn dressing procedure. This reflects that the authors focused on validity of what they had measured. Validity means the ability to figure out the extent of measurement scale to measure what it supposed to measure (Rees 2010). The study measures three hypotheses (see appendix 4). Hypothesis is a way of having a picture or predicts the relationships between two or more variables in terms of expected results of a research (Fain 2009). The main aim of this assignment is keen on the third hypothesis focused on the difference between experimental and the control group. From the P=0.048 value result obtained in the study signifies that the experimental group using the jaw relaxation technique experienced significant reduction in their pain anxiety compared to the control group during post wound dressing. It was supported by Rees (2011) that Small p values same or below the minimum of (0.05) indicates significant changes between the tested variables. The study presented numerous substantial points in the pilot study of the effectiveness of jaw relaxation. It was compelling to use a measurement scale as consistency was measured and reliability from other previous studies. Reliability means the measurement scale used is accurate to use according to previous pilot studies (Rees 2010). Internal consistency (Cronbach’s α=0.70) which mean it covers the anxiety and pain measurement before, during and after intervention reflected the accuracy of findings. By using Burn Specific Pain Anxiety Scale (BSPAs) the authors covered the whole dressing range pain measurement and that leads to increased validity of measurement scale to anxiety pain level. Nevertheless, the main limitation was in the contrasting attitude of the nurses in the dressing rooms and in their way of dressing as that can lead to bias in results of the measurement of pain anxiety after dressing. Pharmacological management was not explained, so there is insufficient procedure reporting which could affect the outcome. Overall, the study supports that jaw relaxation can be taught to patients undergoing burn dressing. Many authors concluded that patients practicing jaw relaxation exercise have low subjective indices of pain and anxiety (Yvonne 2011, Eunok et al. 2013). They examined the validity of jaw-relaxation technique and positive reduction effect on pain anxiety level. They admitted that the use of jaw relaxation is cost effective than the application of analgesic methods. The subjects who followed the practice showed a statistical significant difference when it comes to pain severity. Their results were congruent with the Fakhar et al. (2013) study. Eunok et al. (2013) carried out a quasi-experimental study. The aim was to explore the effectiveness of relaxation breathing (RB) behaviour on pain anxiety level for patient undergoing burn dressing. Comparing two groups of patients suffered from burns’ pain aged from 18 years and above without randomization as through the progress the randomization found difficulty to match both groups which considered importance to support the findings. Accordingly, the researcher adopted a quasi-experimental due to difficulty applying randomization. This type of studies are almost similar to RCT, but without randomization. The research will normally explore the positive effect of the introduced intervention to the outcome, but in term of generalization the findings it considered a limitation to the study because the researcher did not have the chance to measure all participants equally in both groups. The inclusion criterion was stated clearly. Pain measurement was conducted by using the Visual Analogue Scale (VAS), as VAS widely has been identified for its’ reliability and validity to measure the pain (Couper 2006) (appendix 5). Sample size was calculated by power statistics and the estimated number was 60 participants which is a reasonable good sample for the study. These were equally divided: 30 patient in experimental and 30 in control group, which gives accuracy in terms of the sample size to the findings. Both the groups received routine standard dose of morphine formulation and tramadol intramuscular. During the change of dressing, no changes were made to the normal pain relief beyond RB; to prevent a biased result. Although no guarantee on the lasting effect of the medication could lead to a bias on pain anxiety result. In order to facilitate accuracy in performance, the author developed educational video clips and pamphlets to facilitate the quality of training for the participant, which could advance the participant performance to achieve the true or accurate outcome measures. Ethical consideration was approved its’ rigor from TUMS committees and burn centre authorities by obtaining consent prior to the procedure and participants were provided a full explanation of the intervention and its effect on pain anxiety. Patients were asked to rate their pain using a VAS, 5 mints prior to dressing and immediately after dressing. Findings of RB effect on pain showed a significant difference between both the groups (P=0.01). In addition, over a time period, P value calculated showed a significant difference (P=0.001). RB effect on anxiety demonstrated a positive P value (o.o1). P value reflects the good effect of RB on reducing the pain anxiety level throughout the trial. Comparing RB and JR, both are cost effectiveness as it proved it’s’ benefit for stress-related procedures. Both authors focused on educating or training the participant before the study to increase the findings reliability and using measurement tools that cover the whole range of the intervention to increase validity. The effectiveness with regards to burn care in terms of controlling pain might have minimal effect; however it helps in dealing with the psychological stress and trauma that is associated with the pain. Another study by Noor et al. (2011) to analyze the effects of music listening for pain relief among burnt patients concluded that listening to music have a positive effect on the experience of patient with pain. The study adopted Quasi-experimental study in evaluating how music reduces the intensity of pain in two month period. A sample of 30 dressing changes was involved in the study (15 in each group). The researchers were not able to randomize or get a large sample size, as with randomized large sample size researchers can achieve generalization result. The study design was similar to Eunok et al. (2013) in introducing RB. The authors made a detailed inclusion and exclusion criteria, which help the sample to be well designed, representative and decrease bias (Rees 2011). Before the study, the researcher presented them with an ethical letter that required their consent to participate in the study. The study used multi-measurement tools (objective and subject) which has been identified for its’ reliability and validity to capture different aspects of variables during the study. Using multi-measurement scales gave credits to findings reliability. The intensity of pain was measured by numeric pain score which patients score based on the level of pain. A pain behaviour tool was used in measuring pain that is connected to the subject’s behaviour (appendix 6). It was used by researcher in observing indicative pains. Physiological monitoring tool which have proved their reliability and validity was used in measuring wound changes. It also measured the blood pressure and the heart rates. Most patients experience little pain when music was involved. The authors detected a significant differences in the pain which was experienced between the wound dressing with listening to music and pain changed with music listening. In a nutshell, the study demonstrated that listening to music have a positive effect on the experience of patient on pain. The main weakness of the study was that the small sample size did not allow the researcher to analyse the influence of patients on the pain experiences. The authors advised for more studies in the future with large and randomized sample. Several studies had been done to explore the relationship between musical effect and anxiety-pain reduction during burn dressing ( Prensner et al. 2001, Tan et al. 2010). Tan et al. (2010) agreed with Noor et al. (2011) that music could play effective non-pharmacological methods in decreasing pain for burn patients during wound change. Tan et al. (2010) conducted a prospective crossover randomized controlled trial to find out if music can decrease pain, anxiety and muscle tension for patient undergoing wound dressing. This type of study concerns of quality of data collected from point of time forwarded. The authors in these types of studies can control the gathered information for advancing the quality and accuracy of data collected. The study adapted the same measurement tools of subjective and objective for data collection. They conclude to that music can play an effective method to reduce pain (as P value= 0.05), anxiety (as P value= 0.05) and muscle tension (as P value= 0.025 nursing objective rating). Despite that the P values were not that much strong but it shows a significant different between the two groups, which was similar to Noor et al. (2011) findings. A systematic review (SR) was carried out by de Jong et al. (2007) on evidence-based practice of different non-pharmacological methods. According to Holland and Rees (2010) that SR conducted from strong RCT counted as top of the hierarchy of evidence, that is because more than one well designed RCT could affect the decision-making and enhance the new practice with fewer errors. Twenty-one studies met the inclusion criteria. This was reviewing the abstract and published material, the unpublished ones were excluded. The author used a systematic search of key databases like CINAHL, Pubmed, Medline and Cochrance Database for systematic review. The chosen studies included experimental and quasi-experimental designs and pain reduction was the main outcome for selecting the study as it was measured using different parameters which reflects validity and reliability. Overall studies have 21 different intervention procedures which can be divided into two domains: behavioural (17studies) and physical (4studies). Hypnosis, music and rapid induction analgesia (RIA) were the common ones investigated. Relaxation, distraction, therapeutic-touch and imagery were present in eight studies out of the 21. Some limitation of this systematic review is that the methodology of some of the studies was not according to an experimental design; such as a small sample size, no generalization, insufficient reporting about guidance by therapist or audiotape. Overall, the finding of this SR was proofed of the effectiveness of the use non-pharmacological therapies in reducing pain intensity during dressing. Future studies are recommended from the authors. Summary of the Literature Review To summarize, previous literature reviewed illustrates a positive relationship between (independent variable) non-pharmacological methods and (dependent variable) reducing pain level. The applications of JR, RB and music in nursing practice gives a value for effective pain reduction in most, demonstrated by the P value measurement. The three techniques shown to be most effective and less time consuming for treatment and cost effectiveness in clinical practice. A strong point that all authors used a measurement scales which were tested for its reliability and validity to cover the whole range of study before, during and after. Local Evidence In Oman health care institutions, pharmacological role is considered the first intervention in managing burn patients’ level of pain during dressing procedure. There are no training programs that enhance the use of simple non-pharmacological therapy like relaxation breathing. On the other hand, there are no available resources to facilitate the implementation of non-pharmacological methods. The increase in number of burn cases every year has reached 3531 in 2011 as mentioned by Al Shaqsi et al. (2013). This requires qualified health care providers with high standard care in pain management. Recommendations In Oman, non-pharmacological strategies are not implemented. Therefore, it is important to provide the findings of well-structured studies for them to remain valid and applicable in Oman health institutions. There are no local or international guidelines regarding the use of non-pharmacological methods, but the literature provides new practices which can be implemented. JR, RB and music have a clear impact on pain reduction as supported by evidences above. A collaborative work from Oman MOH with stakeholders should be planned to achieve high quality care for burn patients. (Fakhar et al. 2013). Action Plan Proper explanation and assessment about the new treatment process with the support of collaborative health team workers and media advertising, a gradual change can be made. As mentioned in local evidence, Authority have to prove the need for training and qualifying nurses without balanced availability of resources and funds is crucial. There is no strict cultural issue about implementation of the non-pharmacological techniques in Oman; as it needs to be balanced between the patients’ satisfaction and health care service quality. Auditing: to start with a pilot study and if the pilot is effective then roll out the methods to other wards/hospitals. Conclusion In a nutshell, evidence-based practice (EBP) provides open and ethical way to change the practice. Therefore, nurses are encouraged to implement it to enhance decision-making and the quality of health care. According to the literature reviewed earlier, findings support the non-pharmacological treatment as effective methods in reducing pain level with burn patients during dressing procedure. In this assignment, the evidenced literature showed significantly positive statistical results with non-pharmacological methods, in reducing anxiety-pain level. Non- pharmacological methods with the addition of additional methods such as analgesia can be used during dressing procedure, as proved by evidences. It is recommended that health care workers, patients and relatives acknowledge the use of non-pharmacological strategies inside health institutions. Finally, future research is recommended to facilitate the combination of work pharmacological work and non-pharmacological therapy. References Al-Shaqsi, S., Al-Kashmiri, A. and Al-Bulushi, T. (2013). 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Melnyk, B.M. , Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. 2nd Ed. Toronto: LWW. Miller, K., Rodger, S., Bucolo, S., Greer, R. and Kimble, R. (2010). Multi-modal distraction. Using technology to combat pain in young children with burn injuries. Burns, 36(5), pp.647-658. Miller, K., Rodger, S., Bucolo, S., Greer, R. and Kimble, R. (2009). Multi-modal distraction. Using technology to combat pain in young children with burn injuries. .Public med , 25(5):352-6 Mohammadi Fakhar, F., Rafii, F. and Jamshidi Orak, R. (2013). The effect of jaw relaxation on pain anxiety during burn dressings: Randomised clinical trial. Burns, 39(1), pp.61-67. Noor A, Kanageswari s, Yong, T, and Khee x, (2011) A Pilot Study of the Effects of Music Listening for Pain Relief among Burns Patients Proceedings of Singapore Healthcare Volume 20 Number 3 Division of Nursing, Singapore General Hospital, Singapore Oman Ministry of Health. 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Pp. xii–8 Yvonne DArcy MS, (2011) New thinking about postoperative pain management November 2011, Volume 5 Number 6 , p 28 - 36 Appendix 1 Total body surface area Database Keywords Inclusion Criteria Exclusion Criteria Time frame Hits Numbers reduced to Pubmed -Jaw-relaxation -Distraction methods -burns’ drug -Non-pharmacological therapy in burns -Combined therapy in burns -Pain assessment and burns -Burns articles -Review articles -Full text -Articles with abstract -pain assessment during dressing -Medical focused -Other burns anxiety focus -old time frame -Qualitative research 2004 -2014 -80 -6537 -13193 -26 -1466 -3781 -2 -4 -3 -3 -4 CINHAL -Burns and non-pharmacological methods -Non-Pharmacological methods -burns treatment -Pain assessment tools -All burn patients -Peer review -Research articles -Medical focused -Other burns anxiety focus -old time frame -Qualitative research 2004-2014 -1,122 -0 -54 -31,461 -4 -2 -2 GoogleScholar -Burns incidents -Burns therapy -Quantita-tive research -Original research articles -Medical focused -Other burns anxiety focus -old time frame -Qualitative research 2004-2014 -706 -1,320000 -2 -4 Ovid SP -non-pharmacological methods -Pharmacological therapy -Pain assessment tools -Review articles -Articles with abstract -Full text -Medical focused -Other burns anxiety focus -old time frame Qualitative research 2004-20014 -86 -643 -31,461 -5 -2 -2 Appendix 2 Appendix 3 Hierarchy of Evidence for Intervention Evidence from: 1-Systemic reviews or meta-analysis of well-designed RCTs. 2-Well-designed RCTs. 3-well-designed controlled trials without randomization. 4-well-designed case-control and cohort studies. 5-Systematic reviews of descriptive or qualitative studies. 6-single descriptive or qualitative studies. 7-Opinion of authorities or reports of expert committees. (Melnyk and Overholt 2005, p.12) This assignment -One systematic reviews of experimental, quasi-experimental or non-experimental designs. -Two quasi-experimental -One randomize control trials. -Prospective crossover randomized controlled trial. Total of five articles included in this assignment Randomized Controlled Trials (RCTs)”are the most favor sources of evidence in EBP because of the way they attempt to reduce level of errors and offer alternative explanations for the results”(Holland and Rees 2010,p.29) Appendix 4 • Pre-dressing pain anxiety decreases in experimental group with JR. • Experimental group will have a significant difference in pre- and post-dressing pain anxiety after using JR. • Experimental group will have significant reduction in pain anxiety as compared to control group. The first hypothesis showed a significant difference, since the P=0.00 after the J-R intervention. Second hypothesis demonstrated no difference between the pain anxiety level in the pre and post dressing for the experimental group Appendix 5 VAS descriptors used in this trial. Pain 0 = no pain, 10 = pain as bad as it could possibly be Presence 0 = not at all, 10 = totally went into the game world Nausea 0 = no sick tummy, 10 = sick tummy as bad as it could possibly be Appendix 6 (Pain behavioural tool) Observe the patient for 3–5 min and indicate if the behaviours are “N” normal or “U” unusual for the patient. Assign one point for each unusual behaviour. Total the points and determine the pain level using the scale below. Time Before During After Noisy Breathing Frightened Facial Expression Activity Negative Vocalisation Tense Body Language Total Points Conclusion: Mild, Moderate, Severe Total Points: 1–2 = Mild Distress 3–4 = Moderate Distress 4–5 = Severe Distress Appendix 7 Numbers of estimated burns cases according to type of burn during 2012: Type of Burns Number estimated cases in Oman during 2012 ( inpatients) Number estimated cases in Oman during 2012 ( out- patients) Exposure to electric current, radiation and extreme ambient air temperature & pressure 55 306 Exposure to smoke, fire and flames 249 332 Contact with heat and hot substances 345 1,473 Total Number 649 2,111 Reference: Ministry of Health-Oman Appendix 8 Reference Design Aim Participant measures Time period Finding My comments in strength & weakness Fakhar et al 2012 Experimental randomized clinical trail To determine the effective of jaw relaxation on pain anxiety related to dressing change in burn injuries 100(50 in each group) Pain anxiety scale(BSPAS) 2 days of teaching & supervising P=0.787 same in both groups (before intervention) P=0.000 significant different after intervention in experimental group -strength: Scale reliable( α=0.70), random allocation and experimental received complete explanation and practice of jaw relaxation, having convenience sample . -Weakness: sample deferential physiological, emotional, psychosocial and cognitive factors, attitude of dressing nurse in different rooms, the control group received usual care without specifying the care received. Noor et al. (2011) Quasi-experimental study To assess the effects of music listening for pain relief among burns patients during the change of dressings. 30 participant (15 in both groups) numeric pain scale, pain behavioural tool, and physiological monitoring. 2 month period without stating the dates Most of the patients experienced little or no pain before dressing change, moderate pain during dressing change and lesser pain thereafter. There were no statistically significant differences in the pain experienced between wound dressing changed with no music listening and wound dressing changed with music listening. Strengths: Combination measurement tool. Weakness: small sample size, no randomization, environmental adjustment ( multi dressing plases) Park et al. 2013 A quasi- experimental Evaluate the effect of RB on pain anxiety in patients who underwent burn-dressing changes 60 participant & 30 on each group Pain anxiety using VAS June to September 2011 BR effect on pain were significant different between both groups (P=0.01) and over the time passed P value calculated and shown significant different (P=0.001). Regarding the RB effect on anxiety it demonstrate again good P value (o.o1) and with time pass also P value= 0.02 between both groups. Strength: -Good reporting of instructions. -Strong measurement validity and reliability. Weakness: -Medication administer were powerful analgesic as could lead to bias result. Appendix 10 Inclusion criteria Patients who were able to see and understand numeric pain scale; patients who required routine wound dressing; patients who needed wound dressing changes due to graft or wound inspection. 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