University of Massachusetts Amherst ScholarWorks@UMass Amherst Doctor of Nursing Practice (DNP) Projects College of Nursing 2014 Improving Nurses’ Pain Management in the Post Anesthesia Care Unit (PACU) Amelia D. Madenski Follow this and additional works at:https://scholarworks.umass.edu/nursing_dnp_capstone Part of theNursing Commons Madenski, Amelia D., "Improving Nurses’ Pain Management in the Post Anesthesia Care Unit (PACU)" (2014).Doctor of Nursing Practice (DNP) Projects. 36. Retrieved fromhttps://scholarworks.umass.edu/nursing_dnp_capstone/36 This Open Access is brought to you for free and open access by the College of Nursing at ScholarWorks@UMass Amherst. It has been accepted for inclusion in Doctor of Nursing Practice (DNP) Projects by an authorized administrator of ScholarWorks@UMass Amherst. For more information, please [email protected]. Running head: IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 1 Capstone Project: Improving Nurses’ Pain Management in the Post Anesthesia Care Unit (PACU) by Amelia Madenski, DNP-C, BSN RN Submitted to the Graduate School of the University of Massachusetts Amherst in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE May 2014 Approved as to style and content by: Dr. Genevieve Chandler: College of Nursing Committee Chair Dr. Edith Dundon: College of Nursing Committee Member Cidalia Vital, MSN, Perianesthesia Clinical Nurse Specialist IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 2 TABLE OF CONTENTS Abstract………………………………………………………………………………..5 Introduction…………………………………………………………………………...6 Problem Identification and Evidence………………………………………………..7 Review of the Literature…………………………………………………………..8-24 Gaps in Nurses’ Knowledge Regarding Pain Management………….....9-13 Definition of pain…………………………………………………………….14 The two types of pain: acute and chronic…………………………………..14 Theories of pain………………………………………………………………15 Gate-Control Pain Theory…………………………………………………....15 Neuromatrix pain theory……………………………………………………..16 Harmful effects of untreated pain…………………………………………..16 Pharmacologic and Non-pharmacologic……………………………………17 Pharmacologic………………………………………………………………..17 Opioids use in the PACU……………………………………………………..17 Non opioids use in the PACU………………………………………………...18 Regional Analgesia use in the PACU………………………………………...18 Non-pharmacologic………………………………………………………….18 Effective team communication is vital……………………………………...19 Pain Management is essential……………………………………………20-22 ASPAN Pain and Comfort Guideline …………………………………..22-24 Synthesis of Evidence………………………………………………………………..24 Theoretical Framework………………………………………………………….24-27 IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 3 Figure 1 The Knowledge- Action- Cycle……………………………………...26 Project Description, Implementation and Monitoring…………………………27-33 Description of Group, Population and Community…………………….....27 Organizational Analysis of Project Site…………………………………….28 Key Stakeholders…………………………………………………………….28 Resources, Constraints, Facilitators and Barriers to Implementation…...28 Project Design and Feasibility………………………………………………29 Goals and Objectives with Expected Outcomes………………………..30-31 Cost (Budgeting)………………………………………………………….....31 Table 1 Itemized Cost……………………………………………….31 IRB Approval/Ethical Consideration…………………………………...31-32 Implementation and Evaluation………………………………………...32-34 Timeline………………………………………………………………………34 Table 2 Timeline……………………………………………………..34 Project Results…………………………………………………………………...35-38 Table 3 Paired t-test sample (Pain Management and ASPAN)……………....36 Table 4 Paired t-test sample (SBAR)………………………………………...36 Table 5 Item Analysis (Pain Management and ASPAN)…………………….36 Table 6 Item Analysis (SBAR)………………………………………………37 Table 7 Evaluation for Educational Activity #................................................38 Table 8 Evaluation for Educational Activity #2……………………………..38 Discussion………………………………………………………………………..38-40 Limitations/Recommendations…………………………………………………….40 IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 4 Conclusion……………………………………………………………………….40-41 REFERENCES………………………………………………………………….42-50 APPENDICES…………………………………………………………………..49-63 A. Educational Activity 1………………………………………………….51 B. Pre Test Survey Educational Activity 1……………………………52-53 C. Post Test Survey Educational Activity 1…………………………...54-55 D. Evaluation for Educational Activity 1…………………………………56 E. Case Study……………………………………………………………57-58 F. Educational Activity 2…………………………………………………..59 G. Pre Test Survey Educational Activity 2………………………………..60 H. Post Test Survey Educational Activity 2……………………………….61 I. Evaluation for Educational Activity 2………………………………….62 J. Case Scenario………………………………………………………....63-64 K. SBAR Communication Tool…………………………………………….65 L. Research Matrix………………………………………………………66-70 Power Point Presentation…………………………………………………….......71-78 ASPAN Pain and Comfort Guideline……………………………………….......79-83 Figure 2 Theoretical Framework Application …………………………………….84 IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 5 Abstract Pain after surgery is distressing to patients and is a significant problem in post anesthesia care unit (PACU). Ineffective pain management in the immediate postoperative period can prolong the patient’s length of stay in the PACU which may lead to increased cost of care. Nurses, as important members of the team, have a unique opportunity to assess and continuously evaluate pain and its treatment. The nurses’ lack of knowledge regarding pain management and ineffective team communication are barriers to effective pain management. An educational intervention based on the Knowledge- to-Action Model was used to support the implementation of the project. This research translation project was implemented to 22 nurses in the recovery room at an urban hospital. The goals of this performance evaluation project are: 1) to assess the nurses’ knowledge on pain and its management in the PACU, the pain and comfort guideline and structured communication; 2) select, tailor and implement an educational intervention; 3) nurses will demonstrate increased knowledge after the educational intervention; and 4) nurses will report usefulness of the educational intervention to improve pain management in the PACU. A one group pre-test and post-test measure design was used to evaluate education program. The 22 nurses completed the pre and post -test for each educational session. The data was examined in each participant using a paired sample t-test. Educational interventions that target nurses’ knowledge on pain and standardized communication techniques had proven to be effective as management in the PACU (as evidenced by post-test score improvement). IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 6 Introduction Effective pain management is a vital component to quality patient care. Nurses play an essential role in implementing pain management. Empowered nurses equipped with the latest innovative knowledge, skills and information are able to provide safe and compassionate care for patients during their most vulnerable time in the post anesthesia care environment. The dissemination of evidence- based pain management information is crucial to provide the nurse with unbiased resources that could shape their knowledge and attitudes. An environment defined by an open communication and exchange of ideas, would help facilitate the knowledge growth of nurses and empower them in their workplace to provide expert nursing care. Efforts to improve postoperative pain management have been ongoing for many years. (Mackintosh-Franklin, 2013). Nurses are continually faced with the challenges of treating pain despite the findings and recommendation of substantial past research (Wells et al., 2008). This may be due to their lack of knowledge regarding appropriate pain management (Abdalrahim et al., 2011).To ensure the best quality of care for patients, nurses need effective knowledge, skills, and attitudes to address pain issues (Stanley & Pollard, 2013). Increased in knowledge of the mechanism of pain, effective pain assessment and pharmacological and non-pharmacological management will promote positive patient outcomes (Al Shaer et al., 2011). Ineffective communication between clinicians and patients and among clinicians was identified as one of the barriers to effective pain management (Dilhe et al., 2006). Communication about pain is vital to patient comfort, thus clear, concise and timely communication between nurses and physicians is necessary for pain management. Likewise, communication is important in determining effectiveness of the patient’s treatment plan. Nurses’ IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 7 ability to deliver clear, concise and timely communication of evidence – based information on pain and its appropriate treatment and pertinent clinical guidelines is essential to effective pain management. Regardless of the availability of well-defined guidelines to help nurses understand the treatment of acute pain, for most patients postoperative pain management is a challenge Abrahamson, Fox, & Doebbeling, 2012). Poor dissemination strategies are recognized as the key barrier to implementation of evidence-based pain guidelines. The optimal method for implementation of pain guidelines such as audit and feedback is an effective strategy to promote clinical practice guideline use (Dulko et al., 2010). Providing nurses adequate time and sufficient information to carry out pain guidelines will improve guidelines use, thus enhancing appropriate pain management (Manias, Bucknall and Botti, 2005). Problem Identification and Evidence Acute pain is defined as the normal anticipated physiological response to an adverse chemical, thermal or mechanical stimulus associated with surgery, trauma or illness and usually resolves during the appropriate healing period. It often responds to treatment with analgesic medication and maybe accompanied by anxiety of emotional distress (Carr & Goudas, 1991 and Pain Community Center.org, 2013). Pain after surgery is distressing to patients and is a significant problem in post anesthesia care unit (PACU) (Ho, Ho, Pang Yuen, Lexshimi, & Choy, 2013 and Gandhi K, 2012). Recent data suggest 80 percent of patients experience pain post operatively (Wells, Pasero, & McCaffery, 2008). The lack of appropriate pain management results in physiological and psychological harmful effects on the patients including the risk of developing chronic pain (Abdalrahim, Majali, Stomberg, & Bergbom, 2011). Ineffective pain management in the immediate postoperative period can prolong the patient’s length of stay in IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 8 Post Anesthesia Care Unit (PACU) which may lead to increased cost of care (Wells, Pasero, & McCaffery, 2008). Achieving optimal pain-management practices in PACU continues to be a challenge for administrators, nurses, physicians, and other health care providers (Samuels & Fetzer, 2009). Advances have been made in the understanding of pathophysiology of postoperative pain and development of new analgesics and delivery techniques, regardless patients still suffer from moderate to severe postoperative pain (Ismail, Shazad, & Shafiq, 2012). Insufficient knowledge about pain, inadequate assessment and evaluation of pain and various attitudes on pain and its management were among the barriers to effective post-operative pain management (Dihle, Bjolseth, & Helseth, 2006 and Krenzischek, Wilson, Newhouse, Mamaril, & Kayne, 2004). Additionally, outdated attitudes, myths, and misconceptions about pain and its treatment among nurses and patients contribute to unsafe, inadequate, and inappropriate pain management (Dihle, Bjolseth, & Helseth, 2006). Nurses, as important members of the team, have a unique opportunity to assess and continuously evaluate pain and its treatment. Accurate knowledge, appropriate attitudes and assessment skills, and communication be able implement appropriate intervention, and be able to evaluate and communicate the outcomes of treatment in a timely manner (Krenzischek et al., 2004). The implementation of a multimodal, evidence-based, culturally competent educational and behavioral intervention will improve the quality of pain assessment, and improve nurses’ knowledge and attitudes about pain assessment and management in the PACU (Clark, Fink, Pennington, & Jones, 2006). Review of the Literature There is an emerging body of literature that supports the problems related to post- operative pain management. In a review of the literature, the following barriers to effective post- IMPROVING NURSES’ PAIN MANAGEMENT IN PACU 9 operative pain management were identified: 1) nurses’ gaps in knowledge in pharmacological management of pain; 2) ineffective team communication on pain management; and 3) lack of awareness of the guidelines for pain management. The search of the literature was carried out mainly using Pub Med, CINAHL, Academic Search Premier, and Nursing Ovid. The initial search using the search terms: knowledge and attitudes, and pain management and nurses, 245 studies were found. Out of 245 studies, 13 were selected that were pertinent to nurses’ knowledge and attitudes toward pain management. When using the search terms team communication and pain management and nurses, there were 23 studies found of which 4 articles were used that were relevant to the topic. Using the search terms clinical guidelines and pain management and nurses, 108 articles were found 9 of which were relevant to the topic. Thereby the sum total of the relevant studies to the three topics equals 26. The above mentioned search terms were included in the inclusion criteria. Other criteria for inclusion in each data base were English language, full text articles, and studies published within the last 10 years, 2003 to present. The articles were examined based on the nature of research evidence using Johns Hopkins Nursing Evidence-Based Appraisal (JHNEBP). Gaps in Nurses’ Knowledge Regarding Pain Management The gaps in nurses’ knowledge that were identified in the studies reviewed were primarily pharmacological methods of treating pain based on the Knowledge and Attitude Survey Regarding Pain (NKASRP) [32 item questions on assessment, pharmacologic and non- pharmacologic intervention]. Increase in knowledge about pain and its management are associated with greater influence of attitudes on behavior. Attitudes based on high amounts of knowledge are better predictors of behavior. Knowledge is a structural property of attitudes, as such attitudes influence behaviors, decisions, and information processing (Fabrigar, Smith, Petty,