Nurses have their own model of pain assessment and analgesic administration rather than knowledge gain from formal education.
(Willson, H. (2000). Factors affecting the administration of analgesia to patients following repair of a fractured hip. Journal of Advanced Nursing, 31(5), 1145-1154.)
This study apply ethnographic multi-case study approach to identify factors which nurses take into account when administering analgesia to patients following surgical repair of a fractured hip.
The research questions were:
1. What factors influence nurses in the administration analgesia to patients following surgical repair of a fractured hip?
2. What are the enabling and constraining elements?
3. How are nurses enabled and constrained at each stage of administration of analgesia, that is assessment, intervention, and evaluation?
Sample:
Three trauma/orthopedic wards, a district general NHS Trust hospital in the South of England provided the sample for this study. Participants- three female patients with age of around 75 years, one patient from each of those three trauma/orthopedic wards. Key informants- 9 nurses, three from each of those three wards, caring for the selected patients over a 24-hour period (one nurse/shift/ward).
Data collection:
- Unstructured observation of the nurses' assessment, planning, intervention, and evaluation.
- Charts reviewed to confirm diagnosis and operation, to rule out a diagnosis of confusion or other cognitive impairment, to ascertain the analgesic regime and a record of administered analgesia, and to observe written communication about the patients' pain and administration of analgesia.
- One-to-one semi-structured interviews of nine nurses during the last hour of their shift to elicit the informants' views, discuss issues related to pain control and information derived from the observation and patient documentation.
Results
The themes emerged from data collection were: time; organization of care and influence of the shift worked; the impact of members of the multidisciplinary team (MDT); concerns over the use of opioid analgesics; and information giving and collection.
Time
Time constraint appeared to be one of the major factors that influence administering analgesic. Nurses reported: not enough time to write a care-plan, not enough time to spend with patient (making evaluation of analgesia difficult), and not enough time to learn more about administration of analgesia.
A major constraining factor was that the administration of analgesia appeared to be bound to the drug rounds, carried out at set times of the day, making formal assessment of pain problematic. In all of the study cases, goals for patients were set by time, for instance, taking patients off opioid analgesia within 48 hours, and issuing the drugs at a predetermined time.
Nurses in this study therefore relied on information that they carried with them, making a fast decision of the patient's requirements for analgesia while dispensing other medication.
Organization of care and influence of shift
Junior nurses learned from senior nurses regarding analgesic administration practice rather than applying knowledge from formal education.
In all cases, the administration of analgesia was found to be driven by organization strategic goals and set time for drug rounds more than individual patient need.
All nurses in the study utilized non-verbal and verbal cues in a "snap-shot" fashion to assess patient's current requirement for analgesia while doing the drug rounds. It appeared that nurse had to accurately remember a wide variety of information about the patient in order to make an effective decision. The organization of care changed from shift to shift, therefore the nurse who knows the patient may not be the one to make decisions on pain control.
There was no written protocol in the study hospital that patients must not continue on opioid analgesia for more than 3 days, however, many nurses reported that they would not given morphine on day three or even after 24 hours post-op, even though opioid analgesia was prescribed p.r.n. until discharge.
Impact of the multidisciplinary team
Awareness of accountability appeared to influence decision to administer analgesia, in particular strong opioids, in that nurses often referred to more senior colleague for advice. One nurse expressed that crossing professional boundaries, for instance to get the analgesic reviewed, was not comfortable and was a cause of some tension. Member of the multidisciplinary team, for instance physiotherapist and occupational therapist, visited patients at different busier times and did not give a predetermined time for their intervention in advance. The timing of analgesia to coincide with planned mobilization adds another variable to administering analgesia in accordance with patient need.
Concerns over the use of opioid analgesia
Nurses concern over the administration of opioids appeared to be influenced by the shift worked. Nurses on the night shift opposed the use of opioids for purposes other than pain relief due to concerns over the side-effects of opioids and the difficulty in observing patients. Many nurses were not happy with the strong oipoids, preferring weaker opioids and NSAIDs. The rationale of this practice given by nurses on day shifts was the necessity of trading off some analgesia for motivation and mobilization in order to prevent side-effects and achieve the goal of discharge home.
Information giving and collection
Nurses in this study appeared to have their own model of pain assessment and analgesic administration rather than knowledge gain from formal education. Pain assessment tools tends to rely on patient's verbal report of pain. However, patient's report of pain were not well documented since this was viewed as poor management. Many nurses expressed a lack of confidence in their patient's and nursing colleagues' ability to complete the chart accurately on an assessment made by anyone other than themselves. Some nurses felt that using a pain chart slowed the administration of analgesia. Some nurses viewed that negotiation of analgesia were not required information from a pain chart, which might explain their limited use.