Building Expertise in the Workplace: Occupational Therapists Learning Upper Limb Hypertonicity Practice

Introduction Increasingly, novice occupational therapists are working in private practice. It is important to understand how to build clinical experience in complex practice areas. Upper limb hypertonicity management is a complex practice area requiring advanced workplace training. This study aimed to identify the teaching and learning processes that assist occupational therapists to acquire this expertise. Methods Five hospital occupational therapists received 1.5-3 years of apprentice-style training in a specialist hypertonicity clinic. In-depth semi-structured interviews explored their experience. Qualitative Description was used to analyse the data. Results Participants found that knowledge needed to be applied to practice and then revisited in a cyclical way to deepen their understanding and build their clinical skills. They benefited from having responsibilities graded and repeated opportunities for hands-on learning of embodied knowledge. Producing comprehensive progress notes and teaching colleagues and students were useful learning tools. Learning with a group of colleagues involved observation of the expert, intensive correction and guidance, and group discussion, reflection and questioning to build expertise. Conclusion Workplaces need to intentionally support novice clinicians to gain expertise in complex practice areas using pedagogically sound training techniques. Continuous workplace training is needed to promote expertise in the face of changing healthcare funding policies

Barriers to the use of morphine for the management of severe postoperative pain - A before and after study

Aim To reduce the number of patients experiencing severe postoperative pain by prescribing 10 mg Morphine either as oral solution or by IM injection as an alternative to Tramadol Hydrochloride in an analgesic protocol. Materials and methods Patients who received in-patient oral and maxillofacial surgery under general anaesthesia were included. Complex intervention analgesic protocols were developed including staff education, patient educations and analgesic protocols. 80 patients were treated under the original protocol (tramadol hydrochloride for pain unmanaged by other drugs in protocol) over 4 months. 75 patients were treated under the second protocol (oral or intravenous morphine for pain unmanaged by other drugs in protocol). Patient perceptions to their pain management were then assessed. Results Proportion of patients reporting ‘no pain’ increased from 5% of 80 patients to 28% of 75 patients (p < 0.001). Report of severe pain reduced from 37% to 31% and not significant. Pain duration reduced from 18% to 12% for 75–100% time from surgery to discharge and not significant. Staff used protocols for 96% patients. Nurses provided patient information leaflets for 85%–80% patients. Nearly all patients (96% and 95%) reported overall satisfaction with their pain management. Conclusions The use of morphine given orally or my IM injection rather than tramadol was associated with a significant increase in the number of patients reporting ‘no pain’. However the number of patients experiencing severe pain was not significantly reduced. Despite this, most patients reported high levels of satisfaction which suggested that satisfaction questionnaires should not be used in isolation. Most patients received morphine orally rather than by IM injection but the oral dose may not have been high enough in this study

Development of a Management Algorithm for Post-operative Pain (MAPP) after total knee and total hip replacement: study rationale and design.

BACKGROUND: Evidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described. METHODS: In partnership with clinicians, and based on best available evidence, the aim of the Management Algorithm for Post-operative Pain (MAPP) project is to develop, implement, and evaluate an algorithm designed to support pain management decision-making for patients after orthopaedic surgery. The algorithm will provide guidance for the prescription and administration of multimodal analgesics in the post-operative period, and the treatment of breakthrough pain. The MAPP project is a multisite study with one coordinating hospital and two supporting (rollout) hospitals. The design of this project is a pre-implementation-post-implementation evaluation and will be conducted over three phases. The Promoting Action on Research Implementation in Health Services (PARiHS) framework will be used to guide implementation. Outcome measurements will be taken 10 weeks post-implementation of the MAPP. The primary outcomes are: proportion of patients prescribed multimodal analgesics in accordance with the MAPP; and proportion of patients with moderate to severe pain intensity at rest. These data will be compared to the pre-implementation analgesic prescribing practices and pain outcome measures. A secondary outcome, the efficacy of the MAPP, will be measured by comparing pain intensity scores of patients where the MAPP guidelines were or were not followed. DISCUSSION: The outcomes of this study have relevance for nursing and medical professionals as well as informing health service evaluation. In establishing a framework for the sustainable implementation and evaluation of a standardised approach to post-operative pain management, the findings have implications for clinicians and patients within multiple surgical contexts