Nurses\u27 Perceptions of the Pharmacological Management of Acute Pain Experienced by Patients Hospitalised in the General Ward Setting

This study explored and described the experiences and perceptions of nurses managing acute pain in a Western Australian public hospital. The focus was nurses practising in the general ward setting and using current prescribing guidelines. The aim of this research was to explore nurses\u27 attitudes, beliefs and knowledge about pain and pain pharmacology and how this practice setting influences efficient pain management. Qualitative methodology was selected for its ability to explore complex issues in order to build nursing knowledge and guide nursing practice. This study used a descriptive, exploratory design based on a phenomenological approach. The sample comprised ten Registered Nurses who were working on general surgical wards in an acute care public hospital. Data were collected from tape recorded semi-structured interviews. Analysis encompassed transcription, coding and categorising of data that enabled concepts and themes to emerge. Nurses\u27 attitudes, beliefs and knowledge were examined. Nurses were found to accept the subjectivity of pain, to believe patients\u27 self reports of pain and to be generally supportive of numerical pain rating scales. Elderly patients and patients with a history of intravenous drug use were identified as groups that might be disadvantaged in regard to pain management in the general ward setting. Nurses\u27 roles as patient advocates and independent managers of pain at the bedside were highlighted and the lack of consistent pain management across nursing shills was identified as a problem that is potentially widespread. Continuing difficulties were acknowledged when analgesic medications were prescribed to be given as required, rather than on fixed time regimes. In recognition of this, nurses were supportive of the administration of regular analgesia. The hospital\u27s Acute Pain Service was perceived to be a valuable resource and non-pharmacological pain management strategies were recognised as an effective adjunct to analgesic medication and important to nurses\u27 independent practice. Effective pain management is a humane response to suffering, as well as being cost-effective for the health system in terms of reducing inpatient complications. This study provided an indication of current issues in acute pain management from the perspective of nurses in the ward setting. Implications for clinical practice and directions for future research are provided

Exploring the quality of life at the end of life (QUAL-E) instrument with Australian palliative care hospital patients: hurdles and directions

The provision of care that enhances the quality of life at the end of life is a fundamental goal of palliative care services. This pilot study explored the application of the Quality of Life at the End of Life (QUAL-E) instrument in a sample of 52 patients who were hospitalized in two metropolitan Western Australian hospitals. Participants were given the option to complete the QUAL-E either as a self-report (n = 9, 17.3 percent) or, aided by a research assistant, as a structured interview (n = 43, 82.7 percent). The instrument demonstrated patient acceptability and face validity, particularly when it was administered with the assistance of a research assistant. Despite having difficulty with some questions, patients expressed their appreciation at being given the opportunity to contribute to the research and to reflect upon and give voice to their thoughts and feelings. Health practitioners indicated that the instrument could be a valuable tool for holistic assessment and service evaluation. We suggest that minor changes be made to the QUAL-E before it is used further in an Australian context; we also recommend that this instrument be tested in other settings and populations

Family Caregiver Participation in Palliative Care Research: Challenging the Myth

Context: Despite international guidelines emphasizing consumer-directed care and autonomous decisions in research participation, there is a common myth that research can be an additional and unwanted burden on patients and their family members. Objectives: To examine the experiences and impact of research involvement on family caregivers (FCs) of terminally ill people, focusing within home-based palliative care. Methods: Three hundred sixteen of 322 participants (98.1%), who completed an FC support intervention through a stepped-wedge cluster trial (Australia, 2012-2015), participated in a postintervention telephone interview on their study experiences, which included quantitative and qualitative questions. Results: Ninety-seven percent of both the control (n = 89) and intervention (n = 227) groups perceived positive aspects, whereas almost all did not report any negative aspects of being involved in this research; the majority rated their involvement as very/extremely beneficial (control 77%; intervention 83%). The qualitative analysis generated three major themes: "intrapersonal-inward directed"; "connection with others-outward directed"; and "interpersonal-participant-researcher relationship.". Conclusions: This study provided quantitative and qualitative evidence challenging the myth. In contrast to health professional concerns, FCs appreciated the opportunity to participate and benefited from their involvement in research. Research protocols need to be specifically tailored to the needs of family caregivers and include debriefing opportunities for all participants at the end of intervention studies, regardless of which group they have been assigned. Strategies that facilitate health professionals' understanding of the research and risk benefits may help reduce gatekeeping and improve the validity of research findings

Hospital postdischarge intervention trialled with family caregivers of older people in Western Australia: potential translation into practice

There is lack of a suitable assessment tool that can be used routinely and systematically by hospital staff to address family caregivers' (FCs') support needs. This paper describes a novel approach to identifying and addressing FCs' needs following hospital discharge of the older person receiving care. SETTING AND PARTICIPANTS: FC recruitment occurred on the patient's discharge from a tertiary hospital in Western Australia; 64 completed the study; 80% were female; mean age 63.2 years. INTERVENTION: The Further Enabling Care at Home (FECH) programme was delivered over the telephone by a specially trained nurse and included: support to facilitate understanding of the patient's discharge letter; caregiver support needs assessment and prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports. RESULTS: Sixty-four FCs completed the FECH programme. The top three support needs identified by the FCs were: knowing what to expect in the future (52%), knowing who to contact if they were concerned (52%) and practical help in the home (36%). The telephone-based outreach service worked well and was convenient for the nurse and the FCs, and saved on transport, time and money. Most of the FCs appreciated the systematic approach to identify and articulate their needs and were satisfied with the support they received, mainly navigation through the systems, problem solving, self-care strategies, explanation of illness, symptoms and medication and access to after-hours services. CONCLUSIONS: In order to guide services which may consider adopting this systematic approach to supporting FCs and integrating it into their routine practice, this evaluation of the FECH programme has described the processes implemented and highlighted the factors that hindered or facilitated these processes to engage caregivers with appropriate services in a timely manner. Positive feedback indicated that the programme was a useful addition to hospital discharge planning. TRIAL REGISTRATION NUMBER: ACTRN12614001174673; Results

Protocol for a randomised controlled trial of an outreach support program for family carers of older people discharged from hospital

Background: Presentations to hospital of older people receiving family care at home incur substantial costs for patients, families, and the health care system, yet there can be positive carer outcomes when systematically assessing/addressing their support needs, and reductions in older people's returns to hospital attributed to appropriate discharge planning. This study will trial the Further Enabling Care at Home program, a 2-week telephone outreach initiative for family carers of older people returning home from hospital. Hypotheses are that the program will (a) better prepare families to sustain their caregiving role and (b) reduce patients' re-presentations/readmissions to hospital, and/or their length of stay; also that reduced health system costs attributable to the program will outweigh costs of its implementation. Methods/Design: In this randomised controlled trial, family carers of older patients aged 70+ discharged from a Medical Assessment Unit in a Western Australian tertiary hospital, plus the patients themselves, will be recruited at discharge (N = 180 dyads). Carers will be randomly assigned (block allocation, assessors blinded) to receive usual care (control) or the new program (intervention). The primary outcome is the carer's self-reported preparedness for caregiving (Preparedness for Caregiving Scale administered within 4 days of discharge, 2-3 weeks post-discharge, 6 weeks post-discharge). To detect a clinically meaningful change of two points with 80 % power, 126 carers need to complete the study. Patients' returns to hospital and subsequent length of stay will be ascertained for a minimum of 3 months after the index admission. Regression analyses will be used to determine differences in carer and patient outcomes over time associated with the group (intervention or control). Data will be analysed using an Intention to Treat approach. A qualitative exploration will examine patients' and their family carers' experiences of the new program (interviews) and explore the hospital staff's perceptions (focus groups). Process evaluation will identify barriers to, and facilitators of, program implementation. A comprehensive economic evaluation will determine cost consequences. Discussion: This study investigates a novel approach to identifying and addressing family carers' needs following discharge from hospital of the older person receiving care. If successful, the program has potential to be incorporated into routine post-discharge support. Trial registration: Australian and New Zealand Clinical Trial Registry: ACTRN12614001174673

US Cosmic Visions: New Ideas in Dark Matter 2017: Community Report

This white paper summarizes the workshop "U.S. Cosmic Visions: New Ideas in Dark Matter" held at University of Maryland on March 23-25, 2017.Comment: 102 pages + reference

The role of empowerment in the care of patients who experience severe pain : the nurse’s perspective

Hospitalised patients continue to experience significant levels of pain despite advances in pain management knowledge and techniques. Evidence from nurses practicing in specialty and community settings suggests that caring for patients who experience persisting pain has implications, both personally and professionally. This grounded theory study described and explained the effect of caring for patients who experienced severe pain on nurses working in medical and surgical wards of a Western Australian hospital. Data were collected from a sample of 33 nurses through 30 semi-structured interviews and 93 hours of participant observation. Eleven patients who were experiencing severe pain participated in structured observations Audio-recordings of interviews and field notes were transcribed verbatim and analysed using the constant comparative method.The substantive theory of seeking empowerment to provide comfort was developed in this grounded theory study. This substantive theory explained the emotional effects on nurses and their response to caring for patients with severe pain. The provision of comfort to patients and the maintenance of the well-being of the nurse were key elements.The substantive theory of seeking empowerment to provide comfort was developed in this grounded theory study. This substantive theory explained the emotional effects on nurses and their response to caring for patients with severe pain. The provision of comfort to patients and the maintenance of the well-being of the nurse were key elements.In this study, empowerment was found to be an outcome and a process and the core category that integrated the substantive theory. As an outcome, empowerment was the psychological state nurses experienced when they felt able to provide comfort. As a process, empowerment was the means by which nurses sought to avoid the shared problem of feelings of disempowerment to enhance their patients’ and their own wellness. The process of seeking empowerment to provide comfort explained nurses’ actions and interactions to avoid feelings of disempowerment by building connections with patients and colleagues, finding alternative ways to comfort when pain relief was ineffective and quelling emotional turmoil to conserve their resources and protect their own well-being. Nurses were shown to progress through these stages as their experiences of disempowerment escalated.This research illuminates the problem encountered by nurses when they care for patients who experience severe pain and the process they use to manage this problem. A striking finding of this study was the depth of emotional distress experienced by some nurses who felt powerlessness to assist patients in pain. Evidence also emerged of behaviours used by nurses to protect themselves from ongoing feelings of disempowerment. There are significant implications for both patients and nurses in these findings. This study provides direction for interventions to support nurses who practice in acute hospital settings and to facilitate patient comfort and nurse well-being. A number of indications for areas of further research are also provided

Reflections on an international study of non-pharmacological caregiving activities at the end of life

Earlier this year an interesting manuscript authored by Lindqvist et al. was published, “Complexity in Non- Pharmacological Caregiving Activities at the End of Life: an International Qualitative Study” published in PLoS Medicine, 9[2], 1-10. The manuscript provides depth and understanding to an experience we will all share; the end of life. The essence of humanity is captured in this work, through the collaboration of nine countries and sixteen facilities. Common human experiences in nonpharmacological caregiving activities (NPCAs) are revealed and patterns of care identified. As nurses ourselves, we were interested to note that the majority of data used in this manuscript came from statements by nurses. We recognised the diversity of NPCAs involved in end of life care and have provided some personal reflections on four of the categories described: ‘Carrying out or abstaining from bodily care and contact’, ‘Listening, talking with, and understanding’, ‘Creating an aesthetic, safe and pleasing environment’, and ‘Being present and enabling the presence of others’. We have added an additional category of ‘NPCAs for the family and staff’, as we felt this was a theme which came through strongly in the work

Seeking empowerment to comfort patients in severe pain: A grounded theory study of the nurse's perspective

© 2014 Elsevier Ltd.Background: Hospital patients experience significant pain, which can delay healing and increase the risk of developing chronic pain. Nurses are affected by patients' ongoing pain and may cope with consequent anxiety and helplessness by distancing themselves from such patients. Understanding nurses' responses to patients in severe pain will inform strategies to support their coping, their patients and, ultimately, their retention in the nursing workforce. Objectives: The aim of the study was to develop a substantive theory explaining the hospital nurse's perspective of caring for patients in severe pain. Design: The study used grounded theory method. Settings: Data were collected on four acute care wards in a 610 bed Australian hospital. Participants: The sample included 33 nurse participants and 11 patient participants. Selection criteria for nurse participants were those who worked in the four study wards, cared for patients who experienced severe pain, and consented to be included. Selection criteria for patient participants were those who self-reported pain at intensity of seven or more on a scale of 0-10, were aged 18 years or older, could speak and read English, and consented to be included. Methods: Theoretical sampling directed the collection of data using semi-structured interviews with nurses and participant observation, including structured observations of nurses who cared for patients in pain. Data were analysed using constant comparison method. Results: Nurse participants encountered a basic psychosocial problem of feelings of disempowerment when their patients experienced persisting severe pain. In response, they used a basic psychosocial process of seeking empowerment to provide comfort in order to resolve distress and exhaustion associated with disempowerment. This coping process comprised three stages: building connections; finding alternative ways to comfort; and quelling emotional turmoil. Conclusions: The substantive theory proposed a link between the stress of nurses' disempowerment and a coping response that provides direction to support nurses' practice. Strategies indicated include enhanced communication protocols, access to advanced practice nurses, use of nonpharmacological comfort measures, utilization of ward-based pain resource nurses, and unit-specific pain management education. Further research to verify and extend the substantive theory to other settings and nursing populations is warranted