Handling Pain - Applying Theory to Practice - Essay Example

? Applying Theory to Practice Applying Theory to Practice Of the several problems that nurses handle in their professional life, pain has been a significant one. The management of pain has had guidelines from several associations concerning human health and the nursing profession. However the real situation is that the recommendations have not yet been applied. This paper deals with the practice problem of pain and how I would go about managing it in my health institution using one of two theories. I have selected a middle range theory for application to management of pain and then applied a known theory. Applying Theory to Practice Globally the nursing profession was facing a great number of problems in patients. Pain was just one of the many complaints but it was a significant and widespread one. Pain was a physiological complaint which distressed patients by the unpleasant sensation with affective experience (Peterson and Bedrow, 2008). In spite of pain assessment, appropriate management, evaluatory monitoring and educational research having been included in important guidelines like those from the Joint Commission and the National Guidelines ClearingHouse, the under-treatment and negligent management of acute and chronic pain were still evident (Bines and Paice, 2005). The words of Gillaspie (2010) conveyed the depth of the problem: “The delivery of effective pain management has become a pressing national issue in healthcare”. Patients had a right to be managed for pain relief (Zalon, 2008). The problem of pain management has thereby been identified by me as my practice problem. The nursing profession has several theories by which the problems in patient care were managed. Similarly I would be employing a theory to execute effective pain management in my hospital. The theory would be logical for application and concurrent with observations made daily. It would be similar to those previously used in successful programs. Past research would have supported this theory (Croyle, 2005). It would contain the highlights of the nursing profession. Foundations for nursing practice would be made. Generation of better knowledge would be remembered. The direction into which the nursing profession was to develop would be indicated. Patient care would be made better, professional growth would be enhanced, interpersonal communications among the nurses would be motivated for improvement, and guidance would evolve for education and research. The multidisciplinary approach to health care would be targeted. Criteria which improved the quality of care would continuously be identified. Middle-range theories promoted nursing practice by helping to understand the behavior of the client, suggesting useful interventions and offering credible explanations for the efficacy of the interventions (Peterson and Bedrow, 2008). The practice theory could be built up from the critical reflection of experiences. The purpose of the paper is to identify a middle range theory for my selected practice problem of management of pain and then use a borrowed theory to manage the same symptom of pain. Rationale for selection The commonest reason for patients seeking help from nurses was pain. The unpleasant sensation could cause the patient to even lose consciousness. The overwhelming effect could produce long-term adversities (Peterson and Bedrow, 2008). Wound healing became delayed and the immune system lost its activity. Metastasis of tumor cells could also occur. Acute pain was noticed in wounds or injuries, following surgery, in labor and in sickle cell crisis. Chronic pain was evident in skeletal muscle illnesses and gastrointestinal conditions. Hospital procedures like lumbar puncture, venipuncture and removal of chest tubes were accompanied by pain (Peterson and Bedrow). Infants suffered from pain in critically ill conditions or when close to death. The enormous extent of pain faced by the nursing profession was an indication for nurses to learn all the methods of relieving it. Clinical pain had a holistic and emotional impact apart from the physical distress (Peterson and Bedrow). Life could be affected and fears to arise. I am also much worried about the fact that in spite of specific guidelines for pain management, the patients were not being accorded the benefits of the guidelines. Nurses needed to develop their own theories which included interventions for relief of pain (Peterson and Bedrow, 2008). These are the reasons for my selecting the management of pain as my practice problem and using a middle range theory to guide me. Literature review Efficient pain management reduced the experience of pain and prevented the psychological and physiological complications (Gillaspie, 2010). Current research in MEDLINE and Cochrane database indicated that the facilitation of pain management for infants now focused on nonpharmacological pain management (Hardy, 2011). However it could never stand alone or replace pharmacological therapy. Both had to be used strategically according to the assessment of the situation (Hardy). Problems in learning and social adaptation could arise due to unmanaged pain (Carbajal, 2008). Prevention was considered the best management but this was not always possible (Harrison, 2010). Providing sucrose solution, allowing non-nutritive sucking, kangaroo care by the parents, music therapy and breast feeding were some of the nonpharmacological methods advised by Hardy for infants. Theories of relief of pain had become an essential part of a nurse’s life (Peterson and Bedrow, 2008). The symptom of pain was inevitable in patients. The nurse was the closest person in a hospital who could use her techniques for relieving a patient in distress. The moves made by her should conform to the guidelines of the American Pain Society (Peterson and Bedrow). The age-old prescriptive theory indicated that oral or injected opioids provided good relief in patients with moderate or severe pain (Peterson and Bedrow). The injections were given into the blood vessels, muscles, or epidural space. The explanatory theory dealt with the mechanism by which the drugs relieved pain. The opioids were believed to have an affinity to the mu and kappa opioid receptors in the brain. NSAIDS provided relief at the site of pain by lowering the quantity of inflammatory substances released as part of the normal reaction of the body to pain (Peterson and Bedrow). These inflammatory substances caused the sensitive nerve fibers to respond to the pain. The decrease produced reduced the sensation of pain. The mechanism of action of the NSAIDs, Aspirin, Acetaminophen, Ibuprofen and Ketorolac, was different from that of the opioids. They did not bind to the receptors. The nursing profession has to conform to the position statement on pain management and control of distress in dying patients: “Nurses must use effective doses of medications prescribed for symptom control and nurses have a moral obligation to advocate on behalf of the patient when prescribed medication is insufficiently managing pain and other distressing symptoms. The increasing titration of medication to achieve adequate symptom control is ethically justified.” (ANA, 2003 in Zalon, 2008, pg.94). Middle-range theories were most suitable for application as they were based on qualitative research of the phenomenological and grounded theory types. Fawcett (2005) spoke of descriptive, explanatory and predictive theories as varieties of middle-range theories. The descriptive theory was the most basic and easily studied by qualitative or quantitative research. Peplau’s theory of interpersonal relationship was one. The explanatory theory was one which defined the relationship between two or more concepts. Study involved a co-relational research of quantitative design. One example was Watson’s theory of human caring. The predictive variety of theories described how changes occurred in a specific phenomenon. The relationship between concepts was decided by predicting the precise relationship in an experimental quantitative research. An example was the Orlando’s theory of deliberate nursing process (Fawcett). The nursing discipline had built its knowledge by incorporating philosophies of distinguished nurses and other leaders, theories which had provided results, ongoing research with its credible findings and the wisdom born of practice (Smith and Liehr, 2008). Fawcett had explained the metaparadigm of nursing to be a “study of the interrelationships among human beings, environment, health, and nursing” (1984). Middle range theories were better circumscribed and delineated concepts which were definite. They also included the inter-personal relationships which could be the feeling of uncertainty, the level of self-efficacy and how meaningful they were (Smith and Liehr). Application of my Middle-Range Theory for pain management The theory that I have created to suit my personal values would allow me to perform suitably in a crisis management of acute or chronic pain care. Keeping closely to the recommendations of the Joint Commission on Accreditation of Healthcare Organizations for patient safety goals, my theory for pain management includes the following plan which allows me to provide relief to the patient. Experience has convinced me that my singular performance alone would not allow me to manage pain effectively. The policy makers and all the staff have to be convinced about the management plan. A team management of pain is now better accepted (Zalon et al, 2008). A comprehensive plan would be set up for systematic and uniform management of pain in the hospital. Care from initial assessment to planning for discharge would be incorporated. Competency of the staff would be ensured through continuing education. All nurses would have laminated pocket cards with FACES scale and numerical scale for analyzing the pain by the scales (Bines and Paice, 2005). If the card showed an intensity of ‘four” on the scale, intervention was made. Including pain as another vital sign would produce awareness of the distress and decide whether it was time for intervention. A series of questions would be added to the inpatient and outpatient forms so that the features of the pain would be elicited (Bines and Paice, 2005). Electronic devices would be in place for reminding the nurses about the time for reassessment of pain. Screening for pain and assessing its nature and intensity would be an essential step. Details of the pain and how it had affected the patient would be recorded. The patient would be needed to provide informed consent and participate in deciding the individual care plan for pain management. The pain would be assessed carefully and managed appropriately in order to uphold the patients’ rights (Bines and Paice, 2005). The goals for relief of pain must be ascertained. Realistic and safe goals would be identified. The patient would be asked about the activities or functions that he would like to do or perform when he had no pain. Enquiring about the patient satisfaction would provide information and experience of the best techniques to manage pain in a similar situation later. Non-pharmacological management simultaneously would add to the satisfaction level (Hardy, 2011). The patient and the family would be given educative material to familiarize themselves with the plan. This information would help them gain knowledge on the procedures adopted in my institution. They would be reassured about the competency of the staff which also included pain specialists (Bines and Paice, 2005). Their fears about whether staff would believe the patient and respond immediately would be dispelled. The patient’s fears about opioids would be carefully managed. Publishing the information on the internet would help the staff to download it for the patients. Pain-related information would be maintained at the Health Library in the hospital. Computers would be available for patients and families to browse for the information (Bines and Paice). The pharmacological therapy with opioids or NSAIDs would be decided upon by the uniform recommendations of the hospital. The variation in dosage would be by variation of age of the patient, the type of wound, the intensity of pain, the hospital procedure done, the surgery performed and the underlying illnesses. Non-pharmacological adjuvants which could provide relaxing moments would include visual stimuli like photos or pictures or a television programme. (Bines and Paice, 2005). A massage or providing a cooler environment could relax the patient. Instructing the patient to assume certain attitudes to overcome the pain would help. I could also teach the patient to report any oncoming pain early so that I could act to provide some relief. The mere switching-on of the fan, allowing the room to be air-conditioned, changing the mattress, placing a blanket, hugging the patient, putting on some music or whatever activity may seem sufficient for an adaptive response, would be used. Assessment and reassessment and follow-up would be recorded clearly and made available for future evaluation. Self- evaluation and monitoring the competency of associate staff would be effective. Policies would be fixed for prescriptions of pain medications so that uniformity was maintained in my hospital. The process of rehabilitation would be instituted if pain was not present. Information of pain management would be imparted with care and patience to the patient and family (Bines and Paice, 2005). The patient’s needs would be considered for managing symptoms and while planning the discharge. Monitoring of the appropriateness of the pain management would be done at regular intervals to assess the effectiveness of method, drug administration and non-pharmacological techniques. Evaluation would follow. Flexibility would permit me to study, research and practice continuously. My theory would be prescriptive and explanatory at the same time and I would do research to improve on my views of pain management. Application of a borrowed theory to pain management I am borrowing Roy’s Adaptation Model for the pain management. Sister Callista Roy developed the concept of this model. Born in Los Angeles in 1939, her nursing education was all in California (Masters, 2011). In 1963 she obtained her baccalaureate degree, her Master’s three years later and a Doctorate in Sociology in 1973, all from the University of California (Phillips, 2010). Roy began working on her model when she was studying for graduation. Having continuously worked and improved her model, her academic life had been satisfactory. She had delivered many lectures and written many books and is remembered for this successful model which had been and is still popular among nurses. The model visualized the human being as a “holistic adaptive system in constant interaction with the external and internal environment” (Masters). Roy believed that nursing facilitated an effective adaptation in the human system for upholding integrity when faced with environmental stimuli. Optimal health and the feeling of being well were evoked by the adaptation resulting in a life of quality and dignified death. Coping mechanisms in the body could be innate (or genetic) and acquired (learned or developed). Adaptive systems in the human were the regulator and cognator subsystems. Responses of regulator coping mechanisms were through the neural, chemical and endocrine systems. Responses of the cognator subsystem were through the cognitive emotions by “perceptual and information processing, learning, judgment and emotion” (Masters, 2011). Roy’s Adaptation Model was composed of 4 modes of adaptation: physiological,-physical, role-function, self-concept-group identity and interdependence. The problem of pain management could be resolved through the six steps of the nursing process in Roy’s adaptation model. The behavior of the patient could be assessed using the four modes as a first step. The assessment scales could be used for measuring the intensity of pain. The description of the site of pain, when and how it came on, whether it was continuous or intermittent, whether it was accompanied by other distressing symptoms like vomiting, loose motion or headache would be obtained through the physiological-physical mode. The mental status of the patient, how he carried himself in society, the extent of his response and the level of information of the patient were revealed through the different modes. I would be able to understand whether the behavior of the patient could accommodate adaptive processes or not. The data on the pain would be collected through my observational and interviewing skills. The assessment would involve the patient so that perceptions were not wrong. The stimulus for pain would be assessed in the second step. The internal and external stimuli which influenced the patient’s behaviors would be determined. The stimuli would be classified as focal, contextual or residual. I would also identify the stimuli which promoted the adaptive responses and those which proceeded to ineffectiveness. A nursing diagnosis would be made at this stage when the above two steps were completed. The information included in the diagnosis would determine the next process. Appropriateness of the different nursing diagnoses will facilitate the next step of goal setting. Goals may be set for promoting adaptation through the combined effort of the patient and mine (Bines and Paice, 2005). This would require collaborative concepts for coming to an agreement as to what should be the goals for adaptation to the pain. Management of the situation would be through interventions selected together. Behavioral outcomes of the intervention would be decided and the nurse-patient unit would work towards achieving it. In the implementation phase, I would be working towards guiding the patient to a change in behaviors to promote the adaptive process (Bines and Paice, 2005). My efforts would be continuously selecting stimuli which changed the behavior of the patient by understanding the coping mechanisms that the patent was capable of. Interventions would be the evidence-based and current. The management would include the pharmacological therapy and the relevant non-pharmacological interventions. Adaptation will be triggered by changing stimuli for strengthening the patient’s adaptive ability. The management included the frequent monitoring and evaluation of the patient’s responses. This would throw a light on the effectiveness of the interventions. Any additional problems other than pain could be addressed alongside in a similar manner. I could use my observation and interviewing skills along with measurement and my intuitive process for determining whether my patient had attained relief of pain. Conclusion Patients had a right to be managed for pain relief (Zalon, 2008). Adherence to the guidelines of the Joint Commission on Accreditation of Healthcare Organizations (Bines and Paice, 2005), American Nurse Association (2003 in Zalon, 2008) and the American Pain Society (Peterson and Bedrow, 2008) needs to be the target of professional nursing for pain management. Prevention was considered the best management but this was not always possible (Harrison, 2010). Theories of relief of pain have become an essential part of a nurse’s life (Peterson and Bedrow, 2008). Middle-range theories were most suitable for application (Fawcett, 2005). The policy makers and all the staff have to be taken into confidence for a comprehensive plan for pain management (Bines and Paice, 2005). An individual care plan with the collaborations of the patient and nurse is the best one. Pain management must be uniform in the institution (Bines and Paice, 2005). Using the middle-range theory, I have made an effective comprehensive plan for my practice problem of pain management. Borrowing Roy’s adaptation model, I have also been able to apply the model for pain management. However I stand for the technique that I selected as it is more current and involves a wide base for application. The involvement of all the staff in the hospital allows a better management and uniformity. It also conforms to the guidelines mentioned in the JCAHO, ANA and American Pain Society. Frequent evaluation enables one to gauge the level of success of management and patient satisfaction. Reflective practice would ensure a better evidence-based practice and plan over the years. References: Bines, A. and Paice, J.A. (2005). Are your pain management skills up-to-date? Nursing2005, Volume 35, Number 1 Carbajal R, Rousset A, Danan C, et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008; 300(1):60-70. Croyle, R.T. (2005) Theory at a Glance: Application to Health Promotion and Health Behavior (Second Edition). U.S. Department of Health and Human Services, National Institutes of Health, 2005. Available at www.thecommunityguide.org. Fawcett, J. (1984). The metaparadigm of nursing: Current status and future refinements. Image: Journal of Nursing Scholarship, 16, 84–87. Fawcett, J. (2005). Middle range nursing theories are necessary for the advancement of the disciple. Aquichan, October , Vol. 5, Number 1 Harrison D, Yamada J, Stevens B. Strategies for the prevention and management of neonatal and infant pain. Curr Pain Headache Rep. 2010;14:113-123. Masters, K. (2011). Nursing Theories: A framework for professional practice. Jones and Bartlett Learning, 2011. Peterson, S.J. and Bedrow, T.S. (2008) Middle Range Theories: An application to nursing research. Lippincott, Williams and Wilkins, Medical Phillips, K.D. (2010). Sister Callista Roy: Adaptation Model In A.M.Tomey and M.R.Alligood (Eds.) Nursing Theorists and their work 7th Ed.. Maryland heights. MO:Mosby. Zalon, M.L., Constantno, R.E. and Andrews, K.L. (2008). The Right to Pain Treatment. Dimens Crit Care Nurs. 2008;27(3):93/101] Read More