Al-Tawafsheh, Atef M.M.
(2016)
The influence of an Acute Pain Service on postoperative pain management in Jordan: a comparative case study.
PhD thesis, University of Nottingham.
Abstract
Background and Aims: Acute pain services (APSs) have developed worldwide to improve the quality of postoperative pain management (POPM). Although there is evidence that APSs can reduce pain and side effects after surgery and improve nurses’ knowledge regarding pain management, the processes through which APSs influence these outcomes remains unclear. Previous studies regarding the influence of APSs on these outcomes have reported conflicting findings and there has been little research exploring clinicians’ perceptions of the APS, and POPM practice.
The development of a nurse-based, anaesthetist-supervised APS in one of Jordan’s hospitals in February 2010 provided an interesting and timely opportunity to investigate the influence of an APS on POPM in Jordan, as compared to a similar hospital that has yet to develop this service. This study seeks to address the gap in our knowledge concerning the impact of an APS on the quality of POPM, the knowledge and attitudes of clinicians relating to pain, and to explore clinicians’ views and perceptions of the APS, and current POPM practice.
Methods: A comparative multiple-case (embedded) study was conducted between July 2011 and October 2011 at two hospitals in Jordan (Hospital-A has APS, Hospital-B without APS). The case study utilised a combination of quantitative and qualitative methods. Adult patients who underwent elective major surgery (50 from each hospital) completed the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire 24 hours after surgery to examine the quality of POPM in both hospitals. A representative sample of nurses and junior doctors at the two hospitals (89 from hospital-A and 100 from hospital-B) completed the knowledge and attitudes regarding pain (KAP) questionnaire. Documentary evidence including hospital policies and notes of meetings was gathered to illuminate the findings derived from other sources. Finally, a purposeful sample of 25 clinicians (mixture of nurses, anaesthetists & surgeons; 12 from hospital-A and 13 from hospital-B) was interviewed to explore clinicians’ views on the APS and current POPM practice.
Results: The total mean SCQIPP scores for hospital-A (57.28) and hospital-B (51.88) did not reach the ‘high quality of care’ threshold of 63 in either hospital. The findings from clinicians’ interviews suggest that the lack of patient involvement, the lack of regular pain assessment, and organisational challenges in both hospitals have prevented the total quality scores from reaching the international standard for ‘high quality of care’. Patients in hospital-A reported a significantly higher total SCQIPP scores, and in the subscales of communication and action, (P< 0.001) than hospital-B. There was no significant difference in the subscales of trust (P=0.927) and environment (P=0.344) or in the patient satisfaction scores (P=0.059). Patients in hospital-A also reported significantly lower pain intensity scores (P<0.001). Patients in hospital-A used significantly more PCA (P=0.013) and epidural analgesia (P<0.001) whereas patients in hospital-B used significantly more IM analgesia (P<0.001). The findings suggest that the provision of patient education and the more robust approach to pain assessment in hospital-A have positively influenced the achievement of higher total quality scores when compared to Hospital-B. The qualitative findings indicate that the availability of the APS staff 24 hours in hospital-A, the APS’s ‘round’, the specialist pain nurses’ ‘rapid interventions’ and coordination role, and the introduction of PCA and epidural analgesia, were the main activities of the APS that had an impact on the quality of care and patients’ experience of pain in hospital-A.
The median total KAP scores for hospital-A (61.6%) and hospital-B (51.5%) did not reach the internationally recognised scores of 80%. A possible explanation is that the short duration of in-service pain education, lack of education sessions, and the reliance of clinicians on their experience, learning from other colleagues or undergraduate courses to learn about pain management are potential explanations for this shortfall. Clinicians in hospital-A had significantly higher KAP scores than hospital-B (P<0.001). Ongoing education and training provided by the APS; the quality and content of training on different aspects of pain management, and the development of pain policies were the main activities of the APS that had an impact on the knowledge of clinicians in hospital-A. However, clinicians in both hospitals were found to have misconceptions about the side effects of PCA and epidural analgesia, and the use of placebo and behavioural clues in pain assessment. Moreover, clinicians’ interviews indicate that patients refuse to take narcotics because they believe it is Haraam (prohibited) or due to fear of opioid addiction. They also speculate that the presence of relatives (escorts) may lead patients to pretend to be in pain and show Dala’ [spoiled] in front of their relatives.
Conclusions: The total quality scores did not reach the internationally recognised standard for high quality pain management in either hospital. The findings suggest that the presence of an APS is associated with better managed pain experience, a higher quality of patient care, an increase in the provision of patient education and an increase in compliance with performing regular pain assessment. To improve the quality of pain management practice, clinicians in hospitals with an APS need to continue their work to promote patient education, regular pain assessment, and pay more attention to interventions promoting patient involvement. Hospitals without access to an APS need to find innovative ways to integrate regular pain assessment, patient involvement, and the provision of patient education into routine clinical practice. They may also need to invest in establishing APSs to introduce advanced pain management modalities into their hospitals effectively and safely.
The findings suggest that the presence of an APS is associated with a higher knowledge and a positive attitude of clinicians regarding pain management. Despite hospital-A outperforming hospital-B on a number of measures, the total knowledge and attitudes scores did not reach the internationally acceptable scores of 80% in either hospital. To improve the knowledge and attitude of clinicians, it is necessary to improve the content, quality and duration of pain education offered at both the undergraduate and professional levels. It should be noted that this study was carried out in Jordan, a middle-income and an Arabic Muslim country and the internationally recognised thresholds could be too high benchmarks to achieve.
In terms of further research, it would be helpful to validate the suggested ‘high quality of care’ threshold on the SCQIPP questionnaire and explore an adjusted ‘high quality of care’ threshold for low/middle-income countries that are struggling with limited resources. There is also a need for further research to develop a contemporary questionnaire to assess clinicians’ knowledge and attitudes regarding POPM including the use of advanced pain management techniques. In addition, a further qualitative study with patients and relatives is recommended to understand their religious beliefs concerning the use of opioids, and the role of the religious practices in pain management.
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