Article Critique Pain Management in Pediatrics
Nursing Research Critique Utilization Plan Paper July 24th, 2010 Nursing Research Critique Utilization Plan Paper Part 1 Article Selection Qualitative research is investigations which use sensory methods such as listening or observing to gather and organize data into patterns or themes. Qualitative research deals more often with language than numbers. Methods of gathering information might be focus groups or interview panels. It uses a flexible research design and utilizes an inductive process to formulate a theory. The idea is to get in depth information from the participants. The purpose is to understand and interpret social interactions.
Quantitative research is scientific investigations in which numbers are used to measure variables such as characteristics, concepts or things. It generates statistics through large scale survey research. Methods of gathering information might be questionnaires or reviewing patient charts over a certain period of time. Quantitative research uses a controlled design and defines a problem and a solution to the problem in a logical process of steps. The idea is to get generalizable findings that can be applied to other populations. The purpose is to look at cause and effect and make predictions.
Database: EBSCOhost – CINAHL Plus with Full Text Key words: quantitative nursing research; inadequate pain management; united states Limited results by full text and filtered by publication date The article: Shrestha-Ranjit, J. M. and Manias, E. (2010). Pain Assessment and management practices in children following surgery of the lower limb. Journal of Clinical Nursing, 19, 118-128. Part II Article Critique Children have been under treated for pain due to many misconceptions about pediatric pain management. These misconceptions include: children do not feel pain or suffer less than adults, fears of respiratory depression or ther adverse effects from medication, and the lack of routine pain assessment in children (Shrestha-Ranjit & Manias, 2010). This is a very significant problem in nursing that needs to be addressed. The title of this study, “Pain Assessment and management practices in children following surgery of the lower limb” accurately describes what the study is about. The information gathered and the population the study targets is stated in the title. The independent variables in the study are pain assessment and pain management and the dependent variable is the pain level of the pediatric patient.
In the introduction of this study it clearly examines the background on pain assessment, pain management, and pain documentation in relation to pediatric patients. It discusses previous studies that show a lack of use of pain assessment tools, utilizing pain medication on a regular basis, and inadequate documentation of children’s pain. Two studies were reviewed that were in support of the lack of use of validated pain assessment tools by nurses. One example was a survey of pediatric nurses that was reviewed and found that only 2% of the respondents reported using pain assessment tools (Shrestha-Ranjit & Manias, 2010).
Several studies were reviewed and found that children were consistently under treated for pain management. A U. S. descriptive study was reviewed and found that although 74% of children aged 3. 5 to 17 years received pain medication after surgery 51% still complained of moderate to severe pain levels (Shrestha-Ranjit & Manias, 2010). Multiple surveys were reviewed that showed that nurses understood the importance of non-pharmacological pain relief interventions but were constrained by busy workloads and inadequate knowledge (Shrestha-Ranjit & Manias, 2010). Postoperative pain in children has been found to be persistently under-treated.
Pain medication is consistently prescribed and administered on a PRN basis in children. This leads to the under management of pain and high pain intensity scores for children (Shrestha-Ranjit & Manias, 2010). The problem is clearly stated. The background information and findings support the justification for this study. This study used a retrospective clinical audit design that involved a review of medical records of children who had surgery of the lower limb (Shrestha-Ranjit & Manias, 2010). The study reviewed other studies and surveys done on the subject of postoperative pain management in children. Data can be collected and analyzed.
Clinical audits of pain documentation are an effective way of researching, other studies can be created, and surveys can be used. A conceptual model or framework was not identified by the researchers. This study is not based on a theory or conceptual model. The researchers researched the background, posed a research question, selected a design, a sample was chosen, an instrument was created, and then data was collected and analyzed. The basis of the study was not to test a hypothesis or theory, but to answer the research question. The sources listed in the references are dated from 1986 through 2008 (Shrestha-Ranjit & Manias, 2010).
The majority of the references are journal articles. There was a hospital council and audit protocol reference also included. The references are extremely limited. There are other sources that could have been utilized like the American Medical Association and American Nursing Association. The literature reviewed by the researchers was organized into topics. The topics are pain assessment, pain management, and pain documentation. The literature review was followed a brief summary stating that there is a significant gap in relation to trends in pain assessment and management following pediatric surgery (Shrestha-Ranjit & Manias, 2010).
The purpose of the study was clearly stated. The aim of the study was to “examine pediatric nurses’ pain assessment and management practices in relation to postoperative care for children following surgery of a fractured lower limb and to compare these practices with evidence based guidelines” (Shrestha-Ranjit & Manias, p. 118, 2010). The research question was clearly stated. The research question is “How do nurses assess, manage and document postoperative pain in children aged 5-15 years who are hospitalized after orthopedic surgery of a fractured lower limb? ” (Shrestha-Ranjit & Manias, p. 120, 2010).
There is a clear operational definition. “A manual review of medical records of children who had surgery of a femoral or tibial fracture between 1 June 2003 – 31 May 2005 in an Australian, metropolitan, pediatric hospital… inclusion criteria were as follows: all children aged 5-15 years who had a surgical procedure for a fractured femur or tibia and those who had a postoperative duration of stay for at least 24 hours. Exclusion criteria were as follows: children who had multiple injuries; those with fractures to other parts of the body and children who were admitted to the ICU” (Shrestha-Ranjit Manias, p. 120, 2010). The study used a retrospective clinical audit design. The researchers collected data from the past, looking back at what has been happening with pain management in pediatric patients. This helped provide a baseline on what has occurred. However, some disadvantages to this are past patients will not benefit and data may be difficult to collect. The target population was clearly identified, as stated above. A whole population sampling method was used. The method of choosing the sample was nonprobability, consecutive sampling.
The sample was chosen from the accessible population who met the eligibility criteria over the specified time interval (Polit & Beck, 2010). Inclusion and exclusion criteria were used, as stated above. One major threat to the external validity of this study is that it was only done at one hospital. The results of the study would be more powerful if they could be replicated at multiple locations. Replication increases confidence in the generalizability of the results (Polit & Beck, 2010). The steps in collecting data were specifically stated. An audit tool was used and data was collected over a 2 year time period.
A suitable audit tool was not found, so the researchers developed a specific clinical audit tool on the basis of the information obtained in the literature review. The audit tool collects pertinent data appropriate to the problem. The clinical audit tool had 4 sections with a total of 25 items. The information gathered from the clinical audit tool included demographic information and information about the nurses’ pain management practices (Shrestha-Ranjit & Manias, 2010). Validity and reliability were addressed in the development of the clinical audit tool.
A content validity rating survey was done to determine the relevance, clarity and comprehensiveness of the audit tool (Shrestha-Ranjit & Manias, 2010). The clinical audit tool was not designed to be scored; it was designed to obtain specific information appropriate to the problem. However, the content validity rating survey was scored. The ratings were explained, the range of scores was defined, and the high/low score means were explained. An overall content validity index score of 91. 8% signified that the clinical audit tool had good content validity (Shrestha-Ranjit & Manias, 2010).
The only mention of human subject review was the content validity of the tool was assessed by an expert panel of 6 health professionals (Shrestha-Ranjit & Manias, 2010). The content validity indexed was rated by the panel and the inner-rater reliability was assessed using 3 randomly selected medical records (Shrestha-Ranjit & Manias, 2010). There was no direct patient involvement therefore informed consent was not required. Patient information including name and date of birth were not recorded during the audit to maintain patient confidentiality (Shrestha-Ranjit & Manias, 2010).
The statistical procedures were appropriate. The research question was answered by topic: demographics, pain assessment, and pain management. Pain documentation was addressed throughout. Generalizations were not made that were not warranted. There were several limitations of the study. Pain documentation may not fully reflect how nurses actually practice in real clinical settings. The findings are based on a retrospective audit versus a prospective audit of actual pain assessment and management practices.
Observation of the nurses’ pain assessment and management practices in the clinical setting would have been very useful (Shrestha-Ranjit & Manias, 2010). The researchers related the findings of the study to the problem indicated by the literature review. The findings showed that less than 12% of medical records showed evidence of the use of a pain assessment tool. There were discrepancies in the actual and expected frequencies of pain assessment suggesting the nurses assessed pain less frequently than they were expected to according to hospital protocol (Shrestha-Ranjit & Manias, 2010).
The study showed a disproportionate use of parenteral versus oral analgesics, inadequate pain documentation, and a deficiency in nurses’ knowledge of pain management (Shrestha-Ranjit & Manias, 2010). The findings of this study support the findings of the literature review. The findings of the study showed that assessment, management, and documentation of pediatric postoperative pain were inadequate because many patients experienced moderate to severe pain throughout the postoperative period (Shrestha-Ranjit & Manias, 2010). The recommendations made by the researchers were for further research, education, and nursing practice.
Further research is needed. Suggestions include the use of surveys about the effectiveness of current pain management practice and an observational study to differentiate between nurses actual clinical practice versus their documentation. Interventions to improve clinical practice and education were recommended. At the clinical level the study found that nurses need to assess pain more frequently, analgesics should be ordered and administered on a regular basis, and pain documentation needs to be improved. All of these recommendations were based on the study findings. Part III Research Utilization Plan
The ideal location for implementation of the research utilization plan for pain assessment and management practices in children following surgery of the lower limb would be a pediatric hospital orthopedic surgery unit. Children’s Hospital Central California has an orthopedic surgery department that performs 1,800 orthopedic procedures a year (CHCC, 2010). It would also be ideal to implement the research utilization plan at one or more other pediatric hospitals. the results would be more powerful if they could be replicated. Other possible locations for implementation of the research utilization plan would be Children’s Hospitals in L.
A. , Orange County, or San Diego, U. C. Davis Children’s Hospital, Loma Linda University Children’s Hospital, Mattel Children’s Hospital at UCLA, or Packard Children’s Hospital at Stanford. I would use the Iowa model to describe knowledge transformation and to guide the implementation of the research into clinical practice. The Iowa model highlights the importance of considering the entire healthcare system from the provider, to the patient, to the infrastructure, using research within these contexts to guide practice decisions (Polit & Beck, 2010).
The study determined that documented practices were not consistent with the recommendations provided by evidence based practice guidelines regarding effective assessment and management of children’s post operative pain (Shrestha-Ranjit & Manias, 2010). I would institute new guidelines for 3 major areas. First, nurses would assess pain more frequently using an age and context appropriate pain assessment tool by considering different indicators of pain (Shrestha-Ranjit & Manias, 2010). For example, nurse’s pain assessment would be done using an appropriate assessment tool every 30 minutes for the irst 3 hours post-op, then every hour for the next 3 hours, then every other hour for the next 4 hours, and then every 4 hours completing the first 24 hour period. Second, analgesics should be ordered and administered on a regular basis for the initial post-op period when moderate to severe pain is a likely outcome. Corroboration with the prescribing doctors would be essential to the success of implementation of this area. Nurses would administer pain medication on a set schedule and not a prn basis.
Prn medication could be ordered and utilized for break through pain. Third, it is essential to improve pain documentation practices in the clinical setting to enhance communication between health professionals and to provide a legal, permanent, and comprehensive record of patient care (Shrestha-Ranjit & Manias, 2010). A review of current patient care records for ease of pain documentation would need to be done and any problems would need to be addressed. If necessary a pain assessment documentation sheet could be created and submitted for approval to use.
Environmental influences in the nurses actual work environment that might interfere with optimal pain management should be identified. Assessing for adequate knowledge and skills of pain assessment and management are essential for all nurses to be able to recognize and manage pain properly. Assessing the nurse’s knowledge base and creating a refresher course for all nurses to attend prior to implementing the utilization plan is essential to its success. Commitment at various levels within the hospital is essential to achieve positive outcomes in pediatric pain management.
Improvements in pediatric pain assessment and management practices should be monitored and evaluated regularly. This can be done by conducting clinical audits, organizing meetings among the disciplinary teams, and obtaining feedback from the children and their families (Shrestha-Ranjit & Manias, 2010). Evidence based practice is an essential part of quality healthcare and nursing practice. As a nurse I need to be able to understand the process of developing a clinical question that is clear and focused.
Becoming familiar with the Iowa model and the PICO process is a helpful way to help facilitate the development of a searchable question. The Iowa model will help me as a nurse by providing a framework of how to think about evidence based practice within my healthcare system. The Iowa framework will provide a way for me to process a clinical question and use research findings to assure that I am utilizing the most up to date evidence based care. I will need to keep up to date on new research and continue to strive to improve the quality of care that I provide to all of the patients throughout my career.
References Children’s Hospital Central California, CHCC. (2010) Orthopedic Surgery. Retrieved on July 22, 2010 from http://www. childrenscentralcal. org/services/medical/ortho/Pages/Default. aspx Polit, D. and Beck, C. (2010) Essentials of Nursing Research Appraising Evidence for Nursing Practice. Philadelphia, PA: Lippincott Williams & Wilkins. Shrestha-Ranjit, J. M. and Manias, E. (2010). Pain Assessment and management practices in children following surgery of the lower limb. Journal of Clinical Nursing, 19, 118-128.