Original ArticleContext Matters for Nurses Leading Pain Improvement in U.S. Hospitals
Introduction
Pain remains a prevalent and significant problem in hospitalized patients despite decades of research and a multitude of evidence-based guidelines (Gianni et al., 2010, Beck et al, Yao et al., 2013). Numerous barriers contribute to the suboptimal control of pain and involve health care professionals, patients, and health care systems (Luckett et al., 2013). For health care professionals, lack of knowledge, lack of adequate assessment (Beck et al., 2016, Brant et al., 2017, Breuer et al., 2011, Jarrett et al., 2013, Lewthwaite et al., 2011), and fear of addiction (Oliver et al., 2012) are commonplace. For patients, fears about addiction and intolerable side effects often result in reluctance to adhere to analgesic therapy (Luckett et al., 2013). Systems barriers include issues related to access to health care and opioids, reimbursement, regulation of controlled substances, and lack of accountability for pain relief (Food and Drug Administration, 2011, Passik, 2009).
Quality improvement (QI) provides a systematic approach to address these barriers. Yet there is variability in whether or not QI efforts succeed. There is a wide range of contextual conditions unique to a hospital or unit that can influence the process of QI, its efficacy, and its sustainability (Kaplan et al., 2010). Context includes key features or characteristics of the environment in which the work is immersed and has been defined in the recent “Standards for QUality Improvement Reporting Excellence” (SQUIRE 2.0) as follows:
“Physical and sociocultural makeup of the local environment (e.g., external environmental factors, organizational dynamics, collaboration, resources, leadership, and the like), and the interpretation of these factors (‘sense-making’) by the healthcare delivery professionals, patients, and caregivers that can affect the effectiveness and generalizability of intervention(s).” (Ogrinc et al., 2016).
Studies that examine the context for leading pain improvement projects are limited. The purpose of this paper was to describe frontline nurses’ perceptions of organizational context and factors perceived to help and hinder the process of leading a unit-based improvement effort focused on pain.
Section snippets
Background
The importance of organizational context in promoting QI is widely acknowledged and includes key factors such as organizational culture, patient-centered care, leadership, interdisciplinary teamwork, and systems for monitoring and providing feedback on performance. Key to QI is engaging members of the multidisciplinary team who are providing care in the improvement process (Blake et al., 2006, Coles et al., 2017, Kaplan et al., 2010, Keroack et al., 2007). From a nursing perspective, nurses in
Methods
This qualitative descriptive study was part of a larger mixed-methods study to measure and improve pain care processes and outcomes in a sample of 326 hospitals across the United States (S. Beck et al., Under Review). The hospitals were part of the National Database for Nursing Quality Indicators (NDNQI), a national nursing quality consortium. The larger study included an audit of pain quality indicators before and after the implementation and comparative evaluation of three intervention
Description of the Sample
Of 148 nurses who participated as NTLs, 125 completed the interview for an 84% response rate. The interviews ranged from 12 to 62 minutes; on average they were 28.46 minutes (median = 27; standard deviation = 9.15). The study sample (see Table 1) was primarily female (n = 121, 98.4%); most had earned a bachelor's degree or higher. A little more than one-third of the NTLs had at least one certification; of these, most (n = 20) were certified as medical-surgical nurses.
Most NTLs did not have
Discussion
The sample for the larger study was representative of hospitals participating in NDNQI (Beck, Under Review #281). NDNQI hospitals represent all 50 states, and more than one-quarter of the community hospitals in the U.S. NDNQI hospitals tend to be larger and more metropolitan than all U.S. hospitals.
Compared with the “2008 National Sample Survey of Registered Nurses” released in 2010 (U. S. Department of Health and Human Services Health Resources and Services Administration, 2010), study
Conclusions
The study findings from NTL participant interviews elucidate the heterogeneous contexts in conducting a QI project at the unit level in U.S. hospitals. Contexts are dynamic and vary by unit. Awareness of the individual hospital and unit context cannot be overemphasized as a first step in successful quality improvement projects. Nurse team leaders identified helping and hindering forces associated with leading a pain management improvement project. Capitalizing on the current culture of quality,
References (39)
- et al.
Nurses’ knowledge and attitudes about pain: Personal and professional characteristics and patient reported pain satisfaction
Pain Management Nursing
(2017) - et al.
Improving quality and safety education: The QSEN Learning Collaborative
Nursing Outlook
(2009) - et al.
Prevalence of pain in elderly hospitalized patients
Archives of Gerontology and Geriatrics
(2010) - et al.
Assessment and management of adult cancer pain: A systematic review and synthesis of recent qualitative studies aimed at developing insights for managing barriers and optimizing facilitators within a comprehensive framework of patient care
Journal of Pain and Symptom Management
(2013) - et al.
Barriers to change hindering quality improvement: The reality of emergency care
Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association
(2010) - et al.
Creating organizational change through the pain resource nurse program
Joint Commission Journal on Quality & Patient Safety
(2006) Issues in long-term opioid therapy: Unmet needs, risks, and solutions
Mayo Clinic Proceedings
(2009)Kaizen: A process improvement model for the business of health care and perioperative nursing professionals
AORN Journal
(2012)Atlas.Ti (Version 6.2). Berlin Atlas.Ti Scientific Software Development GmbH
(2011)- Beck, S.L., Dunton, N., Berry, P, J. M., Brant, Guo, J., Potter, C., Spornitz, B., Eaton, J., & Wong, B. (Under...
Oncology nursing certification: Relation to nurses’ knowledge and sttitudes about pain, patient-reported pain care quality, and pain outcomes
Oncology Nursing Forum
Analyzing qualitative data: Systematic approaches
Facilitators and barriers to 10 National Quality Forum safe practices
American Journal Of Medical Quality: The Official Journal of the American College of Medical Quality
Medical oncologists’ attitudes and practice in cancer pain management: A national survey
Journal of Clinical Oncology
Kurt Lewin and the planned approach to change: A re-appraisal
Journal of Management Studies
Kurt Lewin’s field theory: A review and re-evaluation
International Journal of Management Reviews
The influence of contextual factors on healthcare quality improvement initiatives: What works, for whom and in what setting? Protocol for a realist review
Systematic Reviews
Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science
Implementation Science
Development and approval process (drugs)
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Jeannine Brant serves on the Speaker's Bureau for Insys and Genetech.
The Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative funded this study. ([INQRI 68223] Beck and Dunton, multiple PIs).
The authors would like to acknowledge all of the participating hospitals, units, nurses, and patients who contributed to the success of this study. They would also like to thank their colleagues at the National Database for Nursing Quality Indicators, Dr. Nancy Dunton, Catima Potter, and Beth Spornitz; without their outstanding collaboration, this study would not have been possible. Special thanks to Karen Lindau (KL), Virginia Lebaron (VL), and Sarah Iribarren (SI), who participated on the research team.