Elsevier

Pain Management Nursing

Volume 19, Issue 5, October 2018, Pages 474-486
Pain Management Nursing

Original Article
Context Matters for Nurses Leading Pain Improvement in U.S. Hospitals

https://doi.org/10.1016/j.pmn.2018.05.003Get rights and content

Abstract

Background: Pain continues to be a problem in hospitalized patients. Contextual factors contribute to the success of pain quality improvement efforts. Aims: This paper describes nurse team leaders’ perceptions of organizational context and factors perceived to help and hinder the process of leading a unit-based improvement effort focused on pain. Design: Qualitative descriptive design. Setting: Interviews took place over the telephone. Participants: Nurses from 106 hospitals across the United States. Methods: Investigators interviewed 125 nurses leading a unit-based pain quality improvement project in partnership with the National Database of Nursing Quality Indicators. Lewin’s Field Theory guided a thematic analysis. Results: Key contextual factors related to the amount of change in the health care environment and characteristics of the organization and providers. Helping forces included characteristics of nurses, teamwork, a culture of quality, opportunities for learning, pain management resources, and accountability for pain management. Hindering forces included: barriers to involvement, attitudes and relationships, lack of knowledge, and types of patients. Conclusions: Overcoming the pervasive barriers of constant change and lack of staff involvement while also capitalizing on the culture of quality and characteristics of the health care team may further enhance and sustain improvement efforts related to pain management of hospitalized patients. New models for influencing quality improvement could be strengthened with involving frontline staff in both planning and implementation of improvement efforts. Clinical Implications: Because of the diverse responses, it is recommended that each unit conduct a force-field analysis to guide successful implementation of improvement efforts.

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,

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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.

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