Factors influencing orthopedic nurses’ pain management: A focused ethnography

Kayla J Denness,Eloise C J Carr,Cydnee Seneviratne,Janice M Rae

doi:10.1080/24740527.2017.1403285

Kayla J Denness, Eloise C J Carr + Show 2 more

Open Access

https://doi.org/10.1080/24740527.2017.1403285

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Abstract

ABSTRACTAim: The aim of this study was to explore the factors influencing orthopedic surgery nurses’ decisions to administer pro re nata (PRN) opioid analgesia for postoperative pain.Background: Fast-track surgery programs reduce length of stay by identifying and addressing factors causing patients to remain in hospital, including pain (H. Kehlet, Lancet. 2013;381:9878(9878)). The management of acute pain is an important component of quality care for patients after total knee arthroplasty.Methods: The study used a qualitative design of focused ethnography. Ten nurses working on an orthopedic surgery unit at a large urban hospital in western Canada participated in semistructured interviews that used a patient vignette to examine factors that influenced participants’ pain management in the context of fast-track surgery. Interviews were transcribed and analyzed using thematic analysis and constant comparison.Findings: Nurses described a complex clinical environment where the interplay of several factors informed decisions to administer PRN opioid analgesia. The unit’s culture and physical space influenced nurses’ assessments of pain and their decisions whether to treat pain with PRN opioids. Each nurse’s self-concept affected pain management decisions because of perceived importance of pain control and perceived duty to provide analgesics. The subjectivity of pain added another layer of complexity as nurses responded to the patient’s expression of pain from within the milieu of the unit culture and their unique self-concept.Conclusion: Understanding the complexity of factors that influence nurses’ postoperative pain management provides clinical nurses and nursing leaders with directions for future education and research, guided by the goal of continued improvement in pain management in the challenging setting of fast-track surgeries.

Highlights

Osteoarthritis (OA) is a painful, debilitating disease characterized by the progressive breakdown of cartilage and bone.[1]
The aim of this study was to identify and explore the question, “What factors do nurses consider when deciding whether to give the first dose of opioid to a patient who has had a nerve block for a total knee arthroplasty?” The research question focuses on nurses on an orthopedic surgery unit within a specific context and aligns with the tenets of focused ethnography
Three interrelated categories emerged from 263 unique codes: (1) unit culture, (2) nurses’ self-concept, and (3) nurses’ perception of the pain assessment

Summary

Introduction

Osteoarthritis (OA) is a painful, debilitating disease characterized by the progressive breakdown of cartilage and bone.[1]. When OA is present in the knees, it can cause severe pain and reduced mobility, and the only effective treatment for severe end-stage OA is joint arthroplasty.[3] In Canada, acute care hospitalizations following joint arthroplasties are necessary but expensive. Among health care providers in the hospital setting, nurses are best positioned to assess pain and carry out plans to meet the needs of patients. Willson[13] used ethnography to identify factors nurses considered when providing analgesia to patients who had surgery to repair a hip fracture.

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