General researches that address pain management after cardiac surgery have been conducted. However, few studies that focus on the nurses working in cardiac setting have been carried out. Therefore, this study will target nurses working in Cardiac Critical Care Unit. It will mainly explore nurses’ knowledge of pain management and identify factors that may impede and facilitate effective post operative pain management following a CABG survey. In order to do this, Data will be collected through semi-structured interview by employing convenience sampling where by a sample of 10 nurses will be considered. In addition to this, to obtain optimum data, the Nurses’ Knowledge and Attitude Survey (NKAS) tool will be applied. In terms of issues of reliability and validity, after conducting extensive literature review, the content of the interview will be reviewed by a group of experienced researchers. The research will also address the issue of ethics in the entire research process.
BACK GROUND TO THE STUDY
About 75% of surgical patients have experienced moderate to severe pain post operation. Tsui et al. (1995), (Apfelbaum, Chen, Mehta, Gan, 2003). Despite advanced and growing research in pain, treatment options, educational development, and technological development, patients experience poorly controlled pain after surgery. Watt-Watson, Stevens, Garfinkel, Streiner, & Gallop (2001), Nash et al. (1999). Pain management is an important aspect of nursing care and nurses play the greatest role in relieving the pain experienced by the patients. Effective pain management is greatly associated with adequate knowledge of the nurse. Awareness of the perceived barriers has also a great contribution to effective management of the pain. Lack of adequate knowledge of pain management and barriers can greatly compromise patients’ well being after the surgery. Research on nurses’ knowledge and perceived barriers and facilitators to management of pain in general, and local research on post op pain management of patients perception after cardiac surgery has been conducted (Saliba, 2003), but, till up to date few research has been conducted specifically on nurses working in cardiac setting, and none of this studies were carried out in Malta.
The purpose of this study will be to explore nurses’ knowledge of pain management and to identify factors that may impede or facilitate effective post operative pain management following a CABG surgery. To prepare this Literature review, various database searches were carried out using Cumulative Index of Nursing and Allied Health Literature (C.I.N.A.H.L.), Medline, and E.B.S.C.O. A manual search was also carried out at the UOM Faculty of Health Care and the Medical School Library. The key search words and phrases used for this study include “pain management” and “knowledge”, “barriers” and ”pain management”, ”post operative” and ”pain”, ”facilitators” and ”pain”, ”pain knowledge” and ”nurse,” and “CABG” and “pain”. The literature search for this study has been carried out with in the time frame of 1994 and 2010.
1.1 BARRIERS TO PAIN MANAGEMENT
A non experimental exploratory pilot study was done by puls-McColl, Holden & Buschmann (2001), a likert scale consisted twelve questions was provided to the nurses to identify perceived barriers to adequate treatment of pain. The highest rated barrier stated was nurses’ care responsibility towards other acutely ill patients. The subsequent rated barriers were: inadequate assessment, nurses’ lack of time to adequately assess and control pain, and patients’ reluctance to report pain respectively. However, since barriers were pre-determined in the questions asked by the researchers, it is possible that other barriers could have been left unmentioned by the respondents that they could state if they had been asked to mention themselves.
This study has limitation in that it is limited to small self selected convenience sample which leads to potential unrecognized bias. The researcher highlights that though the validity of the tool was examined and approved for the study, the reliability of the tool is somewhat in doubt as examining the reliability by Kuder Richardson (KR-20) was 0.5.
However, according to LoBiondo-Wood & Haber (2006) the Kuder Richardson reliability for the entire scale was calculated at 0.75, which is acceptable, however below 0.7, the magnitude of the correlation is not robust.
Rejeh, Ahmadi, Mohammadi & Anoosheh (2009) conducted a qualitative study where 26 Iranian nurses from three general hospitals participated in sharing their experience and perception of influencing barriers to post op pain management. The design used for this study was exploratory in nature, allowing the respondents to explain their experiences by their own words rather than answering predetermined questionnaires. This allowed the researcher to get an in-depth understanding and richer information of the phenomena. In this study, it was found out that lack of nurses’ educational preparation, their limited authority, limited nurse-patient relationship, and disturbance in pain intervention were identified as the common barriers to post op pain management. Participants explained that the nursing educational system did not perform well and that they weren’t provided adequate pain management lectures during their course. Further, they described that the content of the course they obtained during the course mostly included pharmacological interventions. The respondents also described that nurses’ limited latitude for intervention for relief of pain often restricted the management of pain effectively. Nurse-patient relationships were an important barrier to post operative pain management which was pointed out by nineteen respondents. This possibly could be as a result of an increase in non- nursing duties, heavy workloads, and unbalanced nurse-patient ratio which influence adequately assessing and managing the patients’ pain. Rejeh et al (2009).
The limitation to this study is that the sample size is small comparing to the country Iran, and thus the findings in this study cannot generalize the country. (Polit &Beck, 2004).
Fox, Solomon, Raiina, & Jadad (2004) conducted a study based on focus group methodology in Hamilton Ontario in four long term institutions. The participants were 6 physicians, 19 registered nurses, 8 registered practical nurses, 13 health care aides, and 8 occupational therapists or physiotherapists. They were asked to identify barriers to the management of pain in long-term care institutions. The barriers which were identified were categorized in to 3 types- Caregiver-Related Barriers (caregiver insensitivity to patients’ pain and caregiver beliefs and knowledge about pain management), Patient-Related Barriers (cognitive impairment in patients which were identified by all the participants, patients’ reluctance to report pain and difficulty administering medications to patients, which were identified solely by nursing staff, and system-related barriers (which includes frustration that was experienced by the registered practical nurses and Health care assistant, lack of communication, documentation and insufficient time for nursing staff). However, since this study was conducted in four long term institutions which provide rehabilitation service for cognitively impaired people, it made the findings more related to medical rather than surgical. It has been suggested in a variety of clinical setting that barrier to optimal pain management is vast. This includes: fear to addiction and beliefs about pain by patients, nurses’ communication difficulties with patients, their attitude towards pain, lack of nurses’ consultation with peers, difficulty of communicating with physicians, lack of in depth pain assessment at baseline and limited access to clinical pharmacist ,and lack of standardized approaches. Fox et al., (2004); Hadjistavropoulos, Herr, Turk, Fine, Dworkin, Helme, & Williams, (2007); Martin, Williams, Hadjistavropoulos, Hadjistavropoulos , & MacLean, (2005); Tarzian, & Hoffman, (2004); and Titler, Herr, Schilling, Marsh, Xie, & Ardery et al (2003).
1.2 FACILITATORS TO PAIN MANAGEMENT
Rejeh et al (2008) conducted a qualitative approach on 26 Iranian nurses working in general surgical wards in three educational hospitals in Tehran. Data were collected through semi-structured interview and analyzed using content analysis method at the same time each interview was conducted. According to the participants, one of the factors that facilitate pain management was nurse-patient relationship. They explained that establishing an appropriate relationship with the patient was necessary to provide effective pain management. Participants believed that a good relationship with a patient enabled them to find out the ‘truth’ about the patients’ pain. They also pointed out that nurses’ responsibility and accountability has an effect on pain management. Further, they expressed their belief that commitment to professional code of ethics, respect of the patients’ right and a nurses’ conscience could facilitate to effective pain management. The subsequent themes emerged from this study also revealed that ‘knowledge and skills’ of the nurses and considering ‘physician as a colleague’ were identified as a facilitator to post operative pain management. Knowledge and skills were described an important factor that help the nurses to provide effective pain management. Although concurrent analysis of the data with the interview and subsequent interview schedule was conducted, the study has a limitation in that the limited number of participants it considers cannot provide generalization to the large population of nurses.
1.3 NURSES’ PAIN MANAGEMENT KNOWLEDGE
A non experimental exploratory pilot study was done by puls-McColl, Holden & Buschmann (2001) using a standardized instrument to describe the sampled nurse knowledge of pain management. Convenience samples of 25 registered orthopedics/surgical nurses were taken to take part in the study. The instrument for the pain knowledge was sub-divided in 6 domains (pain assessment, barriers to treatment use of terminology, medications, actions and side effects, treatment interventions, and pain management role). The results were calculated by percentage and shown 100%, 88%, 63%, 60%, 84%, and 81% respectively on the given domains. However, on particular questions about pharmacological and re-medication time for a patient, the participants’ answer was too low.
In a study by Rejeh et al (2009), when the participants were interviewed about barriers to post operative pain management, they identified lack of pain management as one of the barriers. They described that their pain management knowledge was not sufficient in general. They further explained that this was due to lack of educational preparation during their nursing course. They added that most of the content of the courses delivered to them focused on pharmacological interventions and not on issues related to pain management.
The above study was not intended to explore the nurses’ pain management knowledge. The researchers only investigated the barriers to pain management and not the nurses’ knowledge level towards pain management.
A recent study by Hsiang-Ling, & Yun-Fang (2010) was carried out in Taiwan. A cross-sectional design was used to survey the knowledge of pain management. Nurses (n=370) were recruited by stratified sampling from 16 hospitals working in an ICU across Taipei country in Taiwan. Nurses’ knowledge of pain management was measured using the Nurses’ knowledge and attitude survey-Taiwan version. (NKAS-T). (Lai et al, 2003, as cited in Hsiang-Ling & Yun-Fang 2010). The total result showed that 53.4% correct answer was rated which indicated poor pain management knowledge by the nurses. Of the total 37 questions asked to the nurses, 10 questions had correct answer of lower than 30% and eight of these were related to knowledge of medication, indicating nurses’ poor knowledge of analgesics.
A study of knowledge of pain after surgery was done by Coulling (2005) in UK. An instrument developed by McCaffery and Ferrell’s called knowledge and attitude survey regarding pain instrument was used as a tool. Questionnaires were sent to 101 doctors and nurses. (n=101) of those nurses (n=49) were working in three acute hospitals, three orthopedics and two surgical wards with a response rate of 81%. The result indicated that nurses’ average result was 71% which was higher than the counterpart junior doctors. They were more knowledgeable in assessment and analgesic delivery system while less knowledgeable in pharmacology. In this study, the non-UK nurses had shown poorer results. This could be attributed to educational back grounds or cultural backgrounds with different beliefs about the meaning of pain.
This chapter will present an overview picture of how this study will be planned, designed, and accomplished. It will discuss the aim and objectives of this study, operational definition of terms used in this study in accordance with the research setting and target population. Finally, it will discuss data analysis method and ethical issues that will be considered.
3.2 AIMS AND OBJECTIVES
The overall aim of this study is to explore cardiac nurses’ knowledge, attitude, and practice of pain management following a CABG surgery.
To meet the goal/aim, the following objectives will be addressed:
To explore the cardiac nurses’ knowledge and attitude of pain management post CABG surgery.
To identify any influencing barriers to effective pain management following a CABG surgery.
To identify factors that may facilitate effective management of pain in post CABG surgery.
According to Polit and Beck (2004) operational definition defined as; a variable defined and specified for the purpose of a particular study and should correspond to its conceptual definition. For the purpose of this study; the following terms are defined as follows.
CABG: (Coronary Artery Bypass Graft) is a commonly performed procedure which involves restoring flow around narrowed segments of coronary artery by using a bypass graft. (Henry & Thompson, 2005).
Cardiac Nurses: Staff nurses (SN), nursing officers (NO) and deputy nursing officers (DNO), working in cardiac setting.
Pain management: The assessment of pain and intervention to relief the pain by pharmacological and non pharmacological methods.
Knowledge: Awareness, consciousness or familiarity gained by experience or learning. (Collins English Dictionary, 1991)
Attitude: The way a person views something or tends to behave towards it, often in an evaluative way. (Collins English Dictionary, 1991)
Practice: The condition of having mastery of a skill or activity through repetition. (Collins English Dictionary, 1991)
THE RESEARCH DESIGN
The aim of the study is to explore cardiac nurses’ knowledge and attitude of pain management and to identify factors that may facilitate or impede to effective pain management. Since the researcher will try to provide a picture of a specific situation, a descriptive non-experimental design will be appropriate. According to LoBiondo-Wood & Haber (2006), descriptive non-experimental design is used to describe a picture of a phenomenon, explore events; people; or situations as they naturally occur; or test relationship and differences among variables. (p.239). The majority of nursing researches are non-experimental in nature as the research involves human subjects. (Polit & Hungler, 2004).
To reach the aim of this study, both quantitative and qualitative approach will be adopted. Qualitative (semi-structured interviews) and quantitative (survey) approach will be implemented. Morse (1994) states that conducting a qualitative study allows the researcher to obtain deep knowledge of issue being investigated (barriers and facilitators to pain management) rather than generalizing. In a quantitative (survey), a standard instrument will be adopted to explore the nurses’ knowledge of pain management.
TARGET POPULAION: INCLUSION AND EXCLUSION CRITERIA.
Target population of this study will be nurses working in CICU (Cardiac Critical Care Unit). The reason why these nurses are selected is because they are responsible of patients after CABG surgery. The inclusion criteria for this study will be nurses working in CICU. Exclusion criteria, people who will not take part in this study, will be caregivers/helpers.
Data collection for this study will be carried out in CICU (Cardiac Intensive Care Unit), in a private room. The NO will be contacted and permission will be sought for the arrangements.
Participant’s sample will be selected from CICU, through convenience sampling. According to LoBiondo-Wood & Haber (2006) convenience sampling is defined as sampling strategy that uses the most readily accessible subject to be studied in a study. A sample of 10 nurses will participate (n=10).
In order to reach the aim and objectives, the researcher will use a semi-structured interview, in which the questions will be developed and formulated after an extensive literature review is done. This interview method will allow the researcher to understand in-depth situation of the nurses’ barriers and facilitators to pain management by their own words rather than predetermined questions.
The NKAS (Nurses’ knowledge and Attitude survey) tool will also be applied in this study. The NKAS is widely used around the world and the developer of this tool will be contacted via email in order to get permission as well as to modify some of the questions which can be more related to this study subject.
DATA COLLECTION AND PILOT STUDY
A pilot study will be done prior to the actual data collection. Polit & Beck (2006) defined pilot study as a small study conducted in preparation for the major study. Polit and Hungler (1999) further stated that pilot testing is a vehicle which helps the researcher in assessing feasibility and function of the data.
An interview will be scheduled with the participants and at the same time the NKAS tool will also be provided to the nurses to answer the questions. Verbal and written instruction will be given prior to the data collection.
The data which will be recorded on tape will be transcribed verbatim and content analysis will follow. According to (Hutchinson and Wilson, 1992), since concurrent transcription of data after the initial of interview minimizes the possibility of bias and inaccurate analysis, data should be transcribed immediately following the interview or the day after. Permission will be sought from the nurses to record the interview data on a tape.
3.10 RELIABILITY AND VALIDITY
Reliability is the degree of consistency or dependability with which an instrument measures the attribute it is designed to measure. (Polit & Beck 2006). Whereas, Validity is the degree to which an instrument measures what it intends to measure. (Polit &Beck, 2006). The NKAS tool has been developed over several years and widely used around the world. The content Validity has been established by review of expert pain. (McCaffery & Ferrell, 2008). Test-retest reliability was also established (r>.80) and internal consistency reliability was established (alpha r>.70). However, some questions will be modified in relation to the study subject, and research experts will be consulted.
The interview will be structured and formulated to its final stage after extensive literature review is carried out. The interview content will be reviewed by a group of experienced researchers and pain management experts.
Ethical approval will be sought from the Ethics board of committee and the University research ethics committee (UREC).
According to Polit & Beck (2006), when caring out a research, participants have the right to expect that any data they provide will be kept in strictest confidence.
The researcher will explain the nature of the study to the participants along with an information letter. Participants will be informed that participation on this study is on a voluntary basis and that at any time of the interview, they can withdraw without providing any reason. An informed consent will be obtained from each participant. Participants will be assured that their confidentiality will be maintained, but anonymity will be lost as the researcher will interact with them. However, they will be informed that all data would be destroyed after the successful completion of the study.
An important and poplar time scale tool which is widely used is a Gantt chart. A Gantt chart is an excellent tool that helps manage the time and it also allows other areas of life can also be included. Tarling & Crofts (2002).
BUDGET AND RESOURCES
Purchasing Articles: App. Euro 200
Printing and Binding: App. Euro 100
Unexpected expenses: App. Euro 50.
Telefone: App. 20 Euro
Transportation: App. 20 Euro