Judy Watt-Watson

Impact of preoperative education on pain outcomes after coronary artery bypass graft surgery

&NA; Cardiovascular diseases cause more disability and economic loss in industrialized nations than any other group of diseases. In previous work [Nurs Res 49 (2000a) 1], most coronary artery bypass graft patients (CABG, N=225) reported unrelieved pain and received inadequate analgesics. This study proposed to evaluate a preadmission education intervention to reduce pain and related activity interference after CABG surgery. Patients (N=406) were randomly assigned to (a) standard care or (b) standard care+pain booklet group. Data were examined at the preadmission clinic and across days 1–5 after surgery. Outcomes were pain‐related interference (BPI‐I), pain (MPQ‐SF), analgesics (chart), concerns about taking analgesics (BQ‐SF), and satisfaction (American Pain Society‐POQ). The impact of sex was explored related to primary and secondary outcomes. The intervention group did not have better overall pain management although they had some reduction in pain‐related interference in activities (t(355)=2.54, P<0.01) and fewer concerns about taking analgesics (F(1,313)=2.7, P<0.05) on day 5. Despite moderate 24‐h pain intensity across 5 days, patients in both groups received inadequate analgesics (i.e. 33% prescribed dose). Women reported more pain and pain‐related interference in activities than men. The booklet was rated as helpful, particularly by women. In conclusion, the intervention did not result in a clinically significant improvement in pain management outcomes. In future, an intervention that considers sex‐specific needs and also involves educating the health professionals caring for these patients may influence these results.

Core competencies for pain management: Results of an interprofessional consensus summit

Objective The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported. Methods An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached. Results The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain. Conclusions These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.

An Interfaculty Pain Curriculum: Lessons learned from six years experience

Abstract Minimal pain content has been documented in pre‐licensure curricula and students lack important pain knowledge at graduation. To address this problem, we have implemented and evaluated a mandatory Interfaculty Pain Curriculum (IPC) yearly since 2002 for students (N = 817 in 2007) from six Health Science Faculties/Departments. The 20‐h pain curriculum continues to involve students from Dentistry, Medicine, Nursing, Pharmacy, Physical Therapy, and Occupational Therapy as part of their 2nd or 3rd year program. Evaluation methods based on Kirkpatrick’s model now include evaluation of a Comprehensive Pain Management Plan along with the previously used Pain Knowledge and Beliefs Questionnaire (PKPQ) and Daily Content and Process Questionnaires (DCPQ). Important lessons have been learned and subsequent changes made in this iterative curriculum design based on extensive evaluation over the 6‐year period. Modifications have included case development more relevant to the diverse student groups, learning contexts that are uni‐, inter‐, and multi‐professional, and facilitator development in working with interprofessional student groups. PKBQ scores have improved in all years with a statistically significant average change on correct responses from 14% to 17%. The DCPQ responses have also indicated consistently that most students (85–95%) rated highly the patient panel, expert‐lead clinically focused sessions, and small interprofessional groups. Relevancy and organization of the information presented have been generally rated highly from 80.3% to 91.2%. This curriculum continues to be a unique and valuable learning opportunity as we utilize lessons learned from extensive evaluation to move the pain agenda forward with pre‐licensure health science students.

Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain.

Cardiac pain arising from chronic stable angina (CSA) is a cardinal symptom of coronary artery disease and has a major negative impact on health-related quality of life (HRQL), including pain, poor general health status, and inability to self-manage. Current secondary prevention approaches lack adequate scope to address CSA as a multidimensional ischemic and persistent pain problem. This trial evaluated the impact of a low-cost six-week angina psychoeducation program, entitled The Chronic Angina Self-Management Program (CASMP), on HRQL, self-efficacy, and resourcefulness to self-manage anginal pain. One hundred thirty participants were randomized to the CASMP or three-month wait-list usual care; 117 completed the study. Measures were taken at baseline and three months. General HRQL was measured using the Medical Outcomes Study 36-Item Short Form and the disease-specific Seattle Angina Questionnaire (SAQ). Self-efficacy and resourcefulness were measured using the Self-Efficacy Scale and the Self-Control Schedule, respectively. The mean age of participants was 68 years, 80% were male. Analysis of variance of change scores yielded significant improvements in treatment group physical functioning [F=11.75(1,114), P<0.001] and general health [F=10.94(1,114), P=0.001] aspects of generic HRQL. Angina frequency [F=5.57(1,115), P=0.02], angina stability [F=7.37(1,115), P=0.001], and self-efficacy to manage disease [F=8.45(1,115), P=0.004] were also significantly improved at three months. The CASMP did not impact resourcefulness. These data indicate that the CASMP was effective for improving physical functioning, general health, anginal pain symptoms, and self-efficacy to manage pain at three months and provide a basis for long-term evaluation of the program.

Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines

Refractory angina (RFA) is a debilitating disease characterized by cardiac pain resistant to conventional treatments for coronary artery disease including nitrates, calcium-channel and β-adrenoceptor blockade, vasculoprotective agents, percutaneous coronary interventions, and coronary artery bypass grafting. The mortality rate of patients living with RFA is not known but is thought to be in the range of approximately 3%. These individuals suffer severely impaired health-related quality of life with recurrent and sustained pain, poor general health status, psychological distress, impaired role functioning, and activity restriction. Effective care for RFA sufferers in Canada is critically underdeveloped. These guidelines are predicated upon a 2009 Canadian Cardiovascular Society (CCS) Position Statement which identified that underlying the problem of RFA management is the lack of a formalized, coordinated, interprofessional strategy between the cardiovascular and pain science/clinical communities. The guidelines are therefore a joint initiative of the CCS and the Canadian Pain Society (CPS) and make practice recommendations about treatment options for RFA that are based on the best available evidence. Concluding summary recommendations are also made, giving direction to future clinical practice and research on RFA management in Canada.

Critical Care Nurses’ Pain Assessment and Management Practices: A Survey in Canada

BACKGROUND Regular pain assessment can lead to decreased incidence of pain and shorter durations of mechanical ventilation and stays in the intensive care unit. OBJECTIVES To document knowledge and perceptions of pain assessment and management practices among Canadian intensive care unit nurses. METHODS A self-administered questionnaire was mailed to 3753 intensive care unit nurses identified through the 12 Canadian provincial/territorial nursing associations responsible for professional regulation. RESULTS A total of 842 nurses (24%) responded, and 802 surveys could be evaluated. Nurses were significantly less likely (P < .001) to use a pain assessment tool for patients unable to communicate (267 nurses, 33%) than for patients able to self-report (712 nurses, 89%). Significantly fewer respondents (P < .001) rated behavioral pain assessment tools as moderately to extremely important (595 nurses, 74%) compared with self-report tools (703 nurses, 88%). Routine (>50% of the time) discussion of pain scores during nursing handover was reported by 492 nurses (61%), and targeting of analgesia to a pain score or other assessment parameters by physicians by 333 nurses (42%). Few nurses (n = 235; 29%) were aware of professional society guidelines for pain assessment and management. Routine use of a behavioral pain tool was associated with awareness of published guidelines (odds ratio, 2.5; 95% CI, 1.7-3.7) and clinical availability of the tool (odds ratio, 2.6; 95% CI, 1.6-4.3). CONCLUSIONS A substantial proportion of intensive care unit nurses did not use pain assessment tools for patients unable to communicate and were unaware of pain management guidelines published by professional societies.

Peer support intervention trials for individuals with heart disease: a systematic review.

Background: Heart disease is a major cause of illness, disability and death worldwide with high personal, community and healthcare costs. Social support affects psychological and physical morbidity, mortality, and adjustment to chronic disease. Peer support, a specific type of social support, has been shown to be an effective intervention for a variety of populations. Aim: The aim of this paper is to critically examine the effects of peer support interventions on health outcomes in individuals with heart disease. Methods: Searches were made of ACP Journal Club, EBM, CDSR, DARE, CCTR (1982–2005), MEDLINE (1966–2005), PsycINFO (1975-July 2005), HealthSTAR (1975-June 2005), and CINAHL (1982-July 2005) using text words and MeSH headings. Results: Electronic and hand searching yielded 27 studies and reviews. Six studies met the inclusion criteria and were assessed using guidelines from The Evidence-Based Medicine Working Group and The Cochrane Collaboration. Inferences about the results were limited to critical appraisal. The trials demonstrated some positive effects of peer support for individuals with heart disease, including higher levels of self-efficacy, improved activity, reduced pain, and fewer emergency room visits. Conclusion: Despite some evidence supporting peer support for individuals with heart disease, methodological problems preclude generalizations. Further research with greater methodological rigor is warranted.

Cost of illness for chronic stable angina patients enrolled in a self-management education trial

BACKGROUND Chronic stable angina (CSA) is a major debilitating health problem in Canada. A paucity of relevant cardiovascular data sets has precluded a detailed examination of the impact of interventions on CSA-related costs and its broader economic burden. OBJECTIVES As part of a larger clinical trial, the authors sought to determine the short-term impact of a standardized self-management training program on CSA-related costs. A secondary objective was to estimate the total annualized cost of CSA per patient from a societal perspective. METHODS Pre- and three-month post-test cost data were collected on 117 participants using the Ambulatory Home Care Record. Mean annualized direct, indirect and system-related CSA costs (2003 to 2005) were estimated; total per-patient CSA costs from a societal perspective were calculated as the sum of these costs. RESULTS The mean (+/- SD) age of participants was 68+/-11 years; 80% were male. The program did not impact costs in the short-term. Direct annual out-of-pocket costs, including money paid for health care, travel to appointments, medication, equipment and home support totaled

Chronic noncancer pain and the long term utility of opioids

3,267. Indirect costs, reflecting the value of all unpaid time spent by those engaged in angina-related care, were

Cardiac Home Education and Support Trial (CHEST): A pilot study

12,963. System costs, including costs paid by public and private insurers, were