Julie Stanik-Hutt

Pain behaviors observed during six common procedures: Results from Thunder Project Ii*

ObjectivePatients frequently display behaviors during procedures that may be pain related. Clinicians often rely on the patient’s demonstration of behaviors as a cue to presence of pain. The purpose of this study was to identify specific pain-related behaviors and factors that predict the degree of behavioral responses during the following procedures: turning, central venous catheter insertion, wound drain removal, wound care, tracheal suctioning, and femoral sheath removal. DesignProspective, descriptive study. SettingMultiple units in 169 hospitals in United States, Canada, England, and Australia. PatientsA total of 5,957 adult patients who underwent one of the six procedures. InterventionsNone. Measurements and Main ResultsA 30-item behavior observation tool was used to note patients’ behaviors before and during a procedure. By comparing behaviors exhibited before and during the procedure as well as behaviors in those with and without procedural pain (as noted on a 0–10 numeric rating scale), we identified specific procedural pain behaviors: grimacing, rigidity, wincing, shutting of eyes, verbalization, moaning, and clenching of fists. On average, there were significantly more behaviors exhibited by patients with vs. without procedural pain (3.5 vs. 1.8 behaviors; t = 38.3, df = 5072.5; 95% confidence interval, 1.6–1.8). Patients with procedural pain were at least three times more likely to have increased behavioral responses than patients without procedural pain. A simultaneous regression model determined that 33% of the variance in amount of pain behaviors exhibited during a procedure was explained by three factors: degree of procedural pain intensity, degree of procedural distress, and undergoing the turning procedure. ConclusionsBecause of the strong relationship between procedural pain and behavioral responses, clinicians can use behavioral responses of verbal and nonverbal patients to plan for, implement, and evaluate analgesic interventions.

Comparison of Labor and Delivery Care Provided by Certified Nurse-Midwives and Physicians: A Systematic Review, 1990 to 2008

BACKGROUND Advanced practice nurses (APNs) in the United States could expand access to high-quality health care, particularly for underserved populations. Yet, there has been limited synthesis of the evidence related to their effectiveness as compared with other providers. The study reported here, part of a larger study that examined all four types of APNs, compares the labor and delivery care outcomes of certified nurse-midwives (CNMs) and physicians. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Proquest (for dissertations), were searched for the years 1990 through 2008. STUDY ELIGIBILITY CRITERIA Only those articles where processes or outcomes of care were quantitatively compared between CNMs and physicians were included. For all APNs, 27,993 citations were reviewed. For CNMs, 21 articles representing 18 unique studies reported either infant or maternal outcomes. METHODS The systematic review followed established procedures (replicable search of relevant databases, sequential review to identify eligible studies, abstraction by two reviewers, assessment of quality, and grading of evidence). RESULTS For measures that relate to the processes of care (e.g., epidural, labor induction, episiotomy), lower use was found for CNMs. For many of the infant outcomes (e.g., low Apgar, low birth weight, neonatal intensive care unit admission), there were no differences between physicians and CNMs. Perineal lacerations were lower and breastfeeding was higher among women cared for by CNMs compared with physicians. LIMITATIONS The review addressed only CNMs practicing in the United States and outcomes measured during labor and delivery. The majority of study designs were observational and the models of care ranged from independent to shared, limiting the control for bias. Moreover, all reviewers were nurses. CONCLUSION Differences in practice between CNMs and MDs seem to be well documented, particularly in the use of technology. Yet, the findings provide evidence that care by CNMs is safe and effective. CNMs should be better utilized to address the projected health care workforce shortages.

Policy Implications for Optimizing Advanced Practice Registered Nurse Use Nationally

This article examines the potential benefits of enhanced use of advanced practice registered nurses (APRNs) given health care workforce projections that predict an inadequate supply of certain types of providers. The conclusions of a systematic review comparing the effectiveness of care provided by APRNs with that of physicians alone or teams without APRNs indicate the viability of this approach. Allowing APRNs to assume roles that take full advantage of their educational preparation could mitigate the shortage of primary care physicians and improve care processes. The development of health care policy should be guided by patient-centric evidence rather than how care has been delivered in the past.

Translating research into practice. Implications of the Thunder Project II.

The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.

Management Options for Angina Refractory to Maximal Medical and Surgical Interventions

Despite the seemingly daily advances in the primary, secondary, and tertiary prevention for coronary artery disease, many patients will ultimately experience progression of their disease and experience angina refractory to further active treatment. In these patients, disabling angina occurs at rest or during simple activities of daily living. When this occurs, symptom management, a predominant focus of nursing, becomes the goal of care. Several medical and surgical alternatives are available to patients with refractory angina. Enhanced external counterpulsation and transmyocardial laser revascularization are Food and Drug Administration approved therapies that can be used to attempt to restore the balance of supply and demand. Modulation of sympathetic tone via procedures such as stellate ganglion blocks has also been employed. Other methods to control the pain are techniques that alter pain perception such as spinal opioids, transcutaneous electrical nerve stimulation, and spinal cord stimulation. Too few patients with refractory angina are referred for any of these palliative therapies. Armed with knowledge regarding these therapies, nurses will be better prepared to provide anticipatory guidance to patients and their families and to support the patients hope for relief as they cope with this devastating condition.

Group cognitive behavioral therapy to improve the quality of care to opioid‐treated patients with chronic noncancer pain: A practice improvement project

Purpose: To enhance outcomes of patients with chronic noncancer pain (CNCP) treated with opioids in a primary care setting by implementing an evidence‐based quality improvement project. Data sources: The project consisted of the implementation of a 6‐week cognitive behavioral therapy (CBT) program. Twenty‐two patients with CNCP completed the program. Impact of the project was evaluated by comparing pre‐ and postintervention participant self‐reports of mood on the Beck Depression Inventory and functional status on the Brief Pain Inventory and Short Form‐36. Patient perception of treatment benefit was also measured using the Patient Global Impression of Change. Qualitative provider perceptions of the program were also collected. Paired t‐test statistics were used to analyze the data. Conclusions: Mood (including negative attitude, performance difficulty, and physical complaints), and patient impression of treatment benefit improved significantly after CBT was added. Primary care providers reported that the CBT supported their overall management of these complex patients. Implications for practice: The addition of a CBT program improved selected outcomes in this self‐selected sample of patients with CNCP treated with opioids.Purpose To enhance outcomes of patients with chronic noncancer pain (CNCP) treated with opioids in a primary care setting by implementing an evidence-based quality improvement project. Data sources The project consisted of the implementation of a 6-week cognitive behavioral therapy (CBT) program. Twenty-two patients with CNCP completed the program. Impact of the project was evaluated by comparing pre- and postintervention participant self-reports of mood on the Beck Depression Inventory and functional status on the Brief Pain Inventory and Short Form-36. Patient perception of treatment benefit was also measured using the Patient Global Impression of Change. Qualitative provider perceptions of the program were also collected. Paired t-test statistics were used to analyze the data. Conclusions Mood (including negative attitude, performance difficulty, and physical complaints), and patient impression of treatment benefit improved significantly after CBT was added. Primary care providers reported that the CBT supported their overall management of these complex patients. Implications for practice The addition of a CBT program improved selected outcomes in this self-selected sample of patients with CNCP treated with opioids.

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