Nurses' clinical decision-making regarding the management of pain.

Effective pain management remains an elusive goal within the profession of nursing. While considerable improvement has occurred, patients continue to experience inappropriate levels of pain. To date, research has focused on objective factors that influence pain management. Few studies have examined attitudinal factors that may influence nurses' decision-making. This quasi-experiment was based on preliminary data showing that nurses' preconceived notions regarding certain patient groups influenced their management of pain. An intervention was tested for its' effect on nurses' preconceived notions regarding specific patient groups. A significant difference in a positive direction was found. Nurses were more willing to spend time and energy managing pain across all patient groups following the intervention.

Nurses' clinical decision-making regarding the management of pain.

Effective pain management remains an elusive goal within the profession of nursing. While considerable improvement has occurred, patients continue to experience inappropriate levels of pain. To date, research has focused on objective factors that influence pain management. Few studies have examined attitudinal factors that may influence nurses' decision-making. This quasi-experiment was based on preliminary data showing that nurses' preconceived notions regarding certain patient groups influenced their management of pain. An intervention was tested for its' effect on nurses' preconceived notions regarding specific patient groups. A significant difference in a positive direction was found. Nurses were more willing to spend time and energy managing pain across all patient groups following the intervention.

Quality of life one year following bone marrow transplantation: psychometric evaluation of the quality of life in bone marrow transplant survivors tool.

PURPOSE/OBJECTIVES: To examine a comprehensive view of quality of life (QOL) post-bone marrow transplant (post-BMT) and to evaluate the psychometric properties of an instrument designed to measure QOL in this population. DESIGN: Cross-sectional, descriptive, mailed survey. SETTING: A large, major BMT referral center for central, eastern, and southern Kentucky. SAMPLE: 41 BMT survivors with an age range of 18-71 years who were an average of 30 months post-BMT. METHODS: Seven mailed questionnaires, including an investigator-developed demographic questionnaire and the Quality of Life in Bone Marrow Transplant Survivors Tool (QOL-BMT-ST). MAIN RESEARCH VARIABLES: QOL, BMT treatment, sexual activities, employment, and uncertainty. FINDINGS: Global QOL was good (x = 6.4 on a 0-10 scale). Subjects experienced several long-term areas of concern: physical strength, sexual activities, fear of cancer recurrence, fear of developing a secondary cancer, unemployment, family distress, and uncertainty toward the future. Psychometric testing of the QOL-BMT-ST revealed adequate to excellent reliability and validity. CONCLUSIONS: Most BMT survivors reported few long-term disruptions and above average QOL. The QOL-BMT-ST has a promising utility in clinical trials. IMPLICATIONS FOR NURSING PRACTICE: Individually structured pre- and post-BMT assessment of physical, psychosocial, and spiritual functioning is significant in identifying vulnerable patients and treating them accordingly.

Hope among patients with cancer hospitalized for bone marrow transplantation: a phenomenologic study.

This article describes a phenomenologic study designed to further an understanding concerning the concept of hope in a purposive sample of nine patients with cancer hospitalized for bone marrow transplantation. The strategies these patients use to sustain and foster hope are examined. Data collection consisted of a one-time semistructured interview using open-ended questions. A phenomenologic-hermeneutic approach to data analysis was used to identify major themes. The findings showed that participants used six strategies to foster their hope during preparation for BMT: feeling connected with God, affirming relationships, staying positive, anticipating survival, living in the present, and fostering ongoing accomplishment. Religious practices and family members were the most frequently identified sources of hope. The findings of this study provide a base for the improvement of nursing practice.

Reliability and validity of dyspnea sensory quality descriptors in heart failure patients treated in an emergency department.

BACKGROUND: Sensory qualities of dyspnea are known to differ by diagnosis. Less is known about whether sensory qualities vary with changes in health status in a given diagnosis. PURPOSE: The goal of this study was to evaluate the reliability, validity, and factor structure of dyspnea sensory quality descriptors in patients with heart failure (HF) treated in an emergency department (ED) and to investigate whether change in sensory quality influences HF patients to seek care in an ED. METHODS: HF patients (N = 57) treated in an ED were interviewed retrospectively. Open-ended characterizations of dyspnea at the time of the ED visit were analyzed qualitatively. A subset of subjects (n = 34) rated the intensity of 13 dyspnea descriptors (0 = not endorsed; 1= very mild; 10 = very severe) as the descriptors applied to the time at which they decided to come to the ED (Decision) and a week before the visit (Week Before). Descriptor ratings were analyzed for congruence with open-ended characterizations, endorsement frequency, internal consistency, factor structure, and correlations (by descriptor and within subjects) between the 2 time frames. RESULTS: Open-ended characterizations of dyspnea provided support for the content validity of most descriptors. Internal consistency of numerical ratings was high (alpha >0.90) in both recalled time frames. Factor analysis of descriptor ratings was unifactorial for Week Before, but suggested multiple sensory quality factors at Decision (suffocation, air hunger, effort/impedance, and, possibly, rate). Within-subject concordance and descriptor-by-descriptor correlations across time frames were mostly low, suggesting change in sensory quality from Week Before to Decision. Correlations in descriptor ratings were lowest among subjects who reported duration of dyspnea (as severe as at Decision) of 3 days or less. Subjects who recalled a duration of 6 days or more gave highly concordant ratings across both time frames. CONCLUSION: Sensory quality descriptor-based ratings were internally consistent and content valid. Low correlations in ratings of sensory quality for most subjects across recalled time frames suggest that change in sensory quality may be an aspect of perceived increases in dyspnea severity before an ED visit. Results require replication and extension with larger samples and other diagnoses.

Dyspnea duration, distress, and intensity in emergency department visits for heart failure.

BACKGROUND: Dyspnea is the most common symptom among patients with heart failure (HF) who present to the emergency department (ED), but it is not clear which dimensions of the symptom prompt ED visits, or whether dyspnea characteristics are related to visit disposition. PURPOSE: The goal of this study was to explore the influence of dyspnea duration, distress, and intensity on decisions of patients with HF to come to an ED and the disposition of visits. METHODS: The study population consisted of patients treated for HF in an urban university hospital ED (N = 57) who were interviewed retrospectively. Open-ended questions pertained to symptoms in general and dyspnea at the time of the visit. Subjects rated recalled dyspnea distress (0 = not at all bothered by breathing; 4 = bothered very much by breathing) for when they decided to come to the ED (Decision) and a week before the visit (Week Before), as well as duration--the number of days before the visit that dyspnea was recalled as having been as severe as at Decision. After the interviews, a subsample (n = 34) rated the intensity of a set of dyspnea sensory quality descriptors for Decision and Week Before (0 = not endorsed; 1 = very mild; 10 = very severe). Charts were also reviewed. RESULTS: Seventy percent recalled dyspnea as the most distressing symptom at Decision, or the primary reason for the visit; 88% were admitted. Dyspnea duration was unrelated to admission. Duration was 3 days or less for 65% of the sample, but 6 days or more for 35%. There was no duration-related difference in dyspnea distress or intensity at Decision, but subjects with a duration < or =3 days reported lower levels of both dimensions for Week Before with significant increases from Week Before to Decision. Those with longer episodes reported high levels of distress and intensity in both time frames with no significant change in either dimension. CONCLUSION: Subjects reported high levels of distress and intensity at Decision, regardless of dyspnea duration. Differences in recalled duration were associated with 2 distinct patterns in distress and intensity ratings but were not associated with admission. Dyspnea duration does not appear to be a valid criterion for judging condition severity in HF-related visits to the ED.

Self-transformation as a factor in the self-esteem and well-being of breast cancer survivors.

Diagnosis with a life-threatening illness can lead to many changes in one's self. These changes, called self-transformation, are not well understood. The present study used triangulation of methods and measures to (i) describe individual differences in self-transformation among breast cancer survivors, (ii) examine factors associated with self-transformation in breast cancer survivors, and (iii) examine the relationships between self-transformation and self-esteem and well-being in breast cancer survivors and age-matched comparison women without cancer. Cancer survivors (n = 60) participated in structured interviews and both survivors and comparison women (n = 60) completed a set of questionnaires. Narrative analysis revealed three categories of transformation among breast cancer survivors: positive transformation, minimal transformation and feeling stuck. These groups differed by age, marital status and income, but not by disease or treatment variables. Breast cancer survivors in the positive transformation group had significantly higher self-esteem and well-being in comparison with (i) survivors grouped as feeling stuck and (ii) age-matched counterparts without cancer. Cancer survivors who reported feeling stuck had significantly lower self-esteem and well-being than the other groups of survivors and lower well-being in comparison with healthy women of the same age. Findings provide support for the concept of self-transformation and a new understanding of disease, demographic and treatment factors associated with the concept. Findings also suggest that self-transformation may be a factor in the self-esteem and well-being of breast cancer survivors.

Barriers to change: a pain management project.

Although considerable effort has been directed toward improving the management of acute pain, ineffective pain management practices remain in many institutions across this country. While educational efforts have increased health care providers' knowledge regarding the management of pain, a concomitant change in practice has not occurred. This project was designed to examine barriers to the effective management of pain encountered in acute care settings. A repeated case study of attempts to change was conducted in six institutions located in the southeastern United States. Results identified seven major barriers to pain management: lack of knowledge, non-facilitative attitudes, inconsistent leadership, poor working relationships, cultural and religious biases, physicians' fears of legal repercussions and a lack of resources.

Elderly people's knowledge of and attitudes to pain management.

Pain is a frequent complaint of elderly people in hospitals and in the community, yet it is often not managed effectively. Barriers to effective management have included fear of narcotic addiction, inadequate assessment of pain, and attitudes of health professionals. Attempts have been made to improve the knowledge and attitudes of health-care professionals. This study examined the attitudes and knowledge of acute pain and pain management among well elderly people in rural and urban settings in the southeastern USA in order to identify possible barriers to effective pain management. Questionnaires on knowledge and attitudes towards pain and pain management were given to 62 rural and 63 urban well elderly people aged 65 years and older. Findings demonstrate a lack of knowledge as well as the presence of non-facilitative attitudes about pain and pain management.

Elderly hospice patients' perspective on pain management.

The literature reports that 70% of cancer patients with advanced disease experience pain. Even with increased emphasis on research and education, problems with effective pain management are still evident. Hospice patients' knowledge and attitudes about pain may contribute to this complex problem. To gain an understanding of hospice patients' perspective on the management of pain, 57 hospice patients were asked to describe their knowledge of pain management and their attitudes toward controlling pain. Results showed non-facilitative attitudes and gaps in knowledge that may contribute to ineffective pain management among hospice patients.

Comparison of patients' ratings and examination of nurses' responses to pain intensity rating scales.

Patients' ratings of pain intensity are an important component of a comprehensive assessment of pain. Although a 10-cm visual analog scale (VAS) is recommended for quantifying subjective pain intensity, a 0 to 5 point numerical rating scale (NRS) is commonly used. These two scales are often viewed as interchangeable or mathematically equivalent, with a 2 on a 0 to 5 point scale seen as equal to a 4 on a 10-cm VAS. The purposes of this study were to compare patients' pain ratings on each scale and to examine nurses' responses to mathematically equivalent pain ratings. Results indicated that patients do not rate their pain in a mathematically equivalent way. VAS ratings were lower than NRS ratings, and more than three quarters of patients provided ratings that were not mathematically equivalent. In addition, nurses provided with fictitious patient scenarios did not provide the same pain medication for equivalent ratings and chose smaller analgesic doses in comparison with experts.

Evaluation of self-esteem of women with cancer receiving chemotherapy.

PURPOSE/OBJECTIVE: To examine the concept of self-esteem as it relates to female patients with cancer before diagnosis and while experiencing chemotherapy-induced alopecia. DESIGN: Descriptive-analytic. SETTING: Oncology unit of a community hospital and an outpatient oncology clinic in a southeastern city of the United States. SAMPLE: 30 women receiving chemotherapy and who have experienced some degree of alopecia. METHODS: Subjects answered demographic questions and were evaluated for degree of hair loss. Subjects completed the Cantril Self-Anchoring Scale (CSA) on the day of the interview and retrospectively prior to their diagnosis. In addition they completed the Rosenberg Self-Esteem Scale (RSE). MAIN RESEARCH VARIABLES: Self-esteem, change over time, degree of alopecia, length of time since diagnosis. FINDINGS: A significant decrease in self-esteem from before cancer diagnosis levels to time of experiencing chemotherapy-induced alopecia; modest correlation between the CSA and the RSE. Four categories of characteristics (physical, spiritual, psychological, social) influencing self-esteem emerged from analysis of the CSA responses. CONCLUSIONS: Self-esteem was not stable in this group of women. Postdiagnosis levels were lower than those before the diagnosis; however, lower levels did not necessarily translate into low self-esteem. The CSA may be a more comprehensive and sensitive measure of self-esteem in patients with cancer because it is based on individual definitions of high and low self-esteem. IMPLICATIONS FOR NURSING PRACTICE: Understanding what specifically may lower an individual's self-esteem can be useful in identifying patient-specific interventions. Future research must explore ways to determine self-esteem consistently and easily.

The effect of a mock trial on nursing students' ability to make clinically sound legal judgments.

In an attempt to enhance nursing students' abilities to make legally sound clinical judgments, a mock trial experience was developed and evaluated. Using a quasi-experimental design, students' learning was assessed using scenarios derived from actual cases involving nurses. Satisfaction with a traditional learning approach was compared to learning through attendance at a mock trial. A significant difference was found in learning before and after the trial (t = 2.26, P < 0.05), and students preferred the mock trial experience to traditional classroom presentations.

Nursing knowledge: acute postoperative pain management in the elderly.

1. The inadequate management of acute postoperative pain among adults is well documented. Studies have shown that 75% or more of hospitalized adult patients following surgery suffer moderate or intense pain even with the use of analgesics. Also, physicians under-prescribe narcotic analgesics and nurses administer less than the patient could receive. 2. Nurses' ineffective approaches to the management of pain have been attributed to inappropriate fears of addiction and respiratory depression, rigid attitudes regarding what constitutes adequate pain relief, and misunderstandings about the physiologic and psychologic components of pain. 3. The results of this study support McCaffery's (1989) finding that nurses do not understand the effective use of narcotics in relation to pain management.

Fiscal and clinical evaluation of patient care. A case management model for the future.

The cost of healthcare within the United States continues to climb as does the number of individuals who have limited access to the healthcare system. By the year 2000, healthcare costs are predicted to comprise 15% of the gross national product. Over the last 10 years, the number of Americans who do not have financial protection from medical costs has risen dramatically. Presently, an estimated 35 million individuals have no insurance or other coverage.

Nursing the system. Key users are sometimes "out of the loop".

Among those with a particular interest in hospital information systems are those who teach nursing students at the college level. To get their views, Southern Hospitals interviewed four Nurse Scholars involved with nursing and research projects for universities across the South. In 1989, Atlanta-based vendors HealthQuest and HBO & Company of Georgia established the Nurse Scholars Program in an effort to help academia stay abreast of technology. It provides nurse educators with comprehensive instruction in emerging technologies and uses of automated patient care systems. The scholars are encouraged to share their new knowledge with students, faculty, practitioners and administrators so that future nurse executives will better understand and communicate what they need and want from information systems.

The role of prior pain experience and expectations on postoperative pain.

The present study was designed to examine previous pain experiences as they relate to expectations of postoperative pain. In the study, 101 patients aged 55-87 (47 men, 54 women) participated in a structured interview that examined 13 factors thought to be associated with presurgical expectations of postsurgical pain. These factors relating to prior pain experience were identified from the literature as well as the experience of clinicians in the areas of anesthesiology, nursing and psychology. The two variables that correlated significantly (multiple r = 0.51) with pain expected postoperatively were: a single item from the general attitude questionnaire about pain (pain is to be expected after surgery even with medicine) and the total of the global ratings of past pain experience. A follow-up study will examine these variables in relation to actual pain experience.

Patients' knowledge of their caregivers' names. A teaching-hospital study.

In busy hospitals--particularly teaching hospitals--ensuring that patients know the names of those attending them is a task often given low priority. Yet such knowledge is a crucial element in establishing the high-priority patient-provider relationship, and certainly one within hospitals' control. In a university teaching hospital, the authors tested patients' knowledge of names before and after the use of an information sheet listing their particular caregivers.

The dying patient: a comparative study of nurse caregiver characteristics.

The nurse's interaction with the dying patient is thought to be influenced by death anxiety, attitudes toward death, and perceptions of control. Differences relative to these three variables between nurses who work on a continuous basis with the dying and those who rarely encounter a dying patient were examined. Using 3 paper and pencil questionnaires, data were collected from 105 nurses (32 palliative care nurses, 44 psychiatric nurses, 29 orthopedic nurses). Significant differences were found between the palliative care nurses and nonpalliative care nurses on attitudes toward death and on 3 of the 4 subscales that assessed death anxiety. Suggestions for future research include a systematic examination of the relationship of attitudes and feelings about death to patient care.