Ethical considerations for nurse practitioners conducting research in populations with opioid use disorder.

ABSTRACT: People with opioid use disorder (OUD) are a vulnerable population who face unique risks of harm when participating in research. Despite a long-standing dialogue, written research codes of ethics, and institutional review board oversight for the conduct of ethical research in vulnerable populations, protections for study populations with OUD is rarely mentioned. Nurse practitioners who conduct research using participants with OUD, especially when recruiting their own patients (i.e., dual role), must be aware of the unique ethical considerations necessary to protect their patients and participants from increased risks. This article explores vulnerabilities and influences that can affect participant recruitment and consent, imbalances in the distribution of risk and benefits to participants participating in research, and the concerns of coercions, undue influence, and unjustifiable pressure contributing to vulnerabilities. Strategies to reduce the risks of influences that are of concern in the vulnerable population of research participants with opioid disorder are suggested. The goal of this article was to raise awareness of the unique potential risks of harm when using people with OUD as research participants and to explore strategies to minimize potential risks of various levels of influence in this vulnerable population.

Attending to the Moral Meaning of Pain.

In addition to a physical and emotional experience, pain is also a morally infused experience with deep, often subconscious, meaning for many sufferers. Whether justified or not, for many people, pain may represent loss, judgement, unworthiness, abandonment, punishment, and even existential suffering and thoughts of death. The moral meaning of pain is what influences the associated experiences of stigma, loneliness, and guilt that contribute to suffering. It is why nurses and other healthcare practitioners have long adhered to a moral obligation to treat those with pain, implying a duty to attempt to make right the wrong of undeserved suffering. Yet the moral meaning of pain is rarely discussed and is often overlooked when establishing a relationship with and a treatment plan for a person with pain. It is the unattended moral meaning of pain that may contribute to unnecessary suffering, futile treatment, and even moral dilemmas in establishing care. In this paper, I explore the definition of morality itself, the moral meaning of pain, and its implications for care. I discuss how moral pluralism in contemporary society contributes to various moral perceptions that influence a person's pain experience and how their pain is treated. Finally, I make the case that using a narrative approach to intentionally look for moral meaning in an individual's pain story may reveal opportunities for more effective pain management options.

Postsurgical Follow-Up Phone Calls: Worth the Investment?

PURPOSE: To analyze differences in health confidence levels regarding discharge instructions between two groups of same-day surgery patients. DESIGN: Comparative and descriptive design. METHODS: Phone surveys to two groups: those who received follow-up phone calls from a registered nurse (RN) and those who received standard care instructions at discharge only. FINDINGS: In 74 same-day surgery patients (n = 37 per group), all participants expressed high health confidence in implementing discharge instructions. Results revealed no higher health confidence levels in patients who received RN follow-up phone calls, no difference between groups attending postoperative appointments, and no relationships between subject demographics, health confidence level, and postoperative complications between groups. CONCLUSIONS: The use of specialized RNs to conduct postoperative phone calls may not be cost effective. When RNs provide excellent instructions to patients in person, it may lead to sufficient patient health confidence. Personal and nurse-provided education should be considered a standard, and the outcomes of costly follow-up phone calls should be examined.

Procedural Pain in the Adult Neurological Intensive Care Unit: A Retrospective Study Examining Arterial Line Insertion.

BACKGROUND: This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures. AIMS: The purpose of this study was to examine healthcare providers' pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions. DESIGN: A retrospective records review design was used. METHODS: 120 electronic patient medical records were reviewed during a one-year period. RESULTS: 100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007). CONCLUSIONS: Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia. CLINICAL IMPLICATIONS: The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

Developing and Evaluating Multiple-Choice Tests for Trustworthiness.

This article provides the nursing professional development practitioner an overview of effective development and evaluation of a commonly used measure of knowledge: the multiple-choice test. Basic principles of test development and assessment are important for evaluating learning outcomes. When the steps needed to determine the fairness, validity, and reliability of multiple-choice tests are followed, the resulting knowledge tests will lead to more trustworthy results for the evaluation of nursing professional development activities.

Effectiveness of a patient education plan on knowledge of post-op venous thromboembolism survival skills.

AIMS AND OBJECTIVES: To investigate the effectiveness of a multimethod venous thromboembolism prevention patient education plan on participants' knowledge retention. BACKGROUND: A potential complication of surgery requiring general anaesthesia, worldwide, is the development of life-threatening venous thromboembolism. Patients need education on preventing, recognising and immediately responding to a suspected thromboembolism. Written instructional materials given to patients at discharge may be inadequate. DESIGN: A randomised controlled trial. METHODS: Setting was multiple general surgery units at a large Midwestern United States academic medical centre. Sample included patients recovering from surgery with general anaesthesia: (N = 66), 68% female, 34 = experimental, 32 = usual care. Prior to discharge, participants in the experimental group were given a multimethod venous thromboembolism prevention education plan including a video, pamphlet and verbal instruction; control group received usual instructional pamphlet. Both groups received a knowledge test immediately before instruction. Two weeks following discharge, a phone call was made to participants to complete the postinstruction test. The relevant EQUATOR guideline, CONSORT checklist, was used for reporting this study. CONCLUSIONS: There were no statistically significant differences in age, gender, race, length of stay, surgery and history of venous thromboembolism among participants and group or test score results. No statistically significant difference in postinstruction score was found between groups. However, there was a trend in greater perception of importance in all groups and higher knowledge scores in the experimental group, with the percentage of participants in the experimental group answering all questions correctly rising from 38.2% correct to 73.5% correct. RELEVANCE TO CLINICAL PRACTICE: Teaching patients the importance of knowing venous thromboembolism signs and preventive/survival skills is potentially life-saving and nurses must know the importance of using the most effective methods for the learning needs of their patients. Further research including different education methods and testing is suggested.

A New Clinical Pain Knowledge Test for Nurses: Development and Psychometric Evaluation.

All nurses care for patients with pain, and pain management knowledge and attitude surveys for nurses have been around since 1987. However, no validated knowledge test exists to measure postlicensure clinicians' knowledge of the core competencies of pain management in current complex patient populations. To develop and test the psychometric properties of an instrument designed to measure pain management knowledge of postlicensure nurses. Psychometric instrument validation. Four large Midwestern U.S. hospitals. Registered nurses employed full time and part time August 2015 to April 2016, aged M = 43.25 years; time as RN, M = 16.13 years. Prospective survey design using e-mail to invite nurses to take an electronic multiple choice pain knowledge test. Content validity of initial 36-item test "very good" (95.1% agreement). Completed tests that met analysis criteria, N = 747. Mean initial test score, 69.4% correct (range 27.8-97.2). After revision/removal of 13 unacceptable questions, mean test score was 50.4% correct (range 8.7-82.6). Initial test item percent difficulty range was 15.2%-98.1%; discrimination values range, 0.03-0.50; final test item percent difficulty range, 17.6%-91.1%, discrimination values range, -0.04 to 1.04. Split-half reliability final test was 0.66. A high decision consistency reliability was identified, with test cut-score of 75%. The final 23-item Clinical Pain Knowledge Test has acceptable discrimination, difficulty, decision consistency, reliability, and validity in the general clinical inpatient nurse population. This instrument will be useful in assessing pain management knowledge of clinical nurses to determine gaps in education, evaluate knowledge after pain management education, and measure research outcomes.

Hospital-acquired pressure injuries: The significance of the advanced practice registered nurse's role in a community hospital.

BACKGROUND AND PURPOSE: Hospital-acquired pressure injuries (HAPIs) continue to be a persistent problem in the acute care arena. The purpose of this retrospective quality improvement study was to examine if the introduction of nurse practitioners (NPs), as wound care consultants (WCCs), without other interventions, impacted the HAPI rates in a community hospital. METHODS: A retrospective, comparison design was used; 48 months of HAPI data (May 2010-2014) reported on the monthly National Database for Nursing Quality Indicators (NDNQI) survey was abstracted from hospital records. Data included the assessment of 10,752 patients and were divided into two groups for comparison: 24 months before and 24 months after NP hiring. CONCLUSIONS: There was a strong, inverse correlation between the presence of NPs and number of patients with HAPIs (r = -0.73, p < .01), indicating that HAPI rates were significantly lower after NPs took on the role of WCCs. The odds of a HAPI occurring following introduction of the NP WCCs were 20% of the odds in the previous years. IMPLICATIONS FOR PRACTICE: Study findings suggest that NPs assuming a leadership role as WCCs may be instrumental in decreasing HAPI rates.

The Pain Experience of Patients Hospitalized With Inflammatory Bowel Disease: A Phenomenological Study.

Pain is personal, subjective, and best treated when the patient's experience is fully understood. Hospitalization contributes to the physical and psychological complications of acute and chronic pain experienced by patients with inflammatory bowel disease (IBD). The purpose of this qualitative phenomenological study was to develop an understanding of the unique experience of pain in hospitalized patients with an admitting diagnosis of IBD and related care or surgery. Following institutional review board approval, purposeful sampling was used to recruit 16 patients (11 female, 5 male, mean age 41.8 years) from two 36-bed colorectal units of a large academic medical center in the Midwest. Individual, audio-recorded interviews were conducted by a researcher at each participant's bedside. Recordings and transcripts were systematically reviewed by the research team using Van Manen's approach to qualitative analysis. Subsequently, 5 major themes were identified among the data: feeling discredited and misunderstood, desire to dispel the stigma, frustration with constant pain, need for caregiver knowledge and understanding, and nurse as connector between patient and physician. Hospitalized patients with IBD have common issues with pain care. Nurses caring for them can provide better pain management when they understand these issues/themes. Further research into the themes discovered here is recommended.

Nurses' Written Responses to Pain Management Values Education: A Content Analysis.

Providing optimal pain care for patients is essential to the work of nursing and a measure of patient satisfaction prompting some hospitals to offer pain management classes for clinicians. Although nurses generally do well on knowledge tests after attending a pain class, actual improvement in pain care for patients may not occur. The personal values of the clinician may be a key driver of pain-management decision making. Therefore, a segment on how clinicians' personal values influence pain care decisions was added to a large Midwestern hospital's pain management class. The purpose of this study was to examine the written answers to questions posed to nurses regarding any practice changes they have made to caring for patients with pain after participating in a class that included a segment on personal values. This study used a qualitative content analysis method. A large Midwestern healthcare system. Twenty clinical registered nurses who attended a pain class in April 2014. Participants provided written answers to two open-ended interview questions. Data were analyzed using conventional content analysis of the text. Four themes were identified among participants' answers: understanding the patient, importance of pain education, nurse's self-awareness, and interpretation of personal values. Nurses who learned how their personal values affect their pain management decisions described new insights into their own approach to pain management. More research is needed to fully understand the impact of knowing one's own values and determining which clinician values are associated with optimal pain care.

Investigating the concept of rest for research and practice.

AIMS: To report an analysis of the concept of rest; to determine the conceptual maturity (consistent use and meaning) of rest in the current scientific literature and to present a theoretical definition of rest, providing a strong basis for research and practice. BACKGROUND: Rest is a physical, mental and spiritual human need, common to all humanity, and is frequently prescribed around the world as a treatment for many maladies. Yet the concept of rest remains subjective, is vaguely defined and is often confused with sleep, limiting its utility for research and practice. Without a clear definition and understanding of rest and its parameters, its restorative benefits may not be realized and the advice to rest, based on little evidence, has limited usefulness and unknown risks. DESIGN: Concept analysis. DATA SOURCES: The scientific, peer-reviewed literature of five healthcare disciplines whose practitioners recommend rest for their patients were queried: nursing, medicine, physical therapy, psychology and occupational therapy. Twenty-seven articles published between 1970-2015 were included. METHODS: The Morse criterion-based method of concept investigation was used. RESULTS: The epistemological, pragmatic, linguistic and logical descriptions of rest found in the literature revealed that the concept of rest remains immature, poorly defined, rarely operationalized and inconsistently used. Nevertheless, a cross-contextual definition of rest based on antecedents, attributes, boundaries and outcomes is emerging. CONCLUSION: Based on the findings, a rudimentary understanding of rest emerged. Further research is necessary to develop an operational, evidence-based, definition of rest so it can be effectively studied and prescribed.

Reviewing the Literature: Essential First Step in Research, Quality Improvement, and Implementation of Evidence-Based Practice.

This article provides nursing professional development specialists with a concise resource on conducting literature reviews: the essential first step of a research project, quality improvement initiative, or the implementation of evidence-based practice. The literature review cannot be overlooked because it sets the foundation for an investigative project's ethical implementation and subsequent success. Conducting a literature review may seem overwhelming for the novice, but these fears can be overcome with knowledge and practical assistance.

Nurses Managing Patients' Pain May Experience Moral Distress.

Bedside nurses care for patients with pain every day but the task is often challenging. A previous qualitative study that investigated nurses' experiences as they treated patients with pain suggested that nurses may suffer from moral distress if they are unsuccessful in providing adequate pain relief. As 20 of the original 48 nurses interviewed described frustration and distress when constrained from doing the right thing to provide pain relief for their patients, the purpose of this secondary qualitative analysis was to answer new research questions on nurse moral distress related to managing pain. Findings indicated that difficulties in nurse/physician communication and lack of pain education were contributors to nurses' frustrations and provided barriers to optimal pain management. Many participants indicated a need for interprofessional pain management education. Further investigation is needed to clarify the impact of moral distress on nurses managing hospitalized patients' pain.

Hospital lighting and its association with sleep, mood and pain in medical inpatients.

AIMS: To describe light exposure, sleep-wake patterns, mood, pain and their relationships in adult medical inpatients. BACKGROUND: The hospital environment may contribute to patient discomfort by providing a lighting structure that interferes with circadian rhythmicity, sleep, mood and pain. DESIGN: A descriptive correlational design was used in this preliminary study. METHODS: Between May 2011-April 2012, data were collected from a convenience sample of 23 women and 17 men admitted to a large academically affiliated hospital in the United States. Over 72 hours, light exposure and sleep-wake patterns were continuously measured with wrist actigraph/light meters for each participant. Mood was measured daily using the Profile Of Mood States Brief™ Form. Subjective pain scores were abstracted from medical records. RESULTS: Light exposure levels were low: mean daytime light intensity was 104·80 lux. Sleep time was fragmented and low: mean 236·35 minutes of sleep/night. Intra-daily stability scores indicated little sleep-wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. CONCLUSION: Medical inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain, suggesting the need for further investigation to determine if manipulating light exposure for medical inpatients would be beneficial in affecting sleep-wake disturbances, mood and pain.

Chronic pain in older adults.

Despite the sophisticated pharmaceutical agents and technologies available today, many people, including older adults, continue to experience chronic pain. Inadequately treated chronic pain can seriously affect one's quality of life. Health care providers are only beginning to understand the structural and functional changes that occur in older adults with chronic pain, but recent research suggests that nurses and other health professionals need to become aware of the unique needs of older adults who live with chronic pain. When health professionals lack specific knowledge of pain management in older adults, patients may suffer needlessly.