"Who's afraid?": attitudes of midwives to the use of information and communication technologies (ICTs) for delivery of pregnancy-related health information.

BACKGROUND: Usage rates for information and communication technologies (ICTs) in healthcare have been increasing in recent years, but often lag behind general usage rates for populations as a whole. Research into such differential rates of ICT use across different segments of the population has identified a number of possible causal factors that limit usage. AIM: The research investigated midwives' attitudes and experiences of ICT use to identify potential causal factors that encourage or inhibit their usage in antenatal care. METHODS: Semi-structured interviews, focus groups and short surveys were conducted with midwives who provide antenatal education at an Australian metropolitan hospital. Thematic and statistical analyses were used to interpret the data. FINDINGS: Although midwives recognised the potential benefits of using ICTs to deliver pregnancy-related health information many had reservations about their use in everyday work. These reservations centred on lack of training in use of ICTs, the perceived legal risks associated with social media, potential violations of patient privacy, misdiagnosis and misunderstandings between midwife and client. CONCLUSION: Midwives face a number of barriers to effective use of ICTs in healthcare including material access, skills access, usage access and motivational access. Motivational access appears to be a key concern due to the high perception of risk associated with social media in particular. Reducing the motivational barriers through a range of interventions with midwifery staff may assist in overcoming other barriers to ICT use in antenatal care. Further research is required to determine whether these findings are generalisable to other healthcare contexts.

Documentation of pain assessment and treatment: how are we doing?

The purpose of this analysis was to evaluate documentation of practice provided by a multidisciplinary team of nurses, physicians, and pharmacists who participated in an educational program on postoperative pain management. Chart audit of 787 patient charts at 6 sites revealed documentation of pain histories in approximately 75% of the charts, most often in the surgeon's history and physical examination. Examination of multiple assessment items indicated that the experimental group, relative to the control group, experienced an increase of more than 10% in the documentation of pain intensity, pain quality, pain duration, numeric rating scale used, pain behavior, factors that increase pain, vital signs, sedation level, cognitive status, social interaction, and mood from before the program to 6 months after the program. Across all sites, documentation of assessment, treatment, and treatment outcome data was infrequent and inconsistent. Calculation of documentation of 4 items that constituted a focused assessment of postoperative pain on the surgical floor revealed a significant program effect for assessment of pain quality and pain intensity. A postprogram survey of participants in the educational program revealed an increase in discussion of postoperative pain management with other practitioners and an increase in use of a 0 to 10 scale to rate pain. More documentation of patient pain history, clinical problems, treatment, and follow-up action is needed to improve practice and research.

Surgical patients' fear of addiction to pain medication: the effect of an educational program for clinicians.

OBJECTIVE: The appropriate and optimal use of analgesics is essential for the adequate management of postoperative pain. Concern that use of opioid analgesics contributes to the development of addiction is a barrier to effective pain relief. The purpose of this study was to determine the prevalence of fear of addiction in postoperative patients in relation to surgical outcomes and staff participation in an educational program. DESIGN: Two treatment levels (program vs. control) and three data collection periods (before program, immediately after the program, and 6 months after the program). SETTING: Six community hospitals with 100-500-bed capacities in a southeastern state. PATIENTS: Seven hundred eighty-seven patients who had undergone orthopedic or laparotomy procedures. INTERVENTIONS: Staff at three of the six hospitals received an educational program to promote implementation of Agency for Health Care Policy and Research acute pain management guidelines. OUTCOME MEASURES: Patient report of preoperative and postoperative fear of addiction, satisfaction with pain treatment, communication with clinicians, and pain intensity. RESULTS: Only 10.8% of the sample reported preoperative or postoperative fear of addiction. Staff participation in the educational program was found to decrease fear of addiction in this sample. Fear of addiction was also related to surgery type, with disc surgery patients more likely to report fear of addiction as compared with patients undergoing other types of surgery. Fear of addiction was not related to other outcomes in this sample. CONCLUSIONS: Fear of addiction is not prevalent among postoperative patients, yet clinician education can further decrease the proportion of surgical patients who fear of addiction to pain medication.

Clinical economics: calculating the cost of acute postoperative pain medication.

Few data are available that address the cost of postoperative pain management, although such knowledge would enhance our understanding of caregiver choices related to direct medical costs, such as type, frequency, and route of medication. This article describes the cost of postoperative pain medications before and after an educational program provided to nurses, pharmacists, and physicians in six community hospitals. Medication costs were calculated by averaging across all brands the average wholesale price of the most common dose administered in the sample for each medication. The median cost of postoperative pain medication across all days, all surgeries, was $9.46. Calculating the cost of acute postoperative pain medication suggested that cost over stay is highly influenced by the use of a few expensive medications. The relationship of medication cost to length of stay (LOS), function, and pain intensity is discussed.

Clinical application of the World Health Organization analgesic ladder.

One resource that has spurred the development of new standards for the assessment and treatment of pain is the World Health Organization (WHO) analgesic ladder, a three-step guide to the administration of analgesia and adjuvant medication for the treatment of pain. Correct application of the ladder is dependent upon knowledge of the interactions and side effects of the nonsteroidal anti-inflammatory drugs, opioids, and adjuvants recommended at each step of the ladder. Equianalgesic conversion can help provide correct dosing when changing opioids. Because of their altered metabolism and increased risk for epigastric complications, the elderly should receive special consideration when such medications are administered.

Organization of hospital-based acute pain management programs.

BACKGROUND: The management of acute pain is an aspect of hospital-based practice that has been neglected. Control of pain is important for ethical reasons, for compliance with new guidelines and standards, and for optimizing patient satisfaction and outcomes. METHODS: Be review the rationale for establishing priority to the control of acute pain, the importance of an institutional approach to improve pain management, and specific steps in the establishment and conduct of an acute pain program. RESULTS: Improvement in pain control depends on an institutional approach to facilitate changes in attitude and prioritization. Pain management programs should provide for patient and staff education, adequate documentation of care, institutional standards for pain control, quality assurance/continuous quality improvement (CQI) activities, and periodic review of practice and policy. CONCLUSIONS: Effective pain management can set the stage for a rehabilitational approach to postoperative care, which should lead to earlier recovery and improved outcomes.

An evaluation of facial expression displayed by patients with chest pain.

OBJECTIVE: To determine whether patterns of facial expressions of patients complaining of chest pain can aid in the diagnosis of myocardial infarctions. DESIGN: Exploratory. SETTING: Southeastern university medical center emergency department (ED). PATIENTS: Twenty-eight patients in the ED who presented with chest pain. Age range was 40 to 84 years, with a mean of 65.4 years. OUTCOME MEASURES: Common patterns of facial expressions among patients diagnosed with myocardial infarction. INTERVENTION: On admission to the ED, patients were videotaped during physical examination. Videotapes were reviewed to code the facial action units exhibited by the patients. The presence or absence of creatine kinase (CK) enzymes was determined; these results were blinded to the coders until after all facial actions were coded. RESULTS: With use of the Facial Action Coding System, 4 facial expressions were found to be associated with true myocardial infarction: lowering the brow, pressing the lips, parting the lips, and turning the head left. CONCLUSION: Additional research with a larger sample of patients presenting with chest pain is needed to validate the findings of this study. However, if these findings are supported, instruction regarding assessment of specific facial expressions in clinical settings may be warranted.

Changing acute pain management to improve patient outcomes: an educational approach.

The United States Agency for Health Care Policy and Research (AHCPR) Acute Pain Management Guidelines were written to provide a scientific basis for practice. Educational programs designed to promote use of the guidelines may change practice in community hospitals. This article describes the development and implementation of an education program for nurses, physicians, and pharmacists in six community hospitals. Program content addressing the use of continuous quality improvement (CQI) teams, detailed pain histories, application of algorithms and dose calculation is described; direct and indirect outcome measures are reviewed. Six months after the program, all three experimental sites reported use of the AHCPR Guidelines in practice. Nurses reported that assessment and documentation of patients' duration of pain were perceived to be the most important caregiver behaviors providing benefit to patients: Across all respondents' reports of regularly performed activities, the activity performed by the largest proportion was assessing and documenting pain using a 0-10 rating scale.

Quality of life and productivity in nurses reporting migraine.

A random sample survey was conducted to determine the prevalence of migraine in nurses and to study its effect on quality of life and productivity. Of the 10,000 nurses sampled, 2949 returned the questionnaire for a response rate of 29.5% The majority (99%) of respondents were employed and worked in hospitals (60%). According to the International Headache Society (IHS) criteria, 17% of the sample (n=495) were classified as having migraine. An additional 25% (n = 750) suffered severe headaches but did not meet IHS criteria for migraine, and the remaining 58% (n = 1704) were classified as not having either migraine or severe headaches. The migraineurs had significantly reduced work productivity and quality of life compared to both the severe headache and the nonmigraine nonsevere headache groups. This study will increase awareness and sensitivity of the profession to its colleagues who are migraine sufferers.

An examination of nursing attitudes and pain management practices.

PURPOSE: The purpose of this evaluation is to examine the relationship among nurses' pain management attitudes and pain management practices and to begin to explore the theoretical underpinnings that may influence this relationship. DESCRIPTION OF STUDY: A convenience sample of 29 female registered nurses working in hospice or home health settings participated in an educational program 1 day per week for 6 weeks. All participants were asked to complete the Cancer Pain Knowledge Inventory and Survey of Expectations and Pain Assessment Questionnaire 5 weeks before, immediately before, immediately after, 6 months after, and 12 months after the program. Seventeen participants completed all questionnaires at the 6-month follow-up; 16 participants completed all questionnaires at the 1-year follow-up. Personal beliefs about pain were evaluated in relation to the dimensions and treatment of pain. Intentions and expectations to perform specific activities were evaluated in relation to in-depth assessments, equianalgesic conversions, demonstration of new ideas, and communication. RESULTS: Nurses' attitudes, beliefs, intentions, and expectations about pain and pain management influenced nurses' patient care and educational activities. Nurses who believed that patients should be pain free and nurses who focused on both the dimensions and treatment of pain implemented more pain management activities. In general, nurses who had high intentions and expectations performed more pain management activities. CLINICAL IMPLICATIONS: Although nurses reported change in attitude, and high expectancy for change, feelings of increased credibility, and increased motivation as advocates for new approaches to practice, nurses sometimes found it difficult to implement new practices because of constraints in time and collaborative efforts. To implement new knowledge and achieve individualized goals for change, nurses must be allowed adequate time to analyze the relationships between their beliefs about pain and the ways that they solve patients' pain problems. In addition, more support for multidisciplinary collaboration is needed.

A call for standardizing the clinical rating of pain intensity using a 0 to 10 rating scale.

Pain is difficult to measure, regardless of etiology. Furthermore, the measurement of pain is complicated by variation in the use of visual analogue scales as well as other pain assessment measures. This brief article reviews situations contributing to confusion regarding pain intensity measures and argues for consistency in its measurements with adults not experiencing cognitive disorders in the clinical setting.

Differentiating the effects of centrally acting drugs on arousal and memory: an event-related potential study of scopolamine, lorazepam and diphenhydramine.

The degree to which apparent amnesic effects of various centrally acting drugs are secondary to their effects on arousal remains a contentious issue. The present study uses two methods to dissociate memory and arousal effects of the cholinergic antagonist, scopolamine (SP), and the GABA-A/benzodiazepine receptor agonist, lorazepam (LZ). First, it compared their effects to those of an antihistamine, diphenhydramine (DPh), to provide an active control for arousal reduction. Second, it used the same measure--event-related potentials (ERPs)--as as a parallel index of both the arousal and cognitive effects of the drugs. Fifty participants were allocated to one of five parallel treatment groups (0.6 mg SP; 2 mg LZ; 25, 50 mg DPh; placebo). ERPs were recorded during a continuous word recognition task as well as during an "oddball" task. SP, LZ and 50 mg DPh produced a similar profile of effects on certain indices of arousal and on early components of ERPs. However, SP and LZ (but not DPh) produced marked impairments of episodic memory, and this pattern was similar to that on later components of ERPs. Memory impairments by SP and LZ were highly significant on retention in the continuous recognition task and further, no drug effects were found on response bias. Subsequent free recall was similarly very impaired by SP and LOR but not by the antihistamine. We conclude that benzodiazepines and anticholinergic drugs both reduce arousal and induce amnesia, but these effects are not interdependent. Our findings provide strong evidence for a dissociation between the effects on episodic memory and on arousal of these centrally acting compounds.

Pain management issues: the cost of medications in rural settings.

Cost of analgesic and adjuvant medications used by rural patients with cancer cared for by 29 nurses participating in an in-depth education program were evaluated before and after the program. Across all time periods, the median daily cost was $5.16 across all medications. Average daily cost and maximum and median cost of all medications were $5.36, $74.38 and $3.58, respectively. Average daily cost did not change over time. Average pain intensity did not change over time and was not related to prescribing patterns or daily costs. While professional education was demonstrated to produce change in prescribing practices, further research is needed to evaluate patterns of medication administration and effectiveness patterns using reliable outcome measures other than self report of pain intensity.

Changing the relationship among nurses' knowledge, self-reported behavior, and documented behavior in pain management: does education make a difference?

An educational program designed to change knowledge in order to change pain management practices and patient outcomes was offered to nurses who provide day-to-day care to patients with cancer in communities in a predominantly rural state. A quasi-experimental time-series design was used to measure the effectiveness of the program in changing nurse knowledge, attitude and behavior, and to evaluate the relationships between the outcomes. Data were collected from nurses (N = 29) and patient charts before (N = 209) and after (N = 163) the program. Nurses' knowledge increased, but the change was not statistically significant; the mean percent of correct answers on the three subtests were different and differences persisted throughout the study. Nurses believed that patients should be "pain free." Documentation of behaviors, for example, practice activities, occurred infrequently and showed little change until 6 months after the program. Increase in documentation of pain-intensity ratings, pain location, number of sites of pain, presence of confusion, anxious or depressed mood, sleep, nausea and vomiting, constipation, and general activity were noted. Documentation of the use of a propoxyphene-containing analgesic decreased; increase in the use of hydromorphone methadone and transdermal fentanyl was noted. Analysis of the relationships between correct responses to nurse knowledge questions and documentation of behavior provided interesting, statistically insignificant results that need to be reexamined in future research. Future programs should emphasize analgesic dosing and calculation of equianalgesic doses. Current practices in chart documentation may provide incomplete information regarding change in practice behaviors; more detailed documentation of pain management practices is needed. Nurses who participated in the program anecdotally reported feelings of increased credibility and effectiveness. Although change in behavior is slow to occur, education does make a difference.

The knowledge and attitudes of experience oncology nurses regarding the management of cancer-related pain.

PURPOSE/OBJECTIVES: To describe the knowledge and attitudes of North Carolina nurses toward the management of cancer-related pain. The analysis focused on knowledge, attitude, and perception of barriers to pain management. DESIGN: Exploratory, descriptive. SETTING: North Carolina. SAMPLE: A survey of 1,400 RNs were stratified by educational background and Area Health Education Center regions of the state; the response rate was 24%. METHODS: An adapted version of The Wisconsin Pain Initiative Survey mailed to participants. MAIN RESEARCH VARIABLES: Nurses' knowledge, attitudes, and perception of perceived barriers to managing cancer-related pain. FINDINGS: Nurses who have cared for patients with cancer are more knowledgeable and have more liberal attitudes toward pain management from nurses who have not cared for patients with cancer. North Carolina nurses report knowledge and perception of barriers to pain management similar to those of Wisconsin nurses. CONCLUSIONS: The experience of caring for patients who have cancer and pain influences nurses to report more liberal attitudes toward pain management. IMPLICATIONS FOR NURSING PRACTICE: Although nurses report increased knowledge of pain management in general, deficits continue to exist. Further research is needed to more fully understand the effect of educational and experience on practice.