Pain1
GNUR 5410 – Theory Critique: Pain
Linda M. Edenfield
University of Virginia School of Nursing
On my honor, I have neither given or received assistance on this paper
Abstract
Pain is a complex. Although unique to each patient, pain is a common condition that nurses in the acute-care setting must assess, treat and evaluate. The etiology, sources and type of pain patients experience in the acute care setting varies dramatically, challenging nurses to employ both pharmacologic and nonpharmacologic therapies to effectively manage acute pain, while minimizing negative side effects often seen with pharmacologic pain management. This paper examines the middle-range theory of management of acute pain and side effects through developmental theories of pain control, the middle-range theory and implications for nursing research and nursing practice.
GNUR 5410 – Theory Critique: Pain
Introduction
Pain is defined as “a complex, multidimensional phenomenon that originates from sensory stimuli, which has obvious motivation-affective properties, demands attention, disrupts thought and behavior and results in activity aimed to stop the pain.” (Blanchard, 2010). Beyond an unpleasant sensory stimuli, “pain can also delay healing and recovery” (Good, 1998). Poorly managed pain is a patient dissatisfier, and has been shown to be contributory in a number of undesirable outcomes for hospitalized patients including infection, reduced mobility, urinary retention, and stimulation of unhealthy stress responses, among others (Good 1998).
With institutions focused on patient satisfaction, reductions in hospital length of stay as well as reductions in post-operative complications, it is critical for nurses to appropriately assess and treat pain for hospitalized patients. Use of appropriate nursing assessment skills is crucial to assess pain in patients and determine if interventions designed to reduce pain are effective (Watson-Miller, 2005). Watson-Miller also proposes that the use of theory, such asmiddle –range theory, can help to clarify and guide nursing practice.
The middle-range theory of pain control is based on the acute pain management guidelines along with theoretical definitions, nursing interventions and measures to accurately assess and treat pain for hospitalized patients. (Good, 1998). This paper explores and evaluates a middle-range theory with a physiological focus on pain and the balance between analgesia and side effects. This paper also considers the use of adjuvant and complementary therapies to manage acute pain and discusses limitations of this theory in the management of acute pain in the complex hospitalized patient.
Background of Pain Theory
Peterson and Bredow (2009) credit Descartes with the first illustration of pain theory in his drawing of a boy whose foot was too close to a fire. Our modern-day understanding of pain sensory transmission pathways in the human body has come a long way from the 17thcentury drawing by Descartes. However, complete theories for managing pain must address bothphysiological and psychological components.
In 1965, Melzack, a psychologist, and Wall, a neurophysiologist, published the Gate Control Theory. This theory revolutionized our understanding of how the psychological components of pain can attenuate the physiological transmission of pain impulses in the body. Later in the 20th century, new discoveries that further differentiated pain receptors provided researchers and practitioners with additional theories regarding the mechanisms of pain: how pain occurs and is modulated in the body (Peterson & Bredow 2009). With this new knowledge practitioners and researchers were able to identify and test pharmacologic and adjuvant treatments for acute pain.
With expanded knowledge of pain transmission pathways, pain receptors and associated pharmacologic treatments for pain, two nursing researchers and theorists, Good and Moore, proposed a middle-range theory of acute pain management to establish a balance between analgesia and side effects for the management of acute pain (Good, 1996). This middle-range theory provides an excellent framework to assist nurses in understanding and guiding nursing practice as it relates to management of acute pain (Watson-Miller, 2005).
Pain: A Balance Between Analgesia and Side Effects
Good’s middle-range theory of “balance between analgesia and side effects to manage acute pain” provides a framework for nurses to structure a pain management plan that can provide an outcome of good pain control while minimizing negative side effects often associated with potent pain medications. Thismiddle-range theory is structured around three main propositionswhich are comprised of intervention or assessment concepts for the management of acute pain (Good, 1998):
- Multimodal interventions that incorporate the use of potent pain medications with adjunctive pharmacologic and nonpharmacologic measures to achieve good pain control with minimal negative side effects.
- Attentive care that incorporates frequent and regular assessments of pain and pharmacologic-related side effects, along with interventions and reassessment designed to maximize pain control while minimizing negative side effects.
- Patient participation that provides patient teaching and encourages patient goal setting for acute pain management.
Multi-modal interventions
Potent Pain Medication / + / Pharmacologic Adjuvant / + / Nonpharmacologic Adjuvant / + / Balance Between Analgesia and Side Effects
Attentive Care
Regular Assessment of Pain & Side Effects / + / Identification of Inadequate Relief and Unacceptable Side Effects / + / Intervention, Reassessment, Reintervention / +
Patient Participation
Patient Teaching / + / Goal Setting for Pain Relief / / +
This middle-range theory is based on multiple randomized control trials and decades of concentrated research on the topic of pain management (Good & Moore 1996). Middle-range theories allow nursing practice to advance by creating hypotheses that can be tested and translated into practice guidelines (Good & Moore, 1996). Broad conceptual models don’t support hypothesis testing for the development of practice guidelines.
In Peterson and Bredow, theories are critiqued through an evaluation of internal constructs (internal criticism) by examining how the theory components relate and external constructs (external criticism),by examining how the theory relates to people, nursing and health. The next sections summarize the analysis of the middle-range theory of pain: a balance between analgesia and side effects.
Internal Criticism
Clarity:
Good’smiddle-range theory clearly states the main components of acute pain management: multi-modal interventions, attentive care and patient participation. These components correlate with the nursing process: assess, diagnose, plan, implement, evaluate, and are well understood by clinicians.
Consistency:
Good’s middle-range theory focuses on management of acute pain. The main components of this theory support acute pain management and suggest recommendations for practice that can be implemented by nursing clinicians in a variety of settings.
Adequacy:
Good’s middle-range theory provides a complete framework for consistent assessment and treatment of acute pain, while minimizing negative side effects associated with pain medication. The theory clearly explains the principle concepts of multi-modal intervention, attentive care and patient participation. The theory also clearly limits the scope to acute pain management. Although the scope of the theory does not address chronic pain management or pain management in pediatric populations, the basic theory is complete when considering acute pain management in uncomplicated patients.
Logical Development:
The components of this theory are based on well-understood physiological pain transmission pathways and proven pharmacologic treatments for acute pain. The components of acute pain management guidelines are well grounded in clinical research, and consistent with nursing workflow and the nursing process.
Level of Theory development:
Good’s theory on managing acute pain is appropriately structured as a middle-range theory. The concepts and propositions are generalizable to a variety of patient populations who might experience acute pain, but explained in sufficient detail so that interventions can be structured with measurable outcomes.
External Criticism
Reality Convergence:
Good’s middle-range theory addresses a topic in health care that is chronically under-treated: Acute pain. There is real-world application of this theory in a variety of acute-care settings. Nurses in clinical practice will find the concepts for management of acute pain in this theory to have practical application at the bedside. Nursing researchers will be able to use this theory to conduct research to refine best practices for a variety of adult patient populations experiencing acute pain.
Utility
Because Good’s theory addresses a topic that is experienced by most hospitalized patients, particularly patients undergoing surgery, this topic has wide utility. Nursing researchers and bedside clinicians can use this theory to study acute pain management in specialty adult patient populations to determine best practices for their practice specialty. Research can be conducted on tools to measure pain, tools to evaluate side effects of medications, nonpharmacologic adjuvant therapies and standards of acute pain management for a variety of surgical populations to establish and refine best practices in acute pain management.
Significance:
Any research conducted to better manage acute pain and side effects of potent pain medications will lead to improvements in assessment and treatment of acute pain. Because nurses are largely responsible for assessment and treatment of acute pain, research in this area will have a direct impact on nursing practice and patient outcomes.
Discrimination:
Good’s theory on acute pain is unique in that it draws on the physiological and psychological components of pain as well as the nursing process to assess, intervene, and evaluate outcomes of current practice. Because this theory is grounded in strong research and the nursing process, new hypotheses that translate into additional research will be of interest to nursing researchers and bedside clinicians alike.
Scope of Theory:
Good’s middle-range theory is appropriately scoped to support further study by nursing researchers and clinicians. This theory provides a framework that could support additional research by specialty surgical populations, nonpharmacologic adjuvant therapies, pharmacologic treatments with adjuvants, to name a few. The theoretical constructs support evidence-based research with measurable outcomes: successful management of acute pain with minimal negative side effects.
Complexity
Good’s middle-range theory focuses on acute pain. Successfully managing pain can be a complex process. By limiting the scope to acute pain, Good has eliminated much of the variability in caring for patients presenting with chronic pain, diabetic neuropathy or long-term opioid use. The theoretical constructs are well understood by nurses as they are grounded in current methods for managing pain, nursing assessment and the nursing process.
Relevance to Nursing Practice
I find the middle-range theory of the balance between analgesia and side effects to be an invaluable resource in managing acute pain in hospitalized patients. The theory provides a framework for assessment, intervention and patient education. Both pharmacologic interventions and non-pharmacologic adjuvants are encouraged as interventions. Often in clinical practice, non-pharmacologic adjuvants like massage therapy, music and relaxationare overlooked. However, many adjuvants, like massage therapy, continue to be recognized as a beneficial healing art that provides comfort and helps reduce pain, anxiety and tension (Anderson & Cutshall, 2007). My clinical area offers music therapy and provides staffing for a massage therapist. After studying this theory, I will be more proactive in offering patients the option to receive therapeutic massage for management of acute pain.
The attentive care described in the theory focuses on regular assessment of pain and side effects, with intervention and reassessment to achieve maximum pain control with minimal side effects (Good 1998). The theory also addresses patient teaching and goal setting which is critical to achieving good outcomes for pain control. Establishing a trusting relationship with the patient is essential to establish goals and accurately assess pain. In Watson-Miller’s research on assessing the postoperative patient, she focuses on the patients’ reactions to nursing assessments: “During the first 24 hours after surgery, the nurse-patient relationship is initiated. All assessments carried out during this period might have lasting consequences on the patient’s views.” Based on recent chart reviews in my area of practice, nurses are good at completing the initial pain assessment and intervention, but have poor follow through with pain reassessment and reintervention. Side effects, or lack thereof, are rarely documented.
When I consider developing hypotheses for further research for the patients I care for in my current area of practice, I do see some limitations due to the fact that the scope of this middle-range theory is acute pain management in adult patients. This theory does not specifically address acute pain management in patients who have a history of chronic pain, severe anxiety, substance abuse, high tolerance to opioids, or in patients who have reduced hepatic or renal function.
Many hospitalized patients have medical conditions such as diabetic neuropathy or chronic pain that complicate assessment and treatment of acute pain. Patients who have a history of long-term ETOH or drug abuse, or have a long history of opioid use due to chronic pain also present challenges with assessment and treatment of acute pain. When working with patients who have decreased renal function or compromised hepatic function, nurses must exercise care in choosing pharmacologic adjuvants for acute pain management. For example, NSAIDs, like Ketorolac, are contraindicated in patients with decreased renal function. Nurses managing care for complex patients must be well-versed in understanding laboratory results and thepharmacokinetics of medications they choose to administer.
Additional research to extend this theory to include the management of acute pain in complex patients, or in pediatric or geriatric practice areas would expand the utility of this middle-range theory to better serve our hospitalized patients.
Conclusion
Nurses know that pain management in the acute care setting is not “one-size-fits-all”. The pain management plan will look very different for the 100 kg 42-year-old male status-post CABG as compared with the 55 kg 83-year-old female status-post aortic valve replacement with DM II and chronic renal insufficiency. The pain management plan for the first 24 hours after surgery will look very different than the plan three days after surgery. Applying Good’s theoretical model in the care of each patient will provide consistent assessment and re-assessment with interventions appropriate to the patient condition.
Pain management in the acute care setting is an aspect of care that is greatly influenced by consistent and excellent nursing care. The National Database of Nursing Quality Indicators (NDNQI) includes pediatric pain assessment, intervention, and reassessment as one of the nursing quality indicators to benchmark quality nursing care.
Watson-Miller states that nursing assessment forms the basis for decision making and provides an accurate picture of the patient’s current condition She also advocates the use of theory, such as middle-range theory, to assist nurses in understanding and guiding their practice. The strength around the middle-range theory of the balance between analgesia and side effects is the regular assessment of pain and side effects, with intervention and reassessment. This structured approach to the theory of pain management increases the significance of its application in practice. Using this theory as a sound framework allows nursing leaders and clinicians to establish guidelines and recommendations for nursing practice and provides a framework for future research.
Having researched this theory, I now have a framework to support my own practice in managing acute pain and untoward side effects for cardiothoracic post-operative patients in my care. I will be more rigorous in my own practice and will also encourage my colleagues to be more cognizant of assessing for and documenting side effects to the medications we use to treat acute pain to maximize pain relief with minimal side effects.
References
Anderson, P. & Cutshall, S. (2007). Massage therapy: a comfort intervention for cardiac surgery patients, Clinical Nurse Specialist, 21(3) 161-165.
Blanchard, J., & Murnaghan, D. (2010). Nursing patients with acute chest pain: practice guided by the Prince Edward Island conceptual model for nursing. Nurse Education in Practice, 10(1), 48-51.
Cutshall, S., Fenske, L., Kelly, R., Phillips, B., Sundt, T. & Bauer, B. (2007). Creation of a healing enhancement program at an academic medical center. Complementary Therapies in Clinical Practice, 13(4) 217-223.
Good, M. (1998). A middle-range theory of acute pain management: use in research. Nursing Outlook, 46(3), 120-124.
Good, M., & Moore, S. (1996). Clinical practice guidelines as a new source of middle-range theory: focus on acute pain. Nursing Outlook, 44(2), 74-79.
Good, M., Stanton-Hicks, M., Grass J.A., Anderson G.C., Lai H., Roykulcharoen, V. & Adler, P.A. (2001) Relaxation and music to reduce postsurgical pain. Journal of Advanced Nursing (33)2, 208-215.
Pellino, T. (1997). Relationships between patient attitudes, subjective norms, perceived control, and analgesic use following elective orthopedic surgery. Research in Nursing & Health, 20(2), 97-105.
Peterson, S. & Bredow, T (2009). Middle-Range Theories: Application to Nursing Research (Chapters 2 and 3). Upper Saddle River, NH: Pearson Education, Inc.
Watson-Miller, S. (2005). Assessing the postoperative patient: philosophy, knowledge and theory. International Journal of Nursing Practice (11) 45-51.
Appendix of Additional Citations
Acute low back problems in adults. (1994). United States Department of Health and Human Services Public Health Service.
Auvil-Novak, S. (1997). A middle-range theory of chronotherapeutic intervention for postsurgical pain. Nursing Research, 46(2), 66-71.
Dunn, K. (2005). Testing a middle-range theoretical model of adaptation to chronic pain. Nursing Science Quarterly, 18(2), 146-156.