Influences on nurses' pain management practices within institutions: a constructivist approach

Abstract

Alleviating patient suffering, providing comfort and pain relief are all central to the philosophical caring position nurses have always espoused. Despite this, patients continue to suffer pain although we have the means to provide pain relief. Research has identified that nurses have a knowledge deficit regarding pain and its management, as well as erroneous attitudes, which combined are blamed for our inability to make significant progress in this area. This study was undertaken to uncover the contextual aspects of working within a New Zealand health care institution that affect nurses' ability to manage their patient's pain effectively. It highlights the difficulties and the complicated nature of working within an institution in the 1990's health care environment, where accountability for pain is absent and where pain is often under-assessed and under-treated. By using focus groups of nurses, I was able to uncover constraints on nursing practice, which have been curiously missing from the literature, but prevent nurses from implementing their knowledge. Using a constructivist research design, I have used nurse's stories and current literature to argue one way forward in the pain management debacle. This study revealed a diverse range of contextual factors that prevent nurses from using their knowledge. Many of the constraints on nursing practice are the result of complex organizational structures within health care institutions. Time constraints and high patient acuity following the health reforms have significantly affected the nurse's ability to provide quality-nursing care. One of the most important factors limiting the management of the patient's pain is the inability of the nurse to autonomously initiate analgesia. While nurses are largely responsible for the assessment of pain, they are usually powerless to access necessary analgesia, without a medical prescription. I argue in this thesis that once an initial medical diagnosis has been made, nurses are usually left responsible for patient comfort and the management of pain. To do so effectively nurses need to be able to prescribe both pharmacological and non-pharmacological measures for the patient. Presently nurses are prescribing using a variety of illegitimate mechanisms, needing the endorsement of a doctor. To fulfill this role nurses must be adequately prepared educationally and given the authority to either prescribe autonomously, or provided with extensive "standing orders." While legislative changes in New Zealand in 1999 extended prescribing rights to a few nurses within certain areas of care, the ward nurse is unlikely to gain prescribing rights in the near future. A way forward may be to encourage and further develop the use of protocols for managing pain via standing orders. Standing orders are common place within nursing practice today, have the support of the Nursing Council of New Zealand and are currently under-going legislative review. An institutional commitment to developing pain protocols for nurses would recognize the nurse's active role and expertise in the management of pain and facilitate expedient relief for the patient.