Focus Group results RN Perspective Category Themes Communication Patient Condition Communicate Expectations and plan of care Early 1. Communicate to patient at beginning of shift and throughout shift (pain plan/schedule) 2. Truthful med timing 3. Pt. expecting pain meds right away, yet unable to get to patient room 4. Communicating/explaining priorities and acknowledging pain (i.e. low BP vs. pain) 5. Communicate actions taken to patient 6. Offer pain meds before pt. calls 7. Setting expectations manageable pain level Communication between MD/RN/Pt/SHA 1. Explain process of pain management 2. During first encounter determine patient preferences 3. Empowering patient to verbalize when in pain 4. All know the same plan (RN/MD/Pt.) 5. Md to be realistic about timing of entering order for patient (now vs after rounds). 6. Doctors frustration with frequent RN calls for medication dosage changes 7. Resident attitude towards pain control 8. Variation of perception of pts pain from RN to RN Chain of Command 1. RN able to use chain of command 2. Responding to MD denial for additional meds 3. Difficult to reach physicians, especially when in clinic and OR 4. Full use of chain of command 5. Empowerment of staff nurse Pharmacy 1. Communication between RNs and pharmacy for pick-up vs. delivery Barriers 1. Language 2. Cultural 3. Religious Drug Seeking Behavior 1
1. Lack of believing patient 2. MD won t give meds beyond what they think patient needs 3. Cardiology will not give meds, not here to satisfy drug addiction a. After work-up, will not give meds 4. Neuro- will order pain meds 5. Surgical will order pain meds 6. Attitude of nurses/physicians 7. Consistency of practice between caregivers 8. MDs lack of knowledge in management of drug seeking patients Unstable patient hemodynamic fragile 1. MD/RN - withhold pain med due to patient condition 2. Sedation vs. pain control a. Respirations meds held b. BP low meds held Barriers 1. Fear of over sedation (withhold pain) 2. No monitoring equipment or tools 3. Hard to get a hold of physicians Complimentary Therapy Medications 1. Lack of use of available alternatives a. Music therapy b. Pet therapy c. Blankets, ice, heat d. Repositioning e. LodgeNet on demand f. Pain kit 2. Some alternatives not available a. Massage therapist b. Acupuncture c. Accupressure d. Not enough pain kit e. Live music therapy less available PCA/IV/PO 1. Underutilize PCA 2. Do not have PCA, PRN not given as much as needed 3. Only have iv pain, no po, Short acting and longer acting 4. Start IV progress to PO 5. Understand decision making from IV to PO 2
ED process Need diet and pain orders before arriving to floor Dose of pain medication prior to transfer Chronic Pain 1. Long term med use not getting same dose while inpatient 2. Home Rx is different than order 3. Chronic pain patients need different meds 4. Physician reluctant to order pain med with patient in chronic pain. Knowledge / Education Process 1. Premedicate prior to line insertion 2. Medicate before shift change (4 out of 5 have pain) 3. Patients are afraid of side effects of meds 4. X1 order helps in between the q4h prin Chronic pain pt 1. Resident and nurse fear of oversedation 2. Fear of combination of high doses 3. Fear of using off-label Rx for analgesia (Ketamine) 4. Resident Non cardiac reason no pain medication ordered 5. Pt understand source of pain. Why havingsocial, spiritual, physical. 6. Md and nurse understanding of mechanism of pain. Lack of understanding of pain and when to seek consult. 7. Other sources of pain. 8. Length of process of pain control 9. Understanding progression from IV to PO process (equal analgesic dosing) 10. RN and MD proper comprehensive, multisystem, pain assessment questions 11. RN and MD utilization of pain scales for assessment and associated medication dosing 12. Pt lack of understanding of pain scale 13. Ability of nurse to read pt body language 14. Education to family difference of peak timing of action differences between orals and IV meds Communication 3
Processes 1. Communicate to pt not to let pain too high 2. Prevent pt waking up in pain 3. Scheduling vs PRN dosing 4. Nurses who won t call MDs between pain doses 5. Attitudes of nurses that some pts are drug seeking 6. Appropriate route of pain meds (ER vs liquid vs IV) 7. Pt says wake me up for next pain med 8. MD not ordering enough pain medications 9. RN understanding procedural physical effects 10. Matching appropriate pain scale to appropriate Rx dose 11. PCA underutilized 12. Starting doses too low and progressing too slow 13. RN underutilizes consultation or chain of command 14. Chain of command issue: authorization to order pain med from fellow to resident is delayed 15. Pts understanding or progression from PCA to PO 16. Not enough follow-up after PRN nurse training. 17. Understanding pain mechanisms from different levels of physical injury/procedures 18. Pain not considered an urgent/emergent issue 19. Lack of escalating chain of command if PRN Rx not sufficient 20. Understanding cultural/gender differences of pain perception (Asians try to hide pain) 21. Access to non-pharmacological interventions 22. Need for further assessment and intervention 23. Family perception of pt being drug seeking, preventing RN from administering meds 24. Family perception that not using PCA will speed discharge process RN asks pain consult from MD and MD refuses Prompt order entry via WOW in pt 4
Resources room!!!!!!!!!! Some RNs will not call MD for pain med unless pt calling frequently Inconsistent pain management between shifts (nurse-nurse or MD to MD) Transferred/admitted pt with no pain meds ordered PRN q1h or q2h pain meds being given, need to escalate to PCA but MD refuses Mismatch between diet order and medication route (POs ordered but diet NPO) Workload If all patients have q1h pain med dosing, not enough staff availability for witnessed narcotic wasting Chest pain only given x1 doses New orders after procedure delayed because of multiple tasks including assessment No pain meds ordered for Tandem heart or back pain from bedrest Transition to PCA Not able to override pain meds from Pixis Elevators down, delay to retrieve meds from pharmacy (because narcotics cannot be tubed) Order process lengthy Pharmacy time to deliver narcotics delayed Lack of follow-up pain assessment from RN after medication administration Notification process RN to MD to pharmacy etc too long Pharmacy takes too long to get med verified Nurses call pharmacy before order is entered Lack of prioritization of pain control during shift report(between RN to RN) Utilization of SBAR during shift report Pt or family report of pt pain to appropriate practitioner (Sha vs RN vs EVS, etc) Computers Wall mounted computers so MDs can enter orders right away RN or other consults 5
Need pain service to consult more and educate other MDs Who do RNs call now that Maria is gone? Lack of communication of available resources (Lan Zheng is not only a unit pharmacist, but a pain pharmacist as well) Uncomfortable beds Beds are uncomfortable Uncomfortable mattresses and makes pain worse Mattresses are too loud Immediate Boss/Influence Help to guide staff Provide reminders of daily goals, necessity of pain control, etc Immediate supervisor (Clin IV, Supervisor, manager, etc) attitudes and culture toward pain control Lack of SBAR reinforcement from Clin IV, supervisor or manager Collaboration RNs unwilling to assist other RNs to provide pain control Workload affects pain control more than beliefs about pain control Team prioritization of pain control differs from unit to unit (unit culture) Pharmacy Request availability of unit pharmacist on every unit 6