Rationale of proposed research

The contextual issue is that nurses tend to have a poor perception of how to handle or manage patients when they are in pain. Pain is a human experience with many interpretations. Under the influence of science, these meanings multiplied adding complexities to managing pain as a clinical problem. Over the last four decades, nurses have made essential contributions to pain knowledge and pain management through research and clinical innovation. Nurses play a crucial role in implementing effective pain management programs and fostering multidisciplinary efforts to advance their services for patients with chronic or acute pain.

Introduction/background

Chronic/acute pain management is a significant element of fundamental patient rights and nursing care in general. If left untreated, it causes adverse results on the patient, which cripples the treatment efforts and responses, triggers hopelessness, and affects their quality of life (Samarkandi, 2018). Pain is stressful to the patient, and therefore, assessment and management are crucial to enhance their well-being.

The main hurdles to chronic/acute pain management include negative attitudes and nurses’ perceptions. Some nurses perceive the patients’ reports of pain as attention-seeking or that some patients are seeking opioids for their addictions. (Krokmyrdal & Andenæs, 2015). As a result, misconceptions and negative attitudes increase the suffering of the patient. Hence, efficient interventions are necessary to ensure that the issue is addressed to minimize the provider-related barriers. Better attitudes and perceptions towards the patient are necessary to improve pain management practices.

The main reason for the proposed research is to assess nurses’ knowledge on pain management as well as have patients participate in their own pain management using non-pharmacological remedies.

Postoperative pain continues to be a concern to both patients and health care professionals. Non-pharmacological pain relief techniques have the potential to complement pharmacological interventions and may provide alternative treatment options as stated by (Andemeskel et al, 2020). In the orthopedic ward, patients are admitted in for fractures located in their neck of femur (NOF), neck of hummers (NOH), fractured tibias and fibulas, are in constant pain whilst nurses attend to their cares.

Nurses do constant turnings of patients in bed to prevent pressure injuries as patients are immobile. Fractures can cause severe pain and distress to patients. This in turn can cause a lot of stress for the patient’s family and the patient’s nurse. Due to the lack of training/knowledge in pain management using non-pharmacological ways, nurses are unable to provide non-pharmacological interventions (Kromyrdal & Andeans, 2015). The contextual issue is that nurses tend to have a poor knowledge of how to handle or manage patients when they are in pain without using pharmacological drugs. Due to a lack of training or knowledge, the usage of opioid medication seems to be the most common intervention used by the nurses on the ward.

There have been times during the shifts where nurses have been told by their patients that they are in pain and when the nurses check their med chart, the pain relief medication is usually not available to be given yet. The nurses end up just waiting for the medication to be available to remove from the pyxis machine. They move on to other patients in the meantime.

Nurses of the pain management unit are the fundamental stakeholders in achieving change. A modification of attitudes towards their job, their patients and change of perceptions will counteract ignorance and improve the patient’s quality of life through timely care (Lee & Shaw, 2010). Patients in the pain management unit can play notable roles in initiating changes in the healthcare setting.

Their reporting of real pain and not seeking attention from the nurses when it is manageable will help prevent addiction. They can also use the interventions independently and in collaboration with the nurses to limit dependence on the practitioners. It will also help nurses recognise actual chronic pain incidences and attend to them quickly. Student nurses are also essential stakeholders. They learn to attend to patients and build the right attitudes towards patients to deliver effective and quality care during practice.

Literature search strategy and Review

Scopus was used to search for the articles published between 2019 and 2021. A structured literature search was used to find the most relevant research for nurses’ knowledge of pain management. The keywords used were nurses’ attitudes and perceptions towards pain, nurses’ competence in pain management in patients with opioid addictions and nurses’ knowledge of non-pharmacological methods.

Synthesis and critique of the five most current relevant research articles
Three out of the four articles chosen were published in 2021, the other in 2019. The first article was a descriptive cross-sectional study that took place in Ethiopia. This study focused on the nurses’ perception towards non-pharmacological interventions for pain treatment. The second article was published in Spain. It describes the results of a transverse descriptive survey-based study.

The third article was published by Munemo & Mwanza in 2019 which took place in Zimbabwe and used a descriptive study method.

The fourth article took place in Saudi Arabia and is a cross sectional design study. In this study the nurses were composed of different ethnicities, 43.1% of the nurses were Indian, 30% were Saudi, 21.3% were Filipino, and 5.6% were of different national origins. Also, the study in Saudi Arabia showed that the nurses were unable to provide therapeutic treatment to patients due to the lack of knowledge.

Improper methods were used by nurses due to their false perceptions regarding quick addiction and respiratory depression following the administration of analgesic. The study also showed consistency with older studies on pain therapy knowledge and attitudes in Middle Eastern countries where similar results were noted in the hospitals.

According to Esthete et al (2021), the main challenge to nurses’ non-pharmacological therapies was their responses. A total of 121 (71.6%) nurses stated burnout was an issue, 130 (77.55%) stated they had insufficient physician partnership, 121 (71.6%) nurses have said there was an insufficient no incentive for using non-pharmacology pain treatment strategies due to low pay, 125 (74.0%) said a high workload was a concern, 122 (72.2%) stated lack of willingness and refusal to use non-pharmacological pain control, and 125 (74.0%) claimed it was due to different factors. 123 (72.8%) felt there had been inadequate nurses per patient ratio, whereas 113 (66.9%) said there were inadequate nurses per patient ratio and insufficient education for nurses regarding non-pharmacological pain treatment strategies was indicated by 113 nurses (66.9%).

A limitation to the Ethiopian study was that there were not a lot of male nurses that took part in this survey. More nurses from medical wards answered to the survey, according to Fernandez-Castro et al (2021). This could be due to the fact that the guidelines were formed, clinical practice recommendations were created, and most of the research was conducted in hospital environments. It looked at whether pain was present in them postoperative period and in terminally ill patients, but not in medical wards.

In the overall research of accurate responses, postgraduate education did not contribute to higher performance, according to the study. But , there is some debate on this point, with some researchers claiming that postgraduate nursing education offered better general understanding of how to control pain, while professional experience, age, level of exposure to people suffering from pain, and location of posting were not connected to greater understanding about how to handle pain incidents.

According to Gwisai et al (2019), more nurses were knowledgeable of visualization (93.3 percent), thermoregulating treatments (93.3 percent), Transcutaneous Neuron Simulation (TNS) (76 percent), acupuncture (69.3 percent), and relaxation (69.3 percent) (97.3 percent ). Non – pharmacologic treatments, according to the majority, have no adverse impacts (56 percent), cannot be substituted (56 percent), have diverse modes of action (62.6 percent), and ease symptoms by changing perception of pain (73.3 percent ).

Despite a rise in heart rates, most respondents believed that non – pharmacologic therapy reduces respiration rates (50.7 percent) and muscular twitches (72 percent) due to relaxation methods (42.7 percent ).
According to a small percentage of respondents, nurses need particular training to provide non – pharmacologic treatments, The majority of nurses, on the other hand, demonstrated a poor understanding of non-pharmacological pain control as a substitute to pharmaceutical pain control.

Overall, a common theme between the four studies was the nurses that did not have a lot of experience were unable to provide holistic pain management interventions on patients complaining of pain compared to nurses who had a greater number of years-experience. Patients left in discomfort which can lead to patients’ families thinking the nurses are not competent in caring for their family members. The literature has led me to a consider an opportunity for further investigation. For instance, the research has only shown the perspective of the nurses and not that of the patients and their family.

Design of proposed research

Background
Acknowledging the increased demand for pain management requires exploring nurses’ attitudes and perceptions to resolving the chronic pain problem. Using relevant professional literature sources in this research is essential in obtaining evidence-based approaches towards resolving the problem.

As such, previous studies on the nurse’s attitudes and perceptions and their effects on healthcare provision are relevant for the research. Other important information includes stakeholders’ role, the effective interventions relating to modifying attitudes, the impacts of negative attitudes and perceptions, and the results on patient recovery from the previous literature studies.

Interventions/proposal:
The proposal for further research calls for:

1. Conducting further surveys – quantitative and qualitative – to refine the current findings, assess plausible root causes of “suboptimal” pain management, hypothesis avenues for improvement as well as the relevance and acceptance of offering “alternative” treatments.

Proposed methodology
a. Quantitative surveys:

i. Nurse population: consider a larger sample more representative of the gender ratio of the nurse population of New Zealand, having the survey conducted in multiple countries. In addition, another survey could be devised for nurses who have taken part in non-pharmacological education
interventions.

ii. Patient population: to understand their experience and “satisfaction” and glean insights on what they view as more satisfying treatment(s) to alleviate their pain.

b. Qualitative surveys/focus groups to explore feelings, perceptions and motivations of nurses and patients and patients’ families

i. Nurse-only to discuss the root causes and effects of nurses’ attitudes and perceptions toward pain management.

ii. Nurse-patient/family group to bridge the perception and communications that likely exist between the two groups and lay the foundations for possible improvements.

2. Ideating in nurses-management workshops ways to improve pain management by discussing evidence-based approaches such as nurse training (initial and on-going), coaching, revisiting time allocation (freeing up time for pain management) and time management. This is likely to lead to establishing Pain Management workshops for nurses to upskill their training to improve their pain management skills and interventions.

3. Running pain management clinics with patients and their families to “hear them” and educate them on the risks and consequences of “opioid-dependence”, thus setting up a forum for interactions where the suitability and acceptance of non-pharmacological interventions is vividly debated.

Proposed Methodology

Complete a questionnaire that includes a scale to rate severity of pain. Like in group therapy sessions e.g., A.A. meetings, encourage them to talk about their pain while stressing on how opioids can cause addiction and further harm to them, then suggest alternate ways to treat their pain. Introduce multi-disciplinary treatments e.g., Cognitive Behavioural Therapy, psychotherapy, exercise programs such as stretching and hydrotherapy, muscle relaxation, nutritional counselling, and vocational and occupational therapy.

Possibly add and have open discussions on areas beyond acute care to prevent chronic pain from recurring. Ask patients to keep a pain journal, tracking the intensity in their daily activities and what makes it better or worse. Consider nicotine cessation programmers for prevention and or treatments for addiction. Make nicotine patches available for the patients who do smoke as smoking contributes to lack of bone density that can lead to increased risk of fractures.

Let patient participate in the choice of non-pharmacological methods of pain relief they wish to take e.g., icing on the pain site, massage therapy, breathing exercises. If those interventions do not work, then the patient can decide if they wish to take weak analgesia. If weak analgesia does not work, then can allow for strong analgesia.

An ethical clearance letter to be obtained from a Research Ethics Committee. The permission and agreement consent to be obtained from the study hospital prior to the study after a brief explanation of the purpose of the study through support letter. Informed written consent to be obtained from all participants after a brief explanation of the aim of study. Confidentiality of information and privacy of participants to be respected. The participants to be told that information they provide will be used only for the purpose of this study. The names of the participants will not be included in the questionnaire survey rather specific codes to be used. This gives all participants protection and respects their rights to privacy.

Te Tiriti o Waitangi

The proposal aligns with Te Tiriti article Oritetanga as it allows collaboration of both the western healthcare model and Maori healthcare model, leading to more significant health outcomes for Maori. Having only the western healthcare model leads to tangata whenua being left out of the healthcare proposal. It is, therefore, essential to include their whanau in the pain management plan.

Tangata whenua has a different healthcare model compared to the typical western healthcare values. They believe in Taha Whanau as they believe that whanau provides them with strength and is the link to their ancestors and ties to their whenua and iwi (Ministry of Health, 2017). By engaging in this healthcare model, Maori patients will feel content to bring their whanau to the proposed clinic to discuss what they think is suitable for managing their pain and letting them take part in their holistic care.

If nurses exclude the beliefs of tangata whenua then they will fail at achieving Maori from opening up and discussing natural, therapeutic ways of handling pain. Graham & Masters-Awatere (2020) stated that Maori patients had negative experiences with healthcare services due to feeling restricted from talking about Tikanga practices regarding hauora. By following Maori Tikanga, healthcare workers and services can implement oritetanga by doing so. Incorporating Maori tikanga upholds the values of Te Tiriti o Waitangi and allows for collaboration of better health outcomes for iwi Maori.