Evidence-Based Practice, Nursing Leadership, and Pain Management

Abstract

This study considers the potential benefits of evidence-based practice (EBP) in nursing in dealing with two concurrent health care crises: opioid overuse, bringing on overdoses and addiction, and the lack of effective pain management. Of the 63,600 who died in 2016 from drug overdoses, two-thirds were due to opioids. On the other hand, 80% of patients in 150 countries lack adequate pain management. Part A of this paper discusses the importance of the emerging role of nursing EBP in the field of pain management. Part B discusses some basic principles of evidence. Part C summarizes and evaluates two research studies bearing on pain management, one discovering and evaluating barriers nurses face in delivering optimal pain care to a population of patients and the other evaluating possible pharmaceutical approaches to pain that do not involve opioids. Part D presents some possibilities for further research and quality improvement projects based on the studies described in Part C.

Evidence-Based Practice, Nursing Leadership, and Pain Management

Currently, the United States is experiencing a medical crisis in pain management. By overprescribing medications such as oxycodone, physicians have created addiction in patients who never thought they would fall victim to any such disorder. Of 63,600 deaths due to drug overdoses in 2016, 66% were due to an opioid overdose (Centers for Disease Control and Prevention [CDC], 2017). The longer patients are on an opioid, they become increasingly tolerant to the drug, requiring higher and higher doses for relief; they may resort to “doctor-shopping” to obtain multiple prescriptions or turn to more potent illicit drugs such as heroin (American Addiction Centers [AAC], 2018). Yet, grave as the dangers of overdose and addiction are, the underlying reason these medications are administered must not be neglected: the pain itself. Some 80% of the population in 150 countries suffer from the lack of effective pain management (Mędrzycka-Dąbrowska, Dąbrowski, & Basiński, 2016, 1050).

Part A

Nurses have a great opportunity to attack both the problems of opioid overuse and poorly managed pain by using evidence-based practice (EBP) in pain management, both with regard to medication approaches that may minimize or even eliminate the use of opioids as well as in relation to organizational or personal obstacles to the communication necessary for effective pain management. However, although the essential ideas of EBP in nursing go back not only to the 1920s (Brown, 2014, p. 11) but to Florence Nightingale herself (McDonald, 2001), relatively few nurses take full advantage of opportunities to put it into use (Häggman-Laitila, Mattila, & Melender, 2016; Melnyk et al., 2018). With the information technology available today, however, it is much easier to gather statistics and other records needed to improve patient care through EBP than in Nightingale’s time. 

Chronic pain is a complex phenomenon, affecting some 116 million Americans annually (American Physical Therapy Association [APTA], 2013). As an example of the complexities that affect the possibilities for effective management, chronic pain is sometimes more associated with psychological issues than with physical ones; on the other hand, psychological pain can manifest itself in physical symptoms. Psychological treatment, in partnership with physical and medical treatment, often leads patients to cope with and manage their pain successfully (American Psychological Association [APA], 2018). Physical therapy also often makes a difference in the lives of patients suffering from chronic pain, particularly as part of a multidisciplinary pain management program (APTA, 2013).

The expanding dimensions of understanding of patient needs and possible treatment approaches mean that it becomes more and more important that the practice of health care professionals reflect the best possible knowledge of the underlying facts. This knowledge is obtained by ascertaining the value of research studies as evidence. By accumulating the insights obtained from the most reliable evidence, evidence-based clinical practice guidelines and protocols are developed (Brown, 2014, 7–9, 12), which the individual nurse should adhere to insofar as they apply to the particular population being treated. As an example of what this can accomplish in the area of pain management, Kim, Brathwaite, and Kim (2017) show how implementing EBP standard care in treating sickle cell disease (SCD) vaso-occlusive episodes (VOEs) significantly reduced the time to administration of analgesia, increased patient satisfaction, and reduced the length of stay.

Part B

Two kinds of activities generate evidence to guide the development of evidence-based practice guidelines and protocols: research studies and quality improvement (QI) projects. As explained by Arndt and Netsch (2012), a research study is a systematic effort to discover new, generalizable knowledge using well-defined rigorous conceptual methods. Because it involves conditions not experienced before, a research study poses some risk to human subjects, so a research study involving human subjects needs to be bound by ethical guidelines and oversight, usually provided by an institutional review board (IRB). Numerical results must be processed and evaluated with standard statistical techniques to ensure that effects are real and not the result of random chance.

A research study should answer a carefully formulated research question, which can be posed in terms of the following concepts, remembered by the acronym PICOT (e.g., Riva, Malik, Burnie, Endicott, & Busse, 2012): which population (P) will be studied, which intervention (I) will be tested, what will the intervention be compared (C) to, what outcome (O) will be measured, and over what time (T) period will the results be collected? It should be possible to fill out a PICOT table for any research study, in which each lettered element can be identified from the publication and written down in its own column.

Depending on how a study is designed and carried out, its result has a certain level of evidence (Ackley, Swan, Ladwig, & Tucker, 2008, 11). The highest level (I) is given to evidence from a meta-analysis that uses a statistical technique that combines results from multiple randomized, controlled trials (RCTs) to get a result more reliable than any of them individually. A single RCT has level II. Level numbers increase as the rigor and therefore the reliability of a study decreases. The lowest levels are VI for a single qualitative or descriptive study and VII for an expert opinion.

In contrast to a research study, a QI project tests the application of an intervention known to be of value to particular nursing practice. It is not intended for publication beyond the practice. Because it uses an intervention already shown to be of benefit by research, it poses little risk to the patients involved, so it does not require the oversight of an IRB. It is not necessary to use rigorous statistical techniques with a QI project, although they can be used (Arndt & Netsch, 2012).

Part C

Mędrzycka-Dąbrowska and coworkers (2016) surveyed nurses on surgical wards at each of the three levels of hospital recognized in Poland (I, municipal, offering only internal medicine, general surgery, OB-GYN, and anesthesiology/ICU, n = 385; II, provincial, offering additional specialties in addition to level I, n = 909; III, clinical, performing research in addition to level II, n = 308) about 40 possible barriers interfering with optimum management of postoperative pain in elderly patients. The barriers were categorized as related to the health care system, associated with physicians, associated with nursing staff, or associated with patients. The nurses rated each barrier on a scale from 1 (never interferes) through 7 (always interferes). The authors tabulate the responses, giving mean and standard deviation rating for each barrier by each hospital level. Of these categories, they found the highest overall mean for barriers related to the health care system (3.89), the next highest for those related to patients (3.76), and finally those associated with physicians and nurses (3.45). They found that when there were significant differences among the types of hospital for a barrier, barriers tended to be somewhat more of a problem in large clinical hospitals than in the other types.

However, the authors did not take the step of tabulating the overall mean and standard deviation across all three types of hospital for each barrier. These overall statistics have been calculated from their broken-out means and standard deviations, and the six barriers with the highest overall mean ratings are listed in Table 2. These are not the same as the ones the authors made a point of mentioning; the remainder of those barriers are also listed in Table 2. This shows that it is sometimes necessary to dig deeper than the descriptions the authors of a study choose to place in their text. In any case, this study, as a single descriptive study, is only at evidence level VI. Note that it does not fit comfortably within the PICOT table framework.

As an example of research that has a bearing on modification of pharmacological pain management in a way that promises to reduce the use of opioids, Chang, Bijur, Esses, Barnaby, and Baer (2017) performed an RCT of single-dose analgesia in patients presenting with acute pain in a limb to two emergency departments in the Bronx, New York City. Out of 104 patients each randomized to one of four groups, for a total of 416 patients, 411 patients were observed. Three of the four groups received a conventional combination analgesic containing an opioid and a nonopioid ingredient (acetaminophen): “5 mg oxycodone plus 325 mg acetaminophen; 5 mg hydrocodone plus 300 mg acetaminophen; or 30 mg codeine plus 300 mg acetaminophen” (p. 1661). Because these are commonly used treatments, they served as controls. The fourth group received a combination of 400 mg ibuprofen and 1,000 mg acetaminophen. There were no significant differences in reduction of pain levels among the four groups; that is, the opioid-free treatment performed as well as the treatments containing opioids. As an RCT, this stands at evidence level II.

Part D

EBP offers the best hope of combating the crises of opioid overuse and inadequate pain management. The numerous barriers to effective pain management in older patients identified by Mędrzycka-Dąbrowska et al. (2016) can serve as the basis for research into methods of overcoming them, possibly with applications to other pain populations. The opioid-free approach to analgesia tested by Chang et al. (2017) can be the basis for QI projects in emergency departments and inspire research into opioid-free interventions in pain from other causes.

(Tables 1 & 2 omitted for preview. Available via download).

References

Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: medical-surgical interventions (p. 7). St. Louis, MO: Mosby Elsevier.

American Addiction Centers. (2018). Oxycodone addiction: symptoms and signs of abuse. Retrieved from https://americanaddictioncenters.org/oxycodone/signs-of-abuse/ 

American Physical Therapy Association. (2013). Manage chronic pain with the help of a physical therapist. Retrieved from http://www.apta.org/Media/Releases/Consumer/2013/12/5/

American Psychological Association. (2018). Managing chronic pain. Retrieved from http://www.apa.org/helpcenter/pain-management.aspx

Arndt, J. V., & Netsch, D. S. (2012). Research study or quality improvement project? Journal of Wound, Ostomy, and Continence Nursing, 39(4), 371–375.

Brown, S. J. (2014). Evidence-based nursing: the research-practice connection (3rd ed.). Burlington, MA: Jones & Bartlett Learning.

Centers for Disease Control and Prevention. (2017). Opioid overdose: understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html 

Chang, A. K., Bijur, P. E., Esses, D., Barnaby, D. P., & Baer, J. (2017). Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. Journal of the American Medical Association, 318(17), 1661–1667.

Häggman-Laitila, A., Mattila, L., & Melender, H. (2016). A systematic review of the outcomes of educational interventions to nurses with simultaneous strategies for guideline implementation. Journal of Clinical Nursing, 26(3–4), 320–340.

Kim, S., Brathwaite, R., & Kim, O. (2017). Evidence-based practice standard care for acute pain management in adults with sickle cell disease in an urgent care center. Quality Management in Healthcare, 26(2), 108–115.

McDonald, L. (2001). Florence Nightingale and the early origins of evidence-based nursing. Evidence-Based Nursing, 4(3), 68–69.

Mędrzycka-Dąbrowska, W., Dąbrowski, S., & Basiński, A. (2016). Perception of barriers to postoperative pain management in elderly patients in Polish hospitals—a multicentre study. Journal of Nursing Management, 24, 1049–1059. 

Melnyk, B. M., Gallagher-Ford, L., Zellefrow, C., Tucker, S., Thomas, B., Sinnott, L.T., & Tan, A. (2018). The first U. S. study on nurses’ evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes. Worldviews on Evidence-Based Nursing, 15(1), 16–25.

Riva, J. J., Malik, K. M. P., Burnie, S. J., Endicott, A. R., & Busse, J. W. (2012). What is your research question? An introduction to the PICOT format for clinicians. The Journal of the Canadian Chiropractic Association, 56(3), 167–171.