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Generating & Testing Multi-institutional Evidence-Based Standards for Pain Management in Home Care : 

Generating & Testing Multi-institutional Evidence-Based Standards for Pain Management in Home Care Marlene Dufault, PhD, RN Principal Investigator

Acknowledgements : 

Acknowledgements This project was funded by: The Eastern Nursing Research Society The Nursing Foundation of Rhode Island The Rody Foundation The URI College of Nursing Weyker Thanatology Endowment

Acknowledgements : 

Acknowledgements Jean Schwaeger, MS, RN Project Coordinator, Roger Williams Home Care Janice Muhlberg, BS, RN Nurse Educator, Roger Williams Home Care Roger Williams Home Care Staff: Patricia Angulo, RN; Darlene Arthurs, RN; Elaine Diguilio, RN; Karen Mulligan, RN; Lynn Viveiros, RN

Acknowledgements : 

Acknowledgements Karen Hockhausen, RN Project Coordinator, VNS Home Health Care Nursing Staff of VNS Home Health Services: Dayle Reese, RN; Mack McGillvrey, RN; Claudette Martin, RN; Charlene Johnson, RN; Debra Barber, RN; Patricia Viveiros, RN

Acknowledgements : 

Acknowledgements Donna MacDonald RN, Project Coordinator, Greater Woonsocket VNS Robin Devin, Ph.D, Health Reference Librarian, University of Rhode Island Cynthia Willey-Temke, Ph.D., Statistical Consultant, College of Pharmacy, University of Rhode Island

Acknowledgements : 

Acknowledgements Claire Cayer, MS., RN Graduate Research Assistant, College of Nursing, URI Robin Maroni, RN Graduate Research Assistant , College of Nursing, URI Members of the Class of Nursing 273 Summer II, 1999; Summer II, 2000; Fall, 2000 Susan Corcoran, RN; Lora Likins, RN; Norma Grills, Rachel Caplan Nursing Students, College of Nursing, URI

I. Description of the Project : 

I. Description of the Project

Purpose : 

Purpose To create a collaborative partnership between nursing practice and academe that fosters research-based pain management in home care

Goal 1. To engage students and clinicians in generating and adopting pain management standards based on AHCPR guidelines and current research : 

Goal 1. To engage students and clinicians in generating and adopting pain management standards based on AHCPR guidelines and current research

Goals : 

Goals 2. To test the effectiveness of these standards on patient & family caregiver outcomes

Goals 3. To provide clinicians and students with an experiential learning opportunity to improve their competency in evaluating and using the discoveries of research for solving day-to-day clinical problems : 

Goals 3. To provide clinicians and students with an experiential learning opportunity to improve their competency in evaluating and using the discoveries of research for solving day-to-day clinical problems

Theoretical Framework : 

Theoretical Framework Roger’s (1983) Adoption of Innovations Theory identified factors that improve research utilization: Strong body of validated predictable knowledge Policy-generating organizational structure that promotes innovation and a supportive climate of inquiry Clinician competency to translate and use research findings

Slide 15: 

COLLABORATIVE RESEARCH UTILIZATION MODEL Research Enhancement System Knowledge-Generating System Clinician/User System Change in Scientist Change in Student Change in Clinician Change in Practice Change in Patient Outcomes

Previous Research : 

Previous Research Dufault, M., Bielecki, C., Collins, E., & Willey, C (1995) “Changing nurses pain assessment practice: a collaborative research utilization approach. Journal of Advanced Nursing, 21, 634-645. Dufault, M., & Sullivan M. (2000). “A collaborative research utilization approach to evaluate the effects of pain management standards on patient outcomes. The Journal of Professional Nursing, 16(4), 240-250. Dufault, M., & Lessne-Willey, C. (1999. Using a collaborative research utilization model to test the effects of clinical pathways on pain management. Journal of Nursing Care Quality, 13(4), 19-33.

Hypotheses : 

Hypotheses Does involving clinicians and students in the generation and testing of research-based pain management standards improve patient/family outcomes?

Outcome variables : 

Outcome variables Decreased severity of pain Decreased interference of pain with quality-of-life indicators Increased satisfaction with interventions & with caregiver responsiveness Decreased family caregiver burden of pain management

Quality of Life Indicators : 

Quality of Life Indicators General activity Sleep Concentration ability Mood Walking ability Relationships with others Enjoyment of life

Caregiver Burden of Pain Management : 

Caregiver Burden of Pain Management Financial burden Sleep disturbances Confines caregiver Family adjustment Time demands Upsetting symptoms Changes in personal plans Overwhelming

Research Design: Two-Group Pretest-Intervention-Posttest : 

Research Design: Two-Group Pretest-Intervention-Posttest STUDY GROUP (n=75) CONTROL GROUP (n=89) Pretest (visit 1) Pretest (visit 1) V V Intervention No Intervention (Research-Based Standard of Care) V Posttest (visit 3) Posttest (visit 3) V V Posttest (last visit) Posttest (last visit)

Subjects & Setting : 

Subjects & Setting 164 patients and their family caregivers: Whose pain is more than the ordinary in the month prior to referral Alert and oriented at admission and discharge Able to respond to questions

Demographics: : 

Demographics:

Instrumentation : 

Instrumentation Brief Pain Inventory (Daut, R., Cleeland, C., Flanery, R, 1983) Caregiver Burden of Pain Management Scale (Ferrell, B.,Grant, M., Chan,J, & Ferrell, B 1995)

Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research : 

Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research Lack of patient & family understanding about pain management following hospital discharge Discrepancies between patients, family caregivers, & health care professionals Fear of side effects of drug therapy Under-use of complementary methods of intervention

Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research : 

Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research

Procedure: Step 2. Evaluation of the research as it relates to the selected problem, agency values, standards, policies, and cost & benefits : 

Procedure: Step 2. Evaluation of the research as it relates to the selected problem, agency values, standards, policies, and cost & benefits In-depth review of 122 studies to determine strength of the evidence by 64 students 8 research roundtables held in 2 project sites with 37 clinicians and students participating

Procedure: Step 3 : 

Procedure: Step 3 Designing a Standard of Care that incorporates the research findings and recommendations generated by staff and students in the roundtables

Procedure: Step 3. Designing a Standard of Care that incorporates the research and recommendations generated in the roundtables : 

Procedure: Step 3. Designing a Standard of Care that incorporates the research and recommendations generated in the roundtables

Procedure: Step 4. Evaluation of the Pain Management Standard of Care : 

Procedure: Step 4. Evaluation of the Pain Management Standard of Care Data collection & testing for applicability, usefulness for practice, and effectiveness in improving outcomes in 75 patients and their family caregivers

Procedure: Step 5. Decision to adopt, alter, or reject the new standard of care : 

Procedure: Step 5. Decision to adopt, alter, or reject the new standard of care Analysis & Presentation of Data

Data Analysis : 

Data Analysis Purpose Method Describe demographic Frequency distr. and outcome variables univariate stats Compare pretest, Independent t-test Categorical, demographic, Chi-square & outcome variables Hypothesis testing ANCOVA

Findings of Statistical Significance : 

Findings of Statistical Significance Patients whose caregiver followed the new standards for pain management experienced significantly: Less pain at its least (p=.04) Less pain right now (p=.0001) Less interference by pain with general activity (p=.03), mood (p=.0001), relationships with others (p=.0001), sleep (p=.03), concentration ability (p=.0001), and enjoyment of life (p=.001)

Pain As It Occurs Right NowAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences : 

Pain As It Occurs Right NowAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-10 Scale P=0.0001

Effect of Pain on QOL Variables:Concentration AbilityAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences : 

Effect of Pain on QOL Variables:Concentration AbilityAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-10 Scale P=0.0001

Findings of Clinical Significance : 

Findings of Clinical Significance Patients whose caregiver followed the new standards for pain management experienced : Less interference by pain with walking ability (p=.07) Greater % satisfaction with nurse caregiver responsiveness to pain (p=.08)

% Satisfied with Health Care Provider Responsiveness to Reports on PainAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences : 

% Satisfied with Health Care Provider Responsiveness to Reports on PainAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-100% Scale P=0.0806

Trends in Data : 

Trends in Data Patients whose caregiver followed the new standards for pain management experienced : Less pain at its worst and on the average Greater % relief from interventions

Trends in Data (con’t) : 

Trends in Data (con’t) Family caregivers of patients whose nurse followed the new standards for pain management experienced less: sleep disturbances from patient’s pain overwhelming financial strain family adjustment upsetting symptoms changes to personal plans caused by pain time demands caused by pain feelings of confinement

Conclusions & Recommendations : 

Conclusions & Recommendations the effectiveness of the evidence-based standard for pain management the usefulness of the model to change clinician ‘s day to day practice The greater satisfaction with relief from interventions may be due to nurses assessing pain at more frequent Trends in caregiver burden need to be further studied.

Procedure: Step 6Dissemination of the New Standard : 

Procedure: Step 6Dissemination of the New Standard Publication in Clinical Journals Publication in Research Journals External Presentations at Conferences

Procedure: Step 6 con’tCelebrate Outcomes : 

Procedure: Step 6 con’tCelebrate Outcomes Emphasize contributions of all members during implementation of the project

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