Reviewing and Researching the Management of Postoperative Pain
In spite of advances in pain management (Apfelbaum et al., 2003; Fotiadis et al., 2004; Powell et al., 2004; Wu and Richman, 2004), postoperative pain still remains a major clinical problem confronting healthcare providers (Klopfenstein etÂ al., 2000; Klopper et al., 2006; Sjöström, Dahlgren and Haljamäe, 1999). Many patients continue to experience postoperative pain (Gilmartin and Wright, 2007; Manias et al., 2005; Schafheutle et al., 2001) with about 69% of them experiencing moderate to severe pain after surgery (Apfelbaum et al., 2003).
According to the International Association for the Study of Pain (1979: 250), "pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage". This definition emphasises on the subjective nature of the pain experience which can be influenced by multiple factors (International Association for the Study of Pain, 2003). As a result of this, McCaffery (1983: 14) defines pain as "whatever the experiencing person says it is, existing whenever she says it does".
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Apart from pain signifying an actual or potential tissue damage, it is of no significance and leads to detrimental effects (Apfelbaum et al., 2003). Unrelieved postoperative pain can lead to disturbed emotional states, sleep deprivation, reduced physical and social performance, impaired quality of life (Reyes-Gibby, Aday and Cleeland, 2002; Strassels, Cynn and Carr, 2000), patient dissatisfaction (Shang and Gan, 2003), delayed discharge (Rejeh et al, 2008), increased use of healthcare resources (Fortner et al., 2003; Mystakidou et al., 2005; O'Mahony et al., 2005) and its associated high costs of hospitalisation (Huang et al., 2001).
From an ethical point of view, postoperative pain should be properly managed to prevent needless suffering and avoidable complications (Kehlet, 1989), so as to increase function and to improve the quality of life (Goudas et al., 2001; Reyes-Gibby et al., 2002; Strassels et al., 2000). Notwithstanding several barriers prevent the successful management of pain.
The aim of this proposal is to justify the need for a study that will explore the barriers to effective postoperative pain management from a multidisciplinary health team approach. The proposal will commence with a literature review on barriers to effective pain management followed by the appropriate research methodology that can be used in carrying out the study. Finally, the contributions of the research in filling the gaps of previous studies will be discussed.
In spite of numerous studies conducted on the different aspects of pain, the factors that affect pain management have not been completely identified (Rao, 2006). Greater research efforts are therefore required to identify the factors that affect the effective management of pain (Weissman et al., 2004). Barriers to effective pain management have been classified into that of the patient, clinician and the healthcare system (Cleeland, 1987; Joranson, 1993; Von Roenn et al., 1993; Ward et al., 1993;).
Specifically, patient-related barriers have been categorised into communication (Glajchen et al., 1995), psychological (Glajchen, 2001) and attitudinal factors (Ward et al., 1993). According to Im, Guevava and Chee (2007), there is poor patient communication concerning pain and undermedication due to language barrier and insufficient money to purchase additional drugs. Psychological issues such as anxiety, distress, depression, anger and dementia have also been shown to cloak the symptoms of pain leading to poor pain management (Glajchen, 2001). Also, patient attitudes serve as the greatest impediment to the effective management of pain. These include fear of addiction (Dar et al., 1992; Ferrell, 1991; Melzak, 1990), tolerance (McCaffery and Beebe, 1989), side effects (Levin et al., 1985), fear of injections (Twycross and Lack, 1984), feelings of fatalism (Diekmann et al., 1989; Levin et al., 1985), association of pain with worsening disease states (Diekmann et al., 1989; Twycross and Lack, 1984), belief that pain is inevitable and unmanageable (Ward et al., 1993), fear of distracting clinicians from treatment focus (Cleeland, 1987; Diekmann et al., 1989) and the desire to please clinicians (Cleeland, 1987; Twycross and Lack, 1984).
On the other hand, insufficient knowledge, poor pain assessment skills, negative attitudes and physician reluctance to prescribe analgesics have also been shown as some of the clinician-barriers to effective pain management (Cleeland, 1993; Von Roenn et al, 1993). A study conducted in Iran revealed that institutional policies and regulations, limited time, poor communication, work overload, powerful physicians and the subjection faced by the nursing profession are some of the nursing-related barriers to postoperative pain management (Rejeh et al., 2008). Another study conducted by Rejeh et al. (2009) also depicted nurses' limited authority, poor patient relationship, inadequate educational preparation and the interruptions in pain management measures serve as impediments in the effective management of postoperative pain in Iran.
Some of the barriers in the healthcare system include strict regulatory scrutiny (Cleeland et al., 1994), changes in reimbursement policies (in cases where older patients have to pay for the cost of outpatient prescription drugs) (Glajchen et al., 1995), the lack of neighbourhood pharmacies, poor means of transportation and the absence of higher doses of opioids in the health system (Glajchen, 2001). Ultimately, these factors lead to inappropriate selection of analgesics and its subsequent poor management of patients' pain (Glajchen, 2001).
It can be realised from the literature that, most of the barrier-related studies on pain have mainly been in the form of quantitative studies conducted on chronic conditions such as cancer(Glajchen et al., 1995; Glajchen, 2001; Im et al., 2007; Joranson, 1993; Ward et al., 1993) and AIDS (Brietbart et al., 1998). This approach often leaves the reader in questioning why and how these factors serve as barriers. Moreover, studies conducted on clinician-related barriers (Rejeh et al., 2008; Rejeh et al., 2009; Van Niekerk and Martin, 2003; Von Roen et al., 1993) have always taken a uni-modal approach (either physicians or nurses) while neglecting other professionals such as the anaesthesiologist/ anaesthetist who also play a part in postoperative pain management. By virtue of this, a comprehensive understanding of the barriers that are faced by the multidisciplinary health team involved in postoperative pain management will enable a more targeted approach to improved patient care (Manias etÂ al. 2005; Schafheutle etÂ al. 2001).
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My research seeks to gain an in-depth understanding of the factors that impede the effective management of postoperative pain from a multidisciplinary health team approach. As a result, a qualitative design will be most appropriate in the conduction of the study in Ghana. The reason for choice of the location is that no previous studies have been conducted on the issue in this geographical area.
Prior to the commencement of the study, ethical approval will have to be sought from the various ethics committees of the hospitals that would be included in the study. Some of the ethical issues such as the participant's autonomy, confidentiality and anonymity during the study period will be addressed appropriately. All participants would be informed of the purpose and design of the study, as well as the voluntary nature of their participation. Informed consent will be obtained from the participants in the form of writing and will be signed by them to serve as evidence for their voluntary participation.
Semi-structured interviews will be used in collecting the data so as to gain in-depth information to specific questions (Hove and Anda, 2005). Like most qualitative studies, the findings of this study cannot be generalised to other settings but would provide rich information on the barriers faced by health care professionals in managing postoperative pain. This will then pave the way for appropriate strategies to be implement in solving this problem.Â Â
Healthcare professionals with a minimum of 5-year working experience in surgical units, in major hospitals in each region of Ghana would be included in the study. The reason is to acquire professionals who have sufficient work experience to enable them analyse barriers affecting the management of post-operative pain. Also, purposeful sampling technique will be used for recruiting participants in this study.
In the conduct of this study, data collection and analysis will proceed concurrently until the development of themes related to health professionals' barriers affecting post-operative pain management is achieved. Data collected will be analysed using content analysis (Morse and Field 1995; Sandelowski, 2000) to generate codes, categories and themes. By means of theoretical sampling, additional participants will be selected until theoretical saturation is achieved and no new information emerges. Â
Participants will be contacted after the analysis and will be given a full transcript of their respective coded interviews with a summary of the emergent themes to determine whether the codes and themes matched their stated barriers. Maximum variation of sampling (in terms of the type of profession, years of working experience) will also enhance the conformability and credibility of data. This sampling strategy will enable the me to capture a vast range of views and experiences (Streubert and Carpenter 2003).
Contributions of the Research
Conducting a research is not an end in itself, but a means to an end. As a way of finding solutions to the problem of ineffective postoperative pain management, it will be prudent to understand the causes of these barriers so as to devise appropriate strategies.
The success or failure of pain management largely depends on factors that influence the health professionals' practical care for patients with post-operative pain. The findings of this study will provide insights into the factors that affect the management of postoperative pain from a multidisciplinary health team approach. By so doing, it will not only integrate diverse perceptions but also incorporate other key stakeholders in postoperative pain management (anaesthesiologist/anaesthetist) who have been left out in previous studies.
Moreover, the proposed study will contribute to already existing literature by giving appreciable insights on the factors that affect the entire health team in the management of postoperative pain. Also, the involvement of the major stakeholders in postoperative pain management will stimulate the interest of each of the professionals groups thereby enlightening each other about the barriers and how they can be solved. Ultimately, this will improve patient care, enhance staff satisfaction and boost the integrity of our health institutions.
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