Challenges of pain management for the 21st century.
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Clinical Competence↗
Biomedical subjects
Kate Seers
Publications and source records attributed to Kate Seers.
A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment.
The aim of the study was to compare five different pain assessment scales for use with people with different levels of cognitive impairment who resided in nursing homes. The verbal rating scale, horizontal numeric rating scale, Faces pictorial scale, color analogue scale and mechanical visual analogue scale were presented in random order to 113 residents. Cognitive impairment was assessed using the Mini-Mental State Examination. The use of the verbal rating scale was the most successful with this group, completed by 80.5% overall, and 36% of those with severe cognitive impairment. Repeated explanation improved completion rates for all the scales. Consistency between scores on the five scales was good for those with none to moderate cognitive impairment and poor for those severely impaired. This study showed no difference in pain scores according to cognitive status.
Aged↗
Clinical validation of the paediatric pain profile.
The Paediatric Pain Profile (PPP) is a 20-item behaviour rating scale designed to assess pain in children with severe neurological disability. We assessed the validity and reliability of the scale in 140 children (76 females, mean age 9 years 11 months, SD 4 years 7 months; range 1 to 18 years), unable to communicate through speech or augmentative communication. Parents used the PPP to rate retrospectively their child's behaviour when 'at their best' and when in pain. To assess interrater reliability, two raters concurrently observed and individually rated each child's behaviour. To assess construct validity and responsiveness of the scale, behaviour of 41 children was rated before and for four hours after administration of an 'as required' analgesic. Behaviour of 30 children was rated before surgery and for five days after. Children had significantly higher scores when reported to have pain than 'at their best' and scores increased in line with global evaluations of pain. Internal consistency ranged from 0.75 to 0.89 (Cronbach's alpha) and interrater reliability from 0.74 to 0.89 (intraclass correlation). Sensitivity (1.00) and specificity (0.91) were optimized at a cut-off of 14/60. PPP score was significantly greater before administration of the analgesic than after (paired-sample t-tests, p<0.001). Though there was no significant difference in mean pre- and postoperative scores, highest PPP score occurred in the first 24 hours after surgery in 14 (47%) children. Results suggest that the PPP is reliable and valid and has potential for use both clinically and in intervention research.
Adolescent↗
Comfort on a ward for older people.
BACKGROUND: Comfort is often considered to be a central part of nursing, although the value placed on it may have diminished over time. Many views of comfort are expressed in the literature but it still remains a diffuse concept that requires further clarification. Research evidence about older people and comfort is limited, and further work is needed to find out how staff and patients view comfort and how it is achieved in practice. AIMS: This paper reports a study to investigate what comfort means both to older people in hospital and their health care workers. RESEARCH METHODS: Ethnography was the methodology chosen, and data were collected using in-depth interviews with 19 older people and 27 staff members, and 130 hours of participant observation, complemented by additional weekly visits to the study ward. FINDINGS: Three themes were identified: the nature of comfort/discomfort; key determinants of comfort/discomfort; and the underlying factors that influence the achievement of comfort/discomfort. DISCUSSION: In this hospital setting, the focus of nursing on relief of discomfort suggested a tendency to react to problems, rather than proactively to create an environment that facilitated comfort. Staff were aware of ideals of practice but found these difficult to achieve in reality. In this study comfort was not consistently provided, and some ways of working actively promoted discomfort. As comfort is central to nursing and nursing is central to the care of hospitalized older people, it is crucial that practitioners are enabled to fulfil their potential in this area.
Aged↗
What counts as evidence in evidence-based practice?
BACKGROUND: Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. AIM: This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. DISCUSSION: Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. CONCLUSION: Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.
Decision Making↗
An exploration of the factors that influence the implementation of evidence into practice.
BACKGROUND: The challenges of implementing evidence-based practice are complex and varied. Against this background a framework has been developed to represent the multiple factors that may influence the implementation of evidence into practice. It is proposed that successful implementation is dependent upon the nature of the evidence being used, the quality of context, and, the type of facilitation required to enable the change process. This study sets out to scrutinize the elements of the framework through empirical enquiry. AIMS AND OBJECTIVES: The aim of the study was to address the following questions: * What factors do practitioners identify as the most important in enabling implementation of evidence into practice? * What are the factors practitioners identify that mediate the implementation of evidence into practice? * Do the concepts of evidence, context and facilitation constitute the key elements of a framework for getting evidence into practice? DESIGN AND METHODS: The study was conducted in two phases. Phase 1: Exploratory focus groups (n = 2) were conducted to inform the development of an interview guide. This was used with individual key informants in case study sites. Phase 2: Two sites with on-going or recent implementation projects were studied. Within sites semi-structured interviews were conducted (n = 17). RESULTS: A number of key issues in relation to the implementation of evidence into practice emerged including: the nature and role of evidence, relevance and fit with organizational and practice issues, multi-professional relationships and collaboration, role of the project lead and resources. CONCLUSIONS: The results are discussed with reference to the wider literature and in relation to the on-going development of the framework. Crucially the growing body of evidence reveals that a focus on individual approaches to implementing evidence-based practice, such as skilling-up practitioners to appraise research evidence, will be ineffective by themselves. RELEVANCE TO CLINICAL PRACTICE: Key elements that require attention in implementing evidence into practice are presented and may provide a useful checklist for future implementation and evaluation projects.
Diffusion of Innovation↗
International content of high-ranking nursing journals in the year 2000.
PURPOSE: To evaluate the extent of an international perspective in publication in nursing journals. DESIGN: Characteristics of 2,581 articles, authors of articles, and journals (editorial purpose and editorial team) of 42 high-ranking nursing journals for the year 2000 were analyzed. METHODS: The characteristics were assessed using seven operational definitions of "international." FINDINGS: Major findings were: (a) 747 (28.9%) articles were identified as international, of which (b) 705 (94.3%) were placed in the scholarly or empirical categories; (c) more articles were categorized as empirical in the international articles; more articles were categorized as scholarly among the noninternational articles; (d) 763 (79.3%) articles met an international definition based on author characteristics; and (e) 20 (47.6%) journals had international editorial teams. CONCLUSIONS: Nearly 30% of articles had international content. Articles with international content were more frequently databased than were noninternational articles. The study provides a baseline indication of the extent of international perspectives in published articles in nursing journals. The extent to which these international articles make substantial contributions to knowledge has yet to be discovered.
Authorship↗
Review: single dose, oral paracetamol reduces moderate to severe postoperative pain.
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Comment↗
Not knowing--the problem of pain in children with severe neurological impairment.
This study uses a grounded theory approach to explore the diagnostic and clinical decision-making processes used by parents and healthcare professionals in relation to pain in children with severe to profound neurological impairment. Three forms of knowledge are required for optimal pain assessment and management (1) knowing the child, (2) familiarity with children with the same or similar conditions and (3) knowing the science. Pain relief can be compromised by systems of care that fragment rather than integrate care. A model which integrates knowledge of child, population and science is proposed together with an intersubjective attitude to assessing pain.
Adolescent↗
An exploration of the concept of comfort.
This paper explores the concept of comfort within conceptual frameworks that identify comfort as a key component. The paper focuses on two main issues: firstly, descriptions of comfort and how comfort is defined; secondly, the relationship between comfort and other core concepts and how it is similar to, or differs from these concepts. The descriptions of comfort identify the difficulty of defining comfort and note that historical interpretations of comfort have changed over time. Key authors provide different perspectives of comfort and hence a uniform definition is not evident. The degree to which patients' perspectives are represented varies within the frameworks which suggests that further clarity is needed in this area. The relationship between comfort and other concepts considers the boundaries between comfort and two concepts: nursing as therapy and caring. Comfort tends to be seen as a minor aspect of these concepts focusing on relief of discomfort or actions that demonstrate caring. The paper concludes that there is a lack of clarity around the use of the term comfort which fits with a view of comfort as an emerging concept. Descriptions of comfort are clearly evident in the literature but differ in relation to the authors' views of nursing. The relationship between comfort and nursing as therapy and caring is also complex and highlights the debate in relation to comfort as a part of caring or as the overall focus of care.
Empathy↗
Getting evidence into practice: the role and function of facilitation.
AIM OF PAPER: This paper presents the findings of a concept analysis of facilitation in relation to successful implementation of evidence into practice. BACKGROUND: In 1998, we presented a conceptual framework that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice. One of the three elements of the framework was facilitation, alongside the nature of evidence and context. It was proposed that facilitators had a key role in helping individuals and teams understand what they needed to change and how they needed to change it. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide theoretical and conceptual clarity. METHODS: The concept analysis approach was used as a framework to review critically the research literature and seminal texts in order to establish the conceptual clarity and maturity of facilitation in relation to its role in the implementation of evidence-based practice. FINDINGS: The concept of facilitation is partially developed and in need of delineation and comparison. Here, the purpose, role and skills and attributes of facilitators are explored in order to try and make distinctions between this role and other change agent roles such as educational outreach workers, academic detailers and opinion leaders. CONCLUSIONS: We propose that facilitation can be represented as a set of continua, with the purpose of facilitation ranging from a discrete task-focused activity to a more holistic process of enabling individuals, teams and organizations to change. A number of defining characteristics of facilitation are proposed. However, further research to clarify and evaluate different models of facilitation is required.
Diffusion of Innovation↗
Getting evidence into practice: the meaning of 'context'.
AIM OF PAPER: This paper presents the findings of a concept analysis of 'context' in relation to the successful implementation of evidence into practice. BACKGROUND: In 1998, a conceptual framework was developed that represented the interplay and interdependence of the many factors influencing the uptake of evidence into practice [Kitson A., Harvey G. & McCormack B. (1998) Quality in Health Care 7, 149]. One of the key elements of the framework was 'context', that is, the setting in which evidence is implemented. It was proposed that key factors in the context of health care practice had a significant impact on the implementation and uptake of evidence. As part of the on-going development and refinement of the framework, the elements within it have undergone a concept analysis in order to provide some theoretical and conceptual rigour to its content. METHODS: Morse's [Morse J.M. (1995) Advances in Nursing Science 17, 31; Morse J.M., Hupcey J.E. & Mitcham C. (1996) Scholarly Inquiry for Nursing Practice. An International Journal 10, 253] approach to concept analysis was used as a framework to review semi-nal texts critically and the supporting research literature in order to establish the conceptual clarity and maturity of 'context' in relation to its importance in the implementation of evidence-based practice. FINDINGS: Characteristics of the concept of context in terms of organizational culture, leadership and measurement are outlined. A main finding is that context specifically means 'the setting in which practice takes place', but that the term itself does little to reflect the complexity of the concept. Whilst the themes of culture and leadership are central characteristics of the concept, the theme of 'measurement' is better articulated through the broader term of 'evaluation'. CONCLUSIONS: There is inconsistency in the use of the term and this has an impact on claims of its importance. The concept of context lacks clarity because of the many issues that impact on the way it is characterized. Additionally, there is limited understanding of the consequences of working with different contexts. Thus, the implications of using context as a variable in research studies exploring research implementation are as yet largely unknown. The concept of context is partially developed but in need of further delineation and comparison.
Culture↗
Review: intensive multidisciplinary biopsychosocial rehabilitation reduces pain and improves function in chronic low back pain.
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Comment↗
Getting evidence into practice: ingredients for change.
Mounting pressure is being exerted to ensure that the delivery of care is evidence-based and clinically effective. However, the challenge this presents to practitioners is complex. The authors propose that successful implementation of evidence into practice is a function of three elements: the nature of the evidence; the context in which the change is to take place; and the way the process is managed. A framework has been developed to represent these factors. For those about to embark on implementation work, this article closes by highlighting a number of key questions for consideration, stimulated by the framework.
Delivery of Health Care↗