Acute pain is a common experience among postoperative patients. Inadequate pain management contributes to the stress response, suboptimal wound healing, inability to deep breath and the risk for pneumonia, inability to ambulate contributing to deep vein thrombosis, and depression (Harsoor, 2011). Recent studies show that patients’ knowledge of postoperative pain management influences pain outcomes and is a practice issue appropriate for quality improvement (QI). The purpose of this paper is to discuss the context of this practice issue and identify theories, models, tools, resources, and evaluation methods for QI.
Background of the Practice Issue
Patients play a role in pain management by reporting information about their pain and participating in decisions with regard to pharmacologic and non-pharmacologic pain management strategies (O’Donnell, 2015). Preoperative education on pain enhances patient knowledge of the relationship between pain control and postoperative complications, treatment goals, the expected level of pain, pain reporting, and pain management options. Education also corrects misconceptions about pain medications and addresses culturally prescribed responses to pain. Pain education enhances safety from postoperative complications, improves the effectiveness of pain management, and promotes patient-centered care by considering the patient’s culture, needs, and preferences. Safe, effective, and patient-centered care is a hallmark of quality (IOM, 2010).
Theoretical Underpinning of Change
Rogers’ diffusion of innovation theory states that change occurs in three stages – awareness of the necessity of change, decision-making as to adopting or rejecting change, adopting the change to test it, and sustaining the change through continued use (Kaminski, 2014). Staff engagement is important because it permits the open communication of input from direct care workers and their receptiveness to information about the practice change. It creates a positive perception or outlook of preoperative pain education and the desire to be part of its planning and implementation. In addition, the staff need empowerment through enhanced knowledge and skills, adequate management support, and sufficient resources in order to enact the change. Engagement and empowerment generate a sense of common ownership of the QI project because of the collective investment of time, effort, and talent which, in turn, increases staff commitment to the practice change.
In addition, Rogers also proposed that practice change is more easily adopted when it is regarded as a relative advantage over the status quo and when it is easy to understand and implement (Kaminski, 2014). Staff education on why they need to provide preoperative pain education to patients and how they can accomplish this is warranted. There must also be guidelines, a standardized curriculum, and adequate resources for implementation. Change is also more acceptable when it is in line with the values, beliefs, and needs of the adopters and when there are associated tangible results. How change is compatible with the organization and profession’s mission, values, and ethics will be highlighted. Outcomes must also be communicated periodically to generate a sense of accomplishment.
The National Patient Safety Agency (NPSA) developed a root cause analysis (RCA) model that involves asking the following questions: “What happened? How did it happen? Why did it happen? What should be done to prevent it from happening again?” (Mengis & Nicolini, 2010, p.18). Asking these questions also involve assigning a priority level to the issue, creating a timeline, identifying the contributory factors and root cause/s, and developing an action plan for prevention (Mengis & Nicolini, 2010). The response to cases of suboptimal pain management will entail prioritization of the issue with regard to continuing quality improvement efforts and collecting data to create a timeline of the events prior to, during, and after each case. Doing so will establish that some patients failed to report pain or request for pain medications or indicated their preference for other methods of pain control. Further inquiry will reveal contributory factors to be misconceptions about pain medications, pain management preferences, and cultural beliefs that have not been taken into consideration during care planning. The root cause will then be identified as the lack of patient involvement in care planning and inadequate knowledge about pain.
Model for the Quality Improvement Project
The Plan-Do-Study-Act (PDSA) model can systematize the development and implementation of the QI initiative (McLaughlin, Johnson & Sollecito, 2012). It involves assessing learning needs, planning the content and sequence of topics, and identifying teaching strategies related to preoperative pain education for patients. Care planning will also be structured to elicit patient preferences for pain control. Subsequently, the intervention will be piloted among a small group of patients. The results of the pilot will be analyzed to determine if effectiveness of the QI intervention that will justify its adoption. In addition, piloting will aid in identifying weaknesses in project design allowing further improvements to the project (McLaughlin, Johnson & Sollecito, 2012). Following the pilot, the project team will then make the decision with regard to full-scale implementation of the QI.
Human resources include nurses capable of designing, delivering, monitoring, and evaluating the educational intervention and enhanced care planning. It also includes a multidisciplinary project team that will plan and implement the intervention. Structural resources include a room dedicated for preoperative patient education on pain and spaces where data on the progress of the project can be displayed to update the staff. Financial resources will cover written literature for patients, teaching aids, salaries for patient educators, and additional work hours for the project team.
Proposed Evaluation Method
Qualitative methods to determine effectiveness include interviews with patients and nurses while quantitative methods are clinical audits and surveys. Outcomes measures include the number of cases of suboptimal pain management, patient satisfaction with pain management, and level of patient engagement. These can be reported using a bar graph or run chart showing monthly measurements and trends over time. Process measures include the number of nurses dedicated to providing preoperative pain education, the number of patients who received the intervention, and the number of care plans that integrated patient preferences and decisions. Qualitative findings allow a more in-depth understanding of project impact. Interviews on patient and nurse experiences elucidate the quality of change management, leadership, teamwork, communication, and implementation that are difficult to quantify but provide insights on the strengths and weaknesses of project implementation that help explain the quantitative results.
Postoperative pain management can be further enhanced by providing patient education on pain and engaging them to participate in making decisions related to pain management strategies. Roger’s diffusion of innovation theory is a helpful guide to implementing the related practice change. Meanwhile, conducting a root-cause analysis helps generate a comprehensive understanding of suboptimal pain control and its relationship to patient knowledge and behaviors. Using the PDSA model provides an assurance of effectiveness and improved design prior to project implementation. It is also important to consider the human, financial, and structural resources needed especially in relation to organizational capacity. Finally, QI projects should be evaluated for outcome and process performance measures using a mix of qualitative and quantitative methods to ascertain the impact and identify areas of further improvement.
Harsoor, S.S. (2011). Emerging concepts in post-operative pain management. Indian Journal of Anaesthesia, 55(2), 101-103. doi: 10.4103/0019-5049.79872.
Kaminski, J. (2014). Diffusion of innovation theory. Canadian Journal of Nursing Informatics, 9(3-4). Retrieved from http://cjni.net/journal/?p=1444
McLaughlin, C.P., Johnson, J.K., & Sollecito, W.A. (2012). Implementing continuous quality improvement in health care. Sudbury, MA: Jones & Bartlett Learning.
Mengis, J., & Nicolini, D. (2010). Root cause analysis in clinical adverse events. Nursing Management, 16(9), 16-20. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20222226
O’Donnell, K.F. (2015). Preoperative pain management education: A quality improvement project. Journal of PeriAnesthesia Nursing, 30(3), 221-227. doi: http://dx.doi.org/10.1016/j.jopan.2015.01.013.