Tag Archives: pain

Ouch! Whose Pain Feels Worse?

levels-of-evidenceIs pain experience as diverse as our populations?  This week I came across an interesting meta-analysis.

A meta-analysis (MA) is one of the strongest types of evidence there is. Some place it at the top; others, 2nd after evidence-based clinical practice guidelines.  (For more on strength of  evidence, click here.)

MA is not merely a review of literature, but is a statistical integration of studies on the same topic.  MA that is based on integration of randomized controlled trials experiment(RCTs) or experimental studies is the strongest type of MA.  MA based on descriptive or non-experimental studies is  a little less strong, because it just describes things as they seem to be; & it cannot show that one thing causes another.

MA example: This brand, new MA included 41  peer-reviewed, English-language, experimental studies with humans:  Kim HJ, Yang GS, Greenspan JD, Downton KD, Griffith KA, Renn CL, Johantgen M, Dorsey SG. Racial and ethnic differences in experimental pain sensitivity: Systematic review and meta-analysis. Pain. 2016 Sep 24 [Epub ahead of print] doi: 10.1097/j.pain.0000000000000731. PMID: 27682208.    All 41 studies used experimental pain stimuli such as heat, cold, ischemic, electrical and others and compared differences between racial/ethnic groups.

Pain reliefMain findings?  “AAs [African Americans], Asians, and Hispanics had higher pain sensitivity compared to NHWs [non-Hispanic Whites], particularly lower pain tolerance, higher pain ratings, and greater temporal summation of pain.” (https://www.ncbi.nlm.nih.gov/pubmed/27682208)  (Temporal summation is the increase in subjective pain ratings as a pain stimulus is repeated again and again.)

Critical thinking:  Given that this is a well-done meta-analysis and that the pain was created by researchers in each study, how should this changequestion your practice?  Or should it?   How can you use the findings with your patients?  Should each patient be treated as a completely unique individual? Or what are the pros & cons of using this MA to give us a starting point with groups of patients?  [To dialogue about this, comment below.]

For more info? Request the full Kim et al. article via interlibrary loan from your med center or school Heart Bookslibrary using reference above.   It is available electronically pre-publication.   Also check out my blog on strength of different types of evidence.

Happy evidence hunting. -Dr.H

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Stand & Deliver: Evidence for Empathy in Action

Patient Pain Satisfaction.  It’s a key outcome of RN empathy in action.CARE

Imagine that you are hospitalized and hurting.   During hourly rounds the RN reassures you with these words:We are going to do everything that we can to help keep your pain under control. Your pain management is our number 1 priority. Given your [condition, history, diagnosis, status], we may not be able to keep your pain level at zero. However, we will work very hard with you to keep you as comfortable as possible.” (Alaloul et al, 2015, p. 323).

Study? In 2015 a set of researchers tested effectiveness of the above pain script using 2 similar medical-surgical units in an academic medical center—1 unit was an experimental unit & 1 was a control unit.  RNs rounded hourly on both units.  handsOn the experimental unit RNs stated the script to patients exactly as written and on room whiteboards posted the script, last pain med & pain scores.  Posters of the script were also posted on the unit.   In contrast, on the control unit RN communication and use of whiteboard were dependent on individual preferences.  Researchers measured effectiveness of the script by collecting HCAHPS scores 2 times before RNs began using the script (a baseline pretest) and then 5 times during and after RNs began using it (a posttest) on both units.

Results? On the experimental units significantly more patients reported that the team was doing everything they could to control pain and that the pain was well-controlled (p≤.05). And while experimental unit scores were trending up, control unit scores trended down. Other findings were that the RNs were satisfied with the script, and that RNs having a BSN or MSN had no effect.

Conclusions/Implications?When nurses used clear and consistent communication with patients in pain, a positive effect was seen in patient satisfaction with pain management over time. This intervention was simple and effective. It could be replicated in a variety of health care organizations.” (p.321) [underline added]

Commentary: While an experiment would have created greater confidence that the script caused the improvements in patient satisfaction, an experiment would have been difficult or impossible.  Researchers could not randomly assign patients to experimental & control units.  Still, quasi-experimental research is relatively strong evidence, but it leaves the door open that something besides the script caused the improvements in HCAHPS scores.

questionCritical thinking? What would prevent you from adopting or adapting this script in your own personal practice tomorrow?  What are the barriers and facilitators to getting other RNs on your unit to adopt this script, including using whiteboards?  Are there any risks to using the script?  What are the risks to NOT using the script?

Want more info? See original reference – Alaloul, F., Williams, K., Myers, J., Jones, K.D., & Logsdon, M.C. (2015).Impact of a script-based communication intervention on patient satisfaction with pain management. Pain Management Nursing, 16(3), 321-327. http://dx.doi.org/10.1016/j.pmn.2014.08.008