Strategies to increase research-based practice: interplay with unit culture.

PURPOSE: A major focus of clinical nurse specialist nursing practice is the integration of research findings into practice. The purpose of this study was to describe strategies used to facilitate research utilization (RU) by nurses in a practice setting. DESIGN: This multiple-case study identified the strategies that clinical nurse specialists and master's degree-prepared nurse educators, working collaboratively, used to facilitate RU. SETTING/SAMPLE: The setting included 8 units in 4 sites of a university hospital with all willing nurses participating. METHODS: Open-ended focus groups and individual interviews and observational sessions were conducted using investigator-designed interview guides. Comprehensive qualitative analysis led to identification of categories and themes related to RU and the unit culture that supported it. FINDINGS: Findings demonstrated that strategies to facilitate RU by staff at the unit level included conducting original research, supporting nurses participating in research, assessing and meeting staff learning needs, promoting staff attendance at conferences, stimulating goal-setting for presentations and publications, encouraging and responding to new ideas, questioning practice and stimulating inquiry, capitalizing on expertise in research knowledge and skills, and generating information and material resources. Characteristics of unit culture were linked to varying degrees of success with these strategies. The interplay of strategies with unit culture and research-based practice is described. CONCLUSION: A wide repertoire of strategies is needed to facilitate RU, and the outcome of these strategies is influenced by the unit culture. IMPLICATIONS FOR PRACTICE: Consideration of the findings and the scope of the strategies used by nurses in the study can help clinical nurse specialist and other nursing leaders facilitate the building of practice on research.

Pain in the emergency department with one-week follow-up of pain resolution.

OBJECTIVES: To determine the intensity of pain in the emergency department (ED), the use of analgesics in relation to pain intensity, which patients are at risk for unresolved pain at one week post-discharge, and the postdischarge treatment of pain. METHODS: Patients (n=871) admitted to two urban, university-affiliated EDs who were experiencing any pain were recruited on different shifts over the summer months of 1997. Pain intensity was self-reported, and chart reviews of the assessment, immediate treatment and follow-up prescriptions were conducted. Patients (n=699) were contacted one week later, and reports of pain intensity, activity, resuming normal functions and patient attitudes toward pain were documented. Descriptive and regression analyses were performed on the results of patients with complete data (n=585). RESULTS: Mean pain intensity on admission was 6.0 (SD=2.5) on a zero to 10 visual analogue scale, and 5.0 (SD=2.9) at discharge (n=871). One-quarter (23%) of patients were given analgesics while in the ED; their mean pain intensity was 7.0 (95% CI 6.7 to 7.3) versus 5.7 (95% CI 5.5 to 5.9) for those who were not given analgesics (P<0.001). At one week, the mean intensity for worst pain in the past 24 h was 5.2 (SD=2.9) and the usual pain intensity was 3.7 (SD=2.6). Using a cutoff point of pain greater than three on the zero to 10 visual analogue scale as residual pain at one week, 35% (n=207) remained in pain, with musculoskeletal pain accounting for half (n=102) of those cases. Logistic regression showed that the following patients were most likely to have pain at one week: women; those with pain present longer than 48 h before ED visit; those with a high discharge pain rating; those who were taking analgesics; and those who had pain of musculoskeletal origin. Both the attitudes and beliefs about pain and the treatment of pain while in the ED or on discharge were unrelated to the presence of residual pain at one week. An examination of the same factors in relation to the return to normal activities found that they were similar, with the exception that admission and not discharge pain intensity was predictive of not returning to normal activities. CONCLUSIONS: More than one-third of patients presenting to the ED with pain do not experience resolution of their pain. Women presenting with severe musculoskeletal pain of more than a week in duration are less likely to have resolution of their pain and to return to normal activities within a week of the ED visit.

Self-reported pain intensity and associated distress in children aged 4-18 years on admission, discharge, and one-week follow up to emergency department.

OBJECTIVES: Pain is the most common complaint among children presenting to the Emergency Department (ED), yet it is poorly managed. Although the poor management of pain has been documented, no studies have simultaneously determined the distress caused by the presenting pain nor have children been followed after the ED visit to determine whether the pain and distress have resolved. The purpose of this study was to describe pain intensity, distress from pain, and treatment of pain in children presenting to the ED and to follow them 1 week later to describe resolution of their pain. METHODS: A survey design with follow up of patients identified with pain in 2 urban university-affiliated pediatric EDs with children between ages 4 and 18 (N = 533). Measures used included the Coloured Analogue Scale (CAS) for both pain and distress related to pain, mobility problems related to pain, and interference with activities of daily living due to pain. Chart reviews were conducted for documentation of pain assessment and analgesic administration and prescription at discharge. RESULTS: Half of the children presenting were experiencing pain due to musculoskeletal injury and two-thirds of the pain problems had an onset within 48 hours of presentation to the ED. Mean pain intensity on admission was 5.2 (SD 2.3) and at discharge was 4.1 (SD 2.7), however, 22% had worsening of pain and for 26%, the pain remained the same. On admission, 12.8% reported pain intensity 8/10 or more but 23% reported distress levels 8/10 or more. Only 39% received analgesics during the visit and 11% were given a prescription for analgesics at discharge. Children (n = 104) were reached 1 week following discharge from ED and only 5% were reporting pain of 4/10 or more but, of those reporting any pain at all, 34% reported distress from their pain of 4/10 or more. CONCLUSIONS: A greater proportion of children report high intensity of distress from pain than of pain intensity itself when in the ED. Only a small proportion of children received analgesics during the visit to the ED and only slightly more on discharge. Although pain seems to resolve by 1 week, distress is less likely to have resolved. More attention needs to be paid both to pain children are experiencing in the ED and equally to the accompanying distress.

Unit culture and research-based nursing practice in acute care.

The purpose of this multiple-case study of research utilization (RU) was to examine whether and how nursing practices in acute-care units are built on research and to identify potential explanations for the observed patterns. Open-ended data were collected from staff nurses and nursing leaders on 8 acute-care units through interviews and observation. RU varied within and across units, but unit culture emerged as the principal factor linked to patterns of RU. Unit-culture themes that formed the links were harmony of research perspective, motivation to learn, goal orientation, creativity, critical inquiry, mutual respect, and maximization of resources. The findings provide a rich description that could serve as a basis for self-assessment of unit culture in inpatient and outpatient acute-care units.