qualitative nursing research

qualitative nursing research

Paper instructions:
This is not a paper. There are about ten questions that need to be answered after reading an article, however, You MUST have knowledge in qualitative research in nursing to answer these questions effectively.

 

QUALITATIVE CRITIQUE ARTICLE
• Select an article to work with. Be sure that is not an integrated summary, review of the literature, state of the science paper or meta-analysis.
• Type your answers directly into the discussion board. Don’t attach it as a document.
• Post the reference, using APA format, for your article immediately in the discussion board – NO duplications allowed. Your next posting should include the following:
1. In the discussion, summarize the research question
2. Summarize the findings.
3. Briefly discuss the choice of research approach, i.e., was a qualitative research approach suitable for the phenomenon being studied?
4. Identify another way that the data could have been collected.
5. List at least three key themes that emerged from the study.
6. List one more question that you would like to have asked of the research subjects.
7. How could you use this study’s findings in your nursing practice?
8. Suggest the most appropriate method of disseminating the findings of this study. . Pay attention of how the points are dispersed to see where you should place your greatest efforts.

Grading Rubric
CRITERIA POINT VALUE POINTS EARNED COMMENTS
1. Research question summarized 10
2. Summary of findings 10
3. Discussion of research approach 10
4. Identify another way the data could have been collected 5
5. Three key themes identified 10
6. One question that you would have asked 5
7. How could you apply the study to your nursing practice? 15
8. What do you think is the most appropriate method of disseminating the findings of this study?
10
9. Posted timely responses to two classmates 5
10. Described an appropriate application of both classmates’ selected articles. 20
TOTAL 100

Barriers to, and facilitators of post-operative
pain management in Iranian nursing:
a qualitative research study
N. Rejeh1 BScN, RN, MScN, F. Ahmadi2 BScN, RN, MScN, PhD,
E. Mohammadi2 BScN, RN, MScN, PhD, M. Anoosheh3 BScN, RN, MScN, PhD
& A. Kazemnejad4 BSc, MSc, PhD
1 PhD Student, 2 Associate Professor, 3 Assistant Professor, 4 Full Professor, Faculty of Medical Sciences,Tarbiat Modares
University,Tehran, Iran
REJEH N., AHMADI F., MOHAMMADI E., ANOOSHEH M. & KAZEMNEJAD A. (2008) Barriers to, and
facilitators of post-operative pain management in Iranian nursing: a qualitative research study. International
Nursing Review 55, 468–475
Background: Unrelieved post-operative pain continues to be a major clinical challenge, despite advances in
management. Although nurses have embraced a crucial role in pain management, its extent is often limited in
Iranian nursing practice.
Aim: To determine Iranian nurses’ perceptions of the barriers and facilitators influencing their management
of post-operative pain.
Methods: This study was qualitative with 26 participant nurses. Data were obtained through semi-structured
serial interviews and analysed using the content analysis method.
Findings: Several themes emerged to describe the factors that hindered or facilitated post-operative pain
management. These were grouped into two main themes: (1) barriers to pain management after surgery
with subgroups such as powerlessness, policies and rules of organization, physicians leading practice, time
constraints, limited communication, interruption of activities relating to pain, and (2) factors that facilitated
post-operative pain management that included the nurse–patient relationship, nurses’ responsibility, the
physician as a colleague, and nurses’ knowledge and skills.
Conclusion: Postoperative pain management in Iran is contextually complex, and may be controversial.
Participants believed that in this context accurate pain management is difficult for nurses due to the barriers
mentioned. Therefore, nurses make decisions and act as a patient comforter for pain after surgery because of
the barriers to effective pain management.
Keywords: Iran, Nursing, Patient, Post-operative Pain Management, Qualitative Research
Introduction
Pain and its management remain one of the major clinical problems
confronting healthcare professionals in general and specifically
in surgery settings (Klopfenstein et al. 2000; Klopper et al.
2006). Continuing pain is associated with morbidity and delayed
discharge. Delayed healing, higher complication rates, anxiety,
sleep disturbance, increased suffering and lowered quality of life
are also significant sequelae (Sherwood et al. 2003). Numerous
studies have demonstrated the inadequacy of pain management.
Despite decades of research and the availability of effective
analgesic approaches, many patients continue to experience
Correspondence address: Fazlollah Ahmadi, Department of Nursing, Tarbiat
Modares University, P.O. Box 14155-4838, Tehran, Islamic Republic of Iran;
Tel: +9821-88011001 (ext: 3550,3553); Fax: +9821-88006544;
E-mail: ahmadif@modares.ac.ir.
Original Article
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses 468
moderate to severe pain following surgery (Gilmartin & Wright
2007; Manias et al. 2005; Schafheutle et al. 2001).
Greater research efforts are needed to identify the factors that
impede or facilitate effective pain management (Weissman et al.
2004). Despite the fact that a variety of research and clinical
studies on all aspects of pain have been conducted in many
countries, the factors affecting pain management have not been
completely identified (Rao 2006). Pain and its management have
been a fairly low priority for receiving time and attention from
healthcare professionals, and nurses seemed to place a lower
priority on activities that directly impacted a patient’s comfort,
such as administering analgesics in an appropriate time frame
(Manias 2003a; Richards & Hubbert 2007). The majority of
studies surrounding the issues of pain management are of a
quantitative nature, with considerably fewer using a qualitative
design (Carr 1999; Clark et al. 2006). A qualitative approach is
valuable for exploring work demands in clinical areas and levels
of accountability surrounding pain management (Rees 2000;
Richards & Hubbert 2007). On the other hand, a comprehensive
understanding of how contextual issues affect pain management
will enable a more comprehensive and targeted approach to
better care (Manias et al. 2005; Schafheutle et al. 2001). Furthermore,
published studies have not explored the interplay between
barriers posed by nurses themselves (ones they may not be aware
of), and those created by the ward setting and policies, within
which they practise (barriers nurses are likely to recognize).
Background: pain management in Iran
There is no qualitative research on pain management in Iran that
gives data and analysis on ‘pain and pain management’. In the
accreditation of hospitals, pain and the evaluation of patients’
pain are not taken into account; there are no acute pain teams;
and there has been no exact algorithm or protocol to address the
problems of post-operative pain.
The only method for controlling post-operative pain in the
surgical wards is pharmacological interventions, and other ways
to prevent pain and the use of non-pharmacological methods are
not popular. Usually, analgesia is prescribed p.r.n. (as required)
by the surgeons in the operating room without any type of systematic
assessment and documentation of pain by the nursing
staff. There is no formal chart for the recording and reporting
of pain.
A non-governmental organization started work in this field in
1993, but its projects have only been encouraged at conferences
and seminars on the topic of pain but do not appear to influence
practice. Therefore, the persistence of this problem provided
the motivation for the investigator to study this area of nursing
practice from a perspective that differed to those taken previously.
This article reports the findings on the barriers and
facilitators that Iranian registered nurses perceive to affect their
post-operative pain management.
The study
Aim
To determine Iranian nurses’ perceptions of the barriers and
facilitators influencing their management of post-operative pain.
Method and participants
A qualitative approach was adopted using semi-structured interviews
with Iranian nurses. The sample consisted of 26 nurses (16
nurses, four head nurses and four supervisors, and two matrons)
all working in general surgery wards in three educational hospitals
in Tehran city. Purposeful sampling was used for the initial
interviews and, according to the emerging codes and categories
data was collected by means of theoretical sampling.
Sampling was targeted based on a set of predetermined
criteria. The researchers made preliminary sampling decisions
to select staff with a minimum of 5-year nursing experience
working in surgical wards, in university-affiliated hospitals. It
was considered that the participants would have sufficient work
experience to enable them to analyse barriers and facilitators
affecting post-operative pain management and its process. The
sampling was based on the maximum variant approach. Sampling
started with a nurse of 20-year experience presented by the
head nurses of a surgical ward and then with selection of a
snowball technique whereby participants were asked to suggest
the names of other participants who worked with high performance
in post-operative pain management, who might be interviewed.
Therefore, sampling extended to other nurses, managers
or supervisors in the same teaching hospital or others. We had
planned to interview nurses with at least 5 years of work experience;
however, emerging codes and categories, especially the
codes related to desensitizing (working a long time had made
nurses grow desensitized), led us to interview a number of novice
nurses with 2-year work experience. Data collection and analysis
proceeded concurrently with the development of themes related
to the reality of the nurses’ perception of barriers influencing
post-operative pain management. Sampling continued until
saturation was reached; this was when no new categories or
subcategories emerged.
Data collection
Upon agreeing to participate in the research, and after signing
the informed consent sheet nurses were given an appointment
for the interview. Individual semi-structured interviews were
conducted in a private room at the workplace. Permission for
tape-recording the interviews was obtained from each partici-
Post-operative pain management 469
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
pant. The interviews lasted from 60 to 120 min. The interview
guide consisted of core open-ended questions to allow the
respondents to explain their own viewpoints and experiences as
completely as possible. In congruence with the qualitative
methodology, the opening question for each interview was
‘please share with me how you care for your patient in pain’;
‘please share examples of times when your efforts to manage a
patient’s pain were successful’; and ‘please share examples of
times when your efforts to manage a patient when your efforts to
manage a patient’s pain were unsuccessful’. The participants were
asked to describe one of their own working shifts and then to
explain their own experiences and perceptions on ‘the barriers
and facilitators’ that affected taking action on the post-operative
pain management.
At the end of each interview session, the researcher asked the
participants to talk about anything they considered important
in the post-operative pain management situation. This could
involve their personal and professional experiences and any
additional comments about their experiences as a nurse in
post-operative pain management.
Data analysis process
Data analysis started at the same time with the data collection
and each interview was transcribed verbatim and analysed before
the next interview took place. The process of interviewing was
stopped when data saturation occurred. The author transcribed
the tape-recorded interviews and the data were analysed
using the method of content analysis (Morse & Field 1995;
Sandelowski 2000). The analysis started by identifying the units
of meanings that could be extracted from the statements, which
were essential for participants’ experiences. It proceeded using
line-by-line coding; codes were freely generated during repeated
discussions between the researchers. Statements that were unrelated
to the study were excluded. Codes with similar meanings
were grouped into categories. The transcripts were reviewed in
order to validate the codes and categories. Regarding trustworthiness,
credibility was established through member check, peer
check and prolonged engagement.
The participants were contacted after the analysis and were
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 experiences. Then three expert
supervisors and two other doctoral students of nursing conducted
the peer checking. Prolonged engagement with the participants
within the research field helped the main researcher to
gain the participants’ trust and a better understanding of the
research fields.Maximum variation of sampling (in terms of the
type of ward, years of working experience and place of duty) also
enhanced the conformability and credibility of data. This sampling
strategy enabled the researcher to capture a vast range of
views and experiences (Streubert & Carpenter 2003).
The analysis was finalized by identifying several themes that
emerged to describe the factors that hindered or facilitated
post-operative pain management. Two main themes emerged:
(1) barriers to manage pain after surgery with subgroups such as
powerlessness, policies and rules of organization, physicians
leading, time constraints, limited communication, interruptions
of activities relating to pain, and (2) factors that facilitated postoperative
pain management. It was found that the nurse–patient
relationship, nurses’ responsibility, physician as a colleague, and
nurses’ knowledge and skills were believed to be influential in
post-operative pain management.
Ethical issues
The Tarbiat Modares University approved the research proposal.
Official permission was obtained fromthree educational hospital
directors, nursing managers and head nurses in order to conduct
the study. Ethical issues were concerned with the participant’s
autonomy, confidentiality and anonymity during the study
period.All participants were informed of the purpose and design
of the study and also the voluntary nature of their participation.
Informed consent was obtained from the participants in writing
and signed by them for all stages of the study.
Findings
General characteristics of the participants
The participants’ age ranged from 23 to 50 with an average of
33.45 years. Nursing practice experiences ranged from 2 to
26 years with a mean of 10.6. Twenty-two of participants had BS
degree in nursing, and four participants had an MS degree.
Twenty-four participants were female and two were male. All the
nurses who worked full-time during the period of study were
considered as potential participants in general surgery wards.
Several categories emerged that explain the process of postoperative
pain management and factors that act as barriers or
facilitators to the process.
Barriers to post-operative pain management
Participants cited ‘Powerlessness’ as a key barrier to pain management.
The following examples illustrate this theme:
Now, it is expected that we [nurses] only obey the orders, give
the drugs, do the injections, monitor the blood pressures and
write the nursing notes, but not to intervene independently.
She (the nurse) is expected to obey as a robot. Unfortunately
the decision-making for drugs or non drugs is not ours.
470 N. Rejeh et al.
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
We are restricted to what’s ordered . . . I mean, if the doctor’s
ordered it, we can’t very well make a decision for pain relief
(supervisor 2).
Several nurses noted that ‘policies and rules of organization’
act as barriers to pain management.Comments that reflected this
include:
There are some rules, we and physician are still unaware of
them or we are not mentioned, of course I know that it is not
in our system (head nurse 4).
When we are faced with some particular organizational behaviors
that are task oriented and inhibit independent decisionmaking
for pain management (head nurse 1).
Almost all of the nurses believed that ‘physicians leading’ was
the most important factor that produced obstacles to pain management.
For example, one participant believed that:
Nurses are usually responsible for the administration of all
medication, but according to a doctor’s prescription (nurse 6).
One of the nurses stated:
They [doctors] are boss, we only have to do their orders . . .
they don’t value nurses’ decisions about pain and nonpharmacological
methods pain management, and the managers
also don’t support us when a conflict occurs (nurse 5).
Informants also noted that ‘time constraints’ forced them to
revise work patterns to complete many tasks in a limited time.
Examples include the following:
Sometimes lack of time means you cannot attend to patients
in pain as quickly as you would like to, e.g. if several patients
need your help at the same time or if there is a staff shortage
(nurse 9).
Having the time to undertake pain relief was also shown to be
crucial; perhaps a patient wants to have a conversation, but time
is pressing and there is still a long way to go before the job is
finished:
We cannot spare time for the patients even if we want to, time
is very important (nurse 16).
‘Limited communication’ was also viewed as an important
barrier for nurses to be as comforter. For example:
Nurses must have relationship with the patient and seek his
sign of pain to achieve patients’ affairs . . . (nurse 2).
or
More time must be allocated to listen to the patient’s words in
detail about quality of pain, but instead, we just watch them
with hurry and do certain routine treatments for them.Unfortunately,
we don’t have much time to sit down and listen to
our patients, listening to their pain experiences, talking about
their personal pain management and reduce patient’s stress
and pain (nurse 15).
Another theme that emerged from the data collected was
‘interruptions of activities relating to pain’.
. . . frequently, we respond to interruptions when carrying
out activities relating to pain, look for doctors and family
members and relatives because most of our patients have one
or more family members to accompany them, or even equipment
and drugs from other wards . . . (nurse 7).
Another nurse commented:
We have to look for nursing care equipments (e.g. blood
therapy devices), and waste our time in other wards to find
them, then this interrupts our continuous nursing care
(nurse 2).
Daily, nurses sought out materials which were not located in
the immediate patient environment.
and
Activities such as answering the telephones, following up laboratory
test and helping medical students induce interruptions
of activities relating to pain (nurse 4).
Pain management facilitators
Informants also spoke about the factors that facilitated the practice
of pain management. The development of a functional
nurse–patient relationship was identified as a key factor to facilitating
pain management. ‘Nurse–patient relationship’ recurred
more than the other themes in this study. From the participants’
perspectives, establishing an appropriate relationship between a
nurse and patients was necessary to good pain management.
The quality of this relationship was described in the following
examples:
. . . nevertheless (despite) restricted time, I try to have a good
relationship with them about pain and suffer, listen to them
carefully, and do as they wish for comfort and relieve, it gives
a more sense of security to him, very often nurses have
closer relationship with their patients than their children . . .
(nurse 3).
It is also important that nurses are present during ward rounds
to enable medical consultants to make informed evaluations
of outcomes, as well as to promote patient decision making.
One nurse said,
Post-operative pain management 471
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
It is really important that she/he talks about her pain with me
so then it does not get too difficult to control . . . (nurse 1).
One supervisor said:
More experienced nurses were more likely to use probing techniques
to encourage patients to talk about their pain more
openly (supervisor 4).
Participants were aware that they exercised this technique of
relationship with repeated questioning and, and believed that it
was an effective way of finding out the ‘truth’ about their
patients’ pain.
Another theme that emerged from the data collected was
‘Nurses’ responsibility’ which could facilitate the pain management.
In the participants’ narratives, nurses’ responsibility and
accountability were two factors that had an effect on pain management.
Also, they believed that a nurse’s conscience, commitment
to their professional code of ethics, and respect of patient
rights, could all facilitate pain management. The subsequent
examples of actions explain this:
When my patient needs narcotics and she/he doesn’t have it, I
call other wards frequently (nurse 3).
When his narcotics finished, I looked for medication in all
wards of the hospital to provide it (nurse 15).
‘Physician as a colleague’ means that taking a team approach to
coordinating patient care and services was reported as a crucial
factor, as the following examples illustrate.
A participant with clinical and management experience
mentioned:
. . . I have developed a respectful relationship with all the physicians
and some physicians easily accept our comments about
patients’ pain levels . . . (nurse 12).
Or
It is very important to think and work as a team for pain
management, it is very important for patients’ comfort . . .
Our activities for pain management cannot be separated from
others, because we work in a team, and our work quality for
pain management depends on others’ work . . . (head nurse
2).
Many nurses noted the importance of developing a friendly
relationship with physicians as a helpful strategy.
This mutual collaboration between nurse and physician
usually culminates in patient effort for pain management
(nurse 9).
Another nurse believed:
Formal communication through the ward round occurred at
the bedside, but informal communication with doctors was
requesting changes in the drug charts especially by phone and
some physicians easily accept our comments (nurse 11).
Communication with health care professionals especially
doctors also affected nurses’ pain management decisions
(matron 1).
All nurses described that ‘Knowledge and skills’ are essential to
pain management. Clinical knowledge and some skills were
reported as crucial factors to feeling competent in effective postoperative
pain management. The following statement by a nurse
clarifies this definition:
In my opinion it’s important, the competent nurse is the one
who has rich knowledge and skill, and is expert in his/her own
activating for pain management (nurse 1).
One of the supervisors also stated:
Well it depends on the level of one’s professional knowledge
and skills, and the ability to use them well for pain management
(supervisor 1).
Participants in this study also believed that in-service education
could improve the knowledge and skill that is needed to pain
management. One of participants said:
In order for the nurse to be a better comforter, he/she must
improve his/her knowledge, and advance braveness and selfesteem
. . . (supervisor 3)
Participants frequently emphasized the ‘proper use’ of knowledge
and skill for pain management.
It was at that time that I feltmy proper knowledge and on time
decision for postoperative pain management could comfort
the patient (nurse 2).
Her professional knowledge, skill and her close relationship
with patient’s pain helped her to reach a comprehensive
understanding of clinical picture problem of pain to make an
effective decision for pain management (matron 2).
Discussion
A comprehensive understanding of how contextual issues affect
pain management will enable a more comprehensive targeted
approach to better care (Manias et al. 2005; Schafheutle et al.
2001). All nurses in this study believed that pain management
was one of the primary and important roles of the nurse. In the
nursing literature, pain management after surgery is embraced as
an essential component of practice. Based on nursing theory,
systematically implemented, excellent pain management is influenced
by several factors (Dealy 2002; Niemi-Murola et al. 2007;
472 N. Rejeh et al.
© 2008 The Authors. Journal compilation © 2008 International Council of Nurses
Terry et al. 2007). The data arising from this study provide evidence
to support the barriers and facilitators to the postoperative
pain management process. In the study, many barriers
and facilitators to manage pain after surgery from Iranian registered
nurses’ perspectives were determined. The factors that were
identified as barriers to manage pain after surgery by the nurses
were powerlessness, policies and rules of organization, physicians
leading, time constraints, limited communication, interruptions
of activities relating to pain and insufficient time to interact with
patients. These findings were congruent with the literature that
describes the barriers to effective pain management. All of the
participant nurses experienced themselves as powerless in practical
pain management as they were dependent on physicians’
prescriptions. Iranian nurses are subordinate to physicians and
surgeons and thus cannot take independent action in relation to
analgesics. The nurses felt that they did not relieve patients’ pain
very well because the often lacked prescriptions. They always
meant to get one, but the surgeon was often difficult to contact,
and this took a great deal of time. Nurses noted that physicians
had strong authority and a physician leading is current practice
in Iran, but Richards & Hubbert (2007) noted that the independent
art of nursing in caring for patients with post-operative
pain is contrary to physicians leading. Dealy (2002) noted that
physician domination could be seen as one of the major difficulties
surrounding the implementation of successful pain management.
Significantly, the power of outside professional groups,
especially those of doctors and managers, makes it difficult for
the individual nurse to operationalize pain management
The policy and rules of the hospital organization did not
prioritize pain management compared with other activities.
These other activities in essence trivialized patients’ pain experiences,
making them seem less important. Other nurse-initiated
activities such as completing wound dressings, conducting vital
sign observations and checking wound sites and drainage tubes,
were perceived to be more important, albeit painful. An important
element in the findings was a reflection of hospital management
policy, which makes the nurses, in spite of their desire to
relieve the patients’ pain, choose to have the attitude that the
patient should be prepared to accept a little pain and also
appeared to accept pain as a normal component of the postoperative
experience. Dealy (2002) believes that ‘one of the
greatest obstacles to manage pain after surgery is the policy of
healthcare institution itself ’ (p. 18).
The literature demonstrates that ward policies place too much
emphasis on medication prescription rather than an individual’s
comfort needs (McCaffery & Pasero 1999; Manias 2003b).
Nurses in the current study pointed out that they did not manage
pain very well because the healthcare system did not specifically
hold them accountable for pain relief, as staffing patterns did not
provide sufficient nursing personnel to evaluate the effects of
analgesics and other pain management. Willson’s (2000) observational
study of three patients after a fractured hip repair examined
people-orientated, environmental and situational factors
that affected nurses’ decision to administer analgesics. Factors
found to influence pain management included time, organization
of care, the shift worked, concerns over information giving
and collection. Unfortunately,Willson’s study was limited by the
use of only three patients for observations.As we interviewed the
nurses, they thought that they have very little opportunity to take
the necessary steps for medical pain management. They complained
of time constrains and pressures during a working shift,
on their pain management decisions. Rees (2000), in a qualitative
study, found time constraints and doing more with fewer acts as
the main pain management barriers. One overriding constraint
on nurses’ management of pain was that of lack of time to
perform duties. This was partly because of staff shortages as well
as other organizational constraints. Time constraints have been
suggested previously as imposing limitations on nursing practice
(Dealy 2002; Van Niekerk & Martin 2003). Problem of lack of
time was pointed out by several nurses to be an important organizing
condition.Nurses on surgical wards claimed that they had
responsibility for several patients during the evening and nights
and there was often no time for individual assessments or to
control the effect of the administrated drugs.
Manias (2003b) found that ineffective and limited communication
was a hindrance to pain management. Overall, interruptions
consumed a major proportion of the nurse’s activity in
interview, impacting significantly on the availability of time
spent on pain management. Being interrupted was reported to be
so pervasive in the nurses’ clinical practice that they moved
rapidly from one task to another and as found by Street (1995),
they were unable ‘to sit at one task in one place for a period of
time without interrupting themselves by thinking of other things
to do’. An effect of the interruptions was that patients did not
appear to communicate openly their pain concerns to nurses.
In the study by Carr & Thomas (1997), patients indicated that
bec