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Resource Manual for Nursing Research: Generating and Assessing Evidence for Nursing Practice

Nursing Research—Principles and Methods

This review is a critical summary of research examining gender variations in clinical pain experience. Gender-comparative pain research was identified through Medline and Psychlit searches and references obtained from bibliographies of pertinent papers and books. Review of this research demonstrates that women are more likely than men to experience a variety of recurrent pains. In addition, many women have moderate or severe pains from menstruation, pregnancy and childbirth. In most studies, women report more severe levels of pain, more frequent pain and pain of longer duration than do men. Women may be at greater risk for pain-related disability than men but women also respond more aggressively to pain through health related activities. Women may be more vulnerable than men to unwarranted psychogenic attributions by health care providers for pain. Underlying biological mechanisms of pain and the contribution of psychological and social factors as they contribute to the meaning of pain for women and men warrant greater attention in pain research.

Gender variations in clinical pain experience.

This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses' background, the context of the situation, and nurses' relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response.

Thinking like a nurse: a research-based model of clinical judgment in nursing.

Context.—Cancer pain can be relieved with pharmacological agents as indicated
by the World Health Organization (WHO). All too frequently pain management
is reported to be poor.Objective.—To evaluate the adequacy of pain management in elderly and minority
cancer patients admitted to nursing homes.Design.—Retrospective, cross-sectional study.Setting.—A total of 1492 Medicare-certified and/or Medicaid-certified nursing
homes in 5 states participating in the Health Care Financing Administration's
demonstration project, which evaluated the implementation of the Resident
Assessment Instrument and its Minimum Data Set.Study Population.—A group of 13625 cancer patients aged 65 years and older discharged
from the hospital to any of the facilities from 1992 to 1995. Data were from
the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology
(SAGE) database.Main Outcome Measures.—Prevalence and predictors of daily pain and of analgesic treatment.
Pain assessment was based on patients' report and was completed by a multidisciplinary
team of nursing home personnel that observed, over a 7-day period, whether
each resident complained or showed evidence of pain daily.Results.—A total of 4003 patients (24%, 29%, and 38% of those aged ≥85 years,
75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age,
gender, race, marital status, physical function, depression, and cognitive
status were all independently associated with the presence of pain. Of patients
with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug,
and only 26% received morphine. Patients aged 85 years and older were less
likely to receive either weak opiates or morphine than those aged 65 to 74
years (13% vs 38%, respectively). More than a quarter of patients (26%) in
daily pain did not receive any analgesic agent. Patients older than 85 years
in daily pain were also more likely to receive no analgesia (odds ratio [OR],
1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors
of failing to receive any analgesic agent were minority race (OR, 1.63; 95%
CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23;
95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65;
95% CI, 0.5-0.84 for 11 or more medications).Conclusions.—Daily pain is prevalent among nursing home residents with cancer and
is often untreated, particularly among older and minority patients.

https://jamanetwork.com/journals/jama/articlepdf/187650/joc71977.pdf

Management of Pain in Elderly Patients With Cancer

The purpose of this study was to investigate whether nurses provide different amounts of narcotic analgesics to male and female patients, and different amounts to white and ethnic minority patients. A retrospective survey was conducted with the medical records of 101 male and 79 female uncomplicated adult appendectomy patients, 40 of whom were ethnic minority members. Narcotic analgesic doses for the entire postoperative period were converted to equianalgesic doses comparable to intramuscular morphine. Male patients received significantly larger initial doses than female patients. There was no gender difference in the total dose received postoperatively. White patients received significantly more total postoperative narcotic analgesics than ethnic minority patients. The gender difference provides modest external validation for prior experimental results. The ethnic difference suggests that irrelevant cues may be used in nurses' medication decisions.

Gender and ethnic stereotyping and narcotic analgesic administration.

Communicating pain and pain management needs after surgery.

The effect of gender stereotyping on nursing care was examined. Eight conditions were created in a posttest-only experiment by completely crossing patient gender (male/female) by memory load (low/high) by patient health status (stable/unstable). One hundred sixty nurses read the same patient vignette. The vignette differed in patient gender, memory load, and patient health status. The nurses then estimated the minutes needed for specific nursing interventions with the patient. Nurses planned significantly more ambulation, analgesic administration, and emotional support time for the male patient, despite the presence of individuating information. More accurate, effective nursing care is possible when nurses are aware of the effect of gender stereotyping on nursing care.

Gender stereotyping and nursing care

https://www.jpsmjournal.com/article/S0885-3924(08)00647-7/pdf

The Effect of Pain Question Phrasing on Older Adult Pain Information

The investigators examined whether elders who have been taught pain management communication skills and pain management information obtain greater postoperative pain relief than elders not taught this information. Thirty-one elders were randomly assigned preoperatively to a control or communication group in this posttest-only experiment with repeated measures. Communication group participants were taught pain management, pain communication skills, and the use of two pain-intensity scales. Control group participants were taught to use the two pain-intensity scales. Pain was measured with the McGill Pain Questionnaire Short Form. The communication group elders reported less postoperative pain over the course of their hospital stay. Pain management knowledge alone may have enabled the elders to obtain greater pain relief. Nurses may want to incorporate similar pain management information and pain communication skills when teaching elders how to obtain greater postoperative pain relief.

Deborah Dillon McDonald

Papers

Gender and ethnic stereotyping and narcotic analgesic administration.

Communicating pain and pain management needs after surgery.

Gender stereotyping and nursing care

The Effect of Pain Question Phrasing on Older Adult Pain Information

Testing a preoperative pain management intervention for elders