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22 December 2014


.................................................................................................................................................................................... 1 Daftar Pustaka...........................................................................................Daftar isi Strategi Pencarian..................................................................................................................................... iii 1..................... 8 22 December 2014 ii ProQuest .. What Were They THINKING? Nursing Students' Thought Processes Underlying Pain Management Decisions..............

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Written rationales in response to two patient scenarios reveal students' thought processes when recording pain intensity levels on a numerical scale and choosing corresponding dosages of analgesics. at the exclusion of verbal ratings. inadequate treatments. * When treatment decisions are based on patients' behavioral responses. Carson. but current research on common misconceptions held by nurses about pain control.Pain Management . Schilling (2003) recommends the following pain assessment technique: "Ask the patient to rank his pain on a scale of 0-10. * As nursing students hold their own beliefs about proper ways to manage pain. But inconsistencies exist in the nursing process." According to McCaffery (1968). Reforming teaching and learning practices when educating students about pain management could decrease patient suffering and lead to improved comfort and satisfaction.Nursing Education . and inconsistent nursing care. &Harrison.Dokumen 1 dari 1 What Were They THINKING? Nursing Students' Thought Processes Underlying Pain Management Decisions Link dokumen ProQuest Abstrak: Patients' pain has not been adequately controlled due to inaccurate assessments. and inconsistent nursing care. 95).Andrew-Robert Survey .Subjective Pain Rating ONE HINDRANCE TO EFFECTIVE PAIN ASSESSMENT AND TREATMENT IS THE INABILITY TO ACCURATELY MEASURE AND MONITOR THE INTENSITY OF A PATIENT'S PAIN. with o denoting lack of pain and 10 denoting the worst pain level. it is important that faculty. misinterpretation is likely to occur. THE PURPOSE OF THIS STUDY WAS TO DETERMINE NURSING STUDENTS' ACCURACY IN ASSESSMENT RATINGS AND TREATMENT CHOICES FOR PATIENTS EXPERIENCING PAIN. existing whenever he says it does" (p. 1995). assess students' knowledge and attitudes about the treatment of pain. and personal experience caring for others. specialty area. AND THEN TO DETERMINE THE THOUGHT PROCESSES LEADING TO 22 December 2014 Page 1 of 8 ProQuest . Health care providers are responsible for assessing and treating pain based on a patient's verbal and nonverbal communication. based largely on such variables as a nurse's educational preparation. Headnote Key Words Pain Assessment . The purpose of the study was to determine the extent of nursing students' accuracy in assessment ratings and treatment choices for patients in a case vignette who were experiencing pain and then to determine the thought processes underlying their decisions. early in the course of study. Data collected from junior and senior nursing students provide insight for nurse educators and point to areas where curricula and instruction may be enhanced. These various factors may influence nurses' responses to and beliefs about pain (Brunier. Data collected from junior and senior nursing students provide insight for nurse educators and point to areas where curricula and instruction may be enhanced. [PUBLICATION ABSTRACT] Teks lengkap: Headnote RESEARCH ABSTRACT Patients' pain has not been adequately controlled due to inaccurate assessments. inadequate treatments. The purpose of the study was to determine the extent of nursing students' accuracy in assessment ratings and treatment choices for patients in a case vignette who were experiencing pain and then to determine the thought processes underlying their decisions. "Pain is what the experiencing person says it is. Written rationales in response to two patient scenarios reveal students' thought processes when recording pain intensity levels on a numerical scale and choosing corresponding dosages of analgesics. Reforming teaching and learning practices when educating students about pain management could decrease patient suffering and lead to improved comfort and satisfaction. The nursing curriculum and instruction should not only include pathology and pain management.

research has repeatedly shown that many patients with pain deliberately smile or laugh. To what extent do nursing students correctly rate patients' verbal reports of pain intensity in two case vignettes? 2. exaggerated fears about addiction. Review of the Literature Although some advancements have been made. either to help themselves cope with the pain or to try to hide their pain from others" (p. McCaffery and Ferrell (1991) developed a case vignette instrument to assess how nurses rate a patient's pain intensity on a numerical rating scale. Three research questions were asked: 1. Chuk (2002) used the same case vignette instrument with 198 nursing students in Hong Kong.6 percent who recorded the grimacing patient's pain as 4.THEIR DECISIONS. who correctly rate a patient's stated pain intensity.7 percent of the nurses recorded the smiling patient's pain as 4.2 percent of the students. The researchers surveyed 456 hospital staff nurses in six cities. 49 (33 percent) participated in a perioperative rotation." and "patients in pain. knowledge deficits and misconceptions held by nurses. To what extent do nursing students. The current study attempted to replicate aspects of Chuk's design to determine if similar results would be found in a sample of nursing students from the United States. 40. Sigsby (2001) recommended enhancing student learning experiences in pain management through perioperative clinical experiences. 2002). Results showed significant differences (p <0. The literature points to numerous reasons why this situation continues to exist in health care. settings included the holding area prior to surgery and the operating and recovery rooms. while another expresses unexpected verbal and nonverbal reactions to pain. the three most prevalent themes were "learning about interdisciplinary professionals. Both schools of nursing had similar learning objectives for pain management. From a population of 147 junior nursing students. patients. and knowledge deficits (Lasch et al. at that time. also correctly administer the recommended dosage of analgesic under the conditions provided in the case vignette? 3. Using this scale. including myths held by the general public." The Research Study The purpose of this research study was to replicate aspects of Chuk's study on the issue of pain assessment accuracy in nursing students (2002). The authors noted that "a simple behavior such as smiling or grimacing isn't strong enough evidence to conclude that a patient's pain rating is anything other than what he says it is.01) in pain ratings documented by the students for the two scenarios. and instruction. Juniors and seniors were selected because they had completed two years of general education requirements and prerequisites and had began upper-division nursing courses. Randomly assigned students spent 16 hours per week with patients having various types of surgical procedures. presented pain content in the first semester of nursing 22 December 2014 Page 2 of 8 ProQuest . curricula. It also expanded on Chuk's design by eliciting written rationales from nursing students for their assessment ratings and treatment choices for two patients who behaved differently in response to pain. the patients rated their pain intensity as 4 on a 0-5 scale. In both scenarios. What rationales do students identify for their ratings of pain intensity and medication administration in the case vignettes? Method The population included classes of junior and senior nursing students at two schools of nursing (N .270 students)." "anatomy and physiology. 37). Both patients rate their own pain as 4 on a 0-5 scale. Data were collected in clinical conferences where students were asked one open-ended question: "What was your overriding impression of learning in the perioperative rotation?" Findings indicated enhanced student understanding of pain by the end of the semester. behavioral differences were the only variation. The focus on qualitative data provides rich findings that have implications for nursing education. and family members continue to inhibit pain relief and limit quality of life. The objective signs of pain overruled the patient's own self-rating in the responses of 59. In fact.. using a vignette where one patient displays expected or typical behavioral manifestations. in contrast to 71.

combining quantitative and qualitative data. respecting. the researcher requested feedback from six nurse faculty prior to data collection to determine validity and the ability to elicit rationales for student responses. Patient Behavior Case Vignette. many students correctly responded with answers based on ethical 22 December 2014 Page 3 of 8 ProQuest ." A senior wrote. they were guaranteed no consequences for declining. quantitative data were viewed in terms of percentage of the entire population of participants. RESEARCH QUESTION 3 Ten themes emerged from the qualitative data. Nursing students were greeted during class time by the researcher and were given the option of participating in the study. 73 (38. The instrument used in this study was the. My assessment would have been much lower. pain is a subjective finding.83 percent) of those students also administered the correct amount of pain medication." developed by McCaffery and Ferrell (see Figure on following page). and documenting the patient's self-report of pain was the correct response. often referred to as the "AndrewRobert Survey. Each school designated three hours of classroom instruction for this topic.courses. "It was his rating of pain. 119 (50. All data remained confidential.42 percent) of those students also correctly administered the correct dosage of morphine. Because these questions were not part of the original survey. This instrument was selected because the data yielded was relevant to the research questions and because of its wide use in other studies. The case vignette requested that participants read two patient scenarios and answer four questions after each case was presented. and the survey was pilot tested at workshops with at least 100 participants. The patient stated 8. and faculty members used lecturestyle teaching methods. Participants were asked to rate the patient's pain intensity level on a numerical rating scale and select a dosage of pain medication from a range of choices. Qualitative data were analyzed to determine the most frequently occurring rationales and then categorized into themes to accurately report the findings. but he rated it. RESEARCH QUESTION 2 Two hundred thirty-six nursing students correctly rated pain intensity in the Robert vignette. Ferrell and McCaffery (1998) discussed the validity and reliability of the vignette instrument." ETHICAL RESPONSIBILITY OF NURSE When asked what influenced their decisions to record pain intensity levels and choose dosages of medications.41 percent of the nursing students in the sample correctly rated pain intensity for Patient A (Robert) in the case vignette. with a statement about the data and narrative examples from students. A junior wrote.63 percent for Patient B (Andrew). A panel of experts in pain management established content validity. and used the same textbook and chapter for teaching pain in the fundamentals of nursing course. and names were not used as part of the research instrument. Rationales for Correct Pain Assessment Ratings DOCUMENT SUBJECTIVE REPORT Accepting. All six educators were in agreement that questions B and D (see Figure) were appropriate additions to the tool and that the multimethod approach. The study received human subjects review board approval after an expedited review process. two questions were added to the original instrument to determine the rationales for students' assessment ratings and treatment decisions. For the purposes of this study. "Even though he is smiling. To answer the first two research questions. The only difference in the two vignettes was the patient's name and his behavior in response to pain. Examples of written statements are presented here. Results RESEARCH QUESTION 1 It was found that 87. so chart an 8. in contrast to 69. 188 students correctly rated pain intensity.78 percent. Each participant signed a written informed consent prior to completing the survey. When responding to the Andrew vignette. which many students chose by circling the number 8 on the pain scale. would enrich the results of the study. The difference for the two patients with differing behavioral manifestations was 17. Rationales for pain assessment ratings and treatment choices are grouped by theme. and joking with his visitor. talking.

but I am not going to load him up just to sleep. "He has not reached a comfortable state of pain management." PATIENT'S USE OF DISTRACTION Nursing students who correctly assessed patients in the vignettes referred to distraction as a possible reason for the atypical behaviors such as talking and joking with the visitor. A junior student who administered the incorrect dosage of pain medication to Andrew provided the following reason: "Because he doesn't appear to be in that much pain and I wouldn't give him anything unless the patient asked for it. "He may not want to show his friend that he is in any pain. does the patient indicate he wants pain medication? Second. it is important to believe he is honest about his level of pain. [this] does not mean that he is not in pain." AVERAGE OF SUBJECTIVE AND OBJECTIVE FINDINGS A curious finding not identified in previous studies was that students averaged subjective and objective findings to yield a numerical pain rating. This rationale emerged several times in the assessment of Andrew. "I gave a 4 because he probably is in pain. but not extremely severe." A senior who administered an inadequate dosage of morphine to Andrew wrote. he needs no further pain meds at this time. his heart rate is not up a great amount. A junior. Even though he is smiling. He probably would not be doing this if he really had pain level of 8. because of context clues. "I would have to trust what he said. A 6 is somewhere between the 8 he says and the 4 you think he is. Students referenced stigma when referring to the visitor present in the Andrew vignette." A junior provided the following reason for the incorrect assessment of Robert: "Even though he is in pain because he grimaces." Rationales for Incorrect Pain Assessment Rating STABLE VITAL SIGNS Students documented incorrect pain ratings for patients in the vignettes due." SOCIAL STIGMA Students referred to the social stigma associated with patients who report pain. 'That is what Andrew stated. vitals are normal range. A junior wrote. but he's probably exaggerating the 8 because he is smiling and joking. Administering the smallest dose first is appropriate because it may achieve his goal and not oversedate him." Another wrote. a senior wrote. so he hides it. Different people perceive pain in different ways and he could have been telling the truth. to behavioral signs and vital signs that did not coincide with the stated pain intensity level.obligations of the caregiver. This may just help him keep his mind off of it." FEAR OF ADDICTION Respiratory depression." Rationales for Incorrect Dosage of Analgesic PATIENT MUST ASK FOR MEDICATION PRIOR TO RECEIVING IT Some students chose not to increase the dosage of morphine because the patient in the vignette did not explicitly ask for more medication. "Because that is what the patient stated and I don't have the right to chart any other answer except what he told me." Another senior wrote. who incorrectly rated pain intensity. "He could be pretending (lying) because of his friend/visitor." BEHAVIORAL MANIFESTATIONS Many students were swayed by behavioral manifestations when choosing 22 December 2014 Page 4 of 8 ProQuest . therefore. A junior wrote. A junior who administered an incorrect dosage of morphine for Andrew wrote. His vitals are within normal ranges and he shows no physical signs of pain. so he is definitely in pain. but do not give the max unless asked for." Another junior wrote." Another junior wrote. "Since pain is subjective. "In assessing the patient. but he may hide pain well." In response to the Andrew vignette. wrote. a senior wrote. in part. addiction." Another senior wrote about Robert: "He is allowed dosage-wise to get more so I would give him 1 mg simply because I see lots of people need pain medicine psychologically to feel better. A senior who incorrectly assessed Andrew's pain wrote. "I wouldn't really believe him because of his actions. and making jokes. "First." Responding to the same vignette. begin with minimal dose unless otherwise indicated by the patient. give up to 3 mg every 1 hour. Do not want to build dependence to drug. "Because the patient still expressed pain and I don't want to overdose the patient. "He says he is in a lot of pain (8) but he is joking and laughing with his visitor. A junior who chose an incorrect dosage of morphine in the Andrew vignette wrote. and withdrawal were listed among the reasons for not increasing the dosage of morphine in the case vignettes. talking." Another junior provided a similar response to the Robert vignette: "If he asks for more.

For example." A junior wrote. rather than 6 to 8. 1999). Some students were cognizant of the visitor present in the room and thought that his presence may have affected the patient's behavior and reported pain level. students were reluctant to increase the dosage.. based on the patient's behavior. "I would give him 1 mg of morphine since it is ordered and would wait to see if he showed any visible signs of pain before I would give him a higher dose. Students calculated a "middle ground" or "average" by documenting a number between the patient's self-report and the number they believed to be correct.. Surprisingly." some students mistakenly thought the patients' current pain level was 2. Qualitative data reveal the reasons why many students continue to hold inaccurate knowledge and beliefs about pain management. One may question whether the students understood the phrase." * "Patient still states 6-8 pain. I only gave 1 mg to see how he would respond. I feel that if he had a pain level of 8. students in this sample did not understand the concept of titration. and documenting the patient's self-report of pain. A junior student who chose the incorrect dosage of morphine for Andrew gave the following rationale: "He seems to not be having relief of pain (even though I felt he wasn't in that much pain). There is no certainty that students would have the same response in an actual clinical situation. "an acceptable level of pain relief. rationales for incorrect dosages of morphine from students at both nursing programs are as follows: * "His pain level is now 2. Conclusion Analysis of the quantitative data reveals that more than half of the students in the sample tended to assess pain accurately. one theme that emerged from students' written rationales for incorrectly rating pain intensity had not been noted in previous research studies. It is also important to note that results were based on responses to a hypothetical patient situation. The findings that students included statements about the ethical responsibilities of a nurse and recognized that Andrew may be using distraction as a comfort measure were also positive. but it does not appear that he needs the maximum dose at this time as evidenced by physical signs and symptoms and nonverbal assessment. It is misleading for educators to believe that students who accurately assess pain will also administer adequate amounts of analgesics. it can be increased until analgesia is achieved if there are no untoward side effects (McCaffery &Pasero. rationales for incorrect pain ratings included references to behaviors and vital signs that remained within normal limits. or that the contents of the vignette were not clear to the students. As expected. When 2 mg of medication was ineffective in controlling the patient's pain at the previous administration. administer 1 [mg] and go from there.. Although question C in the vignettes states. however.." MISINTERPRETATION OF THE CASE VIGNETTE Rationales provided by a number of students indicated that they either misread or did not fully understand the scenarios. the patients rated their pain as 8 on the 0-10 scale. Actually." A senior responded to the same vignette in this way: "He needs pain management. an acceptable level.the medication dosage." The fact that students from the two nursing schools were conveniently selected based on proximity of the researcher to the schools is a possible limitation of this study. many were swayed by behavioral factors. [Patient] has identified 2 as an acceptable level of pain relief. a problem not identified or accounted for in the literature. Morphine is a drug that has no ceiling in its dosage. Misinterpretation of the case vignette may indicate that students were not reading the vignette closely enough. so there is no need for morphine." * "He tolerated the previous dosage well and pain level is still 6-8.. he would not be joking around. rather than documenting verbal ratings provided by the patient. "Half hourly pain ratings following injection ranged from 6 to 8." Discussion It was encouraging that many students understood the principle of accepting. respecting.." * "He has verbalized to me a 2 on the pain scale and this is acceptable to him at this time. Based on the responses provided. 22 December 2014 Page 5 of 8 ProQuest . or starting with a low dosage and slowly increasing until pain relief is achieved.

). (2001). Carr. Pain clinical manual (2nd ed. edu. Learning. &Harrison. attitudes. Los Angeles: University of California at Los Angeles Students' Store.drug therapy (utama). Briggs. Students.. References References Brunier. 34-37.. G.For best practices in teaching and learning. Research. Pain -. 21. R. especially for analgesics that patients can develop a physical tolerance to over time.A.. 5(1). Nurse faculty may also deem it necessary to revisit the topic of pain management throughout the course of study to ensure that students are maintaining appropriate practice. R. E.nursing. bodily pain. Nursing practice theories related to cognition. and misconceptions early in the curriculum prior to the presentation of new content. McCaffery. Springhouse. &Ferrell. M. PA Lippincott Williams &Wilkins. Ratings & rankings. B. 436-445. For the two schools of nursing represented in this study. is an assistant professor in the School of Nursing. McCaffery. M. M. AuthorAffiliation About the Author Crista L. 19-24.. Nursing (utama). Pain -. Greenhill. McCaffery. or additional. Core curriculum. Studies. 10(6).. &Blanchard. K. Behavior. teaching innovations are needed to enhance student learning and understanding.. faculty may wish to consider the written rationales provided by students in this study as a springboard for educating students about common myths and misconceptions. Sigsby. RN. D. Schools. 57-71. EdD. In future development and evaluation of program curricula within schools of nursing. L M.org/pdf/ controlling pain. Effective learning about the concept of pain from a perioperative clinical rotation. Education. (1991). a three-hour lecture in the classroom was not adequate to ensure that all learners would respond correctly to patients experiencing pain. (1999). Educational Measurement. Nurse Education Today.. MO: Mosby. Determining the accuracy of pain assessment of senior student nurses:A clinical vignette approach. For more information. St. Ferrell. 393-400. briggs @wku. Carson.A. January).. (1 995). Evaluation of the research data suggests that alternative.coh. J. faculty should assess students' knowledge. Sigsby's (2001) report of enhanced student knowledge about patients in pain while in perioperative clinical experiences should be considered. United States. Louis. Curriculum revisions are warranted in the area of medication titration. (2002). Bowling Green. M. P. What do nurses know and believe about patients with pain? Results of a hospital survey. Morphine -. &Pasero. R. evidence-based reform will lead to improved critical thinking and decision making on part of nursing students. B. (2003).nursing (utama) 22 December 2014 Page 6 of 8 ProQuest . The Andrew-Robert survey is easily administered in the classroom setting and opens the door for rich classroom discussions.. Retrieved from http://prc. Analgesics. (2002). Best practices: A guide to excellence in nursing care. (1968). Western Kentucky University. Reliability and validity of the pain vignettes. Students should be taught not only to report and document patients' self-reports of pain.. Critical thinking. Male. &McCaffery. contact her at crista. Pain Measurement -. M. G. In response to the findings of this study. Why study pain? A qualitative analysis of medical and nursing faculty and students' knowledge of and attitudes to cancer pain management Journal of Palliative Medicine. MeSH: Adult. (1998. pdf Lasch. Lee. M. Kentucky.administration & dosage (utama). Anatomy & physiology. C. Opioid -administration & dosage (utama). Subjek: Pain management. Pain Management Nursing 2(1). Humans. CNE. Chuk. How would you respond to these patients in pain? Nursing 91. Wilkes. 22. but also to follow through with recommended amounts of pain medication. Schilling. as well as increased patient comfort and satisfaction. D. and man-environment interactions. Journal of Pain and Symptom Management. G.

Inc. Opioid. Tempat publikasi: New York Negara publikasi: United States Subjek publikasi: Medical Sciences--Nurses And Nursing ISSN: 15365026 Jenis sumber: Scholarly Journals Bahasa publikasi: English Jenis dokumen: Journal Article Fitur dokumen: References Nomor aksesi: 20455363 ID dokumen ProQuest: 219961881 URL Dokumen: http://search.Substansi: Analgesics. Inc. Mar/Apr 2010 Terakhir diperbarui: 2014-03-24 Basis data: ProQuest Education Journals 22 December 2014 Page 7 of 8 ProQuest . Crista L Judul publikasi: Nursing Education Perspectives Volume: 31 Edisi: 2 Halaman: 84-8 Jumlah halaman: 5 Tahun publikasi: 2010 Tanggal publikasi: Mar/Apr 2010 Tahun: 2010 Bagian: PAIN ASSESSMENT Penerbit: National League for Nursing.com/docview/219961881?accountid=25704 Hak cipta: Copyright National League for Nursing.proquest. Morphine. Judul: What Were They THINKING? Nursing Students' Thought Processes Underlying Pain Management Decisions Pengarang: Briggs.

Syarat dan Ketentuan 22 December 2014 Page 8 of 8 ProQuest . 84-8. Nursing Education Perspectives. 31. 2. pp. no. . C.L. 2010. vol.Daftar Pustaka Citation style: Harvard Briggs. _______________________________________________________________ Hubungi ProQuest Hak cipta  2014 ProQuest LLC. "What Were They THINKING? Nursing Students' Thought Processes Underlying Pain Management Decisions". Semua hak cipta dilindungi.