CONCLUSIONES Y SUGERENCIAS

On any nursing unit there are routine tasks that are required to be done at different intervals: daily, hourly, weekly. Within different units the

significance of these tasks may be different; an elderly care ward may have more emphasis on nutrition or personal care, while on a short stay surgery ward, observations or mobilisation may have a higher priority. Within

Newcastle Ward there were also regular tasks that were required to be done. What significance and emphasis was placed on them can illuminate the culture of the ward, as does the grade of staff allocated to perform them.

When the nursing handover was completed, the staff would be allocated to teams and bays. A number of tasks were then detailed and allocated to teams, and then to individual members within the teams. At one handover the instructions given by SR Danielle were noted.

Following the handover I counted the instructions Danielle had given to

the staff. There were 14 weights [part of a routine nutrition

assessment], 6 MUST care plans [nutrition assessment], 5 turns [formal

turning of a patient to avoid pressure areas], 5 dressings, 1 drink

[encourage], 1 stoma teaching, 3 catheter care plans, 6 manual

handling care plans, and 1 syringe driver check. Pain care plans, or

One of the staff nurses at interview stated that the sisters did speak about pain tasks following the handover

[SR Alexandra] will, in the morning we have handover and then she

runs through any points and she’ll often mention pain, ‘make sure, you

know if they’ve had so many doses of oramorph’. Alexandra does and

Danielle, Jana and Rene they sort it out as well if they are leading the

handover, they will bring it to light every so often. (SN Tracey,

interview L54)

During the observations, there was no handovers which detailed any specific pain management tasks, nor was pain management mentioned at any of the observed safety briefings.

SR Danielle explained her view of the pain management roles within Newcastle Ward, when she was asked at interview whose role pain management was.

All of us on the ward, down, from the HCA doing the observations and

actually asking the patient their pain score to the staff nurses who are

giving out analgesia and again are assessing patient’s levels of pain,

right up to us, you know obviously dealing with any problems, making

sure that the patient’s pain is managed, it is very important. (SR

Danielle P1, interview L35)

Pain management tasks, as described by the nursing staff in interviews and seen at observations, were pain assessment, comfort measures,

administration of analgesia, and care of pain management pumps (PCA, epidural and syringe drivers).

Pain assessment is considered part of the routine observations, while administration of analgesics is usually part of the drug round. The care of pain management pumps was seen to be outside of the drug round, but was a nurse’s task, while all staff used comfort measures.

SN Jennifer, a relatively new nurse, said at interview:

[The HCA will] be going round every couple of hours doing the obs

[observations] or she will interact with the patient if they need to go to

the toilet or she’s taking commodes and we’re quite busy doing drugs,

so she’ll be there, more hands on, to be doing more of those things, so

she’ll be the one who probably they’ll talk to first and say to her oh I’ve

got some pain actually. (SN Jennifer P35, interview L87)

Pain management did not seem to feature as an integral part of HCA activities however as seen from this field note:

[I assisted HCA Kirsten (P5)] with washes and bed making. No one

mentioned pain. Kirsten did not ask patients about their pain, or if the

washing or movement out of bed were painful. (FN1 L113)

HCA Kirsten is helping a lady behind the curtains to transfer from bed

to chair. I am unable to see but can overhear. Kirsten appears to be

ensuring that the 100 year old lady, with a query bowel obstruction,

the lady is making ‘ooh, ooh’ sounds. Kirsten did not ask about pain,

though when [the patient] was in the chair she did ask the patient if she

was cold and when the patient replied ‘Yes’, went to get her a blanket.

I asked Kirsten if she thought the lady was in pain and she replied ‘she

did not say she was in pain, only that she was cold’. (FN25 L40)

Field notes record further:

Kirsten only asked about the cold, and not the pain. Is this because

she could do something for the cold (blanket), but as an HCA did not

have the ability to do anything about the pain? Or did she just ignore

the possible pain cues because the lady was so old she was bound to

have some pain, or because they were small little noises that old

people make anyway. (FN25 L43)

The pain management tasks performed by the two different staff groups within Newcastle Ward appeared embedded with the culture; a culturally shared pain management strategy. Pain assessment was considered part of the regular observations and the HCA did those. Administration of analgesia was routinely performed during medication rounds, and this was a nurses’ role, the only sister who would do a drug round was the junior sister, if there was more than one sister on. Pain assessment did take place at the

medication round, but rarely were the documented pain scores discussed or considered. The nurse in charge was considered to have the overall picture of the ward, and would take feedback from the other staff.