Interpretación de Resultados de las encuestas realizadas a los usuarios internos

While any organisation will have its own culture, in the United Kingdom the National Health Service (NHS), led by the Department of Health, in part influences the culture of NHS hospitals. Targets are applied to healthcare organisations from the Department of Health, such as: eliminating mixed sex accommodation, waiting list targets, four-hour wait in the Emergency

Department, infection control. While these targets have improved patient dignity, quality of healthcare, and hospital-acquired infections (Bevan & Hood

2006), there has not been a directive which says patients should have their pain routinely assessed, or analgesics given in a timely manner. Pain management has been shown to be ineffective before NHS targets began (Royal College of Surgeons 1990), however this lack of attention and emphasis on pain management through this ‘target’ route may have contributed to pain management remaining outside the public awareness. Political barriers to effective pain management, also imposed by the Department of Health, include the continued restriction to prescribing controlled drugs by non-medical prescribers (Stenner & Courtenay 2007). The authors found 80% of pain management clinical nurses specialists in the study said lifting of these restrictions would enable them to provide more effective pain management. Up until very recently (April 2012), pain management clinical nurse specialists who held a non-medical prescribing qualification, were required to find a doctor to prescribe many controlled drugs. This process caused barriers to effective pain management by introducing increased possibility of prescribing errors, potential inequality of service provision to patients, and extra time to provide timely analgesia (Stenner et al. 2011).

Hospitals produce their own barriers to effective pain management. There is little good quality research into patients’ postoperative pain experience while an inpatient. When research is produced that would impact positively on the patient experience, institutions can be slow to react to this new evidence and slow to change processes to enable this evidence to be used (Brockopp et

consequence differences in adoption of new working practices, may not allow for one a ‘one size fits all’ change to impact on pain management; it may be necessary to tailor strategies to fit to local context (Powell et al.

2009a, b).

Healthcare professionals are busy, with increasing staff pressures. There is an escalating burden of paperwork and inadequate funding available to permit any change to current procedures (Mann & Redwood 2000). Commissioners of healthcare, and perhaps as a consequence, healthcare institutions do not give pain management a high priority (Allcock 2005), making any change more difficult (Brockopp et al. 1998, Powell et al. 2004).

Local hospital policies can also restrict pain management. Despite there being no legal requirement for two nurses to check controlled drugs (Department of Health 2007), almost all UK hospitals still maintain this

practice. There is evidence to show the practice of double checking can lead to as much as a forty minute delay for patients to receive analgesia (Carr 2007), and that this practice may not be relied upon to decrease drug errors (Anderson & Webster 2001).

Brockopp et al. (1998) in a report of a study to improve pain management

throughout a state in the USA, described personal barriers to good pain management: lack of knowledge, difficultly in nurse doctor relationships, fear of opioids. However the most frequent theme which emerged was the lack of attention and importance given to pain management by the participant’s healthcare institutions. This report concludes with a statement that pain

management will not improve until it is considered a priority within the healthcare system (Brockopp et al. 1998).

Some years later in the UK, Powell et al. (2004) administered a postal survey

to explore acute pain services within NHS organisations in the UK (n=325: response rate 81%), over a decade after the publication of a document which called for universal acute pain services in all surgical hospitals (Clinical Standards Advisory Group 2000). Findings indicated 83% of hospitals had an established acute pain service, although only 30% were described by participants as ‘thriving’, with a further 52% stating they were ‘struggling to manage’. There was widespread agreement among the participants in the principles of postoperative pain management, including 24 hour cover, a multidisciplinary team, with corresponding general agreement on the need for the integration of acute and chronic pain management. The key

difficulties in achieving the goals so widely agreed upon, was seen as lack of organisational support including funding of adequate resources (Powell et al.

2004).

Later work from the same group using a case study methodology looked at barriers to improving acute pain services in three NHS hospitals. They concluded acute pain services were separated from the broader

organisational objectives, and were struggling to engage other healthcare professionals in the face of constant organisational change, competition for resources, and professional boundaries. They suggest postoperative pain management should be redefined as a quality improvement issue,

incorporating a whole organisational change strategy (Powell et al. 2009a,

b).

Over thirty years ago findings from a study using observation and interview with staff and patients highlighted a problem with pain management; no one was accountable for pain management (Fagerhaugh & Strauss 1977 p. 278). If no one is delegated responsibility for pain management, and no one is held to account for failures in this responsibility, pain management can always be seen as someone else’s duty. Ely (2001) found support for this when she asked paediatric nurses in a series of focus groups, about organisational barriers to effective pain management. The study found nurses reported the uncertainty of their position, and the perceived lack of power to effect

change, as barriers imposed by their organisation.

Some of the factors which impact on how health institutions effect pain management have been briefly discussed. Healthcare organisations can influence how pain management is performed within their hospitals by not prioritising pain management. Hospitals may not give staff groups explicit accountability for pain management, and local policies around controlled drugs, made in the interest of patient safety, can result in patients not getting timely pain management. Nurses may feel they are unable to change pain management practice in the light of so many other organisational targets and with no explicit pain management priority.

What is unclear from this review however is how these factors influence pain management decisions in clinical areas. In the next section a review of the

literature will focus on the how the culture of clinical area can influence pain management at a local level.