E. G.Ravenstein (1885)
3.5. PARTICIPACION SOCIAL EN REDES PERUANA Y SUIZAS
In order to make effective pain management decisions, ward staff need to have the correct information about their patients. Nursing handover has been shown to be necessary for the continuity and consistency of patient care within a ward (Sexton et al. 2004). Findings demonstrating how nursing
handover is performed on Newcastle Ward, with a particular emphasis on how pain management information regarding patients is transferred, are described.
Newcastle Ward used a variety of nursing handover models during the observation period. For the first few months the allocation to teams was done by the most senior nurse present and then a bedside ward round was done, followed by a ‘safety briefing’ in the clinical room. The safety briefing was an opportunity for the nurse in charge to address all of the staff on shift, and was used both to give broad information regarding, for example, Trust initiatives, or specific cautions regarding clinical incidents which had
occurred.
After a few months the handover was changed from the bedside round, to separate team handovers, held for one team at the far end of the ward by the desk in the corridor outside of a side room, with the second team in the clinical room, again meeting for a safety briefing in the clinical room at the end. The handover model was changed as it became clear the bedside handover had the potential to disclose confidential information about patients. A field note made just before the change said:
The handover was the same end of the bed. I went on male handover.
At one gentleman’s bed a nurse said he was ‘not for CPR’, while
another described him as ‘all very argumentative’. (FN4 L5)
At the weekends and for night shifts, handovers were done with all the incoming shift’s staff in the sisters’ office. Towards the end of the year of observations, comments from patients in the side-room at the end of the corridor, again regarding potential breaches of confidentiality, lead to a further change where all handovers were undertaken in the sisters’ office.
Unless the sister on that day was on an ‘office’ day (when they were not expected to undertake any clinical work), the sister would participate in the handover. If the handovers were separated, there was a third handover following the safety briefing between the nurse in charge and the most senior of the nurses from the other team. Handovers took about thirty minutes regardless of the model used. Either one nurse in charge of the previous shift or occasionally the nurse in charge of the team would do the handover. In terms of revealing the culture of Newcastle Ward with regard to pain management decision-making, handover periods were a rich source of data from two sources: what was written on the handover sheet and what was said.
Handover sheets are a vital part of a nurse’s knowledge about patients, and are routinely taken in and out of pockets all day, as discussions are had about patients with colleagues or relatives. Newcastle Ward’s handover sheets were printed on two sheets of A4 paper, divided along the lines of the
allocation, male and female. As part of the field notes twenty-five handover sheets were compiled with contemporaneous notes written as the handover was being done.
There are eleven columns: bed number, patient name and age, consultant and date of admission, diagnosis and past medical history, diet, intravenous infusion, intravenous drugs, catheter, blood sugar levels, social services referral and handover notes. The diagnosis and handover notes columns contained the most information, with many abbreviations being used, some common nursing terms, and some particular to Newcastle Ward.
The number of patients on the ward as stated on the handover sheet was only correct at handover time, due to the frequency with which patients were discharged and new ones admitted. The number of patients in Newcastle Ward at these handovers was 21 – 30, with an average of 27 patients. This information could inform how busy the ward was, though clearly does not indicate patient complexity. Appendix 7 has a more detailed examination and analysis of the handover sheet information. Two handovers, chosen as being typical, are described in more detail to demonstrate how pain
management information is communicated.
5.3.2.1 Handover twenty-one (HO21)
The handover was for twenty nine patients. The handover sheet had the word pain documented in six patient diagnosis columns, five within the context of ‘abdo pain’ and once ‘RTA [road traffic accident] pleurite [sic]
During the oral handover there was no mention of pain, analgesia or other pain management for four of these six patients. One of those patients who had a diagnosis that contained ‘abdo pain’ had the comment ‘...pain score of
3 this morning’ included in the spoken handover, while ‘just for analgesia’
was the oral handover for the patient with the fractured sternum.
The handover notes column mentioned pain related topics five times, only one associated to pain was mentioned in the patient’s diagnosis column; that of the fractured sternum patient which stated ‘admit for obs and analgesia’.
There were two notes of ‘PCA’ meaning that a Patient Controlled Analgesia
(PCA) pump was in use, one ‘BD MST’ (twice daily long acting morphine),
and another for a patient with ‘?#NOF [fractured neck of femur] and #wrist’
stating ‘if in pain for MRI ’.
At oral handover for these patients, comments included ‘continue ... [BD
MST]’, ‘pain score is about 4’ [PCA]. For the other PCA patient it was
mentioned that the ‘IV cannula is out’ without any further comment. As PCA
devices on Newcastle Ward were always run intravenously this statement meant the PCA was not longer being used. I noted ‘how is the PCA going
then, seemingly no one is worried about that’, as I wondered what the plan
was for this patient’s pain management if the PCA was not continuing; this was not discussed. For the patient with the unconfirmed fractures it was handed over as it was written ‘if in pain she needs an MRI’, but there was no
mention of whether the patient was in pain and no one receiving the handover inquired about it.
For eighteen of the twenty-nine patients that morning there was no mention of pain, analgesia or other pain management in the handover; there was little discussion regarding pain management for any of the patients. There
seemed an absence of consideration of pain management for patients’ with diagnosis which included, ‘Wound dehisced’, ‘Acute pancreatitis’, ‘Tendon
reconstruction’. When it was said of a patient with obstructive jaundice and
cancer of the pancreas, ‘... pain unsettling, given oramorph, but prefers
paracetamol’, I have noted in the field notes, “why no questions here, how
much, how often, why not another drug, what is pain score?” (HO21). This
apparent limited involvement in pain management is discussed further under the theme describing single pain management actions, but the silence of routine pain management communication is becoming evident.
5.3.2.2 Handover twenty-four (HO24)
A few weeks later another morning handover sheet for twenty-five patients had ten mentions of pain in the diagnosis column; seven included ‘abdo
pain’, one ‘ureteric pain’, one ‘flank pain’ and one ‘upper Q [quadrant] pain’.
The handover notes column mentioned pain, analgesics or other pain management for six patients; one ‘abdo pain’ patient had ‘PCA’ noted,
though it was not discussed in any way during the oral handover. One patient had ‘BD MST / Not for PCA / PRN Entonox’ written in the handover
notes column. Following the brief oral statement about this patient, the nurses felt they had something to add about her. The field notes recorded:
Everyone had something to say. ‘The consultant said there was nothing
wrong with her’, ‘she is just drug seeking’, ‘she is not really in pain’,
‘consultant says strictly no PCA or entonox’, ‘drug dependent’, ‘she
hasn’t asked for entonox, only PCA’, ‘seen by pain team’, ’need to take
entonox away’. (FN24 L7)
With a further comment:
Some of the things said were contradictory, for example the entonox.
Everyone had an opinion and it seemed to not really matter what was
said but to get it said, get it off their chests about this patient who was a
‘bad’ patient. (FN24 L11)
Another patient caused further discussion; this gentleman had a diagnosis that included “ureteric pain...”
SN Andrea handed over, ‘He complained of pain all night long but still
managed to get downstairs. He wanted to talk to doctors and when
they came the first time he wasn’t here. He insisted on talking to a
doctor so they had to come up again’. SR Danielle asked ‘What did he
have for pain?’ The reply from SN Andrea was ‘analgesia’. (FN24 L15)
The field notes recorded here were:
There was no follow up question about the type of analgesia, or pain
scores, or how was he now. There seemed a general acknowledgment
The gentleman who had a diagnosis on the handover sheet of ‘flank pain’,
was described by SN Andrea as, ‘This man is really in agony’. (FN24 L22)
The field notes recorded:
Is this a figure of speech or some way to differentiate between those
patients who are pretending to be in pain and those who are genuine?
(FN24 L22)
SR Danielle asked ‘How is his pain now? When I saw him this morning
he was kneeling by his bed in pain’. SN Andrea said, ‘Still in agony’.
(FN24 L26)
The handover at that point moved to the next patient and field notes recorded:
I found this very disturbing. He was in pain (agony) yet no one was
doing anything, they had done all they could do, call the doctor, give
oramorph (10mg I checked later), not give diclofenac (as it was
prescribed incorrectly, protecting themselves or the patient?). It was
important that they had done these things, but there was no sense that
they could do any more. (FN24 L30)
While demonstrating what happened around pain management
communication on Newcastle Ward, again these comments also link to the theme regarding single pain management actions.
There was no mention of pain, analgesia or pain management in the oral handover for twenty-seven of the thirty patients. There had been a great
deal of discussion about two patients who had more complex pain
management needs with the tone suggesting the nurses thought the patients were not in pain, but nothing was said for example about a young patient who was awaiting surgery for ‘? perforated appendix, cholecystitis,
peritonitis, small bowel obstruction?’, a condition which may have been very
painful.
This could demonstrate a culture of acceptance of pain as normal, though when asked at interview about how important pain management was, nurses said it was very important. These findings could also be linked to the
subtheme ‘inattention to pain cues’ where nurses did not appear to consider pain when given an opportunity, though it seems more of a general
inattention to pain management because pain was not a priority. 5.3.2.3 Other pain management communication opportunities
When SR Danielle was asked, as a clinical leader, to explain how she decides what information to put on the nursing handover sheet, she replied:
Things that are relevant, there’s lots of things that are put on here that
aren’t relevant and I don’t know about you but when I look at handover
sheets and see loads of stuff on there I don’t actually read it, so I try to
take out some of the stuff that isn’t relevant. (FN13 L249)
On another occasion SN Janine (P23) who had given the outgoing handover that morning, was questioned how she decided which patients required pain management issues discussed at handover.
Some of them if their pain tolerance may be different, and they keep
asking for their painkillers every 2 hours, every half hour, ... so we need
to consider more about giving painkillers. We don’t mention those on
regular painkillers who are fine with that, for them … we know not to be
over concerned about the pain for them. (FN22 L11)
I think people mention it if it’s been an issue on their shift, so if
someone has had IM morphine every four hours then ... it will be
brought up, but if someone is just on regular analgesic, and maybe they
haven’t had any PRN, or maybe they’ve had it once in a 12 hour shift it
probably won’t be ...it does depend on who’s handing over again. (SN
Tracey P37, interview L64)
SN Lorraine was asked how she felt about the handover that had occurred that morning; this was a Saturday morning with a handover for twenty-five patients, with a discussion or mention of pain management for three of the patients. The handover is detailed previously.
I was trying to get some more information about why only three people
were spoken about regarding pain, and what effect this had on how she
thought about the patients. She did not think that handover affected
her views at all about patients. I asked her specifically about the
gentleman who had been described as ‘really in agony’ at handover,
but his pain is better now so Lorraine appeared to think my questions
It seems nurses felt a discussion of a patient’s pain management on Newcastle Ward was only required for those patients where the
management of the patient’s pain was more challenging; there was a silence of routine pain management conversations.
It appeared this silence of routine pain management communication is founded within the culture of Newcastle Ward specifically, as supported by a field notes reported:
Handover for the bay was by an agency nurse, she mentioned pain for
all her patients ‘No pain overnight’, ‘prn oramorph’. Once her handover
was completed SN Emma did the other bay and it was back to what I
found more normal for the ward, NMOP [no mention of pain]. (FN11
L9)
Nursing handover in Newcastle Ward could be a lengthy resource heavy process with up to ten people being involved for that time. Very little pain management information was offered and the incoming nurses rarely asked for clarification. The pain management information on the written handover sheets was largely restricted to pain management pumps (PCA, epidural, syringe driver), or long acting analgesics (BD MST, BD OxyContin®, fentanyl patch). The majority of patients did not have pain management discussed in the oral handover, and those who did were those patients which the nurses were concerned about for a number of reasons. They divided largely into two groups: the bigger group were those patients who were perceived as
having dissonant pain and analgesic needs, and a smaller group whose pain was seen as genuine and difficult to manage.
There are other handovers of patient information; other opportunities to discuss pain management and gain information to inform decision-making. Below are some comments from a brief informal catch up with the nurse in charge and staff members from the male team late morning. Pain was discussed for four of the fifteen patients:
‘How’s his pain?’ was asked, SN Lorraine replied, ‘he has been asleep
and walking around’. Nothing further was said, the implication is that
there was no pain.
Another patient was described as, ‘He was in tears, so I turned him’.
There was no further discussion about this, the implication that this
simple comfort measure was enough.
SR Danielle said another patient ‘needed a pain care plan’. There was
no discussion about why he needed this or any question about how his
pain was, only that he was missing this piece of paper.
And a further patient: ‘How’s his pain?’ ‘He is in no pain, much better
than before’. (FN24, L114)
Handovers for patients being admitted to the ward were another opportunity to communicate routine patient pain management details. SR Danielle was asked about her decision not to seek pain management information at the
handover of a new patient admission. She replied, ‘The patient looked
comfortable and the other nurse did not mention it’. (FN13 L82)
When she was asked for her thoughts around this she said:
I guess nobody actually brings it up that pain is being a problem. We
just assume that the pain is being controlled and I saw the patient
arrive on the ward and she looked comfortable so, I suppose I didn’t …
if she was showing signs of being in pain, I would have questioned, but
because she looked comfortable and because there was nothing
mentioned in the handover about her requiring analgesia or that she
was in pain, I didn’t. (FN13, L207)
Findings demonstrating the silence of routine pain management
communication within Newcastle Ward have been presented. It has been shown that during handovers of patient details, either formally at shift changes or more informally throughout the day, pain management is mentioned only for those patients where the pain is difficult to manage; it is not routinely discussed.
It could be said that at formal, and informal, handovers nurses were not getting sufficient pain management information about their patients to make effective pain management decisions, although they may have been getting it from other sources.
The next section will examine how pain management is done on Newcastle Ward within the roles and tasks and how these fit into the hierarchy of the ward environment.