Improving Quality of Care Through Pain Management

Improving Quality of Care Through Pain Management Patrick Bobst A Qualitative Study Quantitative research involves testing hypotheses, making predictions, studying specific variables, collecting numbers and statistics, identifying statistical relationships, and making observations under controlled conditions (Johnson Christensen, 2008). None of the aforementioned attributes appear in chapter 17 â€Å"Improving the quality of care through pain assessment and management†. Hence. this chapter written byWells, Pasero, McCaffery, (2008) is a detailed deductive qualitative analysis which aims to increase opportunities to develop empirically supported ideas and theories with applicable relevance in the field of pain management for healthcare practitioners. Unlike inductive analysis, applied when not enough former knowledge about a phenomenon is known, deductive content analysis is used when the structure of analysis is initiated based on previous knowledge and with the intent to test a theory(Elos Helvi, 2008). The authors of chapter 17 provided qualitative resea rch by studying the issue of pain control as a whole without immersion into variables. They defined the purpose of the study by subjectively understanding and interpreting interactions with words, identifying patterns and themes, and making observations of occurrences in a natural environment(Johnson Christensen, 2008). Qualitative research is more concerned with describing social meaning and therefore provides the flexibility to follow ideas and explore processes(McGonigle Mastrian, 2012). Research Problem The level of pain a patient experiences is emerging as the fifth vital sign in health assessments statuses (Ju-Ling Wen-Chu, 2013). Pain is a common occurrence and an expectation in hospitalized patients especially during the postoperative period; yet despite the availability of analgesics along with national guidelines to manage pain a disconnect remains in in proper pain management resulting in undertreatment for about 50% of patients with moderate to severe pain(Wells et al., 2008). Inadequately managed pain can lead to an arsenal of negative adverse physical and psychological outcomes including immune system suppression resulting in infections and poor healing, sympathetic activation causing cardiac ischemia and ileus, reducing mobility resulting in deep vein thrombosis, as well as pulmonary embolus, or pneumonia(Nwachukwu, 2012). All mentioned adverse conditions carry along the potential consequence of extending a patient’s length of stay in the hospital decreasing patie nt satisfaction and increasing organizational costs(Nwachukwu, 2012). The Affordable Care Act of 2010 has established changes in the way hospitals are reimbursed for services. Value-based purchasing has come to the forefront in the healthcare industry with the centers for Medicare and Medicaid services (CMS) withholding full reimbursements for poor quality care or even nonpayment for patients readmitted within 30 days. Low patient satisfaction score indicators being tracked by CMS will not only affect an organization’s bottom line but also stand to lose its reputation(Wells et al., 2008). When pain is not managed properly through an organization’s pain management policy and procedure guideline the entire collaborative team responsible for managing a patient’s pain may be liable for legal action(Wells et al., 2008). Research Translated Into Practice The Agency for Healthcare Research and Quality (AHRQ) focuses on current issues, patient safety and quality of healthcare providing practitioners the best research for optimal patient outcomes. AHRQ is an active participant in pushing evidence forward into practice with its Translating Research Into Practice (TRIP) initiative to generate knowledge about evidence-based care and with the TRIP-II initiative the focus is on utilizing information technology to affect translational research and health policy (McGonigle Mastrian, 2012). The TRIP database is a clinical search engine designed to identify high-quality clinical evidence for clinical practice that utilizes contextual issues such as the magnitude of the health issue, economic costs of the problem, the reliability, relevance, and validity of the data along with the quality and consistency of the evidence (Glasgow Emmons, 2007). The authors in the pain assessment and pain management research study utilized the TRIP database probi ng for the terms â€Å"pain assessment† and â€Å"pain management† in the literature search, filtered only the English language and publications dated within the last 10 years, meta-analysis, practice guidelines, literature reviews, clinical trials, and random clinical trials (RCT). To use evidence in practice, the validity of research is evaluated on an evidential hierarchy that is defined and the value is assigned to the information source on a scale from 1 to 6, one being the highest evidence from a systemic review and six being the evidence from the opinion of experts(McGonigle Mastrian, 2012). The evidence table provided by the authors in the pain assessment and pain management study exhibits excellent research validity with multiple design types rating high on the evidential hierarchy scale listing. The authors utilized evidence from a meta-analysis study (Level 1), twelve RCT studies (Level 2), seven systematic literature reviews (Level 5), three literature rev iews (Level 6), and one qualitative massage study (Level 7)(Melnyk Fineout-Overholt, 2011). The RCT is considered the most reliable source of evidence in the hierarchy and the meta-analysis is the best quality evidence because it uses a multiple individual research studies to come to a consensus (McGonigle Mastrian, 2012). Practice Implications The implications of this TRIP intervention designed to increase the use of evidence-based practice (EBP) in pain assessment and management highlights scientific evidence for practitioners to augment their clinical decision-making. Recommendations for successful implementation of pain assessment and management include education, the utilization of appropriate tools in pain assessment, a multimodal analgesic approach, continuous evaluation, and an established organizational pain management guideline. Patient and family education has been a central recommendation regarding pain management prior to any surgical procedure in that comprehensive pain evaluations can uncover patient’s attitudes, beliefs, level of knowledge, and unrealistic expectations that can be addressed(Wells et al., 2008). Wells et al. (2008) found that frequent communication, shared goals, and shared knowledge in education contributed to better pain outcomes. The most critical aspect of proper pain management is assessing pain levels on a regular basis using a standard format, and in order to meet the patient’s needs pain should be reassessed after each intervention evaluating the effects and determining whether modification is needed(Wells et al., 2008). Based upon systematic reviews of pain quality improvement studies the emphasis has shifted from processes to outcomes where clinicians recognize and treat pain promptly, involve patients and families in pain management plans, adjust pain management plans as needed, and monitor processes and outcomes(Wells et al., 2008). Utilizing a multimodal approach for pain management is recommended which includes opioids, and non-opioids such as nonsteroidal anti-inflammatory drugs, and adjunct medications such as anticonvulsants can improve the safety of the therapy (Wells et al., 2008). With safety issues regarding the use of morphine, hydromorphone, and fentyal clinicians need to be educated about safe pain management to help prevent undertr eatment of pain and the resulting harmful effects. A series of systematic reviews indicate poor results and outcomes using the intramuscular route (IM) administering of an opioid analgesic (Wells et al., 2008). The IM route is painful, has an unreliable absorption time and can be dangerous since patients are often alone at the time of peak affect and can become excessively sedated, vomit, and aspiratenevertheless produces the poorest outcomes (Wells et al., 2008). Unfortunately,Wells et al. (2008) describe the evidence for nondrug techniques of pain management including relaxation, music, massage, heat and cold therapies are neither supportive nor consistent, are considered weak in reducing acute pain, and may not improve outcomes. Ample evidence revealed the appropriate use of analgesics with the proper drug at the correct interval can provide good pain relief for the majority of patients, and organizations should place their emphasis on improving assessments and administration tec hniques (Wells et al., 2008). The psychological, emotional, and financial toll of uncontrolled pain is monumental and everyone experiencing discomfort because of pain justly expects and needs to receive appropriate pain management. Research Implications The research provided supports the evidence-based treatments with analgesics in the management of pain, and appears to be effective in controlling acute pain. However, the undertreatment of acute pain remains prevalent due to the clinician’ behaviors, which includes inadequate pain knowledge, assessment skills and administration of analgesics (Wells et al., 2008). Krenzischek, Wilson, Newhouse, Mamaril, Kane (2004) also assert a lack of pain management knowledge and the reduced usage of clinical practice guidelines is a high contributor in poor pain management. Research is needed for effective strategies in changing clinician attitudes and behaviors that will result in better pain management for patients as well as non-drug therapies (Wells et al., 2008). Wells et al. (2008) asserts, â€Å"Lack of standardization of nondrug therapies is one of the drawbacks of the current literature† (p. 11). Integration of Informatics The authors of this study integrated informatics through data, information and knowledge to support clinicians and patients in their decision-making regarding the best practices in accomplishing favorable outcomes and to improve the quality of care through pain assessment and management. Wells et al. (2008) utilized the informatics infrastructure to seek and manage validated studies from various sources, capture proper demographic, treatment and outcome information, and the AHRQ to share project information, results, and insights. The informatics infrastructure is critical to EBP and promotes the use of clinical judgment and knowledge with procedures and protocols to what is scientifically proven rather than what is customary(McGonigle Mastrian, 2012). The paradigm of â€Å"this is the way I’ve done it for years â€Å"is no longer acceptable and it is upon clinicians to apply the aforementioned viable knowledge, experience, understanding, and insight derived from EBP throug h informatics to gain and synthesize the effervescent wisdom needed for high quality patient care and optimal outcomes. References Elos, S., Helvi, K. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115. http://dx.doi.org/10.1111/j.1365-2648.2007.04569.x Glasgow, R., Emmons, K. (2007). How can we increase translation of research and to practice? Types of evidence needed. Annual Review of Public Health, 28, 413-433. http://dx.doi.org/10.1146/annurev.publhealth.28.021406.144145 Johnson, B., Christensen, L. (2008). Educational research: quantitative, qualitative, and mixed approaches. Thousand Oaks, CA: Sage Publications. Ju-Ling, H., Wen-Chu, W. (2013). Factors of accepting pain management decision support systems by nurse anesthetists. BMC Medical Informatics and Decision Making, 13(16), 1-13. http://dx.doi.org/10.1186/1472-6947-13-16 Krenzischek, D. A., Wilson, L., Newhouse, R., Mamaril, M., Kane, H. L. (2004). Clinical evaluation of the ASPAN pain and comfort clinical guideline. Journal of PeriAnesthesia Nursing, 19(3), 150-159. http://dx.doi.org/10.1016/j.jopan.2004.03.003 McGonigle, D., Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones and Bartlett. Melnyk, B. M., Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott, Williams and Wilkins. Nwachukwu, C. N. (2012). Decreasing pain and length of stay in the post anesthesia care unit (PACU) by implementing the ASPAN pain and comfort guidelines (Doctoral dissertation, The Catholic University of America). Retrieved from http://aladinrc.wrlc.org/bitstream/handle/1961/10269/Nwachukwu_cua_0043A_10311display.pdf?sequence=1 Wells, N., Pasero, C., McCaffery, M. (2008). Improving the quality of care through pain assessment and management. Rockville, MD: Agency for Healthcare Research and Quality.

Character Growth in Conrads Heart of Darkness Essay -- Heart of Darkne

Character Growth in Conrad's Heart of Darkness      Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Joseph Conrad's Heart of Darkness explores the intellectual, emotional and moral growth of characters throughout the novella. This character growth has been a recurring theme in literature, with the poet William Blake, among many others, exploring theories of the movement between innocence to experience. Although Conrad does not strictly address character growth in this manner, characters that do and do not undergo psychological growth are portrayed quite differently. Those who undergo these psychological changes are portrayed favorably, that is Marlow, the frame narrator, and Kurtz. These characters throughout the novel undergo significant change, for some it is gradual (Marlow), but for others such as Kurtz, this growth or realization occurs rapidly, and almost too late. While European colonialists - characters that do not grow, or remain at the stagnant psychological level - are used to represent the anti-colonialism theme to the readers. Conrad utilizes c haracters, and their psychological growth (or lack of growth) to distance himself from the narrative and endorse or criticize many themes that would be seen as revolutionary in the context of its publication. A large gap is then depicted between the characters who grow, portrayed as "enlightened" beings, and the pilgrims and European colonialists, who are seen in a colonial point of view as perfect examples of good, however portrayed by Conrad as stagnant, "Hollow men", whose aims and ideals are criticized.       The frame narrator, although not a major character in the novella, undergoes significant psychological growth throughout the text. This growth can be broadly divided into three phases - the initia... ...hed ways of thinking, have a faà §ade of bringing culture and progress to a world devoid of these elements, yet are merely "hollow men". They are merely acting as products for the indefinable aims of colonialism and in turn, move the readership to reject their ideals, emphasize the "enlightened" (those who grow) and encourage a similar psychological journey of the readership.          Bibliography    Conrad, J. (1995). Heart of Darkness. London: Penguin Group.    Dintenfass, M. (1996, March) Heart of Darkness Lecture. [WWW document]  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   URL http://www.lawrence.edu    Maes-Jelinek, H. Notes on Heart of Darkness    Moon, B. (1992). Literary Terms A practical Glossary. Perth: Chalkface Press P/L    Analysis of Major Characters. [WWW document]  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   URL http://www.sparknotes.com/lit/heart/characteranalysis.htm      

Psychoanalysis of Crime Essay

An individual’s sense of self has always been an issue that fascinated people. Under the notion that most people enjoy talking about themselves, the realm of psychology opened its doors to investigate the underlying conditions that make people who they are and how they perceive others and the world. Many theories have been developed in order to understand the complexities that make up the human psyche and it is in this aspect that this paper will center upon. The theory which I have chosen for this particular case study is the Psychoanalytic theory by Sigmund Freud and I believe this theory will address most of the behavioral patterns that the subject is situated in. Freud’s psychoanalytic style in examining an individual’s motives for behavior has established the grounds for in-depth analysis into a person’s psyche and though it has its limitation, it offers a refreshing viewpoint as to why such behaviors have endured and its significance to an individual’s interpretation of the world (Shoham, 1993). Psychoanalysis has helped in putting into perspective the many ways in which behaviors of an individual or groups of individuals could be determined by the examining their upbringing and isolating internal and external desires. One of the major conjectures of psychoanalysis is that individuals are inherently sinful and they are controlled by certain instincts which are buried in one’s subconscious. The psychoanalytic theory attempts to realize these internal desires in order to determine the right kind of action in which the individual might be able to control a problematic behavior from recurring (Elliott, 2002). In order to see the application of the psychoanalytical theory, a brief background of the case study should be presented to comprehend the situation. The case study involves a twenty-eight year old man named Bert who was convicted of committing larceny. In the article, Bert was condemned to serve a four year sentence in prison with eighteen months non-parole. Admitting to the crime he had committed, he was said to have been accompanied by two accomplices whom he knew from his previous prison sentence. It was relayed that Bert had entered a pub one night and was approached by the two accomplices who urged him to join them rob a factory. Nine weeks before the incident, Bert was out of prison after serving a year in prison for getting caught with stolen goods. In Freud’s Division of the mind, he enlists the concept of the Id, Superego and Ego. The Id is supposed to uphold the baser instincts that are present in each individual. It dispenses on the precepts of pleasure to satisfy the innate wants of the individual. The Superego comprises the ethical or moral aspect of the individual that appeals to an ideal sense of being. The Ego is said to be the balancing aspect of the individual’s personality as it maintains the needs and wants of both the Id and the Superego. The Ego represents the awareness of an individual regarding his/her state of being (Shoham, 1993). If the processes that harmonize these three should ever be disrupted, it would render uneasiness to the individual’s psyche and cause him/her to employ some defense mechanisms that would be able to shield the ego. The psychoanalysis in Bert’s case encompasses a great deal of struggle between his superego and id, as can be denoted when he points out that he is frustrated with himself for not being able to avoid criminal activities. This is described as an over-developed superego, which imposes an excessive need for punishment with regard to the things the individual has wrongly committed or the unpleasant experiences that has brought misery into the individual’s life (Shoham, 1993). In the text, Bert was said to have grown-up in a dysfunctional family and that his absentee father was also a criminal who often displayed a violent attitude towards the family whenever he was home. In this aspect, Bert’s rationale on punishing himself was an act of regression in an early state of his life that involved his father (Shoham, 1993). The illegal acts Bert has committed during his early teens and the subsequent trips to juvenile and adult institutions has led him to think that he should be penalized for the things that he has done and for belonging to a family that breeds criminals.. In a sense, Bert might be trying to compensate for his father’s mistake of abandoning his children with regard to his wife and kids and most especially, his brothers and sister. This kind of rationalization instills tension into his being, which makes him unconsciously commit illegal activities despite his efforts to reform his life (Shoham, 1993). As a result of this conflict, Bert reasons out in a defying way that even though he acknowledges his wrongdoing, he believes that it is under the influence of alcohol and the two conspirators with him the night of the criminal activity. Bert also pointed out that the long sentence designated to the criminal act that he had committed was a bit unreasonable since he only stole goods from a factory and not a private residence. Based on these statements, Bert had shown feelings of contradiction between his guilt for what he had done and his comprehension of the situation as he puts the blame on other sources in lieu of himself. In the case study, Bert was thought of to be a pushover by the law officers as the former would get caught up in situations that force him to do things that should best be avoided (Elliot, 2002). Parallel to his over-developed superego, Bert’s behavior also displays a weak Ego in conjunction with his Id. His inability to stand his ground in moral situations and his inadequacy in delivering good judgments makes him a pawn for manipulative individuals like the two conspirators whom Bert met at the pub (Shoham, 1993). In this situation, it is quite clear that he is still in denial of what he has done since he has not fully accepted the responsibility for the criminal act. However, in another statement, he also did not want to cooperate with the law enforcers in identifying who were his accomplices in committing larceny. This posits a rather confusing behavior as Bert did not want to admit fully to the crime committed yet he does his conspirators a favor and refuses to give out their names to the law officers as he believes that he is not one to break the code of brotherhood. This act alone concurs with the insight made earlier about his desire to be punished for being a criminal (Rosen, 1996). On another note, Bert has tried to justify the crime he had committed by rationalizing the triviality of robbing the factory and that a long sentence was not necessary. He seems to suppress the mere fact that he has a long track record of criminal activities that warrants for the current court verdict. With this in mind, one can deduce that Bert still thinks of himself as a misguided youth. Such display of reasoning implicates how the environment he grew up in greatly influenced his decisions in life (Shoham, 1993). His lack of a formal education and emotional nurture at home resulted to his rebellious conduct and misplaced aggression that could only be attributed to his family’s situation. Bert’s leanings toward alcoholism may be credited to his undeveloped oral stage, which his mother could not properly provide as the strains of his father being in prison and the abuses that his mother and siblings received from him deprived Bert of a normal transition into the next stages of development (Shoham, 1993). In addition, his father’s drunken presence at the puberty stage predisposed him and his older brothers to acclimate a life of criminal activities since that might have been the only way that he could be with his father who was gone most of the time. While he was third among the two boys in his family, he could not look up to his older brothers as they too were undependable for the nurturing in which he sought from his parents (Shoham, 1993). It is in this aspect that one can observe the oedipal complex that Freud has included in his Stages of Development theory as it demonstrates the lack of attention and love that Bert wanted from his father (Shoham, 1993). Bert’s unresolved intimacy issues from both his parents compelled him to project this in an unhealthy lifestyle through alcohol and a string of criminal records. In defense of the two conspirators, Bert might have felt a sense of belongingness in their company since they understood his situation more than anyone, which is why he was adamant to not cooperate with the law enforcers (Shoham, 1993). Bert’s yearning to successfully reform may be hampered by his own moral perceptions as he is not able to grasp the consequences his actions have merited him. While he is affected by what happens with his wife and two children, he cannot instinctively change his ways without going through therapy or some form of rehabilitation to straighten his ways. Bert’s situation could have been easily avoided if he has learned to act on his own. Since his lack of education poses a hindrance to the development of his being, one could suggest that individuals like Bert who are frequently law breakers should be also be subjected to an education in their correction facilities aside from the terms that they serve (Kline, 1987). According to Lester and Van Voorhis’ book â€Å"Psychoanalytic therapy†, criminal convicts like Bert should not be subjected to environments that derail their development. Since most these convicts are not well-equipped with the right attitude to stay off the streets, correctional facilities should be able to provide such services that will be able to aid them to commit to reformation. Support from family and close friends should also be encouraged though for most of these convicts, it would seem quite difficult as most of them don’t have a strong support base (p. 122). From Kline’s book â€Å"Psychoanalysis and crime†, it has been suggested that creating a viable environment for these convicts when they got out is necessary as that will sustain their progress for development and would make them not want to seek the confines of the prison walls as they will be able to feel part of the society again. This entails releasing them in an environment where temptations would not abound and provide them with jobs that does not degrade their sense of being (p. 60). Analyzing Bert’s case in the psychoanalytic perspective has provided grounds on in which correctional facilities should be able to help convicts to maintain a reformed life.

Free Trade V.S. Command Economy Essay - 797 Words

Free Trade V.S. Command Economy =============================== Introduction: Politicians, countries and ideologies from all over the world have for years been torn between what they should follow and believe. Countries quarrel over which policies should be adopted and what, how, for whom have been the economists fundamental question. Adam Smith preached for market economies often referring to the invisible hand Karl Marx preached for command economies often referring to The proletariat will over run the capitalist class These two men have substantially shaped the way countries have decided to run their economies. Not forgetting the names of a great deal of other Their works were published in volumes,†¦show more content†¦E.g.(Sweden uses a similar system to that described above as it uses market forces to determine consumer goods, but has an important welfare system, I consequence income tax is relatively high.) Economists use two terms to describe the different options in producing goods. Labour intensive: small workshops with highly skilled technicians using little machinery. Capital intensive: Complex machines are used, accompanied by few semi or unskilled workers to operate them. In a planned economy, although planners can easily plan production, it is a harder task for them directly decide about distribution. For capital goods (education, defence, housingà ¢Ã¢â€š ¬Ã‚ ¦) distribution can prove successful, but consumer good wise there poses a problem because the consumer or the wage earner will want to decide on what he/she spends his/her wages on. Inevitably there will be shortages or surpluses of certain goods because of the absence of a price mechanism. In using the latest the communist authorities believe It would be unfair to use the price mechanism as only the privileged earners would simply pay more. In response to this prices remain the same and physical rationing is put intoShow MoreRelatedCaribbean Crucible: History, Culture, and Globalization4302 Words   |  18 Pagesfrom Africa, Europes periphery, India, China, and even Java. Not only was it in the Caribbean where the first sustained European external colonizations occurred, but these colonies required and stimulated the creation and marshalling of far-flung trade and governmental networksÂâ€"a truly global undertakingÂâ€"with the aim of enriching imperial treasuries and creating dependent territories in their service. Reconsidering the Caribbean as an origin-point of the modern global system means more than an understandingRead MoreCultural Analysis For Doing Business8067 Words   |  33 Pageswestern Europe, discovered their way to the island at some point between around 600 and 150 BC and stifled the past tenants. About the season of Christ the island was sorted out into five kingdoms, the customary Five Fifths of Ireland. By AD 400 seven free kingdoms had developed. The rulers of these kingdoms regularly partnered their armed forces to assault neighboring Roman Britain and the Continent. On one of these strikes a chap of 16 was caught, come back to Ireland and sold into subjection. AmidRead MoreGp Essay Mainpoints24643 Words   |  99 Pagespersonal opinions about who was likely to win but New York Times invited experts to do a state-by-state analysis presenting results in a full-page spread, culminating in a detailed map showing states Democrats were likely to win) †¢ Anonymity: given free rein to publish any thought that comes to mind †¢ E.g. For every worthwhile video present on the site (think Annie Leonard’s â€Å"The Story of Stuff†) there are a multitude of videos featuring otherwise inane and banal individuals indulgently bangingRead MoreDamodaran Book on Investment Valuation, 2nd Edition398423 Words   |  1594 PagesINVESTMENT VALUATION: SECOND EDITION I will be putting my entire second edition online, while the book goes through the printing process - it will be available at the end of the year. This may seem like a bit of a free lunch, and I guess it is. I hope, though, that you can do me a favor as you go through the manuscript. If you find any mistakes - mathematical or grammatical - could you please let me know? It would help me ensure that the typos do not find their way into the final version. Chapter