Objectives Participants will be able to: Conflict of Interest Disclosure. Author s Conflicts of Interest: E. Bernhofer, No Conflict of Interest

Transcription

1 September 19, 2015 ASPMN 25th National Conference Esther I. Bernhofer, PhD, RN-BC Senior Nurse Researcher Pain Education Specialist Office of Nursing Research and Innovation Cleveland Clinic Conflict of Interest Disclosure Author s Conflicts of Interest: E. Bernhofer, No Conflict of Interest Objectives Participants will be able to: 1. Describe the importance of adding lessons on values, ethics, culture, and self reflection to clinical pain management classes. 2. Identify how to assist themselves and nurses they teach in understanding the way they approach pain management. 3. Discuss implications and future research opportunities. 3 1

2 On going challenges to providing optimal pain management 1. Inadequate pain education? may not be entirely due to the course content or teaching style, but rather the biases and culture that the learners bring with them 2. How pain care decisions are made? Do we understand the process? 4 Current state of affairs Nurses and other clinicians may be unaware of how their values/biases, culture, and beliefs shape the way they make assessment and treatment decisions, affecting the pain care that they provide. 5 Is there anything wrong with this picture?? 6 2

3 How do you decide?????? 7 Maybe you just decide on this 8 How do we make pain care decisions? Emotions? Gathering all the facts and options? Ownership of the problem? Personal values/biases? Ethics? How should we make our decisions? 9 3

4 Decision making Theories Principlism : Using the Principles of Ethics to make the right decision Decision Criteria Theory: a) Organizational, b) Professional, c) Personal, d) Policy, e) Ideological Theory of Planned Behavior: cognitive self regulation vs. social attitude and personality trait Theory of reasoned action (Fishbein, 2008) medical intention Transtheoretical model (Prochaska, 2008) Evidence based practice Fuzzy trace theory (Reyna, 2008) subconscious intuition Hammond s Cognitive Continuum Theory much like levels of evidence 10 A Melding of Theories Since human behavior is so complex, no ONE theory explains and predicts all decision making 11 What about? Personalized medicine? Individualized nursing pain care? The population we care for? 12 4

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6 Adding to the Nursing Pain Class Realize that changes to values/biases, cultural beliefs, and perceptions take more than aclass it s just a beginning Add understanding of how decisions are made Add ethical expectations and reflection of personal bias 16 Important pain class elements Include: a) lecture on how pain is a unique symptom ; how values/bias, ethics, culture, and personality can drive pain treatment b) self insight survey such as Pain Management Approach (PMA ) to gain insight into their own strengths and challenges c) case studies d) group discussions 17 Nurses Experience Following Education on Clinician Values and Culture A qualitative, phenomenological study Purpose: to examine the experiences of nurses who have participated in a pain management class that included a segment on the importance of examining the clinician s own values and culture when making pain management decisions for their patients. Written interviews obtained from 20 clinical bedside nurses 18 6

7 Interview questions 1. Think about a time before the pain management class when you were taking care of a patient with challenging pain issues. Then think of how you helped a patient with their pain after you attended the class. Did participating in the class segment on understanding your own values regarding painand its treatment (yourpain Management Approach) help you utilize your knowledge and resources to help manage the patient s pain? If so, please explain the difference. If not, please explain why not. Feel free to tell a story about helping a patient before and a patient after attending the class. (do not use any identifying patient information) 2. As you take care of patients with many different backgrounds, comorbidities, socio demographics, cultures, and illnesses, please describe your experience in helping a patient manage their pain in light of understanding their cultural uniqueness and your own values and culture. 19 Results Overarching theme of desiring to understand patients better irrespective of their own opinions: "I realize my own prejudices can interfere [with treatment]." desire for more pain education varying levels of willingness to understand patients pain importance of listening to patients' stories confusion over what to do with patients who appear to be addicted to opioids and other substances 20 Results Four Major Theme Categories 1. Understanding the patient I came to a better understanding of how to document and treat the patient who rates his/her pain 10/10, but the patient is eating and drinking and chatting either on the phone or with a family member. 2. Change in nurse s perspective My biggest take away was to understand the different philosophies around pain management and to acknowledge these differences and how they affect my practice AND The class did help me be more attentive to my perceptions. 21 7

8 Results Four Major Theme Categories 3. Importance of education Taking this class helped me to understand my values and the possibility that my own prejudices could interfere with the patient's choices for pain treatment. But not necessarily on culture and values equianalgesic dosing for chronic pain patients has helped me provide better pain management. 4. Do personal values really come into play? I think the class segment on my personal values regarding pain & its treatment didn't really make much of a difference. AND My own values do not come into play I know that pain is the patient's experience. 22 Values what do people mean? Official Definition level of worth or importance beliefs shared by the members of a culture influence behaviors, attitudes, and serve as guidelines of behavior I learn more each day about pain and about how I cannot force my values or culture on others but have to work within the boundaries of each of our differences. 23 Values what do people mean? But how do folks define values for themselves? I needed the information about assessment, treatments and CCF resources so I had something to offer more than just understanding my own values & the patient's pain experience. Does the word create strong feelings and evoke passionate justification? I know my values and my strengths and weaknesses Is there a better word or phrase to use in defining what shapes cultural bias? 24 8

9 How does knowing these themes and descriptions help? Remember what the essential take home messages of a pain class are: Basic pain physiology and psychology Assessing pain How managing pain is unique and subjective Treatment options Special populations Resources and how to find/use them Ethics and how to approach and treat all patients 25 So let s go back to our own way of making decisions and using resources Something as fairly inconsequential as choosing an ice cream flavor. Choosing a place to live.. Disciplining your children. Financial decisions. Choosing a cancer treatment How do decisions change when the input is subjective, objective, or dependent on others? 26 PMA Theory Understanding the way you make decisions in other areas of your life will influence your Pain Management Approach (PMA ) and may help determine how you will make decisions regarding the use of your knowledge and resources to care for patients with pain. 27 9

10 Understanding PMA Pain care approach categories are based on how the individual clinician may approach patients from their personal life perspective, values/biases, intention, and goals. Self Reflection telling oneself the truth about how they chose to care for their patient. 28 Pain Management Approach Decision-Making Model (Preliminary) Emotions Intuition Values or Biases Culture Ethics Pain management decision Ownership/ Intention Reflection 29 Primary Benefits of understanding PMA Prediction Determining the likelihood of making certain decisions. Self reflection/understanding Changing decisions for better care Personalized Pain Care 30 10

11 Determining your PMA 1. Consider how you respond and make decisions in other areas of your life. 2. Consider your own values. 3. Take a fun quiz a. R b. E c. P d. C 2. a. P b. C c. R d. E 3. a. E b. R c. C d. P 4. a. C b. E c. P d. R 5. a. R b. E c. C d. P PMA answer key 6. a. C b. R c. P d. E 7. a. P b. E c. C d. R 8. a. E b. P c. R d. C 9. a. R b. E c. C d. P 10. a. C b. E c. P d. R 32 Four types of PMA o The Cautious o People s pain is hard to figure out. o The Restrained o The cure is worse than the pain. o The Pragmatic o Life is pain. It is what it is. o The Empathetic o We have to do everything we can

12 Four types of PMA 1. Cautious Can t believe every patient s report of pain Doesn t understand the whole pain thing Strengths: can prevent being manipulated; may lead to better assessment Challenges: cynicism can damage trust; may lead to moral distress/confusion; may refrain from spending much time with patient 34 Four types of PMA 2. Restrained Afraid that medication will hurt/kill the patient. Doesn t really know how to talk to someone in pain. Strengths: aware of potential dangers; always cognizant of patient safety Challenges: may cause harm by not treating pain aggressively; can suffer moral distress; may not spend much time with patient 35 Four types of PMA 3. Pragmatic Just get the job done life is pain. It is what it is. Besides, the patient s pain is not their big problem Strengths: protects self from moral distress; usually administers meds without question; can make unemotional decisions Challenges: rarely thinks outside the box ; may not seek out resources to help patient beyond the usual

13 Four types of PMA 4. Empathetic Really feels for those in pain. Wants to do everything possible no matter how long it takes Strengths: will go to great lengths to advocate for better pain care; will be present with patient Challenges: may overlook harmful side effects; suffers moral distress; may not communicate well in high state of emotion 37 Discussion Questions 1. Do you think that the quiz results accurately portrayed your PMA? 2. What are the strengths of your particular PMA? 3. What challenges do you face with your PMA? 5. Recall a difficult pain care situation that you ve had to deal with in the past. Would you change what you did? Does knowing what you know now make any difference? 38 Remember Optimal pain care often falls victim to the values and culture of the caregiver despite what they learn in a class! The commanding influence of the personal biases and culture that each nurse learner brings to a pain management course cannot be overestimated

14 Where does this lead? Emphasizing the importance of teaching clinicians what REALLY drives pain management behavior/decisions Awareness of self can lead to personal practice change. 40 Where does this lead? Awareness of how pain treatment decisions are made can lead to better pain management education new research and interventions individualized pain care optimal patient outcomes 41 Contact Information: Esther Bernhofer, PhD, RN-BC