According to the International Association for the Study of Pain (IASP), pain is defined as an unpleasant sense or feeling due to potential tissue damage (Iasp-pain.org, 2017). Pain is not just a physical condition; it is caused by personality, attitudes, and social beliefs and effect the person’s emotional and mental health as well. There are different type of pains that affects elderly people, at the end of their life. Acute, chronic, break through, bone related, nerve and total pain are several kind of pains that affect people (Abdulla et al. 2013, p. 42). Therefore, pain management of these elderly patients about to face the end of their life becomes important. Priorities are to relief the symptoms of pain to make their end –life little relaxed. It also helps to create a proper physician-patient relationship.
There is a broad array of patients suffering from life threatening diseases such as cancer, HIV and many more, which ultimately leads to end of life. These life-threatening diseases knows no borders and affects rich, poor, young, old irrespective of race, gender and ethnicity. The knowledge attitudes of nurses towards such patients in pain and their pain management strategies has been studies by several researchers. According to Barry et al. (2012, p. 1260), nurses has the central role in understanding and treating patients with dementia, where pain was prevalent among older adults. The methodology they chose to find out the attitudes and knowledge of nurses while providing care was random questionnaires comprising of six sections. These questionnaires was sent to 244 nursing homes. After the data collection, it was seen that pain management guideline strategies was not been followed by nearly 40 percent of nursing staffs. The managers of those care centers were uncertain about managing the pain in residents. Usage of opioid analgesic drugs was prevalent.
Another research by Gardiner et al. (2016, p. 210) was aimed to find out the attitudes healthcare workers while prescribing opioids in end-of-life care. The methodology they chose was to create two focus groups in both general practitioner chambers and hospitals. Total 31 healthcare professionals took part in the experiment. It was finally revealed that there are some barriers exists in appropriate use of opioid drugs. These healthcare workers lack proper training of pain management and tend to provide high dosage of opioids to patients. The families of the patient are generally concerned about the dose of opioids and it is the duty of specialist nursing staffs to lessen these issues and concerns. In another research article by Livingstone et al. (2012, p. 646), researchers tried to find out and examine the potential barriers and enhancers while improve the end-of-life condition in patients. Individual interviews to identify the qualitative results was carried out in a hospital having 120 beds and 58 nursing staffs. The interview was continued until the researchers gathered a variety of samples and theoretical saturation was achieved. The results was positive in this case as the staff was emotionally attached to the patients in their end-of-life. However, the communication between nurses, health staff and the relatives of the patient was very poor. The staff was often worried about being blamed and hence, they lacked the communication.
According to Alberts et al. (2014, p. 5), the researchers studied a national survey to find out the attitude of nursing staff in their role in end of life decisions and pain management. Survey study was used, which is a national paper of Dutch research sample and consists nursing staffs, healthcare professionals home cares and were sent questionnaires related to the topic. Only 58 percent of the healthcare workers agreed to get completely involved in the care process during end of life decisions (ELDs). Whereas, 64 percent thought the role of nurses is much important than the physicians and nurses need to be involved more frequently than physicians are. Therefore, majority of the nurses want to get involved in the care process and factors like educational level and settings of work determines the situation during ELDs.
From above literature review, it can be understood that to assess the attitude and knowledge of nurses about pain management in end of life patients, maximum researchers have been used questionnaires and personal interviews. One organizations have been used for each research so that a proper qualitative analysis, without random selection of population can be achieved.
From the above literature review, it can be stated that lack of knowledge about pain management strategies is the primary problem. Pain management in end-of-life patients is important as ignorance can lead them to face early death as well (Barr et al. 2103, p. 271). Healthcare professionals are either lacking on knowledge about management tools or they are facing educational barriers while treating such patients. Nurses are need to be aware of usage of analgesics and other pain reliefs however, they lack the authority to administrate the drug, as the physician did not prescribe it. Therefore, improvement in pain management skill is necessary, as unsuccessful pain relief is harmful for patients as well as healthcare providers (Williams Eccleston & Morley 2012). Unsuccessful pain relief increases the period of healing and cause different life-threatening complications in patients. Chronic pain may lead to depression in patients and in extreme cases; suicidal attempts can also be seen (Dworkin et al. 2013, p. 2257). Therefore, it is important to make the nursing staff aware of the pain management strategies so that they can deal with any adverse situation. A proper knowledge of facilitators and barriers is also needed so that the barriers can be removed permanently.
Furthermore, the aim of this research is to understand the attitudes and knowledge of such nurses related to pain management strategies. The research question is ‘what are the attitudes of nursing staff towards pain management during the end of life?’ the purpose of this research proposal to figure out the strategies to improve pain management and to carry out the need assessment to keep up with the strategies.
A qualitative methodology can be designed to describe the study. Interviews can be conducted and those in-depth interviews can be of semi-structured (Liamputtong 2013). The researcher should keep a track of these interviews so that it is easier for him/her to interpret the data. The researcher also relied on the reliability and ethics at the time of performing the research. Such research method allow the researcher to study the research in suitable manner as it deals with the technical or logical ways (Marshall & Rossman 2014).
Research onion is an important step for research methodology as it explains the each layer of research design. Research onion is generally comprised of many layers and every layer consists steps that need to be followed one after another (Johnston 2014, p. 210). It provides the researcher a methodological structure depending on which systematic review is done. However, there are researchers who do not agree that research onion is simple process and helpful to carry out qualitative research, unfolding each layer of it.
Research philosophy helps the researcher to find out a relevant and essential knowledge about the research. There are generally four types of research philosophy, such as positivism, interpretivism, realism and post-positivism (Ford Herselman & Botha 2014, p. 118). Here to carry out the research, realism research philosophy can be used, as it is a mixture of interpretivism and positivism philosophies.
In general, there are three main types of research design, which may be broadly classified into exploratory research design, explanatory or hypothesis testing research design, and descriptive research design (Lewis 2015, p. 474,). The researcher adopts the exploratory research design in situation when the research problems are not clearly identified or stated thereby leading to lack of clarity surrounding the topic of investigation. Contrarily, descriptive research design is carried out when the research aims and objectives are distinctly stated and detected and the researcher is entrusted with the responsibility of relating the findings with the theme of the research. Relevant theory and concepts in this context guide the research. On the other hand, explanatory research design calls for establishing a set of variables necessary to perform the research. In this type of design that is also termed as hypothesis testing design, the research is essentially base on the development of a hypothesis and the study is operational to prove the hypothesis either correct or incorrect (Creswell 2013).
For this particular study, the descriptive research design will be the chosen form of design of all the research designs to conduct the proposed work. The aims and objectives of the research being clearly defined by the researcher, this design will be most suitable and pertinent to the projected study (Rea & Parker 2014). The study will be a cross-sectional and qualitative one whereby interview with the chosen respondents by virtue of close-ended questionnaire will aid in emanation of definite themes for clearly elucidating the chosen topic of research.
Two principal methods of sampling are normally followed in course of research procedure. They are probability sampling method and non-probability sampling method. According to the propositions of the probability sampling method, the selection of the sample and respondents is conducted on a random basis (Salazar, Crosby & DiClemente 2015). Therefore, this method of sampling is beneficial to get an overview of the overall response of the group relevant to the chosen topic of investigation. On the other hand, non-probability sampling method does not allow for random selection of the subjects (Liamputtong 2013). Hence, it is vital on the part of the researcher to have clarity about the target population who are appropriate for performing the study.
For the projected study, the investigator shall rely in the non-probability sampling method. The chosen group of respondents for the study will be Registered Nurses having experience of greater than one year and are appointed at the Palliative Care unit of a hospital in Australia. The sampling size for the study will be 20 Registered Nurses working in the clinical setting of Palliative Care unit of the hospital.
The participants for the proposed study will be recruited subjected to receipt of informed consent declaring their willingness to participation in the research in addition to clearance from the nursing manager of the concerned hospital to conduct the research (Faden, Beauchamp & Kass 2014, p. 767). Precautions will be further streamlined so that no ethical or legal violation might take place.
In-depth interviews will be developed by the researcher to using a semi-structured interview model. This will help in gaining an insight into the knowledge and attitude of nurses towards management of pain among people who are at a terminal stage of their life. The interview will contain dialogues that will assess the knowledge of nurses based on attitude towards pain, pain management, and the strategies that they need to adopt in elderly people. The data collection procedure will involve maintaining silence for a few minutes before entering the audio-taped dialogues. This time will allow the nurses to reflect on their preconceived ideas about pain management (Tse & Ho 2014, p. 5). The participants will be asked the ways by which they identified pain among patient who were in the end of their life. Most of participants will be asked to report whether they assessed pain by making an observation of patient behavior like facial expression, uncontrollable cry or abnormal posture. The interview will include questions that will ask if the nurses identified pain just by looking at surgical interventions or diagnosis reports (Scharloo & Kaptein 2013, p. 103).
Questions will be asked on the use of vital signs or physiological measures to evaluate pain. In addition, majority of participants will be asked if they knew the usage of FLACC or Faces scales of pain assessment (Stites 2013, p. 70). The participants will be questioned on the techniques they adopt to treat pain in elderly people. They will be required to explain the analgesic ladder for pain management as proposed by WHO. The areas on which they should gain more knowledge will be identified. Questions will involve their opinion on pain feelings among the old and their ability to explain the severity of pain they feel. The interviewees will be asked to provide demographic information on them and the reasons for working will terminally ill patients (Doody & Noonan 2013, p. 30). Their responses will be collected based on few hypothetical situations that deal with advanced pain treatment. They will be asked about their views on current pain management practices that are followed in the concerned care unit. Their experiences of administering morphine to the elderly patients will be heard. Moreover, the interview will also inquire about the different barriers that create a hindrance in effective management of pain, as perceived by the nurses. The audio interviews will also contain questions focused on their ideological and religious views.
The information collected will contain audio-taped interviews of the responses of the nurses for specific questions (Al-Yateem 2012, p. 33). Every recorded interview will be transcribed verbatim by the researcher or interviewer. Transcription of the interviews will lead to accuracy and completeness of the data. The transcripts will be read several times. Thematic content analysis will be used to assess the collected data. Multiple copies of the interview transcripts will be made, including the post interview notes. The sentences that contain relevant information will be identified and marked with a real or electronic highlighter. The categories and codes of information will be developed. Furthermore, the essential themes and subthemes will be generated. These themes will be labelled as piled as separate categories. The fact that some nurses may display lack knowledge on a specific pain management will not necessarily mean that they are unqualified for undertaking treatment of patients who suffer from pain.
The data will be analysed using NVivo software. NVivo software acts as a retrieving, coding and theory building tool (Castleberry 2014). It will allow the interviewers to replicate all of the responses of the audio-tape interview transcripts into the software. The software will make use of the rich text that will allow an integrated emphasis on the responses through fonts, colour and character style. Once the information is imported, the texts will be continuously emphasized for manipulation of fonts, colour and character style through the rich internal text editor. The selected relevant data will be coded in vivo and through accumulated tree structure as well (Zamawe 2015, p. 14). The editing will be dynamic. The text will be edited simultaneously while it is being coded. The software will allow the interviewer to add comments and memos throughout the text. This will allow progressive and easy reflection of the responses (Azeem, Salfi & Dogar 2012, p. 264). In addition, there will be provisions of the attaching documents that contain demographic information of the nurses.
On the issue of validity and reliability, the articles that have been used for the literature review are up to date and address all the major aspects of the research proposal. Furthermore, the review included the latest peer reviewed scientific journals that elaborated on specific segments of pain management and the related attitude of nurses. The reliability of the collected data and analysis after using the NVivo software will be enhanced by including evaluative and informative feedback from the supervisors who will monitor the research. Theoretical sampling will also add to its reliability. Theoretical sampling signifies that the researchers and interviewers will strive for a sample that will be as heterogeneous as possible (Liamputtong 2013). This will be done to increase the possibility of new data discovery. Hence, the evolving theory related to attitude of nurses towards pain management can be elucidated. To increase the validity of the research results, the outcomes will be continuously discussed with the supervisors while conducting the data collection and analysis steps simultaneously. The supervisors will be asked to comment on the results obtained after analyzing it in NVivo software and suggestions will be asked for to improve data interpretation. To ensure rigour, the transcripts will be repeatedly read and the identified themes will be checked against one another to get an idea of the representativeness of the study proposed. The interviewers will return to the participants again for validation and verification of their responses (Noble & Smith 2015). Furthermore, an effort will be taken to move aside any bias and preconceived notions before the interview dialogues are begun. A reflective journal conducted on a similar study will ensure the trustworthiness of the themes that will be evaluated.
In any research study, it is imperative for any researcher to abide by the legal and ethical guidelines as laid down by appropriate authority in order to achieve optimal outcomes. The investigator is to emphasize and observe all the necessary dictums and procedures associated with the study to enhance the credibility and reliability of the project undertaken and no ethics is breached in between the process. According to the Data Protection Act, 1998 a researcher is obliged to maintain the privacy and confidentiality of the data retrieved in course of the research (Protection 2014, p.7). The researcher needs to be proficient about the research aims and objectives from the very outset so that no ethical or legal violation may set in. For the proposed study, efforts will be taken so that all data procured in due course of the research is kept safe and under no circumstances, data will be leaked to any unauthorized person (Marshall & Rossman 2014). Anonymity of the respondents will also be safeguarded. Data will be kept in safe custody of the principal investigator in the laptop with secured password. No one other than the research team will be allowed to access data. No coercive or unfair methods will be adopted to retrieve data from the concerned subjects (Best & Kahn 2016). Further, it will be taken care of so that data acquired will be applicable for academic purpose only. It will be ensured that the data are not made available for any other purpose other than research reason and commercialization of data will be prevented. All the governing standards and legislations will be diligently followed in the study.
The study provides a holistic way to analyze the condition compared to any other studies that focuses on single factors of pain management. However, these methods can lead to superficial side of research focusing on every mater, making it complex and vague. The findings of this research are completely dependent on the research sampling. Therefore, possibility of nurses having thorough knowledge of pain management strategies are out of the research can also occur. Therefore, research results having data from novice nurses cannot determine the success or failure of research. Small sample population can be another major limitation where only 20 nurses are being involved. Inclusion and exclusion criteria for those participant nurses also can be reason to get limited results. Conducting structured interviews in only two organizations are limiting as well as it does not defines the trend or knowledge of a pool of healthcare worker working in close vicinities. Lack of targeted questions to assess the attitude and knowledge of nurses can also lead to restricted findings.
Conclusion:
To conclude the research proposal, it can be said that nurses have proper knowledge about pain management and its treatment, however there are major gaps that exists. Educational level and work culture does not allow them to use their methods to treat patients in pain. Moreover, there are some negative attitudes that are prevalent certainly in the treatment of children. These findings clearly reflects on the educational level of nurses about pain management, lack of pain scales, and not having proper support to link their theories with practical examples. Leaders and trainers of nurses need to create more occasions for a comprehensive pain management practical classes and user-friendly pain management scale. Nurses also need to be trainer to use these assessment scales freely or provided with guided supervisions in the clinical settings. Implementations of these steps are supposed to improve the pain management process and enhance positive outcomes of care during end-of-life situation.
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