The Influence of Context on Utilizing Research Evidence for Pain Management in Jordanian Pediatric Intensive Care Units (PICU)
Introduction
Children have the right to access appropriate pain management provided by adequately-trained health care providers (International Association for Study of Pain [IASP], 2015). However, pain management in the Pediatric Intensive Care Unit (PICU) has been reported to be suboptimal (Agarwal et al., 2010, Grant et al., 2012). In a study of adverse events in PICUs in the United States of America, uncontrolled pain was one of the most common major adverse events reported, with 82% of these pain events considered to be preventable (Agarwal et al., 2010).
Pain management in children in the PICU may be more challenging than in other populations. Many factors can challenge health care providers to effectively assess and treat children's pain in the PICU such as children's physical and cognitive development, the nature of the child's critical condition, and the complexity and severity of illness in the critical care setting. In addition, the self-report of pain in the PICU (widely considered the gold standard for pain assessment and treatment) is complicated by the administration of sedative agents, paralytic agents, mechanical ventilation, and, often, altered and changing levels of consciousness (Gelinas et al., 2004, Ismail, 2016, Oakes, 2011, Srouji et al., 2010, Turner, 2005).
The use of research evidence is a critical factor in providing appropriate pain management (Samuels and Fetzer, 2009). However, there is a gap between knowledge and practice (Hanberg and Brown, 2006, Samuels and Fetzer, 2009). To design successful interventions aimed at improving the use of research evidence for pain management, there should be a clear understanding about the nature of the research evidence being used, the quality of the context, and the type of facilitation needed to ensure a successful change process (Rycroft-Malone et al., 2002). Context (the environment in which a health care providers work) is widely considered a significant factor that can influence the successful implementation of research evidence in healthcare settings (Dopson et al., 2002, Estabrooks et al., 2003, Fleuren et al., 2004, Greenhalgh et al., 2004, Meijers et al., 2006, Rycroft-Malone, 2004, Wallin et al., 2006). However, little is understood about the organizational factors (embedded in context) that may influence health care providers' use of research to guide the practice (Stevens et al., 2011). What is known is primarily from a Western context, where human and financial resources are less challenging than in developing countries such as Jordan (Finley et al., 2008). Based on ownership and governance, hospitals in Jordan can be categorized into five types: Ministry of Health (public funded by the government), Royal Medical Services (military hospitals), private (private funded and work for profit), non-profit non-governmental (self-operated and mainly funded by money donated by people), and university hospitals. Jordan Ministry of Health supervises health services offered by all sectors (Jordan Ministry of Health, 2013a). These five types have different organizational contexts affecting the way of delivering patient's care. In Canada for example, the health care system is publicly funded. Without paying out-of-pocket, all residents have access to hospital services. The standards for health care are set and administered by the federal government (Goverment of Canada, 2016). Therefore, organizational contexts of the hospitals can be less different.
Several studies that have been conducted in Western countries demonstrated the importance of context for research utilization. In Canada, Cummings et al. (2007) found that registered nurses working in a positive environment with supportive leadership, constructive work culture, and effective evaluation process reported significantly more research utilization in clinical practice (IRU) than nurses working in less positive environments. In addition, they found that responsive administration (administration that listens and responds to staff concerns e.g., providing resources), relational capital (social capital), and hospital size (number of beds) positively, but indirectly, influenced nurses' research utilization by acting through staff development, opportunities for nurse-to nurse collaboration, and staffing and support services. In a subsequent study, Cummings et al. (2010) found that pediatric nurses who reported more positive perceptions of their context, including culture, leadership, and evaluation, reported higher instrumental research use (IRU) and higher conceptual research use (CRU). Instrumental research use (IRU) is the direct application of research findings, and the conceptual research use (CRU) is being aware of research findings that could alter the way of thinking and/or practicing (Cummings et al., 2010).
From responses of 2361 nurses working across different care settings in Canada and Australia, Squires et al. (2015) found that contextual factors such as leadership, culture, evaluation, formal interactions, informal interactions, structural and electronic resources, social capital, organizational slack-time, organizational slack-staffing, and organizational slack-space correlated positively with both IRU and CRU. Organizational slack is described as the unit cushion of resources (actual or potential) that helps the unit to adapt to internal and external pressures e.g., staffing and space (Estabrooks et al., 2009). In a study conducted in Canadian pediatric hospitals which included medical, surgical and critical care units, Squires et al. (2013) found that organizational culture and the proportion of nurses having a baccalaureate degree or higher were predictors of IRU and leadership, culture, evaluation, formal interactions, informal interactions, and organizational slack-space were predictors of CRU. These studies focused on the general research use for any condition. This study only focused on the research use for pain management in Jordanian PICUs.
Several studies have been conducted investigating pain management in Jordanian hospitals (Abdalrahim et al., 2011, Abdel Razeq et al., 2016, Al Qadire and Al Khalaileh, 2014, Ayasrah et al., 2014, Batiha, 2014, Finley et al., 2008, Forgeron et al., 2006). Yet, no studies have evaluated the influence of context on research utilization for pain management in Jordanian PICUs.
Section snippets
Purpose
The purpose of this study was to gain a beginning understanding of the contextual factors that influence research utilization by nurses to guide pain management in Jordanian PICUs. The specific aims were to:
- 1)
Examine the relationship between each of the contextual factors and each kind of research utilization for pain management.
- 2)
Identify the significant predictors for research use.
Methods
The Promoting Action on Research Implementation in Health Services (PARiHS) model guided the planning and conduct of this study (Kitson et al., 1998). The PARiHS model consists of three main constructs: (1) evidence, (2) context, and (3) facilitation. These three elements are interrelated, and each is positioned on a “high” to “low” continuum (Kitson et al., 1998, Rycroft-Malone et al., 2002). Successful implementation of research evidence is purported to be a result of interplay between the
Results
Data collection took place between August 2015 and October 2015 in the four participating Jordanian PICUs. Missing data was minimal; all nurse questionnaires had > 90% complete data. If there were missing data, it was declared as missing. Missing data on any variable were treated by pairwise deletion that maximized the data available analysis by analysis. Any nurse questionnaire with missing values was used in all analysis except the GEE. In the GEE analysis, questionnaires with missing values
Discussion
Results of this study showed that the majority of contextual factors on the ACT tool were correlated with research use (IRU and CRU) for pain management, and two contextual factors (social capital and structural and electronic resources) were significant predictors of research use by nurses working in Jordanian PICUs. Results of the study are consistent with those found in the literature (Cummings et al., 2007, Cummings et al., 2010, Estabrooks et al., 2009, Squires et al., 2015). The higher
Conclusion
Context plays an important role in Jordanian PICU nurses' use of research for pain management. A majority of the contextual factors correlate with the IRU and CRU for pain management. Social capital was the contextual factor that significantly predicted both instrumental research use and conceptual research use by Jordanian PICU nurses. Contextual factors described as structural and electronic resources also significantly predicted instrumental research use both pain assessment and pain
Acknowledgments
Researchers gratefully acknowledge the contributions of Amer Aridah, King Hussein Cancer Center, Jordan for his assistance in obtaining the ethical approval and collecting data from one site. None of the researchers has conflicts of interest with respect to this work.
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