Pain management assignment
Pain management assignment
Pain management assignment
Key Words: Holism, nursing theory, pain management, caring, relationship-centered care, theory-practice gap, nursing practice, holistic theory, client-centered care
Introduction The use of theory to guide practice
has been advocated for decades, but the translation of theory into practice has been difficult for clinicians. Poor understanding of theory and its purpose inhibits the nurses ability to apply theoretical constructs in practice, thus reducing practice to a task- oriented enterprise rooted largely in habit. Dosseys (2008) theory of integral nursing has recently emerged as a new holistic theory that provides opportunities for clinicians to invest in a worldview that embraces the caring behaviors central to the delivery of nursing care and encourages nurses to design care that is relationship centered and focused on healing. This theory holds promise for application in many care situations, though the client experience of acute pain presents itself as a uniquely universal opportunity to demonstrate the prospective value of the theorys application. Pain management assignment Pain management assignment Pain management assignment Pain management assignment Pain management assignment Pain management assignment
It is widely known that pain is one of the most common symptoms experienced by all clients and that knowledge about effective pain-relieving strategies is important and essential in guiding practice. Despite Pain management assignment Pain management assignment
numerous advances in pain management, pain continues to be insufficiently managed. Inadequate understanding and use of theory to guide pain management practice may obscure nurses ability to rely on theoretical knowledge as a basis for pain management care. Insufficient knowledge about the theory of integral nursing precludes effective application of its theoretical concepts in clinical practice, thereby inhibiting nurses ability to improve pain management practice while also inhibiting clients ability to participate in the co- creation of personalized interventions to relieve pain. Failure of the nurse to engage in holistic care, to capture the clients perspective in the design and delivery of care, and to create a sacred space for carrying out the holistic caring process thwarts achievement of the mutually sought after goal of healing. By embracing the broader and deeper view of care offered by the theory of integral nursing, the nurse and client collaborate in the development of trusting relationships as they intentionally strive to improve client outcomes and ultimately enhance client, nurse, and provider satisfaction with care.
Pain management assignment
Background Pain management has remained enigmatic
for clients and healthcare professionals for decades. When caring for clients, pain is the
most common symptom for which nurses need to intervene, yet it continues to be one for which they may be least prepared to successfully mediate (Lui, So, & Fong, 2008; Montes-Sandoval, 1999; Wilson, 2007). Pain is a multidimensional, subjective phenomenon and experience. As such, the meaning and impact of any pain experience differs for each client, family member, nurse, and provider. Many definitions of pain have surfaced over the last four decades and offer multiple interventions to alleviate clients pain. At the 2007 council meeting for the International Association for the Study of Pain (IASP), in Koyoto, Japan, the council confirmed its 1992 definition of pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (www.iasp-pain-org). In its monograph on understanding, assessing, and treating pain, the American Pain Society supports both the IASP definition of pain and McCafferys definition of pain as whatever the experiencing person says it is, existing whenever s/he says it does (APS, 2006, p. 4; McCaffery & Passero, 1999, p. 17). While the IASP definition has been described as the most widely used definition of pain, McCafferys definition has gained substantial support over the past 30 years and is widely used in clinical practice as a foundation for all types of pain management care. Both definitions help capture the intricate nature of the pain experience. The IASP definition infers the multidimensionality of the phenomenon of pain by stating it is both physical and emotional, though an emphasis is noted on the sensory nature of pain. McCafferys definition emphasizes the subjective nature of the pain experience and situates clients
Pain management assignment
Exploring the Theory of Integral Nursing with Implications for Pain Management Practice Susanne M. Tracy, PhD, RN and Pamela P. DiNapoli, PhD, RN, CNL University of New Hampshire
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Abstract Inadequate attention is paid to the role of theory in guiding practice. Three main factors affect the use of theory to guide clinical practice: insufficient theory knowledge, insufficient administrative support to encourage the development of theory-based interventions, and the busy task-oriented climate of many nursing settings. Pain management is a vexing problem confronting clients and healthcare professionals. The primary purpose of this paper is to introduce scholars and clinicians to the basic tenets of Dosseys (2008) theory of integral nursing to aid nurses in designing client-centered pain management interventions grounded in the theorys main constructs of holism and healing.
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as the primary authority on the pain experience, thereby prompting clinicians to pay closer attention to clients description of their lived experience of pain rather than relying on a standardized definition of pain. From a holistic perspective, all elements that comprise the pain experience are equally important and frame clients perception of pain, the behaviors clients use to manifest the impact of the pain experience, and clients responses to varied methods used to treat pain. Being knowledgeable about pain management practice is an expected competency of every registered nurse, yet many nurses continue to describe barriers that impede the management of clients pain (Rejeh, Almadi, Mohammadi, Kazemnejad, & Anoosheh, 2009). The literature supports the notion that nurses knowledge and attitudes about pain management is linked to their ability to help clients successfully manage pain; updating knowledge about methods for relieving pain is key to improving practice (Duignan & Dunn, 2008; Lui, So, & Fong, 2008; Matthews & Malcolm, 2007; Xue, Schulman-Green, Czaplinski, Harris, & McCorkle, 2007).
Many strategies have been developed to help bridge the gap between what nurses know and what they actually do in practice to help manage clients pain (Dihle, Bjølseth, & Helseth, 2006). The problem of under-treated pain persists and is likely complicated by the lack of application of theory to guide pain management practice. When coupled with nurses uncertainty about how to autonomously treat clients in pain, pain relief outcomes are often unsatisfactory. Theories, particularly theories that have the potential to resonate with clinicians and impact care of the whole client, may be particularly powerful in narrowing the theory-practice gap and providing clues to more effective, comprehensive pain management. The application of a holistic philosophy of care emphasizes the role of clinicians in partnering with clients in the design and implementation of mutually agreeable plans for the relief of painplans that sufficiently
address the dimensions of the whole persons lived pain experience. Holistically, the ultimate goals for the nurse are to better understand the pain experience from the clients perspective, foster healing, and deliver care that strives to provide the greatest extent of pain relief possible. Anchored in the Scope and Standards of Holistic Nursing (2007), the five foundational concepts of Dosseys theory of integral nursing articulate the qualities and way of being that characterize the holistic, integral nurse and prompt the nurse to attend to the many dimensions of pain affecting the whole client. In this way, the nurse invites the client experiencing pain to participate in the development of potentially transformative, relationship-centered interactions and to provide feedback on interventional success or the need for further improvement.
Pain management assignment
The primary purpose of this paper is to introduce the basic tenets of the theory of integral nursing to aid clinicians in designing caring interventions focused on healing and grounded in the theorys holistic, relationship-centered approach. Following the unfolding of the basic tenets of this theory, examples of the application of the theory to pain management are proposed. A secondary purpose is to stimulate scholarly interest in designing studies that test the theorys concepts and holistic framework in practice. A peripheral aim of the paper is to suggest how application of the theorys main concepts, especially the concept of healing, may be used to help define the emerging role of the nurse in the 21st century regarding the holistic care of the client experiencing pain.
Pain management assignment
The Theory of Integral Nursing The experience of pain transcends the
physical body and requires a theory-driven, tailored, whole-person approach to ensure all effects of the pain experience on and in the person; body, mind, and spirit are addressed. The theory of integral nursing is a composite theory developed by Barbara Dossey in 2008 and built largely on the work of Wilber (2000), whose integral
theory outlined the four dimensions of all that is and represent what Wilbur believed to be the true realities of life. Wilber posited that understanding of these four dimensions influences a persons interpretation of reality and carries the potential to affect ones relationships with others. Many of the concepts within Dosseys theory stem from an amalgamation of concepts pivotal to theories from within and outside of nursing. The following commentary is a paraphrased interpretation of Dosseys theory with the intent of aiding clinicians, academicians, students, and others in understanding the overall thrust of the theory. In this way, partners in healthcare may find ways to apply the theorys core concepts to guide the design of interventions in all areas of practice, but especially in the area of pain management practice. The concepts that provide the organizing structure for the theory of integral nursing are healing, recognition of the metaparadigm of nursing, patterns of knowing, quadrants, and all quadrants/all levels (AQUAL). Appreciating the richness and complexity of the theory is a longitudinal process that begins with unpacking each of the theorys main concepts and developing ways to apply the concepts in clinical practice.
Healing The central concept in the theory
of integral nursing is healing and is conceptualized as a process that includes knowing, doing, and being (Dossey & Keegan, 2009, p. 21), as part of a life-long journey toward increasing personal harmony, harmony that is conveyed to clients through caring actions and integral dialogues. Integral dialogues are transformative and visionary explorations of ideas and possibilities within and across disciplines. The healing process brings clinicians to a place where they introspectively encounter their fears, search for and manifest their full self, and express their full self through creativity, trust in life, zeal, and love. No single aspect of healing is any more important than any other. The
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interplay between and among aspects of healing brings greater understanding and meaning about the complexity of illness, wellness, and healing to interactions with clients, families, colleagues, and others in ones life. The concept of healing is informed and transformed by the four dimensions of reality that exist at any moment, also known as quadrants: (a) Individual interior (personal/intentional) the I space, (b) individual exterior (physiological/behavioral)the It space, (c) collective interior (shared/cultural) the We space, and (d) collective exterior (systems/structures)the Its space (Table 1). The dimensions of reality examine values, beliefs, assumptions, meaning, purpose, and judgments related to how the individual structures action based on the nature of the experience at hand and the quadrants of reality that are most influenced by a given situation. A personal examination of each aspect of reality enables the individuals to be more in touch with their authentic self in many different types of situations and/or environments.
A fundamental assumption of the theory is that every human is born with healing capabilities, so that it is not the clinician who heals the individual but the individuals themselves. By being open to opportunities for healing, clients create a space for healing to occur. Through creation of trusting, client- centered relationships, nurses facilitate the clients ability to invest in self-healing. Self- healing is not seen as some magico-religious phenomenon, but as the process of addressing issues that block personal wellness. Self-healing allows the person to be centered in the potential for the body, mind, and spirit to work synergistically to enhance the combined benefits of prescribed, complementary, and safe alternative therapies, all of which are focused on improving health. Intentionality is a key factor in healing and a quality of the healer and healee that speaks to a determination or commitment to achieve a higher level of wellness. Without intentionality, healing progresses less efficiently.
The Meta-Paradigm of Nursing The theory of integral nursing
encompasses the meta-paradigm of nursing (Fawcett, 2005), which includes person, environment, health, and nursing. The meta-paradigm also captures the essence of Wilburs previously described quadrants of reality, embracing both the fullness of the human experience and the fullness of the experience of nursing. The meta-paradigm of nursingperson, environment, health, and nursingsurround the theory of integral nursings core concept of healing in overlapping circles to demonstrate the continuous nature of interactions that occur between healing and the meta-paradigmatic aspects of the theory of integral nursing. Within the theory, the integral nurse engages in care-related actions that foster client wellness while also striving to create a deeper, more meaningful connection with the Divine, however interpreted or recognized.
The concept of integral person captures how the client interrelates with the nurse in ways that value and respect the life experiences of each member of the relationship, be that of an individual, family, colleague, or group. The idea of integral health is viewed as a process that helps convey ways of restructuring basic assumptions and beliefs about well-being, to include perceiving death as a natural part of life. One metaphor for integral health may be the notion of a helix, which can be transformed into more or less complex forms depending on the situation and ones personal growth. Symbolically, a more complex helix would represent greater growth toward higher levels of consciousness and an increasing awareness of the essence of the human experience of being. From this view, the unique pattern of ones energy fields and ones expression of wholeness is manifested through a higher personal and collective understanding of the physical, emotional, mental, social, and spiritual dimensions of health, a homeodynamic view similar to that espoused by Rogers (1983, 1992) in her
theory of unitary human beings. Important to understanding integral health is the understanding that various types of health, such as mental health, physical health, emotional health, and spiritual health, are not to be viewed as separate and equal, but as unique structural strands that create and frame the wholeness and stability of the metaphorical helix of health. The integral environment consists of both internal and external aspects. The internal aspects of environment relate to clients feelings and emotions, the meaning of events, and the way in which the client enacts their understanding of spirituality and caring. Through flashes of memory, sounds, dreams, images, and/or smells the internal environment acknowledges and is influenced by current and past relationships with living and non-living people and things, such as family members, pets, or precious possessions. The external environment consists of things that can be objectively measured in the physical and social realms of reality, such as ones pulse, the level of adrenaline present in ones body in a specific situation, skill development, and anything one can touch or observe scientifically in time and space. The inextricable links between the internal and external aspects of clients integral environment shape the context in which the client exists and help frame the meaning of the reality of the client.
Patterns of Knowing Rooted in Carpers (1978) depiction of
the four fundamental ways of organizing nursing knowledge and nursings pattern of knowingpersonal, empirics, aesthetics, and ethicsthe additional pattern of not knowing proposed by Munhall (1993) and the pattern of socio-political knowing described by White (1995) create the six patterns of knowing applied in the theory of integral nursing. These six patterns are superimposed on the quadrants of reality and work to bring nurses to the fullness of knowing and expression of being in each caring experience. By acknowledging the
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integration of science and aesthetics, knowing and not knowing, and the influence of socio-political knowing, nurses confirm the value of patterns of knowing in clinical practice. Through the patterns of knowing, nurses are encouraged to develop a flow of ethical experience through thinking and
acting in ways that promote self-assessment and self-healing while generating a sacred space for care that promotes client healing.
Quadrants Quadrants in the theory of integral
nursing can be understood as dimensions
of reality that are permeable, integrally transforming, and empowering to all other quadrant experiences. Each quadrant is intricately linked and bound to each other quadrant, carrying along its own truths and language. The language of I, We, It, and Its that characterizes the concept
Exploring the Theory of Integral Nursing
Table 1 Dimensions of Reality within Quadrants in Pain Management
Dimension or perspective
Focus of the dimension Aspects included in the dimension Sample pain management questions by dimension
Personal/intentional The I spacethe individuals internal sense of reality
Self-consciousness Self-care, self-esteem Feelings, beliefs, values Moral development Cognitive capacity Emotional maturity Personal communication styles
Am I feeling stressed? Thinking clearly? Am I open to the clients assessment of their own pain? Am I ethically assessing the clients pain and making moral decisions about options for pain management? Am I communicating clearly and compassionately?
Physiology/behavior The IT spaceobjective or tangible aspects of the individual that influence reality
Brain and organisms Pathophysiology Physical sensations Neurotransmitters Chemistry and biochemistry Behaviors and skill development
Am I able to envision by bodily presence changing? Can I fully describe the sensations I feel? Can I feel my open presence changing my clients responses to my pain management efforts? Do I feel more able to do my pain management work skillfully?
Shared/cultural The WE spacethe collective sense of engagement within the individuals reality
Relationships to others cultures and worldviews Shared visions Shared leadership Integral dialogues Morale
How am I relating to others involved in pain management efforts? What is the meaning of my pain management relationships with my clients? My peers? My supervisors? Other healthcare professionals? Am I fully engaged in using integral dialogues to enhance my pain management relationships with others?
Systems/structures The ITS spacethe broader sense of being part of an external reality whose systems and structures govern practice
Relations to social systems and the environment Organ structures and systems Financial systems Policy development Regulatory structures and systems Information technology
How do pain management policies and procedures influence my connection with my clients? What is my group role in meeting or changing pain management regulatory guidelines? How do I use systems and structures to improve pain management practice? Do I allow technology to help me deliver better pain relief care or does it interfere?
Adapted from Dossey, B., & Keegan, L. (2009). Holistic nursing: A handbook for practice (5th ed.). Sudbury, MA: Jones & Bartlett.
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of quadrants are terms used in everyday language to convey the direction of our communication and the direction of ones experiences in the world. Each quadrant helps provide a framework for interpreting the theory and is guided by four main principles: (a) Nursing requires the development of the I, (b) the discipline of nursing is built upon the We, (c) It is about behavior and skill development, and (d) systems and structures are embedded in and frame the understanding of Its. Each principle continues to remind us that being an integral nurse is first, more than being a holistic nurse, and, secondly, an evolving process that becomes clearer and more meaningful over time through ongoing practice and reflection.
All Quadrants, All Levels (AQUAL) The final concept in the theory of
integral nursing is all quadrants, all levels (AQUAL). Wilber (2000) recognized that the quadrants of reality are connected to levels, lines, states, and types that help the individual create a comprehensive map of reality. Levels refer to aspects of the self that change over time and become permanent as one moves through stages of growth and development. Lines refer to the complex aspects of self that enrich and enhance ones development, such things as multiple intelligences, cognitive awareness, etc. States refer to temporary and changing forms of awareness, such as consciousness, unconsciousness, dreaming, waking, meditative states, recollection of peak experiences, etc. Types refer to differences in personality and expression that may mediate ones experiences of reality. Because interpretation of reality is fluid, many human experiences, both temporary and permanent, affect ones movement toward higher levels of consciousness. Aspects such as physical growth and development, dream states, multiple intelligences, peak experiences, personality, gender, shifts in physiology, moods, etc. are considered. Through the application of the dimensions of AQUAL,
as depicted in Table 1, individuals open themselves to evolving insights about the complexity of the human experience and about the ongoing quest for higher levels of consciousness that characterize the integral person.
Relevance to Clinical Pain Management Practice
Client reliance on the internet to provide knowledge about care is becoming a more common phenomenon in a technological world. Returning to basic notions about centering care on the client is an important issue for the nurse in the 21st century whose clients are becoming increasingly impatient with the faceless, computerized nature of care. The nurse of the 21st century must take advantage of the power of technology to search for and create evidence for emerging holistic practices, understanding that practice increasingly relies on a growing knowledge base and a willingness to risk implementing novel changes in practice targeted on improving both client outcomes and clinical nursing practice. The theory of integral nursing offers nurses the opportunity to act on their desire to create a healing environment for clients through the synthesis and application of knowledge rooted in metaparadigmatic and quadrant realities. Relationship-centered communication anchored in the theoretically driven holistic caring process is essential, especially when it comes to the very personal experience of pain management care.
In a world where social capital is increasingly being lost, clients want to know that nurses see them as individuals and value their personal experience of pain. For example, application of the notion of creating a sacred space for care that is described in the theory of integral nursing has the potential to narrow the theory- practice gap by emphasizing the importance of dedicating oneself to the personalized pain relief clients seek and nurses strive to deliver. In this sacred space, nothing else is allowed to interfere with the interactions between the client and the nurse. The nurse
is totally focused on what he/she is doing and what the client describes as their experience of that particular episode of pain. The theory brings a more open vision of the client-nurse relationship, especially as it relates to the role of each partner who is part of the pain management experience. Nursings primary role is to carry out theoretically driven nursing interventions with and for the client; interventions that promote health and healing and convey caring and respect for the individual while facilitating pain relief. The clients role is to remain open to participating in their own care, to aid the nurse and healthcare team in the co-creation of care, and to provide feedback to the nurse about the effects of co-created care on their overall physical, mental, and spiritual well-being. Nursing process has been a blueprint for care for many decades and is the foundation upon which the holistic caring process has been developed. Within the context of the holistic caring process, the following practice suggestions are offered.
The Holistic Caring Process The optimal delivery of nursing care is
guided by the theory of integral nursing. The theorys holistic caring process expands the assessment of clients to ensure gathering of objective and subjective data, not only about ones physical status, but also regularly gathers and integrates data about the emotional and spiritual status of the client. Application of the theorys core concept of healing facilitates conversations (integral dialogues) between clients and physicians, clients and nurses, nurses and physicians, and nurses and other members of the healthcare team. Using the pain experience as an example, the outcomes of such dialogues have the potential to change practice by inviting clients to tell their pain story (and history) so that a more useful and meaningful plan of pain management can be developed, a plan whose openness respects and values the voice and experiences of the client, as well as the knowledge and expertise of nurses, physicians, and other
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healthcare team members. Table 1 is an exemplar that depicts the application of the dimensions of reality within quadrants as they apply to pain management. Each dimension affords nurses opportunities to center themselves on aspects of pain management care that foster internal reflection and wholeness in the delivery of care. Sample pain management questions for each dimension focus on the internal self-assessment carried out by nurses as they prepare to deliver personalized pain management care anchored in the dimensions of reality within quadrants.
Central to success in the holistic caring process approach is a trusting client- nurse/client-provider relationship. Openness of each member of the integral partnership to perceptions about pain and pain management that may be foreign to them is critical. When coupled with a determination to find a mutually beneficial approach to managing the clients pain, this non-judgmental approach invites clients to engage in self- care initiatives that help free them from issues and concerns that block healing. Caregivers must be willing to see the pain experience through the clients eyes and frame solutions in such a way as to obtain outcomes that work to relieve client pain. For example, in Table 1, one of the sample questions in the Individual Interior dimension asks clinicians to reflect on their openness to believing the clients assessment of their own pain. Another question in this same dimension asks clinicians to reflect on their moral responsibility to be open to considering various pain relief options. This reflective approach requires nursing decisions about the moral and ethical delivery of care, as well as decisions about the safe and responsible use of complementary and/or alternative methods desired by clients, even if they do not possess the strength of evidence so often sought by allopathic practitioners.
Caregivers and clients alike must be willing to not only talk about, but also engage in partnerships that foster healing. Before caring for others, caregivers must
spend time on self-assessment and self- healing in order to be prepared to engage clients fully in the delivery of holistic care. By listening actively and openly to client communication about the pain experience, caregivers build trust with clients, demonstrate caring and other- centeredness, and actively work to encourage clients to disclose more about their experience of pain. In so doing, caregivers demonstrate their willingness to validate the clients experience of pain and open the door for teaching the client about reasonable pain evaluations, safe pain management strategies, and the benefits and limitations of pharmacological and non- pharmacological pain management options.
Without these caring relationships, teaching seems inconsequential to clients (i.e., just another task the nurse has to complete) and its benefits often wither after discharge. Throughout the care experience, the use of caregiver intuition expands opportunities for nursing investigation of aspects of pain management care that may not initially be apparent. Practice expertise fosters the development of intuition. As a part of pain management, nurses use of intuition may help clients identify and reveal potential blocks to healing, thereby promoting active, collaborative engagement in the design and development of solutions that advance healing. The power of holistic communication cannot be overemphasized as a critical activity for promoting healing. Clients must be open to accepting the knowledge and expertise of caregivers regarding the efficacy of various treatments for pain relief but also have the responsibility for learning more about pain management and taking an active role in decision making that fosters healing. At the same time, clinicians must remain open to hearing the clients story, inviting clients to partner in designing pain relief interventions, and trusting in the value of the clients experiences of pain. Client openness to describing the meaning of the pain experience may foster their ability to address issues that have previously blocked
healing. Such breakthroughs contribute to deeper integral dialogues between client and nurse, and aid the clinician in seeking the expertise of other members of the healthcare team in the restructuring of transpersonal care.
To be sure, application of the dimensions of reality within quadrants does not end with the individual nurses holistic preparedness. Table 1 also describes the importance of applying integral knowledge within group contexts so as to transform pain management practice through integral dialogues that promote engagement with shared interdisciplinary, sociocultural, and leadership worldviews about the meaning and value of efforts to collectively address and enhance pain management care. Finally, application of the dimensions of reality within quadrants requires nurses to tap into their social consciousness about regulatory issues that may influence pain management care. Through the collective exterior dimension, nurses are compelled to work toward systematic changes in pain management policy and practice by assessing the current status of pain management structures and policies, both locally and nationally, and working t