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NEWSLET TER
VOLUME 18 ISSUE 3
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 2
Message from the Editor Welcome to this new edition of our newsletter. This edition is important for the
fact that it is the last before the National Conference. Speaking of which, have you
registered yet? It isn’t too late, jump on to the website now and secure your place.
Don’t forget also that we have the preconference cocktail evening on Friday 31st
October at 730pm. This free event also needs you to register for catering purposes.
All information can be found at the website.
Call for Poster Presentations on 31st October 2014 at the members cocktail party.
Submissions to [email protected].
Early Bird Registrations have been extended to 30th September.
Members $200 before September 30th, after $250.
Non-member $300 before 30th September, after $350
Welcome and thank you to Jerome Wang (Vic and National Committee) who has taken on the role of Webmaster
and will continue to work with our web partners, Beyond the Pixels in the maintenance and further enhancement
of the website. We welcome your feedback on the website or any other matter via email at
In the upcoming AGM to be held during the national conference, there will be several national committee roles
vacated. Please consider nominating for one of these roles. We are a group of volunteers that depend on our
members to continue to provide targeted education for our sector. If you don’t feel up to the national committee,
then consider helping out your state committee, especially those of you in Queensland,
South Australia and Northern Territory.
The Australian Society of Post Anaesthesia and Anaesthesia Nurses (ASPA AN) was convened to promote
the professional development of post anaesthesia and anaesthesia nurses through regular meetings, study days,
educational forums, and publication of newsletters. Membership is open to Registered Nurses or Enrolled Nurses
working in the specialties of Anaesthesia and Post Anaesthesia care, Associate membership is open to others
(eg: Representatives of Trade Companies and other Health Professionals) with a genuine interest in the field.
To join ASPA AN click here
How can you help us enhance Perianaesthesia Nursing?
• Become a member
• Be involved in your state branch or national committee
• Share your knowledge and ideas with the other members
by submitting an article or letter to our newsletter
• Take advantage of the education grants available to further
your knowledge and be published in our newsletter
• Present at state seminars and national conferences
• Promote peri-anaesthesia nursing as a fulfilling career.
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 3
Presidents Repor t The next two months bring with it a flurry of ASPAAN
activity with state seminars in Victoria and Tassie,
and of course the National conference which is in beautiful
Darling Harbour in Sydney!
Speaking of which... I would like to urge members to get in early to avoid
disappointment as the venue capacity is less than our National conferences
in Melbourne and tickets are selling fast.
Early-bird registration closes soon so have the chat at work and get to our website
to register for what promises to be an amazing conference at an amazing location!
Just a reminder that for ASPA AN members that have been with us for greater than
2 years, our grant process may help with meeting some of the costs associated with
getting to and attending the conference... Checkout our website for more detail.
Well that’s about it from me, please enjoy the read, get along to your state seminars,
and I look forward to seeing you in Sydney!
Jamie
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 4
National Conference
ASPAAN National and NSW Committees present:
NATIONAL CONFERENCE ‘BACK TO THE FUTURE’
Dockside Group Cockle Bay Wharf, Darling Harbour, Sydney, Saturday 1st November 2014 Click here to register for the conference
(make sure you are logged in to receive your member discount.)
PRE-CONFERENCE COCKTAIL EVENING… AT
THE STAR ROOM DARLING HARBOUR!
Date: Friday 31st October 2014
Time: 1930 – 2130
Poster presentations to be held during this time.
Please send in your poster abstracts to [email protected]
Click here to register
(make sure you are logged in to access this members only event.)
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 5
National Conference Program
WELCOME A D DR E SS
Jamie Mann-Farrar
ASPAAN National President
K E Y NOTE A D DRE SS
Dr William McMenimen
“Back to the future?”
Dr Janet Smith
Director of Anaesthetics
Concord Repatriation Hospital Sydney NSW
“Back to the future: trends, fads and failures in anaesthesia”
Lyell Brougham, RN
“A long, hard look at recovery - change is the process”
Dr Paula Foran, pHD, RN
“Back to the future? Developing PACU skills in ICU nurses
for the direct surgery transfer patient”
PANEL DISCUSSION
Jamie Mann Farrar, Dr Paula Foran, Lyell Brougham
A SPA AN ANNUAL GENER AL MEE TING
Courtney Player, RN & Catherine Fraietta, RN
“Save Our Sisters”
Jenny Sutton, RN
Calvary Mater Newcastle, NSW
“The role of religion for the surgical patient
in the operating theatre”
PR E SENTATION OF AWAR DS & PRIZE S
Pete Smith, CNS & John Gibbs, RN
Barwon Health, Vic
“Below 10000: Reducing noise in the operating suite,
a team safety initiative”
Mbene Letsamao, RN
“Is there Room in the Recovery Room ?”
A review of the literature of the Nurse Anaesthetist role in Australia.”
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 6
Commit tee Members NATIONAL COMMITTEE
NAME POSITION
Jamie Mann-Farrar President (TAS)
Suzanne Querruel Vice President & Conference Organiser
(NSW )
Meg Bumpstead Treasurer (VIC)
Anthea MacDonald Secretar y & Public Officer ( VIC)
Jerome Wang Technical Web Officer ( VIC)
Melanie Murray Newsletter Editor (WA)
Ken Hancock General Committee (TAS)
Positions Vacant Membership Officer
Merchandising & Marketing Officer
General Committee
STATE COMMITTEES
WA NSW/ACT
Paula Holland, President Suzanne Querruel, NSW President*
Sandy Presland, Treasurer Donna Hopley, Secretary & Treasurer
Melanie Murray, Secretary* Bernadette Huang
Jilda Levene Trevor Court
Shauna Fatovich Jane Nichols - ACT
Bronwyn Hegarty
Georgina Walker
VIC TAS
Angela Fraser, President Ken Hancock*
Rachael Ambatali Stephen Bagshaw
Jerome Wang* Elizabeth Cotton
Beth Schubel
QLD SA/ NT
Contact Contact: [email protected]
To view the Committee Members and the roles they perform click here.
If you or a friend is interested in education within the perianaesthesia environment,
contact [email protected] to express interest to your state committee or join
the National committee!
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 7
Commit tee Updates
WA
Meeting to discuss new options for seminar delivery.
NSW
Holding the national conference this year with the theme “Back to the Future”.
Register now via the website. The early bird date has been pushed back to the 14
September, so get in quick.
VIC
Seminar “Critical Minutes Be Prepared”
Saturday 23 August 2014: held at the Lecture Theatre
of St Vincent’s Hospital Melbourne.
TAS
Seminar “Renal study day – How well do you know your Kidney?”
Saturday 23rd August 2014: held at the Lecture Theatre of Hobart Private Hospital
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 8
State Seminar Reviews
VIC – “CRITICAL MINUTES” SEMINAR SUMMARY
The Victorian committee’s second free seminar for 2014, Critical Minutes: be prepared, was held at St Vincent’s Hospital in Melbourne on Saturday the 23
rd August. The seminar attracted interest from 100 nurses from across all aspects of the
perioperative field.
As well as a very interesting and pertinent cat video, Dr Suzi Nou’s talk on paediatric crises was a great start to the day leaving us with the acronym SOAP ME STABLE, which I’m sure, will assist us all in the future.
Dr Raja Rengasamy updated our knowledge of malignant hyperthermia; a crisis few of us have been involved with yet one that looms quite frighteningly in the background of all operating theatres.
Following morning tea, Eliza Wilson CNS and Pauline Fogarty NUM explained to us the process by which they were able to develop and instigate their Massive Blood Transfusion (MBT) protocol across all the Epworth Hospital campuses in Melbourne. Pauline explained that the most important aspect to the success of this protocol was the educational package that Eliza developed involving the use of a simulation lab at the Epworth Richmond Hospital.
Our final speaker for the day was Dr Gabe Snyder whose informative lecture on anaphylaxis will have all who attended ready when next this crisis raises its ugly head.
Of course the day could not have been as successful had it not been for the assistance afforded us by our sponsors – 3M, Pfizer, MSD and Ambu – all of whom we hope to see at future seminars.
On a final note I think the theme of the day was summed up well with a quote from Dr Suzi Nou’s talk – “it is poor practical application rather than lack of knowledge that leads to critical crisis”.
We look forward to seeing everyone back in March 2015 for – Before and After: the best surgical outcome.
Side note
We understand some people had issues registering with Miiytix for the Victorian
Seminar. For National Conference we expect all members to register using this
site - remember to be signed in to the ASPAAN website to get the member discount.
If it is your first time using Miiytix please remember to register for Miiytix separately
as the password and username on this site is not the same the ASPA AN site. Finally if
having any further issues please call the phone number on the screen.
TAS – “RENAL STUDY DAY – HOW WELL DO YOU KNOW
YOUR KIDNEY? SEMINAR SUMMARY
In conjunction with ASPA AN and the Hobart Private Hospital a half-day seminar was
held on the 23 August. The topics focused on anaesthetising renal patients and
chronic kidney disease (CKD). The study day was very well attended by nurses from
Hobart Private, Calvary, Hobart day surgery and one keen member from interstate.
The day was hailed as a great success with very positive feedback from all
attendees. Speakers included Dr Mark Hamilton, a surgeon specialising in renal
disease, in par ticular the formation of fistulas in patients requiring
long-term haemodialysis. Dr Hamilton frequents Northern Australia on a regular basis to provide his expertise
to the large indigenous population where there is an epidemic of CKD sufferers
waiting for haemodialysis. Dr Anna McDonald provided a very detailed analysis on the
challenges of anaesthetising the CKD patient while Joanne Wilkinson; a Clinical Nurse
specialist (CNS) discussed the difficulties faced by the renal patient and the issues
surrounding the long-term effect of haemodialysis. Ben Terr y gave a first-hand description of his life; first as a renal transplant recipient
and now a regular at the renal unit for haemodialysis. Despite Terry’s positive outlook
his very personal account of his life with a chronic illness reminded us all of the very real
difficulties that these patients face as well as their family and friends. We wish
to thank all our speakers for giving up their Saturday; it was very much appreciated
by all. We would also like to thank Liz livingstone from Fresenius Kabi for her support
and supplying a wonderful morning tea.
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 9
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 10
Events and Announcements ASPA AN GRANT INFORMATION
ASPA AN was formed with the idea of providing continuing education,
research and professional development opportunities for nurses in the
specialty of Anaesthesia and PACU Nursing.
Study days, combined group Seminars and conferences have all contributed
to furthering education and providing the networking opportunities so important in
this area. All of these events contribute to providing our patients with optimal care.
With all of this in mind, the committee is keen to encourage members to make use
of grants available through ASPA AN.
An Education and Research Fund has been established and the ASPA AN committee
extends to members an invitation to apply for these grants. We would like to see an
enthusiastic response to the research challenge. There must be a lot of questions out
there, and you may be able to solve some dilemmas or at least give us your educated
(and well researched) opinion. For further information about our education and
research grants, please go to http://www.aspaan.org.au and click on the grant link
found in the footer section.
PERI ANAESTHESIA JOB OPPORTUNITES
The website now includes a job page which will be free for Australian Hospitals
to advertise peri anaesthesia job opportunities.
To advertise on the website please email the ASPA AN National Secretary
info@ aspaan.org.au with the following details:
Job Title
• Position
• Company/Hospital
• Closing Date
• Name and contact details of contact for position
• url link to the full job advertisement and full job description.
A SPA A N NE W SL E T TER VO LU M E 18 I SSU E 3 11
Adver tising
ADVERTISING
ASPAAN is a non for profit organisation and our quarterly
newsletter is distributed to RN Clinicians, Educators, Hospitals
and to some businesses who are members of ASPAAN.
ASPA AN provides its members with seminars, study days, a national conference
and of course this newsletter. This is an ideal medium to market your products
to clinicians in the field of perianaesthesia nursing. Your help allows us to provide
these services to our members.
ASPA AN Advertising Fees:
• eNewsletter, full page, $400
• Website advertising, logo and link to your page
as a sponsor on our Jobs page $1000
• National Conference Program advertising: $800 one full page, colour
• National Conference showbag drop with your flyer, brochure, or product,
$500 or $1200 for both National Conference Program and showbag drop
Don’t forget, online right now are recent back issues of the newsletter which are
available to members for download and your advert (If in the newsletter) will always
be there! International advertisers, please send your expression of interest to
[email protected] for further details regarding your advertising.
For more information, please email [email protected]
13
Ar ticles of interest
ABSTRACTS
P OS T- DISCH ARGE N AUSE A AN D VOMITING:
M AN AGEMENT S TR ATEGIE S AN D OU TCOME S OV ER 7
DAY
Jan Odom-Forren, PhD, RN, CPAN, FA AN;
VallireHooper, PhD, RN, CPAN, FA AN; Debra K. Moser,
DNSc, RN, FA AN; Lynne A. Hall, DrPH, RN; Terry A.
Lennie, PhD, RN, FA AN; Joseph Holtman, PhD, MD;
Melissa Thomas, BSN, RN; Zohn Centimole, APRN,
CRNA, MS; Carrell Rush, MPH; Christian C. Apfel, PhD,
MD
Published online 24 February 2014.
Journal of PeriAnesthesia Nursing Volume 29, Issue 4,
Pages 275-284, August 2014
PURPOSE
The purpose of this study is to determine patient
management strategies and outcomes for self-care
of postdischarge nausea and vomiting (PDNV).
DESIGN
Prospective, comparative, descriptive,
and longitudinal study.
METHODS
The sample consisted of 248 patients aged 18 years
or older undergoing a procedure requiring general
anesthesia. Patients recorded incidence and severity
of nausea and vomiting, the impact of symptoms,
and actions taken to alleviate symptoms for 7 days
postdischarge.
FINDINGS
The prevalence of PDNV was 56.9%. The methods
used to relieve symptoms included antiemetic use
by a minority and nonpharmacologic techniques of
self-management by some. The effect of nausea on
QOL, patient functioning, and patient satisfaction
was significantly worse for those who experienced
postdischarge nausea on all days.
CONCLUSION
Patients with PDNV use minor self-care strategies
to manage symptoms. The presence of PDNV affects
overall quality of life, patient functioning, and patient
satisfaction.
PATIENT S’ PERCEP TION OF NOISE IN THE OPER ATING
ROOM — A DE SCRIP TI V E AN D AN ALY TIC CROSS -
SEC TIONAL S T U DY
Dorthe Hasfeldt, MSC, RNA; Helle Terkildsen Maindal,
PhD, MPH; Palle Toft, PhD, MD; Regner Birkelund, PhD,
MSC Published online 16 June 2014.
Journal of PeriAnesthesia Nursing PURPOSE
Noise is a general stressor that affects the
cardiovascular system, resulting in increased blood
pressure and heart rate, both of which can be
problematic for the patient preparing for anesthesia
and surgery. The purpose of this study was to
investigate the patient’s perception of noise in the OR
before anesthesia, the correlation between the actual
noise levels and the patient’s perception of noise,
and if there are particular patient subgroups that are
especially vulnerable to noise.
DESIGN
This cross-sectional study was performed within a
mixed descriptive and analytical design, including
120 patients (60 acute/60 elective) undergoing general
anesthesia for orthopaedic surgery.
METHODS
Data collection consisted of registration of
demographic variables and measurements of noise
levels in the OR combined with a questionnaire.
FINDINGS
Results showed that 10% of the patients perceived
noise levels in the OR as very high and experienced
the noise as annoying, disruptive, and stressful.
There was no correlation between the actual noise
levels to which patients were exposed and their
perception of noise. Acute patients perceived
significantly more noise than elective patients
(P <. 01), although they were actually exposed to less
noise. Of the acute patients, those undergoing major
surgery perceived more noise than patients undergoing
minor surgery (P < .01), although actually exposed to
less noise. There was a significant correlation between
patients’ sense of coherence (SOC) and their perception
of noise (P < .01). Most patients who perceived noise
levels as very high had a SOC below 50 (scale: 13-91).
CONCLUSIONS
Perianesthesia nurses need to maintain their focus on
keeping noise levels in the OR as low as possible.
When caring for acute patients, patients undergoing
major surgery and patients with a low SOC
perianesthesia nurses should be particularly aware,
as these patients might be more vulnerable to noise.
14
Ar ticles of interest
PATIENT RISK A SSE SSMENT IN THE PACU:
AN E SSENTIAL ELEMENT IN CLINIC AL DECISION
M AK ING AN D PL ANNING C AR E
Pat Smedley
British Journal of Anaesthetic and Recovery Nursing
British Journal of Anaesthetic and Recovery Nursing/
Volume 13 / Issue 1-2 /February 2012, pp 21-29
Copyright © British Association of Anaesthetic
and Recovery Nursing 2012
Published online: 08 August 2012
ABSTRACT
Decision making in post-anaesthetic care practice is
an underresearched area. The patient undergoes rapid
and profound physiological change in the early stages
of recovery. The practitioner is required to assimilate
information about the patient, assess his clinical
status, plan proactive care and provide an immediate
reactive intervention depending on his/her condition.
Knowledge and understanding of the standard risks
of anaesthesia and surgery ensure that the practitioner
is able to prevent complications arising in the routine
recovery. This article investigates the role that risk
assessment plays in clinical decision making and
planning care in the post-anaesthetic care unit.
ANE S THE SIA AN D AL ZHEIMER ’S DISE A SE: TIME TO
WAK E UP!
David A. Scotta1, Brendan S. Silberta1 and Lisbeth A.
Evereda1
International Psychogeriatrics
International Psychogeriatrics / Volume 25 / Issue 03 /
March 2013, pp 341-344
Copyright © International Psychogeriatric
Association 2012
Published online: 02 November 2012
a1Centre for Anaesthesia and Cognitive Function,
Department of Anaesthesia, St. Vincent’s Hospital,
Melbourne, Australia Email: [email protected]
It has long been observed that some patients suffer
a significant cognitive impact following anesthesia
and surgery. This should not be surprising when
considering that not only is the target organ for
general anesthetic agents the brain itself but also
that the process of anesthesia is a form of deep,
pharmacologically induced coma rather than “sleep.”
The expectation that such a process should be fully
reversible with transient neurophysiological effects
contradicts our experience with repeated abuse of
other central nervous system depressants such as
glue, petrol, and alcohol. Of great concern is that,
while approximately 10% of populations in developed
countries undergo anesthesia and surgery of some
form each year, the proportion of the elderly making
up this group is much greater. In addition, it is the
elderly who are potentially at a greater risk of cognitive
impairment following such procedures because
many have decreased cognitive reserve, either due to
pre-existing mild cognitive impairment (MCI) or frank
dementia, which may be diagnosed or unknown.
The impact of anesthesia on these individuals is poorly
understood, as are the implications of the emerging
laboratory data that suggest an effect of anesthetic
agents on the pathological processes of Alzheimer’s
Disease (AD) itself.
E X PLORING PAIN M AN AGEMENT BAR RIER S IN PACU Original article by Jerome Wang – National Committee ABSTRACT
Postoperative pain management remains a challenge in
current clinical nursing practice. Through the discussion
of two vignettes this article will highlight major barriers
to effective pain management within the PACU (Post
Anaesthesia Care Unit). The practical awareness
of these barriers is essential to constantly improve
nursing practice, education and research.
INTRODUCTION
Pain is a subjective and unique personal experience1.
The most commonly recognised definition of pain is
“an unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage”2. Effective pain
management is essential to minimise patient’s distress
or suffering, reduce postoperative complications
and facilitate a rapid recovery3. Postoperative pain management is “perhaps the most
difficult and challenging arena for pain management”4
(p.441). Literature indicates that poor postoperative pain
control can cause significant physiological, emotional,
mental and economic consequences5. Achieving
good postoperative pain management still maintains
a challenge. For instance, in the U.S, each year over
80% of surgical patients report postoperative pain
among a hundred million operations6. Australian
data reveals that a significant number of postoperative
patients are still in pain after discharge, with 86% of
patients reporting pain after discharge and 41% of
those reporting moderate to severe pain7. Pain management barriers influence effective pain
management in the PACU. Identifying and recognising
common pain management barriers is a key step
toward optimal post-operative pain management.
These barriers can be categorised into three areas:
patient-related barriers, professional-related barriers
15
Ar ticles of interest
and organisation-related barriers8. Patient-related
barriers include patient’s knowledge, attitude, beliefs
and unique culture regarding the pain8. Professional-
related barriers include deficit knowledge, lack
of competency on pain assessment and personal
attitudes8. Organisation barriers may consist of policies,
increased workload, staffing shor tage and poor
time management8, 9.
The following case vignettes are a compilation
of various case examples drawn from clinical
experience. Patients represented here are not
identified in any way.
CASE VIGNETTE ONE
Ms. Jane (pseudonym), 45 years of age, arrives to
the PACU in the busy evening hour after a right
rotator cuff repair under general anaesthesia. She has
mild sleep apnoea and 10-year smoking history. Prior
to the anaesthesia she refused to accept any shoulder
nerve block. During the operation, Ms. Jane received
200mcg Fentanyl, 8 mg morphine, 40mg paracoxib
intravenously additional to 20ml 0.75% Naropin locally.
The anaesthetist concerns about Ms. Jane’s sleep
apnoea and requests the PACU nurse, who is a new
graduate nurse, to “cautiously” give the pain medicine.
Upon emerging from anaesthesia, Ms. Jane starts
to moan and cry, with a pain score of “10”. 100mcg
Fentanyl is gradually given and followed with 10mg
morphine as ordered. Besides the initial analgesia,
she still rates the pain with score of “9” even
though her breathing is becoming shallow. Her BP
is 180/100mmHg, respiratory rate is 8 and oxygen
saturation is 91% on 6L oxygen mask. Besides offering
psychosocial support and encouraging her with deep
breathing, the PACU nurse repositions Ms. Jane’s arm
with pillow and applies the ice pack to her shoulder
side instead of seeking further opioids order. The PACU
nurse suspects that Ms. Jane may have addictive issue
and explains to her again that no more pain medicine
could be given because of her current respiratory
status. Ms. Jane is still moaning and becoming
agitated. A senior nurse comes to help the graduate
nurse to deal with the agitation issue and she observes
that Ms. Jane seems reluctantly to take a deep breath
due to the pain it causes. Upon further discussion with
the anaesthetist, a multimodal analgesia approach is
adopted and Tramadol and Clonidine are given. After
receiving 150mg Tramadol and 100mg Clonidine, Ms.
Jane’s pain is gradually reduced to a tolerable level,
respiratory rate is increased to 11 with 97% Oxygen
Saturation and BP is down to 142/70. Finally,
Ms. Jane is successfully discharged from the PACU.
DISCUSSION FOR VIGNETTE ONE
In this case, Ms. Jane’s postoperative pain brings a
challenge to manage due to her history of sleep
apnoea and long-term smoking. It has been
consistently shown that smokers have increased
requirements for opioids perioperatively, resulting
from either an increase in metabolism of the
substrates or alteration of the pain threshold10.
Respiratory depression is also a well-known side effect
of opioids11 and for this reason clinical nursing staff
are especially cautious about administering opioids to
sleep apnoea patients. In addition, cigarette smoking
decreases mucociliary clearance of the lungs, reduces
forced expiratory volume and impairs oxygen delivery
by shifting the oxygen–hemoglobin dissociation curve
to the left that decreases oxygen availability
to the tissues12, 13. Initially the graduate nurse had to give opioids
gradually based on the “cautious” order from the
anaesthetist and did not give second thought on pain
management through use of further opioids or other
multimodal analgesia. It was not until an expert nurse
noticed that the insufficient pain management as the
root cause of inhibited breathing efforts based on
her experience and the cues of assessment. Dihle,
Bjolseth and Helseth14 (2006) suggest that insufficient
knowledge of pain management, inadequate
assessment and evaluation of pain, and various
attitudes towards pain may contribute to the
suboptimal pain relief.
Knowledge plays an important role in effective clinical
decision-making for pain management. Inadequate
knowledge about pain management principles among
clinical nursing staff is a significant barrier to pain
management. Several studies show that there is a
relationship between educational intervention and
improved pain management8. As a result, a nursing
education program needs to emphasise crucial parts
of clinical decision-making applying on complex pain
management issues15.
On the other hand, personal attitudes and beliefs must
be left aside when assessing and managing patients’
pain. The nurse should be able to deliver evidence-
based pain management care with competency in order
to meet the patients’ need9. Good pain management
skills include regular pain assessment that is acted upon
with appropriate drug administration. PACU nurses
need to realise their own biases and prejudices to
avoid unconsciously misguiding toward own
practice16,17. Pain management is a two-way process.
Trusting the patient and finding the cues on
patient’s body or behaviour are the first steps in
building a therapeutic relationship to enable
effective pain management.
16
Ar ticles of interest
Furthermore, increased workload and lack of
experienced PACU staff could directly cause lack
of sufficient time on pain management. Evidence
shows that nurses have prioritised caring for the
physical issues of the patient higher than caring
for the pain management of a patient because
of the strained caring time8. In Ms. Jane’s case,
a less experienced graduate nurse had to care
for a complex pain management patient initially
without expert help in the climate of staff shortage.
Finally, inadequate pain management education
and training for clinical nursing staff can be another
key organisational-barrier on pain management8.
CASE VIGNETTE TWO
Mr. Lin (pseudonym), 32 years old immigrant from
China with limited English capacity, arrives in the PACU
after an open reduction and internal fixation (ORIF)
procedure on his left arm under general anaesthesia.
He is a regular community soccer player and his arm
was fractured during an intense game. He received
10mg Morphine, 5mg Oxynorm and 40mg Paracoxib
during the procedure. The surgeon also added 20ml
local anaesthetic to the site before the closure.
Identifying and recognising pain
management barriers in PACU
would facilitate clinical nursing
practice in effective
postoperative pain management,
tolerate certain pain without a painkiller. The PACU
nurse tells Mr. Lin that postoperative pain management
is an extremely important step towards a quick
recovery and minimising postoperative complications.
It is important to control the pain at its early stage.
After careful reassessment of the pain, 100 mcg
Fentanyl is then gradually given intravenously. Finally,
a relieved smile is appeared on Mr. Lin’s face and he
reports that his pain is much improved.
DISCUSSION FOR VIGNETTE TWO
In above case, the postoperative pain management
issue for Mr. Lin specifically reflects cer tain barriers
on effective communication, patient’s beliefs, values
and cultural attitude toward pain. Pain management
is greatly affected by cultural factors of pain at is
has psychological, social, spiritual and physical
dimensions16. Culture is the conditioning influence
in forming the individual’s patterns of responding
to and expressing pain18. Effective communication
between the nurse and patient for a comprehensive
pain assessment leads to successful pain management.
Language can be a major barrier to effective pain
assessment and management where English is not the
first language for those patients in English speaking
countries. Without competent interpretation available
for the patient who lacks of proficiency in English, it is
impossible to adequately assess pain and educate the
patient on the pain management16, 19.
Although a nurse may be equipped with good
knowledge of disease processes and pharmacological
methods for pain management, he/she may still lack
insight into the patient’s culture. This can be a barrier 18
further enhance nursing to pain intervention . The pain not only represents
education on advanced pain
In the PACU, Mr. Lin is quiet and alert without being
bothered by the busy evening environment. His oxygen
saturation is 98% on room air, but BP is up to 158/82
mmHg and pulse is 99. The PACU nurse suspects that
the patient may have pain but Mr. Lin seems to deny it
by slightly shaking his head with hesitation.
No hypertensive history was recorded and no
increasing BP medicine was ever used intra-operatively.
Upon applying sling and repositioning Mr. Lin’s arm
with a pillow, the PACU nurse notices that Mr. Lin frowns,
and his forehead has some sweat. In order to better
communicate with Mr. Lin, a clinical staff member who
speaks Mandarin is called in as a temporary interpreter.
The interpreter tells the PACU nurse that
Mr. Lin does have pain and it is getting worse now.
Initially, he tried not to bother nursing staff when
they were so busy as he thought he might be able to
a physiological response to a painful stimulus but
also includes behavioural and emotional elements as
determined by cultural values and beliefs20. Certain
cultural groups may feel ashamed to publically display
pain or only have behaviour cues such as grimacing
to express a pain because they believe that it would
be disrespectful to ask for pain relief19.
According to Carteret , patients’ culturally based
responses to pain are often divided into two categories:
stoic and emotive. Stoic patients seldom reveal their
pain and tend to “grin and bear it.” Patients from Asian
cultures like Mr. Lin may often express stoicism under
surgical pain such as keep low profile and reluctant
to speak out his pain, which directly relates to strong
cultural values about self-conduct21.
Pain is a bio-psycho-social experience and culture plays
an important part in determining how we interpret and
express pain. Providing culturally sensitive nursing care,
and identifying and addressing barriers to effective
17
Ar ticles of interest communication can avoid insufficiency
and inequality on the pain management19.
SIGNIFICANCE TO NURSING
Identifying and recognising pain management barriers
in PACU would facilitate clinical nursing practice in
effective postoperative pain management, further
enhance nursing education on advanced pain
management topics and promote future nursing pain
management research by exploring and overcoming
the barriers effectively.
IMPLICATIONS FOR FUTURE PRACTICE
Postoperative pain management continues to
be a challenging field and it should be a
clinical priority task for all healthcare
professionals. The pain response is not
restricted to a physiological reaction to noxious
stimuli or tissue injury, but also encompasses
emotional and behavioural responses as well.
Through above presented two cases study,
major postoperative pain management barriers in PACU
are identified and analysed. In order to achieve an
effective postoperative pain management, it is crucial
to recognise and remove the existing barriers that
directly impact on nursing practice. Nurses must not
only have advanced pain management education and
training, but also need to equip with high competency
assessment skills and high-level clinical decision-
making knowledge when facing complex postoperative
pain management scenarios. In addition, it is critical
to implement culturally sensitive pain management
to provide optimal care for the patient, and integrate
daily postoperative pain management into evidence-
based policies and guidelines, standards of practice,
continuing education and quality improvement programs.
ACKNOWLEDGEMENT
A special thank to A/Prof. Karen-Leigh Edward and
Researcher fellow Ms. Cally Mills for their expertise
guidance, diligent reviews and valuable suggestions
on the paper. Thanks Ms. Annette Silinzieds from
Education Department who offered valuable nursing
research workshop.
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