The study under consideration entitled as Achieving organizational change in pediatric pain management was conducted by Dowden, McCarthy and Chalkiadis in 2008 at the RCH, a pediatric hospital in Melbourne, Australia for the purpose of evaluating the current pan management practices, defining the main barriers to their improvement and providing the recommendations for improving the pain culture, Regardless of certain weaknesses of the procedures aimed at ensuring sampling, data collection and the neglect of the internal validity parameter, the findings of Dowden et al (2008) can be applied to the evidence-based nursing practice.
The variables measured in the research under consideration include the perceived barriers to improving the acute pain management at RCH, a pediatric hospital in Melbourne, Australia and the reported inconsistencies in the actual children’s pain management practices.
In the context of this study, the perceived barriers can be defined as independent variables because in this research these concepts are regarded as the presumed antecedents of inconsistencies in nursing practices and undertreated children’s pain (Fawcett & Garity, 2009, p. 29). United under the umbrella of the hospital culture, these independent variables include the outmoded beliefs and misconceptions concerning children’s pain and analgesia, inadequate education at the undergraduate level and the lack of human and physical resources at the hospital setting. As to the reported deficiencies and inconsistencies in the nursing practices, these variables can be labeled as dependent because they are influenced by the perceived barriers. These variables included the lack of the proper clinical practice guidelines, protocols, preparation of children and parents and dedicated sedation service.
Taking into account the fact that neither of these variables can take a distinct number of variations, the variables of the perceived barriers and the reported inconsistencies in nursing practices can be labeled as continuous variables taking a continuum of possible variations (Fawcett & Garity, 2009, p. 29). The qualitative research was intended to identify a wide range of attitudes and perceptions in the nursing staff and establish the link with the reported quality of the provided services.
The estimation of the independent variables affecting the quality of the pediatric pain management labeled as dependent variables is aimed at identifying the barriers to improving the nursing practices significant for outlining an effective solution for the existing problem.
A qualitative research methodology was adopted by Dowden, McCarthy and Chalkiadis (2008) for measuring the independent variables of the nurses’ perception of the changes in pain management practices and the existing barriers which need to be overcome for improving them. For measuring the dependent variable of the quality of the actual pain management practices, a review of the pain services at RCH was conducted. A clinical quality audit was based on the reported practices of various departments regarded as the most influential stakeholders in the adopted pain management practices, including project workers from orthopedics, rheumatology, physiotherapy and pain management departments and a mental health clinician who was not involved in pediatric pain management directly and allowed adopting an external perspective of a cultural perspective for evaluating the collected materials.
The semi-structured interviews with open-ended questions were conducted for both individual and group consultation and constant comparative analysis of the received responses. This approach was intended at collecting the widest possible breadth of the opinions and individual perceptions for the purpose of eliciting a wide range of responses. The open-ended questions used in the interviews allowed the participants to have their say, express and support their positions (Keele, 2011). The collection of the opinions on the perceived quality of pain management procedures and major hurdles for their improvement were used for indentifying specific concerns with pain management and associated procedures. The comparative analysis of the collected interview responses was implemented for identifying the recurring themes and providing the basis for the following generalizations and appropriate conclusions for outlining the solution for eliminating the inconsistencies in pain management practices.
A review of the hospital practices coupled with the comparative analysis of the nurses’ responses to the open-ended questions of semi-structured interviews allowed measuring the identified variables, providing the basis for the generalized conclusions and outlining an effective practical solution for the existing problem.
Strengths of the study
The main strengths of the study under consideration include the problem statement, design and interpretation of the findings.
As to the problem statement in the study, it should be noted that Dowden et al (2008) not only indicted the need f conducting the research, but also clearly identified particular purposes for conducting it. It is significant that the objectives were compliant with the primary goal of conducting the investigation and specific stages of the research process. Labeling the objectives with a, b, c, the researchers outline a plan for further investigation, dividing it into logical parts which are required for drawing a conclusion. After reviewing the current management practices for various types of pain, including those of acute, chronic and palliative, the scholars evaluate their quality and identify the opportunities for their improvement.
As to the study design, it was appropriate for solving the stated problem and was described in details to provide the rationale for this specific choice. A review of the current pain management practices preceding the semi-structured individual and group interviews which allowed identifying the main deficiencies and comparing them to the nurses’ perception of the major inconsistencies. Regarding the first part of the research in which the pain management practices in different departments were reviewed, the involvement of the mental health clinician who is not a key stakeholder in the pain management procedures was valuable for obtaining the perspective of a cultural outsider. As to the design of the semi-structured interview, it can be stated that the flexibility of the interview questions allowed the researchers to adapt them to the specific needs of certain individuals and groups and obtain a broader scope of answers and opinions to enhance the reliability of the collected materials.
Regarding the interpretation of the findings, they were clearly discussed and compared to the findings of similar studies for providing the basis for the following generalizations. Thus, pointing at the small sample as a potential limitation of this study, Dowden et al (2008) mentioned that the findings of their investigation are compliant with the findings of similar studies conducted by other scholars. It is significant that the recommendations provided for improving the current pharmacological and non-pharmacological pain management strategies were not limited to the scope of only a hospital in which the audit was conducted. The specific recommendations outlined in the discussion part would be valuable for any pediatric hospital setting.
Weaknesses of the study
Apart from all its strengths, this study has a number of weaknesses, including sampling, internal validity and data collection.
As to the sampling parameter, it should be noted that the sample population was not discussed in details. It was mentioned that a total of 454 staff counting for approximately 27% of the hospital staff were involved into the survey. It is obvious that the convenience sampling approach chosen by the researchers because these were the nurses working within one hospital setting who participated in the research and gave their consent to answering the questions (Polit & Beck, 2004, p. 311). The details concerning the age, gender, ethnic, educational and working background of the participants were not properly discussed though these parameters could affect the participants’ responses.
As to the internal validity of the collected data, the measures taken for minimizing the possible threats to internal validity were not properly discussed in the study. Though the enrollment of the mental health clinician who is not a key stakeholder in the hospital pain management and can be regarded as a cultural outsider in that regard was mentioned, the rationale for this decision is missing.
Regarding the weakness of data collection, it can be stated that though the procedures of data collection were described in detail, the evidence of high reliability and validity of the collected data was not provided. Thus, the study under consideration contained separate citations from the interview results, but lacked the discussion of their reliability and the details of the data collection and analysis. In general, Dowden et al (2008) focus more on the conclusions they have drawn after the analysis of findings and underestimate the importance of the detailed discussion of the data collection procedures and measures taken for enhancing its validity and minimizing the potential threats to its reliability.
Application of evidence-based practice
The information contained in the study under consideration can be beneficial for the evidence-based nursing practice. Taking into account the main hurdles to implementing the research findings in actual practice, Dowden et al (2008) outlined the measures which are required for overcoming the potential difficulties and improving the current pain management practices.
Boswell & Cannon (2011) pointed out at the nurses’ education, beliefs and available resources as the main hurdles which can complicate the application of the research findings in nursing practice. In that regard, Dowden et al (2008) gave serious consideration to each of these deterrents. In the implication section of the study under consideration, the scholars recommended the enhanced training on the pharmacological and non-pharmacological strategies and the associated protocols and procedures as an important condition for improving the existing pain management culture. As to the second criterion of the nurses’ beliefs, the perceived barriers were the main issue discussed in the study, and specific steps were recommended for making the necessary changes in the pain management culture, including the organization of forums and committees aimed at enhancing the nurses’ awareness and controlling the improvements. The issue of the availability of resources was also taken into account by Dowden et al (2008). The recognition of the necessity of the organizational rearrangements and the proper funding for improving the quality of the pain management practices was a significant advantage of the study under consideration which allows it to be applied to evidence-based practice (Fawcett & Garity, 2009).
Analyzing the main strengths and weaknesses of the study design and data collection and interpretation procedures, it can be stated that the recommendations provided by Dowden et al (2008) can be valuable for improving pain management culture in pediatric settings and overcoming the main hurdles in applying the research findings to evidence-based practice.
Boswell, C. & Cannon, S. (2011). Introduction to nursing research: Incorporating evidence-based practice. Sudbury, MA: Jones and Bartlett Publishers.
Dowden, S., McCarthy, M. and Chalkiadis, G. (2008). Achieving organizational change in pediatric pain management. Pain Research and Management, 13(4): 321- 326.
Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-based nursing practice. Philadelphia, PA: F. A. Davis.
Keele, R. (2011). Nursing research and evidence-based practice: Ten steps to success. Sudbury, MA: Jones and Bartlett Publishers.
Polit, D. & Beck, C.T. (2004). Nursing research: Principles and methods. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins.