THE NUTS, BOLTS, AND RESULTS OF MULTI-SITE PROJECTS
Helen N. Turner, DNP, RN-BC, PCNS-BC, Pediatric Pain Management Center, Doernbecher Children’s Hospital, OHSU, Portland, OR
Michelle Czarnecki, MSN, RN-BC, CPNP; Jane B. Pettit Pain and Palliative Care Center, Children’s Hospital of Wisconsin, Milwaukee, WI
Sharon Wrona, MS, RN-BC, CPNP, Comprehensive Pain Services, Nationwide Children's Hospital, Columbus, OH
The Nuts
The Results
Implications for Practice
Nurses are constantly challenged to deliver evidence-based care. Yet often the evidence is weak or
lacking. When nurses get together at professional conferences, conversations seem to quickly identify
common themes and issues. Invariably somebody says, “We should do a study!”
When designing research studies or evaluating practice (quality improvement projects) two major
considerations are sample size and the ability to generalize the findings. These two factors effect the
strength of the results and can be difficult to achieve at a single site, making multi-site studies tempting.
The benefits, limitations, and logistics of multi-site projects are described.
All hospitals employed online surveying methods. However, there are a few
methodological differences to note among the sites.
The results suggest that nurses are experiencing barriers to pain management in a number of different
areas. Based on the factor analysis, interventions that target each category of potential barriers to optimal
pain management can be developed. More research should explore the implementation of such
programs, as well as the association between demographic information and barriers identified.
Children’s
Hospital of
Wisconsin
Doernbecher
Children’s
Hospital
Nationwide
Children’s
Hospital
Length of
Survey
Availability
4 weeks
4 weeks
3 weeks
Electronic
Reminders
No
Yes
Yes
Incentive for
Participating
Yes
No
No
GETTING STARTED
While at the ASPMN national conference, one of the authors (MC) was describing a project she was
working on at her organization which involved having RNs complete a survey to identify perceived
barriers to optimal pain management. The other two authors were interested in looking at barriers within
their own organizations, and it was suggested that it would be interesting to compare between the
organizations. Collecting data from three organizations would provide a larger sample size and possibly
make the findings easier to generalize thereby adding more robust evidence to nursing knowledge.
THE LOGISTICS
One of the greatest challenges to clinical research and practice evaluations is the lack of resources;
especially funding and personnel. Each of the authors added this project to already busy full time
practices.
Protection of subjects and information is critical in any project and will likely involve approval by
Institutional Review Boards (IRB). Depending on organization-specific IRB requirements this may be an
onerous endeavor.
Challenges
 Keeping the project alive
 Developing interventions to decrease identified barriers
 Repeating the process—original plan was to repeat survey every two years
 Publishing the results
 Expanding to include other disciplines—physicians, pharmacists, child life therapists, and physical
and occupational therapists
Approximately, 38% of nurses responded to the survey from the Children’s Hospital of
Wisconsin, 41% responded from Doernbecher Children’s Hospital, and 11% from
Nationwide Children’s Hospital.
45
Preservation of consistent survey methodology is an additional challenge when working with multiple
sites. Consideration must be given to how the survey is administered (paper and pen vs. electronic);
subject access to survey; length of time survey is available to subjects; and whether to use notices,
reminders, and incentives for subjects to complete the survey.
Analysis of data collected also presents a challenge. Most clinicians do not have easy access to
statistical analysis support—software or personnel. It is critical to preserve the integrity of the data and
minimize the analysis variability.
Children's Hospital of Wisconsin
Doernbecher Children's Hospital
Nationwide Children's Hospital
40
35
30
25
20
15
The Bolts
SIGNIFICANCE AND BACKGROUND
Children are identified as a vulnerable population at risk for under treatment of pain. Untreated or
poorly treated pain affects every system in the human body and can lead to poor healing, delayed
recovery, developmental regression, longer hospital stays, reoccurrence of illness or injury, and in
some cases, death. Nurses providing direct care spend the most time and are in constant contact with
the patients and are positioned to make the greatest impact on improving pain care.
Barriers to optimal pain management generally cluster into three areas: patients and families,
healthcare providers, and health care systems. Examples of these barriers previously identified in the
literature include: inadequate physician orders, reluctance of children to report pain, parents reluctance
to have children receive medications, limitations in knowledge, fear of addiction, poor working
relationships, and competing demands on nurses’ time.
MEASURES
Demographic Information. Nurses were asked to provide demographic information, such as gender,
ethnicity, years of experience, education level, and role. The Barriers to Optimal Pain Management
Questionnaire developed by Vincent (2004), was modified to 30 items by MC (with permission) and
asked nurses to rank how much each barrier interfered with their ability to provide optimal pain
management (0 = not at all a barrier, 10 = a major barrier). RNs were also asked to describe “optimal
pain management”, list any barriers not specifically identified, and provide any additional comments
about pain management at the specific hospital.
10
5
0
< 2 yrs
2- < 5 yrs
5- < 10 yrs 10- < 15 yrs 15- < 20 yrs 20- > yrs
Data from all three sites were compiled due to the similarities in demographics across
the participants. The mean and standard deviation of each pain barrier, as well as
those identified as the five most significant and the five least significant barriers to
optimal pain management were reported.
The most significant barriers (in order) were: insufficient time allowed to pre-medicate
prior to procedures, inadequate/insufficient physician medication orders, insufficient
pre-medication orders prior to procedure, low priority given to pain management by
medical staff, and parents’ reluctance to have children receive medication.
The least significant barriers (in descending order) were: low priority given to pain
management by nursing management, low priority given to pain management by
nursing staff, limitations in my ability to assess pain, concern about children becoming
addicted, and low priority given to pain management by me.
Selected References
• Brockopp, D. Y., Brockopp, G., Warden, S., Wilson, J., Carpenter, J.S., Vandeveer, B.
(1998). Barriers to change: a pain management project. International Journal of
Nursing Studies, 35, 226-232.
• Tanabe, P. & Buschmann, M. (2000). Emergency nurses; knowledge of pain
management principles. Journal of Emergency Nursing, 26(4), 299-305.
• Titler MG. Herr K. Schilling ML. Marsh JL. Xie X. Ardery G. Clarke WR. Everett LQ.
(2003). Acute pain treatment for older adults hospitalized with hip fracture: current
nursing practices and perceived barriers. Applied Nursing Research, 16(4): 211-27
•Twycross, A. C. (2007). Challenges of setting up a multi-centered research study.
Nursing Standard, 21(49), 35-38.
• Vincent, C.V. & Denyes, M.J. (2004). Relieving children’s pain: Nurses’ abilities and
analgesic administration practices. Journal of Pediatric Nursing, 19(1), 40-50.
• Vincent, C.V. (2005). Nurses’ knowledge, attitudes, and practices: Regarding children’s
pain. MCN, 30(3), 177-183.
ANALYSIS
A factor analysis was conducted to determine if the barriers group together in a certain way. The 18
barriers from the measure were entered into a Principle Components Factor Analysis, employing
Eigen-values above 1 and factor loadings of .5. After this, the factors were calculated and reliability
analyses were run to determine how the barriers hung together. Based on these analyses, 3 factors
were identified : institutional barriers, patient barriers, and beliefs and biases. Descriptive statistics
were used to report the demographic characteristics of the sample and significance of each barrier
item.
Contact Information:
Mczarnecki@chw.org
Sharon.Wrona@nationwidechildrens.org
turnerh@ohsu.edu