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Pain: A Balance Between Analgesia & Side Effects
Kristen Sanders, Jason Simick, & Sarah
Smyth
Johns Hopkins University School of Nursing

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Objectives

Describe the identified problem and its significance

Discuss the purpose and relevance of the selected
middle range theory, a balance between analgesia and
side effects

Analyze this middle range theory using Fawcett's criteria

Understand the theory guided solution proposed for the
problem and its implications for practice

Identify potential problems with implementing the theory
guided solution and ways to circumvent those obstacles

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Background
 Pain:
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A balance between analgesia and side effects
Middle range physiological theory
Proposes multimodal therapy in conjunction with attentive
nursing care and patient participation for the treatment of
acute pain
Applicable to inpatient settings and patients experiencing
acute post-operative pain or trauma
Purpose of theory is to provide a holistic method for acute
pain management that provides better relief while minimizing
the unpleasant side effects of opioid analgesic medication

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Case Presentation
 This
presentation will be focusing the theory of a
balance between analgesia and side effects on
abdominal surgical patients experiencing acute postoperative pain in an inpatient hospital setting

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Problem-Pain in Abdominal Surgical Patients
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Acute post-operative pain has significant impact on a patient's
physical and emotional health
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Unpleasant and distressing
Unmanaged post-operative pain can lead to slower wound healing,
longer recovery time, and an increase in complications and morbidity
Undermanaged post-operative pain continues to be an important
problem in health care today
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Of 80% of postoperative patients experiencing pain, 71% report
moderate to severe pain
As many as 50% of postoperative patients report their pain as poorly
controlled
Patients may feel that pain is a necessary and normal part of the
postoperative period or be afraid of being labeled as a "drug seeker"
resulting in underreporting of pain
Many barriers to providing adequate pain relief including as needed
(PRN) medication scheduling, under-utilizing appropriate pain
medications, uncontrolled side effects of opioid analgesics, underreporting of pain by patients, lack of pain assessment by providers, and
technology issues

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Nursing Relevance

Nurses have a responsibility to relieve suffering of their
patients
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Code of ethics for nurses calls on nurses to treat every patient
with dignity and respect, meet the comprehensive needs of the
patient, and perform assessments and interventions to relieve
pain and suffering
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Nurses must treat pain as a fifth vital sign - they play an integral
role in assessing pain, helping to coordinate a treatment plan,
and implementing appropriate interventions
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Nurses must adequately assess and treat pain in order to
increase patient satisfaction, decrease recovery time and length
of hospital stay, reduce health care costs, and meet Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO) standards

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Description of Theory
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Theory for patients experiencing both moderate and severe pain
from trauma and/or surgical procedures in a hospital setting.
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Focuses on creating a balance between analgesia and side
effects.
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Theory for adult patients only (does not include children or the
elderly).
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Assumptions of theory:
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Doctors and nurses work together effectively when managing pain in
the acute setting.
Certain methods of pain management are necessary including epidural
and systemic opioids, in addition to anesthetics.
Medications will be given to curb side effects of pain medications when
needed.
Patients are able to learn about pain control and to verbalize their
symptoms, while also establishing goals for their pain management.
Nurses have an up to date understanding of pain control.

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Description of Theory
 Three
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Main Propositions
Multiple methods should be used to control pain
(nonpharmacologic & pharmacologic).
Nurses should not only assess and intervene in relation to
their patients’ pain, but also should reassess and alter their
interventions when necessary (i.e. adding additional therapy,
increasing dosing, etc.).
The patient should be taught about pain management and
should set goals for their pain control.

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Evaluation – Fawcett’s Criteria
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Significance
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Highly significant - it is the initial integrative prescriptive middle
range theory for acute pain management
Theory provides nurses with the means to make a difference in
the pain level of their patients in order to promote healing,
relieve suffering, and prevent potential long term complications
Provides a more comprehensive and parsimonious overview
than current pain management guidelines and is supposed to be
a guide for both nursing practice and research
Theory was created with idea that its clinical principles and
research propositions would be used to promote further
research and the dissemination of pain relief information to
nurses
Particularly useful in randomized controlled trials and for
postoperative surgical floors

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Evaluation – Fawcett’s Criteria
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Consistency & Clarity
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Theory has internal consistency - context and content of the
theory are in agreement
Theory is meant to be used in the context of acute
postoperative pain and trauma which is congruent with the
propositions multimodal therapy, attentive care, and patient
participation
Theory has semantic clarity and semantic consistency - very
specific and clear definitions of concepts and consistent use
of the same terms and definitions throughout the explanation
of the theory
High degree of parsimony - theory is stated simply and
concisely with minimal concepts and propositions while still
providing enough detail to have a high degree of clarity

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Evaluation – Fawcett’s Criteria
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Adequacy
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Empirical – claims made by theory must be consistent with
empirical evidence
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Theory is supported by a multitude of empirical evidence
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All three components (multimodal therapy, attentive nursing
care, and patient participation) of the theory have specific
empirical research to support their effectiveness including
credible organizations’ guidelines and meta-analyses
Pragmatic – degree of usefulness of theory in real world

Theory is already being implemented in clinical practice by a
majority of hospitals
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Use of multimodal therapy, attentive nursing care, and patient
participation has proved useful and effective in real world
settings

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Evaluation – Fawcett’s Criteria
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Feasibility
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In acute care settings nurses are on the forefront of patient care
and are uniquely positioned for the effective implementation of
this theory
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Three propositions of patient participation, multimodal
interventions, and attentive care are directly linked to the daily
practice of effective nursing
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This in turn allows practical feasibility for the implementation of
this theory
These three propositions required for the feasible
implementation of the theory of the balance between analgesia
and side effects are now standard behaviors that are expected
of nurses in the acute care setting

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Rationale for Using Theory
 Many
aspects of the theory relate to this problem
and population:
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Addresses adults experiencing surgical pain in an acute care
setting.
Pertains to adults experiencing pain that is moderate or
severe.
Seeks to educate patients about pain control.
Suggests assessing and reassessing patients’ pain in order
to alter the plan of care when needed.
Suggests giving medications to curb side effects of pain
medication when necessary.

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Solution to Original Problem

Establish a positive and proactive relationship with patient to
identify and manage pain involving the entire healthcare team.
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Doctors and nurses must work together to effectively manage pain
for patients and have appropriate therapeutic pharmacologic and
non-pharmacologic plans in place and be prepared to adapt them
for the patient
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A relationship should be built with the patient establishing through
education, the expectations of pain control and the plans for pain
management
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Early communication between the patient, nurses, and physicians
should be facilitated to establish a proactive versus reactive plan

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Solution to Original Problem
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Establishing both pharmacologic and non-pharmacologic
treatment plans for managing acute post-op pain
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As recommended, multiple approaches should be utilized and a
plan should be developed specifically for the patient
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Pharmacologic pain management plan must include management of
side effects of pain control medication to include nausea,
constipation, sleeplessness and potential withdrawal
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Non-pharmacologic interventions must be adapted to specific
effectiveness for each patient to include relaxation, music,
positioning, hot and cold therapy, companionship, and distraction
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Evaluation of effectiveness must remain fluid and dynamic with
constant adaptation to the specific needs of each patient.

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Solution to Original Problem
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Summary of solution given the propositions of the theory
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Given large percentage of patients reporting pain (71%) and
proportion reporting poor pain control (50%) patients must be
involved in the pain control plan
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Assessment and adaptation must be continuous to maintain
effectiveness, pain is personal, specific, and unique to each patient,
and the plan for its management must be as well
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Pain management plan must include multiple methods for pain
control, both pharmacologic and non-pharmacologic, to maintain
highest level of effectiveness for each patient and most effective
management of side-effects

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Managing Potential Complications
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Poor communication regarding pain control plan
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Patients may have unrealistic expectations or uncertain of
expectations at all
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Nurses must foster an environment of open communication and
patient education regarding pain control. Expectations should be
established early and continually re-visited as assessments are
conducted to determine effectiveness of pain control plan.
Nurses and physicians not coordinating efforts
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Multi-disciplinary communication must be maintained to ensure all
members of the health care team are following the same plan and
adjusting it when not effective

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Managing Potential Complications
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Effectiveness of pain control not reassessed
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Pain control must be reassessed and adjusted as necessary to
meet the patient’s needs
Non-pharmacologic interventions not implemented
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To balance analgesic side effects non-pharmacologic interventions
are effective in minimizing pharmacologic dependence for pain
control. These basic but sometimes time consuming interventions
must remain part of the focus and not forgotten for the overall plan
to be successful

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References

American Nurses Associations. (2001). Code of ethics for nurses with
interpretive statements. Retrieved
from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/C
odeofEthicsforNurses/Code-of-Ethics.pdf
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Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science
Quarterly, 18(2), 131-35. doi:10.1177/0894318405274823

Peterson, S. J., & Bredow, T. S. (2009). Middle range theories application
to nursing research. Philadelphia, PA: Lippincott Williams & Wilkins.

Viscusi, E. R., & Schechter, L. N. (2006). Patient-controlled analgesia:
Finding a balance between cost and comfort. American Journal of HealthSystem Pharmacy, 63(1), S3-13. Retrieved
from http://ehis.ebscohost.com.ezproxy.welch.jhmi.edu/ehost/pdfviewer/pd
fviewer?sid=5c2843cb-29f4-497d-89b107d5368ba9b6%40sessionmgr115&vid=4&hid=104