Abstract
A meta-analysis targeting the studies that investigated the associations that exist between several dyads on self –report on pain ratings. The child and parent, parent and nurse and the relationship between the nurse and the child were among those investigated. Online databases were preferred in this study due to the ease of accessibility and large pool of information available. The study utilized systematic methodologies that ensured that the results were feasible and offered statistically significance. The findings are imperative in informing the policy development in nursing practice since they offer the best available evidence on the pain assessment. The meta-analysis on pain reporting has great implications to the nursing practice and education since it dwells mainly on patient care, particularly for the in-patients. With the input of the meta-analysis, the nurses are better placed to improve and offer satisfactory services and care to recovering patients especially in post-operative. The study is crucial since it recommends the application of more efficient pain assessment tools in order to achieve the precise ratings with regard to the pain experienced thereby informing the practice.
Introduction
The availability of a large volume of statistical information on certain fields of interest has occasioned the development of meta-analysis and systematic reviews. Meta-analysis is a study conducted with the aim of combining the results from a pool of studied thereby resulting in a common position that integrates the findings (Whitehead, 2002, p. 1). Meta-analysis provides the researchers with similar methodological rigor imperative in the literature review required from the holistic study of experimental study. In line with this, meta-analysis generally refers to the development of a report of the available primary research by utilization of statistical methodology achieved through the assistance of computer based databases and to a large extent on statistical software. The development of meta-analysis was occasioned by the shortcomings in the narrative reviews. The narrative reviews failed to take into account the variation in the characteristics of the primary studies. The fact that the meta-analysis is informed by the observation of laid down guidelines makes its findings more valid and viable than the narrative reviews (Beck, 1995, pp. 14). This paper will review a meta-analysis with particular interest in critiquing it using the Whitmore criteria while also discussing it in the context of the nursing practice.
Locating the materials is demanding task owing to the immense information found on the academic databases. However, this is crucial and helpful since it helps the researcher to narrow down the search to a specific field. The selection of the databases was carried out in October 2007, targeting the studies carried out from the year 2000 and 2007. The meta-analysis targeted the studies that investigated the associations that existed between several dyads on self –report on pain ratings. The child and parent, parent and nurse and the relationship between the nurse and the child were among those investigated. Online databases were preferred in this study due to the ease of accessibility and large pool of information available. In particular, medical databases employing the English language such as CINAHL, Ovid, psycINFO & Medline were preferred since they provided the most consistent primary research materials and meta-analysis in the western world. More importantly, some technical terms such as meta-analysis on children pain ratings were utilized as the reference terms during the search. The article was chosen for meeting the few requirements such as publication was done using English language and consistency and statistical significance was clearly explained. The article was selected from among 10 meta-analyses due to the fact that the primary research articles employed statistical methodologies and in particular reported Pearson’s r as part of the outcome measure.
The selection of this meta-analysis was achieved through application of stringent statistical procedures. The current nature of the article influenced its selection since it contained the most recent information on the topic. In addition, the methodology utilized in coming up with the meta-analysis showed a lot of consistency and therefore was instrumental in imparting its choice. Moreover, my interest in understanding and improving pain management especially in children made the article important for me. The fact that there are a lot of conflicting studies that dwell on the topic but fall short in their methodologies and in producing convincing findings made the meta-analysis the best option since it contained a review of the conflicting findings (Bero et al, 1998, p. 467). The meta-analysis also acts as a foundation for my future research studies owing to the fact that I have great interests in pain management.
Stringent procedures in the methodology were utilized in coming up with the twelve articles that formed the basis of the meta-analysis. The target population of the meta-analysis was children suffering from illnesses that occasioned their admission into hospitals where they underwent surgical procedures or any other procedures that contributed to their pain. Data collection encompassed the interviewing of the admitted patients for a period not less than three weeks to help remove bias. The age of the participants ranged from birth and stretched up to late adolescence. More importantly the studies that utilized the Pearson’s statistical analysis as the main measure for the outcome were useful in the determination of the articles. The studies also ensure that the articles selected were published in English with the publication dates ranging from 1990 and 2007.
Meta-analysis usually offers the best alternative for effecting far reaching changes in the areas of education, practice and administration (Anello & Fleiss, 1995, p. 112). The fact that it provides a review of the latest trends in certain fields of interest makes it provide a basis for introducing policy and administrative changes in the nursing practice. The meta-analysis on pain reporting has great implications to the nursing practice and education since it focuses mainly on patient care, particularly for the in-patients. The practice is therefore well informed on the attitudes of the patients with regard to the care given to them. With the input of the meta-analysis, the nurses are better placed to improve and offer satisfactory services and care to recovering patients especially in the post-operative wards. The study is crucial since it recommends the application of more efficient pain assessment tools in order to achieve the precise ratings with regard to the pain experienced thereby informing the practice.
Whitmore criteria
The lack of criteria for the evaluation of the various forms of reviews and meta-analysis necessitated the development of the Whitmore tool in 2005. A rise in the number of integrated reviews and the need for concrete findings vital in directing the nursing practice saw the initiation of efforts aimed at improving the application of evidence based practice. Data abstraction, literature search, statistical techniques and the publication form the criteria employed in the evaluation of the presented findings. The purpose of the study and sampling play a major role in directing the researchers in the development and process of meta-analysis. It is therefore worth noting that the synthesis of the results must follow a systematic method to minimize the occurrence of bias and also boost the confidence needed for the results to be applied in the nursing practice and education.
The meta-analysis on pain reporting utilized studies published in some of the leading English databases. The fact that the literature search involved the review of the database means that little input on the meta-analysis was received from unpublished studies. The meta-analysis has also provided the key words such as “children/adolescents” and “pain assessments” that played a major role in the literature search. Usage of the key terms ensured that the study met one of the condition set by the Whitmore criteria. The inclusion and exclusion criteria applied are also provided by the researchers. Initially, the researchers identified twenty studies that were relevant to the study topic. Six studies were eventually excluded due to their failure to provide for the Pearson’s correlation coefficients that play a significant role in ensuring outcome measures are useful in calculation of the effect size. The study also excluded other studies that had ages of the sample population outside the desired range of 1-18 years. Abstraction was achieved through standardized procedures that explained in depth the procedures employed in the achievement of high quality information that met the set criteria regarding statistical significance and effect size model. The correlation aspect of majority of the studies enhanced the application of the raw data from the Pearrson correlation coefficient in setting the foundation of the estimation of the effect size. As stated in the Whitmore criterion, the study applied the fixed effect model due to the small size of the sample and the similarity in the effect size parameter. The utilization of parameters that relied heavily on the effect sizes with involvement of other distribution model such as fisher-z transformation makes the analysis more statistically significant. The results were collected from studies undertaken on different groups of people thereby minimizing overlapping and duplication (Sweet, 2004, p. 45-46). More importantly, the results were inclusive of raw data and correlation coefficients that enhanced the analysis and also served to reveal any existing and undetected discrepancies. The application of the fixed effect model meant that a summary statistic for the effect of the intervention was provided. It also helped in deducing whether the study had any impact on the development of the nursing practice particularly in the area of pain management in children. The statistical test for homogeneity also showed that some homogeneity existed among the 12 studies thereby making the combination of the results feasible.
The meta-analysis employed literature search that entailed English databases and also referenced materials that failed to get published. This enhanced the minimization of publication, although to a small extent. The assessment was undertaken through a funnel plot that showed a relative distribution of the effect sizes from the vertical base line. From this assessment, the publication bias was found to be minimal and hence did not pose concern with regard to the integrity of the analysis. The publication bias was also minimized through the inclusion of those studies that had clear effect sizes. The results of the meta-analysis has great impact on nursing practice since it affects the lives of children recovering from surgical operations. Considering that children form a sizeable population of the in-patients, the meta-analysis offers a foundation for informing the care and the policy development (Sweet, 2004, p. 45-46).
Potential use of meta-analysis study in health policy development
Sound research coupled with concrete evidence based practice has always formed the backbone of improvements in the healthcare particularly in the United States. The incorporation of research in the delivery of healthcare services has resulted in an overall positive impact on the general treatment outcome in the patient. While the utilization of evidence based practice has received wide application in nursing practice, the policy makers and the decision makers are faced with a difficult task of selecting the most appropriate evidence. In addition, the cost effectiveness and the sustainability of the measures are some of the factors that hinder the application in nursing practice and education. However, a great shift has occurred in research and practice with increased improvement on curriculum aimed at integrating new evidence into practice. In the case of this meta-analysis, its implications on the management on the post-operative care of patients will strengthen the laid down guidelines especially on the assessment of pain in children.
The assessment of pain in surgical patients is an essential task that enhances the proper management while ensuring that the children enjoy optimum comfort during their stay in the hospital and recovery period in the community. Dickson & Flynn (2005, p.20) noted that the fact that nurses spend considerable time with the patients, makes them carry the burden of implementing policy changes that will enhance the achievement of better patient outcomes. The continued reliance on ineffective scales for assessing pain in patients may have contributed to dire consequences for the patients since they fail to bring out the feelings of the children. The advantages conferred by self-report over observational and physiological methods have led to an immense push for it to be considered for application in major hospitals in the United States (Kingdon, 2003, p. 128).
It is therefore worth noting that the study can help hospitals to initiate pain management reforms by incorporating self-report combined with observational method as a standard for assessing pain in children. The nurse should also be informed that the perception of pain given by the parent or fellow nurse forms an estimate rather than an expression of the actual pain. Policy development aimed at allowing the patient to self-report the pain should be encouraged in order to ensure the patients receive the best care (Dickson & Flynn, 2005, p.22).
The meta-analysis is also imperative to the management since its offers a foundation for future research. The institutions can therefore set aside funds to boost studies that would help shed more light on the association of the various dyads. The study further informs the institution policy makers since it calls for the initiation and development of training sessions for nurses to enhance their capability in the management of pain. Policy makers would therefore insist on re-training of new nurse entrants on assessment and management of pain in the patients as part of the measures to alleviate the problem. The policy makers could go a step further and propose the integration of the programme into the curriculum of medical training institutions so that all graduates are overly acquainted with the new developments. Furthermore, the accreditation and regulatory authorities would find it useful particularly when issuing certification and conducting monitoring and evaluation. Making the pain management as one of the areas in patient care would serve as a big boost to the children. The healthcare institutions would be compelled to observe certain measures such as training the nurses on pain management and also the application of more effective pain assessment tools. The introduction of age appropriate assessment tools is also important in ensuring there are improved outcomes in the children. The policy makers and the accreditation institutions would require the institutions to lay down quality improvement strategies for implementing advanced pain assessment guidelines that take into account the ages of the children.
Treadwell, Franck & Vichinsky (2002 p.39) asserted that significant improvements have been reported by patients, nurses and family members when strict adherence to the guidelines is observed. The study further observed that the nurses and patients reported increased satisfaction on the advanced tools and on the services offered respectively (Treadwell, Franck & Vichinsky, 2002, p. 39). However, care should be taken when applying the procedures since the tools might not have the same effect in all patients. Franck & Bruce noted that there is need to understand the effectiveness and the genesis of the assessment tools before embracing them. Overall, the meta-analysis on pain offers ample evidence to inform the development of policy measures aimed at introducing advanced pain assessment tools and quality improvement strategies in nursing practice (Manchikanti, 2008, p. 161).
Steps needed to incorporate the meta-analysis study into health policy
Healthcare faces broad influences from external and internal forces that eventually lead to policy changes especially in nursing practice and patient care. The evidence from meta-analysis and systematic reviews has greatly informed the development of clinical guidelines and assessment tools (Treadwell, Franck & Vichinsky, 2002, p. 51). The rigorous processes and the systematic approaches that are characteristic of meta-analysis and reviews have endeared them to policymakers unlike the inconsistencies that exist in available primary research articles and expert recommendations.
Whilst there are different approaches to implement the research evidence into nursing practice, the applicability of the evidence into the nursing setting and sustainability of the practice must always take first priority. The systematic application of research evidence into practice enhances the delivery of quality care. The existence of a problem is instrumental in making the policy makers and other stakeholders to seek the best available evidence. The existence of a problem is important since it brings out the need for change to be instituted in the nursing practice. Communication by the affected stakeholders such as the nurses also aid in the spotting of the problem or shortcoming in the delivery of healthcare services. After the selection of the knowledge, the stakeholders embark on a journey whereby it is analysed to ascertain its applicability and in the nursing setting (Lavis, Oxman, Moynihan & Paulsen, 2008, p. 53). The shortcomings in the practice are usually linked with interventions while ensuring that the outcomes have positive bearing to the patients and the staff. Designing of the change practice is initiated whereby round table discussion involving several stakeholders are held with the aim of exploring strategies of implementing the intervention (Rosswurm & Larrabee, 1999, p. 317). This allows for the step to step application of the evidence into the clinical and nursing practice. With time, the application of the research finding is up scaled particularly when the pilot application bears positive fruits.
The stakeholders are obliged to put monitoring measures to enhance its success. At this point, the expansion of the intervention requires the development of health policy so that its utilization can have a major effect or outcome on the practice (Steinberg et al, 1997, p. 921-922). The evaluation of the implementation of the evidence into practice forms the basis for the development of the health policy from the findings in the meta-analysis. In this regard, success in the implementation stage plays a major role in influencing the incorporation of the interventions in the health policy by the relevant government authorities. The achievement of the health policy is also pegged on the ability of the health systems to maintain the change practice. More importantly, the policy is imperative since it helps in the setting of guidelines to be followed when implementing the intervention (Sackett, Straus, Richardson, Rosenberg & Haynes, 2000, p. 16)
Incorporation of the research evidence into practice requires collaboration and working closely with other interested partners or organisation. Collaboration enhances the pooling of immense ideas and initiatives that allow the generation of a solid framework and foundation for sound health policies. The establishment of strong links with stakeholders and to a larger extent with the policymakers will add more technical expertise required during the development of the policy. A clear framework must be set up so that disputes and conflicts within the group or external forces can be solved amicably without bringing undue pressure on the team (Steinberg et al, 1997, p. 922). Furthermore, the stakeholders must be encouraged to work as a team in order to enhance efficiency while bolstering the chances of coming up with a concrete policy that will promote quality patient care. The policy must be accompanied with technical capacity in terms of the workforce, hence the need to train the stakeholders on the processes involved in the development of the policy in pediatrics.
The development of a successful health policy must rely on solid evidence that has the ability to persuade the stakeholders to shift from one approach to another. The regular and continuous monitoring of prior implementation of the desired strategies must be carried out so that its limitations and benefits can be understood.
Role and impact of nursing research on policy development and nursing profession
Research in nursing has continued to play major role in the development of the nursing profession particularly in the last three decades. The fact that majority of policies are developed due to availability of better and improved strategies calls for radical changes in the functioning of the nursing. Evidence based practice has helped improve the working conditions of the nursing working while ensuring that the patients receive the best available care. Moreover, the incorporation of evidence in policy has caused paradigm shift in the delivery of healthcare and the management of the healthcare institutions. Of particular importance, is the role played by the nursing research in enhancing the accreditation of healthcare organization into magnet status.
For the last few decades, nurses have benefited immensely from research based evidence carried out in their area of operation. For instance, the introduction of technology in hospitals and use of sophisticated medical devices has brought forward the need for the nurses to undergo training on information communication technology. The successful completion of this course has helped them access the latest information and evidence on the nursing field. Effective utilization the available research evidence and systematic reviews has made it possible to deliver timely and quality patient care. The nurses are also better equipped to persuade and explain to the patients the reasons why they chose to utilize a certain treatment method. Information on the efficacy of the various regimens is overly available while wastage of time is minimized due to the simplicity offered by the technology. Tracing of health and patient records becomes easier thereby improving the diagnosis and treatment procedures in the hospitals.
Nursing research has led to the achievement of magnet status, which is the highest recognition received by hospitals that achieve high standards in nursing care, due to the promotion of best practices in the functioning of the nurses (Kitson & Antrobus, 1999, p. 750). For a centre to achieve magnet status, nursing practices that lead to optimum patient outcomes, job satisfaction and minimal turnover of the nurses, and effective mechanisms to address grievances. This means that magnet hospitals and leaders are more interested in working with the nurses. Achievement of magnet status ensures the nurses enjoy transformational leadership, exemplary professional practice, research and evidence based practice. Nursing research helps in the improvement of the policies in the hospitals. This is mainly evident in hospitals with magnet status where all nurses are provided with a safe environment to conduct their daily duties. Exposures to different environments help them to make changes in the staffing and encouraging the collaborations between the nurses and the other professionals working in the institutions. Evidence based practice is used in improving the diagnostic process and the management of patient care (Ward, House & Hamer, 2009, p. 158-159).It basically utilizes the most current evidence in informing the care givers decisions on the delivery of patient care. Since it is an approach that integrates the clinical appraisal with the clinical experiences, it tends to put into consideration the preferences and values of the patient. Evaluation of the practice is important to ascertain its effectiveness. It is practiced in order to enhance the achievement of good results and benefits such as professional development. Professional development has been embraced in nursing since it allows the nurses to gain the desired knowledge that is vital in the selection of the best components to be incorporated in patient care. This is through helping them to assess the viability and usefulness of each element of the professionalism.
Evidence based practice is taken as the only avenue that an institution makes improvement in delivery of patient care. Professional development is therefore important to instill the needed confidence and knowledge to help the nurses in explaining the processes involved in patient management. Their interventions are always supposed to offer better and cost effective results and outcomes. The ability to take accurate data from the patients is also enhanced thus the nurse is able to assess whether there is need for change or not. The nurse is well equipped to link the knowledge about the problem with the possible interventions. A consideration for relevant outcomes through the review of the available evidence helps the nurses to come up with the design of an ideal nursing practice. Continuing education is also pivotal in bringing change in the health care institutions since new knowledge on cost effective and efficient methods in patient are learnt. Nursing research also ensures evaluation and monitoring of change practice take place thereby providing the required impetus for nurses to advance their professionalism in specific areas of nursing. Professional development has also helped the nursing fraternity to embrace the relevant knowledge and skills in research (Happell, Johnston & hill, 2003, pp. 255-256).
Nursing research has also imparted on bridging the gap that exist in application of knowledge nursing practice. Application of current knowledge in evidence based practice helps in minimizing the barriers to its application. Professional development on current nursing practices has resulted in effective patient care that has helped address the problem of acute shortage of nurses in the hospitals. Evidence based practice also benefits largely from the efforts made by the scholars who are tirelessly carrying research studies on ways of bettering the practice by addressing the barriers and problems plaguing the sector (Grol, 2001, p. 1149). The care providers are also equipped with the requisite knowledge that enhances their critical thinking and evaluation of available nursing practices. Their ability to utilize data which is imperative in making decisions on clinical interventions is improved.
Moreover, the proper utilization of this knowledge helps the nurses to meet the patient needs while taking into considerations the trends in healthcare (Centre for Nursing Studies and the Institute for the Advancement of Public Policy, 2001, para. 2-3). The retention of nurses in health facilities is also boosted thus creating a solid foundation for developing evidence based practices. Providing advanced training on research methodology to lecturers has played a major role in improving professional development in nurses. This is because the professional become more research oriented and recognize the positive impacts of utilizing the findings in practice (Titler, 2007, p.26-31). Exposure to research results leads to enhanced applicability of cost effective and quality care improvements in areas such as diabetes care.
Conclusion
The meta-analysis offers useful information on the association of pain assessment in the three dyads. The study utilized systematic methodologies that ensured that the results were feasible and offered statistically significance. The findings are imperative in informing the policy development in nursing practice since they offer the best available evidence on the pain assessment. The study met most of the criteria set by Whittemore thereby adding credibility to the findings and boosting their applicability in policy development. Findings in the study indicate that designing of age appropriate assessment tools for pain is imperative, meaning that there is need to develop policy that encourages the utilization of self-reports as the main assessment tool. The incorporation of the meta-analysis findings on the policy development has enhanced the advancement of nursing profession through professionalism observed in nurses in terms of career advancement and utilization of research into practice. Evidence should be integrated into practice and in policy development in order to ensure that the patients receive quality care in the hospitals.
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