BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

Survivors of physical trauma may be at increased risk for developing suicidal ideation and behavior both during and after their inpatient hospitalization for medical treatment of wounds. It remains to be understood why a population hospitalized for nonpsychiatric reasons may ultimately develop a desire to take their own life. The current study sought to answer this question by hypothesizing that symptoms of posttraumatic stress (PTS) and depression during the recovery period individually mediated the relationship between physical pain and suicidal ideation. Researchers assessed these relationships in 246 patients who were receiving emergency medical treatment for wounds associated with a physically traumatic event. Patients were interviewed using a battery of assessments, including the PTSD Checklist-Civilian, Beck Scale for Suicidal Ideation, Medical Outcomes Study Short Form, and the Patient Health Questionnaire. Regression analyses provided support for the role of PTS and depression as mediators of the relationship between physical pain and suicidal ideation. These findings suggest that it may be important for behavioral health professionals to monitor symptoms of PTS and depression during a trauma survivor’s painful recovery period, as this may provide a crucial window of intervention during which the escalation of suicidal feelings can be prevented.

Thesis (MCur)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Pain management is a vital component of post-operative nursing care. Orthopaedic patients in particular experience severe pain following surgical intervention. Since effective pain management is crucial in the post-operative recovery of orthopaedic patients, it was essential to explore the knowledge and clinical practice of nurses in orthopaedic wards. The aim of the study was to establish nurses’ knowledge and clinical practice for adult postoperative pain management of orthopaedic patients. A non-experimental, descriptive self-administered survey using a quantitative approach was applied. The total population of N=97 registered professional and enrolled nurses working in dedicated orthopaedic wards in two central hospitals in the Cape Town Metropole district, South Africa were invited to participate in the study. A structured questionnaire was used to collect the data. Reliability and validity was assured by means of a pilot study and consultation with nursing experts and a statistician. Ethical approval was obtained from the Health Research Ethics Committee of the University of Stellenbosch. Permission for access to the hospitals was obtained from the hospital and nursing managers. Informed written consent was obtained from the participants. The data was analysed by the statistician and presented in frequencies, tables and histograms. The variables were compared using either the Pearson chi-square test for differences in nursing category or the Mann-Whitney U-test for differences in years of experience. The analysis of the results illustrated knowledge deficits, inconsistent clinical practices and limited training in post-operative pain management. The recommendations include training courses, revision of the patient’s observation chart and formulation of policies and guidelines for pain management. Appropriate knowledge and clinical skills of nurses are critical to ensure optimal pain management for post-operative orthopaedic patients. / AFRIKAANSE OPSOMMING: Die bestuur van pyn is ’n essensiële component van post-operatiewe verpleegsorg. Ortopediese pasiënte ervaar spesifiek fel pyn na afloop van ’n chirugiese intervensie. Aangesien effektiewe pynbestuur belangrik in die post-operatiewe herstel van ortopediese pasiënte speel, was dit nodig om die kennis en kliniese praktyke van verpleegpersoneel in ortopediese sale te verken. Die doel van die studie was om verpleegpersoneel se kennis en kliniese ervaring van volwasse post-operatiewe pynbestuur van ortopediese pasiënte vas te stel. ’n Nie-eksperimentele, deskriptiewe, self-toegediende opname is toegepas wat gebruik maak van ’n kwantitatiewe benadering. Die totale populasie van 97 geregistreerde professionele en ingeskrewe verpleegkundiges wat in toegewyde ortopediese sale van twee sentrale hospitale in die Kaapstad Metropol distrik, Suid Afrika werk, is genooi om aan die studie deel te neem. ’n Gestruktureerde vraelys is gebruik om data in te samel. Betroubaarheid en geldigheid is verseker deur middel van ’n voortoets en konsultasie met verpleegkundige kenners en ’n statistikus. Etiese goedkeuring is verkry van die Gesondheidsnavorsing Etiese Komitee van die Universiteit Stellenbosch. Toestemming om toegang tot die hospitale te kry is verkry van die hospitaal en verpleegbestuurders. Ingeligte, geskrewe toestemming is van die deelnemers verkry. Die data is geanaliseer deur die statistikus en is aangebied in frekwensietabelle en histogramme. Die veranderlikes is vergelyk deur of die Pearson chi-vierkant toets te doen vir verskille in verpleegkategorieë, of die Mann-Whitney U-toets vir verskille in jare ervaring. Die analise van die resultate het kennistekorte, teenstrydige kliniese praktyke en beperkte opleiding in post-operatiewe pynbestuur uitgewys. Die aanbevelings sluit opleidingskursusse, hersiening van pasiënte se waarnemingsgrafiek en die formulering van beleid en riglyne vir pynbestuur in. Toepaslike kennis en kliniese vaardighede van verpleegpersoneel is krities om optimale pynbestuur vir post-operatiewe ortopediese pasiënte te verseker.

Psychosocial functioning is a key component of screening and treatment of Temporomandibular Disorders (TMD) in adults; however, psychosocial functioning in adolescents with TMD has received little empirical attention. The present study aims to examine group difference between adolescents and adults with TMD on pain and prominent psychosocial factors, such as anxiety, depression, and somatization, as well as to explore additional developmentally sensitive psychosocial factors that may be associated more with the adolescent TMD pain. Participants included 35 adolescents aged 12-17 (M=14.89 years, SD=1.84) with TMD muscle pain who completed pain questionnaires and a comprehensive dental examination. Patients and their primary caregivers completed behavioral questionnaires to examine psychosocial functioning. Thirty-five adults matched on gender, diagnosis, and duration of pain were selected from a large pre-existing database of previous orofacial pain patients. Adolescents and adults reported descriptively similar TMD pain and equivalent rates of anxiety, depression, and somatization; however, the relationship between these psychosocial factors and TMD pain appear to be more salient for adults compared to adolescents. In adolescents, increased pain-related interference was significantly associated with positive attitudes toward school, better anger control, and deficits in functional communication; whereas, more frequent TMD pain was significantly associated with sense of inadequacy and parent-reported withdrawal, though not in the expected direction. Screening for TMD in adults typically focuses on anxiety, depression, and somatization; however, these psychosocial factors overall did not appear as salient in adolescents as attitude toward school, anger control, sense of inadequacy, withdrawal, and functional communication, suggesting that adult psychosocial screen may need to be revised to include developmentally sensitive targets that may be particularly important for screening of TMD in adolescents.

Chronic non-terminal pain (CNTP) is defined as pain lasting longer than three months, serves no functional role in healing, lasts beyond normal tissue recovery time and is unresolved despite appropriate treatment. CNTP triggers a complex set of central nervous system responses and a decline in social function. Opioids have been used to treat moderate to severe pain when non-opioid analgesics have not been sufficient. Multiple factors have led to increased use and higher prescribing dosages of opioids to manage CNTP in primary care. Higher dosages of opioids are associated with higher risk of adverse events, including death. Nationally, between 1999 and 2011, opioid related deaths rose over 300%. In Arizona, 41% of drug mortality is attributed to opioids and in 2011, the state ranked fifth in the nation for opioid prescribing rates. Statewide, a multi-professional, multi-agency strategy has been initiated to address this problem. The impact evaluation of the prescribing initiative led by the Arizona Criminal Justice Commission has been positive but little information exists regarding prescribers' practice patterns, prescribers' knowledge of evidence based recommendations synthesized in the guidelines, or the barriers to safe opioid prescribing in Arizona. The Statewide Interprofessional Practice-Based Research Network (IP PBRN) identified chronic pain management as a top research priority during their planning conference in 2012. The purpose of this project was to create and formalize a survey, eliciting responses that describe current practice patterns and identify implementation barriers to evidence-based recommendations for prescribing and monitoring opioids for patients with CNTP in Arizona primary care settings.

The purpose of this dissertation is to explore potential barriers nurses experience in providing effective pain management for preterm and critically ill infants in neonatal intensive care units (NICUs). The specific aims of the study conducted are to examine (a) NICU caregivers’ knowledge about pain, (b) scales used to evaluate pain in infants, (c) NICU nurses’ documented pain practices, and (d) bias in treating pain of certain types of infants. This dissertation is comprised of three manuscripts. The first manuscript is an integrated review of the literature describing caregiver knowledge, barriers, and bias in the management of pain in neonates. The second manuscript is a systematic review of multidimensional pain scales developed for use in preterm and critically ill infants. The final manuscript reports a descriptive exploratory study designed to examine nurses’ knowledge of pain, knowledge of intensity and appropriate management of procedural pain, bias in treating pain of certain types of infants, and documented pain management practices. Over the past 25 years, caregiver knowledge of pain in preterm and critically ill infants has advanced from beliefs that neonates do not feel pain, to the knowledge that preterm infants experience more pain than term infants, older children, and adults. Nine multidimensional pain scales with varying levels of reliability and validity have been developed, yet a gold standard for pain assessment in preterm and critically ill neonates has not emerged. In this study, baccalaureate prepared nurses (BSN) and nurses with higher total years of nursing experience had better knowledge of pain in this population than associate degree nurses (ADN). However, pain management was inconsistent, resulting in pain that was untreated as often as 80% of the time. Nurses reported that physician practice was the primary obstacle to providing effective pain management. Additional concerns included knowledge deficits of nurses and physicians, lack of communication and teamwork, and rushed care. Nurses reported biases in managing pain and were less likely to invest time and energy treating the pain of infants experiencing neonatal abstinence syndrome.

Bakgrund: Inom den palliativa vården är patienter med cancersjukdom vanligt förekommande. Att ha en cancersjukdom kan generera smärta. Som vårdgivare är det viktigt att förstå att smärta är multidimensionell och en subjektiv upplevelse, för att ge en adekvat smärtlindring. Smärtlindring kan ske på olika sätt, dock är den farmakologiska lindringen med analgetika i fokus. Men vilka omvårdnadsåtgärder finns att tillgå? Syfte: Att beskriva smärtlindrande omvårdnadsåtgärder och dess inverkan på patienter med cancersjukdom i palliativ vård. Metod: Tio vårdvetenskapliga artiklar har använts i en litteraturöversikt för att besvara syftet. Artiklarna har granskats och analyserats. Resultat: I resultatet framkommer det att smärtlindrande omvårdnadsåtgärder i kombination med analgetika förespråkas av såväl sjuksköterska som patient. Massage och fysisk beröring var de mest förekommande omvårdnadsåtgärderna. Något som också genererade smärtlindring var sjuksköterskans närvaro, att denne tog sig tid för att skapa kontakt, och att sjuksköterskan besatt kunskap kring smärtlindrande omvårdnadsåtgärder. Betydelsen av omvårdnadsåtgärder vid smärtlindring belyses då de lindrar patientens smärta utifrån ett holistiskt synsätt. Den existentiella smärtan kunde reduceras, till skillnad från när endast analgetisk behandling användes. Diskussion: En diskussion har förts utifrån resultatet samt den teoretiska utgångspunkten De 6 s:n, som är en modell tillämpad i palliativ vård. Det centrala i De 6 s:n är patientens Självbild, som den palliativa vården bör formas utifrån. Betydelsen av en god kommunikation mellan patient och sjuksköterska diskuteras, samt vikten av att patienten får möjlighet till kontroll över sin situation. Kontroll kan uppnås genom smärtlindrande omvårdnad och därmed påverka patientens självbild positivt. För att smärtlindrande omvårdnadsåtgärder ska impliceras krävs kunskap och tid, något som både sjuksköterskan och organisationen har ansvar för. Ett gott samarbete inom vårdteamet krävs. / Background: Patients with cancer are common within palliative care. Having cancer can generate pain and to provide adequate pain relief it is important to understand that pain is both a multidimensional and a subjective experience. Pain management can be approached in different ways however the current focus is on pharmacological relief with analgesics. But what pain relieving care options are available? Aim: To describe pain relieving care options and their impact on patients with cancer in the palliative care. Methods: Ten nursing articles were studied in this literature review to answer the purpose. All the articles were reviewed and analyzed. Results: Pain relieving care in combination with analgesic treatment is advocated by both nurse and patient. Massage and physical contact were the most commonly used care option. Pain relief also resulted from nurses being present and nurses taking the time to make personal contact with patients. It was also seen to be significant for nurses to possess knowledge of pain relieving options. The importance of nursing care in pain relief is highlighted as they can offer a holistic approach to treating the patient's pain. Existential pain can also be reduced which analgesics alone cannot treat. Discussions: A discussion has been based on the results and the nursing model of care; The 6 S-words. The patient’s self-image is central in the 6 S-words, and something that the palliative care should be shaped around. The significance of good communication between patient and nurse is discussed, stressing the importance of the patient being in control of his or her situation. Control that is achieved by non-pharmacological therapies that can positively affect the patient´s self-image. Implementing pain relieving care requires knowledge and time meaning that it becomes the responsibility of both the nursing staff and the organization as a whole. Good cooperation within the care team is essential.

Socioemotional selectivity theory posits that as people age, they become motivated and successful at maximizing positive emotions and minimizing negative ones. Yet, 70% of older adults report physical pain, which is associated with negative affect. The strategies and resources that older adults use to maintain positive affect in the face of pain remain largely unknown. Specific positivity-enhancing strategies include recalling, recognizing, and responding to positive stimuli and prioritizing close over knowledgeable social partners. Executive functions (EF, i.e., task-switching, working memory, and inhibition) and heart rate variability (HRV) may be important resources for coping with pain. The current project used two studies to test whether older adults used positivityenhancing strategies and maintained emotional wellbeing following pain more than younger adults; associations with EF and HRV were also investigated. In Study 1, 50 older and 50 younger adults experienced a control and a pain condition, were given the chance to employ positivity-enhancing strategies, and provided EF and HRV data. Study 2 used longitudinal data from community-dwelling older adults (n =150) to test whether task-switching moderated the within-person relationship between pain and wellbeing. In Study 1, after the pain condition, younger adults demonstrated lesser preference toward knowledgeable social partners than older adults (γ = -0.15, p = .016). No other age group x pain condition x valence interactions were found. Older and younger adults did not differ in changes in positive or negative affect following pain. Task-switching and HRV were both associated with reduced preference for knowledgeable social partners following pain, but no other significant EF or HRV interactions were found. Study 2 failed to support the hypothesis that task-switching protected against pain-related declines in wellbeing. Future research on strategies that older adults use to maintain emotional wellbeing in the face of pain is needed.

Bakgrund: Smärta är en av de vanligaste orsakerna till varför patienter uppsöker vård. Akut smärta beskrivs som subjektiv och individuell vilket styrker nödvändigheten av ökad kunskap och förståelse för akut smärta och patienters olika upplevelser av den.  Detta skulle kunna generera i en bättre omvårdnad, där utvecklingen från akut smärta till en kronisk långvarig smärta samt ett lidande för patienten skulle kunna minimeras. Syfte: Syftet var att beskriva patienters upplevelse av akut smärta och vårdpersonalens betydelse i samband med den. Metod: En litteraturöversikt som baseras på 13 artiklar, sju kvalitativa och sex kvantitativa. Resultat: Fyra teman identifierades; "Vikten av adekvat smärtbehandling", "Vårdpersonalens kompetens inger trygghet", "Att underkasta sig vårdpersonalen" samt "Betydelsen av kommunikation och information". Konklusion: Akut smärta är fortfarande ett stort problem och alldeles för många patienter lider av akut smärta. Vårdpersonalen har stor betydelse för dessa patienters upplevelse då det kan lindra smärtan och förebygga onödigt lidande. För att förbättra vården för patienter med akut smärta behövs en ökad förståelse och kunskap för deras subjektiva upplevelser men även betydelsen av hur sjuksköterskan agerar, behandlar och utvärderar är viktig. / Background: Pain is one of the most common reasons why patients seek healthcare. Acute pain is described as subjective and individual, which proves the need for greater knowledge and understanding of the acute pain and the patient's different experiences of it. This could generate in a better care, where the development of acute pain to chronic prolonged pain and the suffering of the patient could be minimized. Aim: The aim was to describe the patients’ experience of acute pain and the significance of health care professionals associated with it. Method: A literature review based on 13 articles, seven qualitative and six quantitative.   Results: Four themes where identified; "The importance of adequate pain management",”To submit to the health care professionals”, “How the health care professionals’ competence incites a sense of safety” and ”The significance of communication and information”. Conclusion: Acute pain is still a major problem and too many patients suffers from it. The health care professionals have a great importance for these patients’ experience since they can ease the pain and prevent unnecessary suffering. To improve care for patients with acute pain, a greater understanding and knowledge of their subjective experiences is required but also the significance of how the nurse act, treats and evaluates should be of importance.

Symmetry in biological systems is the occurrence of an event on both sides of the system. The term bilateralism was introduced to represent this phenomenon, and it was defined as the conditional co-occurrence of two events given that at least at one of them has occurred. This phenomenon is highly associated with the prevalence of each of the events. Two parameters were developed to evaluate the presence of this phenomenon, testing whether events co-occur with higher probability than would be expected by chance. Nonparametric confidence intervals were constructed using the bootstrap percentile method. These non parametric confidence intervals were used in testing the null hypothesis of no bilateralism.A simulation study was performed to examine the properties of the two bilateralism parameters' estimates. The size and power of the tests of bilateralism were examined under a variety of sample sizes and prevalences of the two events. The simulation study showed that both parameter estimates have similar properties, and the tests have similar size and power. The power of the test was affected by the prevalence of either event, the differences in the prevalences, the sample size and by number of events that occur simultaneously. The methodology of testing for bilateralism was applied on data from the Pain in Sickle Cell Epidemiology Study (PiSCES). This study collected up to 6 months worth of daily diaries about pain and medical utilization from patients with sickle cell disease. Each diary recorded the body site and side where pain was experienced over the past 24 hours. The sample consists of 119 subjects who completed at least 50 daily pain diaries (reference). Information about the subjects age, gender and sickle cell genotype were also available. Nine body sites (5 upper peripheral, and 4 lower peripheral site) were analyzed to test for bilateralism. Bilateralism was tested for each subject and each site separately. The associations of prevalence of bilateralism on each site, and percentages of sites that hurt bilaterally with age, gender and genotype where studied.The results show a high prevalence of bilateral pain among sickle cell patients at all sites. Age gender and genotype were associated with higher prevalence in bilateral pain in some, but not all sites. The percentage of sites that have bilateral pain is also associated with the number of sites that have pain.