International Emergency Nursing 22 (2014) 172–176
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International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen
Contemporary Issues
The use of action learning as a strategy for improving pain management in the Emergency Department Gabrielle Dunne MSc, FFNMRCSI, RGN, RANP, (Emergency Nurse Practitioner) a, Rachel Jooste MB ChB Pret., (Registrar Emergency Department) a, Catherine McCabe PhD, MSc, BNS, RNT, RGN, (Assistant Professor) b,⇑, Geraldine McMahon PhD, FRCSEd, FRCPI, FCEM, BSc, (Consultant Emergency Medicine) a a b
St. James’s Hospital, James’ Street, Dublin 8, Ireland School of Nursing & Midwifery, Trinity College Dublin, 24 D’Olier Street, Dublin 2, Ireland
Introduction This paper discusses the use of action learning to improve the management of moderate pain in the Emergency Department (ED) of a large adult hospital. It addresses two specific issues. The first is the failure to treat pain promptly in EDs and the second is the introduction of action learning sets as a means of using an interdisciplinary approach to improving the time to treatment for patients with moderate pain.
Background The problems in relation to either the absence of (Stalinikowicz et al., 2005), ineffective (Muntlin et al., 2006), or delayed (Arendts and Fry, 2006) analgesia for patients attending the Emergency Department (ED) are clearly outlined in the literature. Reasons for this include overcrowding, age bias, type of trauma, inadequate knowledge and training in acute pain management, opiophobia, and the ED culture (Hwang et al., 2008; Todd et al., 2007; Wilsey et al., 2008; Motov and Khan, 2009; Mills et al., 2009). This issue is problematic particularly as acute pain is cited as the most frequent cause of people presenting to the ED (Johnson, 2005; Mills et al., 2009). There is clear evidence that the response by health care professionals to the management of acute pain in the ED is sub optimal which means that many patients remain in a distressed condition and dissatisfied with care (Motov and Khan, 2009; Mills et al., 2009). This is somewhat surprising given the extensive education that health care professionals receive in relation to the management of pain and also the specific pain management policies that provide further guidance in clinical practice. However, there is a great deal of evidence that demonstrate large gaps between the knowledge that health care professionals have about what is best practice and how they implement that knowledge into practice (Davis ⇑ Corresponding author. Tel.: +353 1 896 3019. E-mail address:
[email protected] (C. McCabe),
[email protected] (G. Dunne). 1755-599X/$ - see front matter http://dx.doi.org/10.1016/j.ienj.2013.10.005
et al., 2003). This explains why effective management of pain in the ED has remained problematic over the years in spite of initiatives such as educational interventions and departmental pain management protocols (Johnson, 2005; Todd et al., 2007). Strategies for implementing successful and sustainable changes in practice within and between health care professions in relation to the provision of effective pain relief needs to take this into account and also consider local environmental and service pressures such as short staffing, and overcrowding. The College of Emergency Medicine (CEM, 2010) provide guidelines for the appropriate management of pain in the ED which recommend that 98% of patients with severe pain (7–10 on pain scale) should receive or be offered analgesia within 60 min of arrival. Ninety per cent of patients with moderate pain (4–6 on pain scale) should receive or be offered analgesia within 60minutes of arrival. Pain is assessed at triage and is one of the six general discriminators of Manchester triage system (MTS), the national standard used in Ireland (Mackway-Jones et al., 2006). The CEM also recommend an annual audit of practice in relation to pain management.
Action learning Action learning is described as ‘‘a dynamic process that involves a small group or ‘set’ of people solving real problems. . .’’ (Schwandt and Marquardt, 2000, p. 58) Action learning is used to solve complex problems and to significantly increase the quality of the team/ organisational learning (Soffe et al., 2011). In this project action learning facilitated a reflective and critical assessment of practice related to pain management by focusing on the collective experience of the relevant ED staff (Soffe et al., 2011). The reason for establishing the action learning set in this case was because, through the audit process, nursing and medical staff became aware of deficiencies in practice concerning moderate pain management, treatment of severe and mild pain were not problematic in this audit. The ED staff did not believe that a system existed within the ED for addressing problems with practice identified by audits. A structured sustainable approach to improving this fundamental aspect of service to patients was required.
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Fig. 1. St. James’s Hospital (SJH) ED pain management guidelines.
The staff felt that an interdisciplinary approach was essential and following discussion with an academic from the local University, agreed that action learning sets were an ideal way of bringing about real and sustained positive changes in practice. Action learning sets are traditionally associated with non health care settings such as industry but it is becoming increasingly common in health care as a means of achieving collaborative and consistent practice
development (Bell et al., 2007). Action learning sets are informal meetings held at regular intervals until the desired outcome is achieved. With the guidance of a facilitator who can be external to the process or a member of staff, education, reflection and questioning, participants are supported towards taking specific actions to bring about the desired change and its subsequent evaluation (Smith and O’Neill, 2003).
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First audit and results As part of a quality initiative in our Emergency Department (ED) a detailed analysis of pain management for adult patients presenting with pain was undertaken. This review of pain management was in line with the Clinical Effectiveness Committee of the CEM Best Practice Guidelines for Pain Management of Adults (CEM, 2010). As recommended by the CEM (2010) an audit over a 24 h period of 137 patients presenting to the ED with pain was undertaken in a large teaching hospital in the Republic of Ireland using the Manchester triage pain assessment tool. Twenty-five per cent (n = 34) of those audited reported moderate pain caused mainly by musculoskeletal injury. Practice was measured against the clinical standards for pain management produced by the CEM (2010) (Fig. 1). Of these, 25% (34) reported moderate pain levels. Management of pain in the moderate pain group was poor; no patients had analgesia administered within 30 min and only 9% (3) received analgesia within 60 min (Fig. 2). Action learning sets were considered by the senior staff (Advanced Nurse Practitioner and ED Registrar) to be potentially the most effective way of bringing about immediate and sustainable improvements in practice related to pain management. An action learning group or ‘set’ was formed to include 7 key stakeholders including an advanced nurse practitioner (emergency), clinical nurse manager, ED consultant, ED registrar and 2 staff nurses. People joined the group voluntarily because they were interested in its purpose and they were representative of the disciplinary mix required. Junior Doctors were excluded because they only spent six months in the ED. It was facilitated by the Advanced Nurse Practitioner who received instruction from an academic with knowledge and experience in using action learning. This centred on the use of facilitation/communication skills to achieve the predetermined objectives for the inaugural learning set which were; review of the audit results, review of the ED’s pain management protocol
which is based on CEM (2010) guidelines, and identify specific actions to improve and, evaluate practice around pain management. The outcomes and planned actions of this learning set were as follows: Agreement to review/revise the general department pain guideline based on the CEM (2010) guidelines and to include a Paracetamol administration protocol for triage nurses. Place secure, clearly visible, laminated information cards at triage stations. Place the revised protocol on the desktop of all computers in the department and in a clearly marked folder on the intranet. Provide multi-disciplinary education programme to all nurses and doctors on the revised ED pain management guideline/protocol. This included information on the outcome of the audit, CEM clinical standards for moderate pain, pain assessment, pain management (pharmacological and non pharmacological) and evaluation. Re-audit 3 months later. Due to the nature of working in such an unpredictable environment and staffing issues, ensuring that all staff participated in the education programme required flexibility. Education sessions were delivered. by one of the senior members (Advanced Nurse practitioner and ED registrar) of the action learning set over a one month period and consisted of powerpoint slides delivered using a laptop which provided mobility and flexibility to the sessions. They took place either in the seminar room if availability and staffing permitted or in smaller groups at the nurses’ station or treatment area depending on the space and time available. Two or three sessions were held each day and allowing time for questions and discussion, each session lasted approximately thirty minutes. One hundred percent of the ED medical staff and 85% of nursing staff received the education programme. Maternity and sick leave were reasons why all nursing staff did not received the education programme prior to the re-audit. A second action learning set took place 4 weeks later. It was attended by the ED consultant, registrar and advanced nurse practitioner and its purpose was to discuss if the implementation of the agreed actions was successful and also address any additional concerns that may have arisen during the education sessions in relation to factors that influence how staff manage moderate levels of pain or issues they may have had in relation to the revised protocol.
Second audit and results
Fig. 2. Pain audit results compared with CEM Guidelines (2010).
Table 1 Chi-square tests. Pearson chi-square Likelihood ratio Linear-by-linear association N of valid cases
27.023 27.493 1.465 123
2 2 1
.000 .000 .226
Three months after introduction of these changes, a second audit over a 24 h period was undertaken of a further 258 patients with a specific focus on the management of moderate pain. On this occasion, thirty-four percent (n = 89) reported having moderate pain. In contrast to the first audit, 27% (n = 24) of patients reporting moderate pain received analgesia within 30minutes and 52% (n = 46) received analgesia within 60 min. This demonstrated a substantial improvement with 27% more patients with moderate pain receiving analgesia within 30 min and 43% more patients within 60 min between the first audit and the 2nd. A chi-square test for independence (with Yates Continuity Correction) indicated a significance level of .000 in terms of improvements between the first and second audit (Table 1). Although the audit results are very welcome, there is still a great deal more room for improvement. In order to address this, a further action learning set took place to review the results of the audit where it was agreed that the education sessions would continue and staff would be reminded regularly by senior staff to familiarise
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themselves with the revised pain management protocol at the triage stations and on the desktop of each computer located in the ED. It was also agreed that a 3rd audit would take place 3 months later and this would continue until 90% of patients (CEM standard) that reported moderate pain received analgesia within 60 min.
Discussion Pain management is an important quality indicator for Emergency Medicine. Using action learning methodology we achieved an improvement in the management of pain in our ED. One of the key changes that contributed to this improvement was the introduction of a pain management protocol and nurse administration of Paracetamol at triage. Possible reasons for this include increased awareness of the need for pain assessment, intervention and evaluation and the protocol which clearly outlined the perameters in which nurses could and should administer paracetamol. Although few international studies exist that examine the effect of interventions to bring about change in pain management, those available indicate that the introduction of protocols or educational interventions which appear to be the primary means of attempting to improve pain management, do not have a significant effect on the management of pain in the ED (Singer et al., 2003; DuCharme, 2005; Todd et al., 2007). In this case, the use of action learning sets may have resulted in staff feeling more directly involved in the initiative, therefore, were more confident in using the protocol. However, it is clear that further improvements are required. Auditing of practice in relation to the management of pain is an important quality initiative and should be undertaken as part of a continuous quality improvement initiative with analysis of variances, appropriate modifications of systems that contribute to poor performance and regular feedback to all members of the multidisciplinary team. The use of action learning as a framework to address the issues identified by the audit demonstrates its pragmatic nature in that it identifies realistic ways of what works in practice and what can be done to improve the management of pain in the ED in a way that is sustainable. Trehan and Pedler (2011) describe action learning as also having a ‘moral’ philosophy because it stimulates an individual and collective goal of making a positive difference to working practice and providing a better service for users. This was very evident in the process and outcome of this project. This was a very positive outcome in relation to the inconsistent and poor management of moderate pain in the ED. The interdisciplinary approach appeared to provide a cohesive and collaborative approach to addressing the problem. Use of action learning sets proved to be an effective way of bringing about positive change by supporting and facilitating collaboration between the health care disciplines and also as a realistic method for sustaining such changes. Reflecting on practice and exchanging ideas in relation to a particular practice issue such as pain management appears to increase staff ‘buy in’ and promote a critical thinking approach to practice development as evidenced in the literature (Lamont et al., 2010). Participants in the action learning sets, particularly senior staff, valued the flexible, informal and inclusive nature of this process. The collaborative and interdisciplinary approach to this initiative was successful both in terms of a management/professional strategy for improving the management of moderate pain but also minimised obstruction or failure of ‘buy in’ from staff. The ED continues to use this method of practice development and change management to improve services to patients. Although the experience of action learning sets was successful and reported as a positive and inclusive way to introduce change
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in practice in this particular case, it should be noted that, without a ‘champion’ for effective change and the appropriate knowledge and training, action learning sets could fail like other initiatives described in the literature (Singer et al., 2003; DuCharme, 2005; Todd et al., 2007). It should also be noted that this paper reports a practice development initiative that is new and innovative and over time, the enthusiasm for engagement with the process may diminish. However, success and positive outcomes for patients will provide further support, motivation and encouragement for continued commitment in the use of action learning.
Conclusion This paper has outlined how action learning sets can be used effectively to improve the management of moderate pain in the ED in a cost effective and efficient manner because it does not require staff to leave the treatment area, is delivered by staff and its flexible, informal approach means that it becomes an integral part of the daily work rather than being perceived as ‘extra learning’ or an additional burden. This process provides a framework that facilitates engagement by encouraging and supporting staff to reflect, critique their own practice and learn new ways of practice. The ED is probably one of the most challenging environments in health care but the authors suggest that action learning sets provide a feasible, flexible, economical and sustainable process by which to effect change. References Arendts, G., Fry, M., 2006. Factors associated with delay to opiate analgesia in emergency departments. The Journal of Pain 7 (9), 682–686. Bell, M., Coen, E., Coyne-Nevin, A., Egenton, R., Ellis, A., Moran, L., 2007. Experiences of an action learning set. Practice Development in Health Care 4, 232–241. College of Emergency Medicine, 2010. Clinical Standards Guidelines: Guidelines for the Management of Pain in Adults. CEM4681-CEC – Guideline for the Management of Pain in Adults – June 2010 (accessed 04.01.13). Davis, D., Evans, M., Jadad, A., Perrier, L., Rath, D., Ryan, D., Sibbald, Straus, S., Rappolt, S., Wowk, M., Zwarenstein, M., 2003. Learning in practice, the case for knowledge translation: shortening the journey from evidence to effect. British Medical Journal, 33–35. http://www.collemergencymed.ac.uk/Shop-Floor/ Clinical%20Guidelines/ Accessed 4th January 2013. DuCharme, J., 2005. Clinical guidelines and policies: can they improve emergency department pain management? Journal of Law, Medicine & Ethics 33 (4), 783– 790. Hwang, U., Richardson, L., Tolulope, O., Sonuyi, B.S., Morrison, S., 2008. The effect of emergency department crowding on the management of pain in older adults with hip fracture. Journal of the American Geriatric Society 54, 270–275. Johnson, S., 2005. The social, professional, and legal framework for the problem of pain management in emergency medicine. The Journal of Law, Medicine & Ethics 33 (4), 741–760. Lamont, S., Brunero, S., Russell, R., 2010. An exploratory evaluation of an action learning set within a mental health service. Nurse Education in Practice, 298– 302. Mackway-Jones, K., Marsden, J., Windle, J., 2006. Emergency Triage: Manchester Triage Group, second ed. Blackwell Publishing Ltd. Mills, A., Shofer, F., Chen, E., Hollander, J., Pines, J., 2009. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Academic Emergency Medicine 16 (7), 603–608. Motov, S.M., Khan, A., 2009. Problems and barriers of pain management in the emergency department: are we ever going to get better? Journal of Pain Research 2, 5–11. Muntlin, A., Gunningberg, L., Carlsson, M., 2006. Patients’ perceptions of quality of care at an emergency department and identification of areas for quality improvement. Journal of Clinical Nursing 15, 1045–1056. Schwandt, D.R., Marquardt, M.J., 2000. Organizational Learning: From World-Class Theories to Global Best Practices. St. Lucie Press, Boca Raton, FL. Singer, A.J., Chisum, E., Stark, M.J., 2003. An educational intervention to reduce oligoanalgesia in the emergency department. Annals of Emergency Medicine 42 (4), 41–45. Smith, P., O’Neill, J., 2003. A review of action learning literature 1994–2000: Part 1 – bibliography and comments. Journal of Workplace Learning 15 (2), 63–69. Soffe, S.M., Marquardt, M.J., Hale, E., 2011. Action learning and critical thinking: a synthesis of two models. Action Leaning: Research and Practice 8 (3), 211–230. Stalinikowicz, R., Mahamid, R., Kaspi, S., Brezis, M., 2005. Undertreatment of acute pain in the emergency department: a challenge. International Journal for Quality in Health Care 17 (2), 173–176.
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