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An Exploratory Study of Patient Preferences for Pain Management During Intravenous Insertion: Maybe We Should Sweat the Small Stuff
An Exploratory Study of Patient Preferences for Pain Management During Intravenous Insertion: Maybe We Should Sweat the Small Stuff Francesca C. Levitt, MSN, RN-BC, ACNS-BC, Mary Ziemba-Davis The purpose of this exploratory study was to add to the body of knowledge about patient preferences for pain management during intravenous (IV) insertion. A convenience sample of 30 patients who were scheduled to undergo surgical or nonsurgical procedures requiring an IV catheter were given a choice among intradermal lidocaine, guided imagery, or no pain control strategy. Only four participants chose no pain management strategy, the traditional standard of care. Most (86.6%) desired a pain control strategy. Mean pain ratings on IV insertion were very low for all the three groups, although pain was significantly lower in the intradermal lidocaine group. This study illustrates that patients have preferences for pain control during IV insertion and believe that they should be involved in decisions about pain management. Keywords: intravenous catheter insertion, intradermal lidocaine, guided imagery, patient preferences, pain management. Ó 2013 by American Society of PeriAnesthesia Nurses
PATIENTS REQUIRING INTRAVENOUS (IV) access are faced with the necessity of an invasive and uncomfortable procedure known as IV cannulation. Peripheral IV catheter insertion is one of the most frequent, painful, stressful, and dissatisfying invasive procedures performed on hospitalized patients.1-4 Approximately 25 million people in the United States and 90% of all hospitalized patients require IV catheter insertion.5,6 Moreover, although current guidelines are under scrutiny, most hospitals require that patients undergo an IV Francesca C. Levitt, MSN, RN-BC, ACNS-BC, is a Perioperative Clinical Nurse Specialist, St. Vincent Hospital Indianapolis, Indianapolis, IN; and Mary Ziemba-Davis is a Neuroscience Research Director, St. Vincent Hospital Indianapolis, Indianapolis, IN. Conflict of interest: None to report. Investigation was performed at St. Vincent Hospital Indianapolis, Indianapolis, IN, USA. Address correspondence to Francesca C. Levitt, St. Vincent Hospital Indianapolis, 2001 West 86th Street, Indianapolis, IN 46260; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.11.008
Journal of PeriAnesthesia Nursing, Vol 28, No 4 (August), 2013: pp 223-232
site change every 72 to 96 hours to control infection and IV site complications.7 The Joint Commission standards8 endorsed by the American Pain Society9 require health care providers to assess and manage pain. The standard of care for managing pain associated with invasive procedures is to anticipate and ameliorate pain to the greatest degree possible.10,11 Pain management is a crucial component of good care and positively impacts patients psychologically and physiologically.12 Aiello et al13 found that nearly half of the variance in patient satisfaction with nursing care was attributable to patient-provider interactions. Wolosin14 demonstrated that patients want to: (1) have their personal circumstances and special needs taken into consideration while they are receiving care, (2) receive information about their care, and (3) have a say about treatment decisions. A qualitative study established patient interest in involvement in health care, ranging from basic needs for information to sharing or
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controlling health care decisions.15 Patients who desire to be involved in health care decisions want to be given options for participation.15 The American Nurses Association’s (ANA) Scope and Standard of Practice16 emphasize that nurses should collaborate with patients in their plan of care, treatment goals, and decisions related to the services rendered. The ANA’s Code of Ethics for Nurses with Interpretive Statements17 defines collaboration as providing necessary information for informed decision making. Involving patients in decisions about their care through deliberate and systematic sharing of evidence-based knowledge may give them a sense of control in an otherwise process-driven setting. Due in large part to advocacy efforts, patient involvement in decisions related to major health care issues such as cancer care and joint replacement has become more common. However, other care processes, from IV insertions to bath times, are still largely driven by providers who implicitly control day-to-day provisions of care.
Purpose The scarcity of evidence on patient preferences regarding pain management during IV insertion and patient desire for more information and involvement in pain management decisions15 led to this study. The purpose of our exploratory study was to add to the body of knowledge about patient preferences for pain management during IV insertion. Specific aims were to elucidate (1) patient desire to be involved in decisions about pain management, (2) whether patients have a preference for different pain management strategies, (3) patient satisfaction with the pain management choice, and (4) pain ratings and satisfaction with IV insertion. Intradermal lidocaine was offered as a pharmacologic pain management option because it is a proven anesthetic that decreases sensory perception of pain.18-21 Guided imagery was offered as a nonpharmacologic pain management strategy because it is well accepted by patients and has been shown to decrease preoperative pain and anxiety.22,23 Guided imagery has been shown to reduce stress, anxiety, and pain through relaxation, concentration, and body awareness. A calming voice combined with easy-listening
music guides the patient through an exercise, which may stimulate the release of endorphins and modify the perception of pain through distraction.24 Pain reduction is not predictable when using nonpharmacologic methods such as guided imagery; however, these techniques may make pain more bearable, improve mood, decrease distress, and give the patient a sense of control.8 No pain management strategy before IV insertion was offered as a third option consistent with traditional standards of care.
Materials and Methods Participants This study of hospital patients about to undergo surgical or nonsurgical procedures requiring an IV catheter was approved by an Institutional Review Board before data collection. The study was conducted at an 800-bed quaternary care referral hospital located in the Midwestern United States. Patients consecutively admitted to private procedural preparation rooms were greeted by the researcher (F.C.L.) and asked if they would be interested in participating in a research study on patient satisfaction with IV insertions. The researcher was not simultaneously working as nursing admission staff. Because this was an exploratory study, recruitment was capped at 30 volunteer participants. Participants were informed that they would choose among three different options for managing pain on IV insertion (intradermal lidocaine, guided imagery, or no pain management strategy) and answer some questions before and after IV insertion. Interested participants were screened to ensure that they were aged 18 years or older, could read and speak English, were able to provide informed consent, and could verbally rate pain and satisfaction on IV insertion. Pregnant patients, those who indicated a history of difficult IV insertions, those allergic to lidocaine, and those who took or received pain medications within 6 hours of hospital admission were excluded. Measures DEMOGRAPHICS. Participant sex, annual household income, highest grade completed in school,
PREFERENCES FOR PAIN MANAGEMENT DURING IV INSERTION
year of birth, relationship status, and race/ethnicity demographics were collected. Participants were asked if they ever had an IV (yes or no), whether they were afraid of needles (yes, no, or it depends followed by explanation), and pain tolerance (defined as the capacity to endure pain) on a numeric rating scale ranging from 0 (no tolerance for pain) to 10 (extremely high pain tolerance). Participants’ satisfaction with their pain management choice was measured using O’Connor’s25 decisional conflict scale (DCS) modified with permission. The unmodified 16-item DCS has demonstrated good reliability with test-retest coefficients exceeding 0.80 and internal consistency coefficients ranging from 0.78 to 0.89 in diverse test samples.26 Items included: I felt I made an informed choice (yes or no) The choice was easy for me to make (yes or no) I was aware of the options I had in this choice (yes or no) I felt I knew the advantages (pros) of using lidocaine (yes or no) I felt I knew the disadvantages (cons) of using lidocaine (yes or no) I felt I knew the advantages (pros) of using guided imagery (yes or no) I felt I knew the disadvantages (cons) of using guided imagery (yes or no) I had enough information about my options (yes or no) Perception of pain on IV insertion was measured on a numeric rating scale anchored by 0 (no pain at all) and 10 (worst pain ever experienced). Agreement with the statement ‘‘I think the nurse who inserted my IV was very concerned about my comfort during the procedure’’ was rated on a five-point Likert scale (strongly disagree, disagree, neutral, agree, or strongly agree). Three-point Likert scales were used to measure participant satisfaction with IV insertion (not at all satisfied, fairly satisfied, or very satisfied) and comparison of this IV insertion to past IV insertions (better, worse, or about the same). Whether or not participants expected to make the same decision the next time they need an IV (yes or no followed by why or why not) also was measured.
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Four-point Likert scales (not at all important, somewhat important, very important, or extremely important) were used to measure participant views on the importance of (1) being offered different options to manage pain on IV insertion and (2) involving patients in the decision about how to manage pain on IV insertion. Opinions on who should decide how to manage pain during IV insertion—the clinician starting the IV, the patient, or the clinician and patient together—also were assessed. Procedure On completion of the informed consent process, demographic and past IV experience questions were asked of participants, followed by presentation of the three options for pain management before IV insertion—intradermal lidocaine, guided imagery, or no pain management strategy. Decision aids (informational materials on lidocaine and guided imagery; see Tables 1 and 2) were provided because they have been shown to increase patient knowledge of medical issues and satisfaction with decision making.27-30 Lidocaine was defined as a traditional anesthetic or ‘‘numbing agent’’ used to dull pain associated with IV insertion. Guided imagery was defined as a relaxation technique, which uses a directed daydream to provide a feeling of temporary escape, detachment, sleepiness, and/or relaxation. Participants were informed that the guided imagery audiotape used for this study contained easy listening music in the background and the voice of a person guiding them through a daydream. The advantages and disadvantages of lidocaine and guided imagery were presented to participants (Tables 1 and 2). Face validity of written information about lidocaine and guided imagery, respectively, was verified by three anesthesiologists and the creator of the guided imagery audio tape. After learning about pain management options, participants changed into a hospital gown and were prepped for their procedure in the customary fashion. Before IV insertion, participants chose either lidocaine, guided imagery, or no pain management strategy. Registered nurses with 10 or more years of experience and trained in the
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Table 1. Information for Patients—Lidocaine Advantages of Lidocaine May decrease or eliminate the pain of IV insertion Blocks the pain impulse to the brain Has been safely used for years Recommended by anesthesiologists Takes 30-60 seconds to work
Disadvantages of Lidocaine Requires extra stick with small needle Briefly feels like a pinprick or bee sting or burn Extremely rare allergic reactions May make vein harder to see Adds about 1 minute to insertion process
IV, intravenous.
intradermal lidocaine technique started the IVs. The study investigator was not present at the time of IV insertion. PROCEDURE FOR INTRADERMAL LIDOCAINE. After ascertaining no allergy to lidocaine, washing hands, and donning clean gloves, 0.2-mL lidocaine without epinephrine (1%) was drawn into a tuberculin syringe from a dated multidose (30 mL) vial after cleansing the stopper with an alcohol pad. The 25-gauge needle was replaced with a 30-gauge needle expressing any air. A tourniquet was applied to the participant’s arm and the venipuncture site was selected. After topical cleansing of the IV insertion site with chlorhexidine and adequate time to allow the solution to dry, a small wheal (0.05 mL) of 1% lidocaine was injected intradermally (bevel up 1/4 to 1/3 cm) into the skin lateral to the vein. Allowing 30 seconds for full effect, the vein was stabilized, and a 20-gauge safety catheter was inserted directly into the vein through the skin wheal. After confirming proper catheter placement via blood return, 1 L of lactated ringers solution (or prescribed fluid) was connected to the catheter at a keep-open rate. The IV was secured with a transparent dressing, taped to the extremity, and documented in the medical record.
PROCEDURE FOR GUIDED IMAGERY. The guided imagery audiotape was started by the study investigator 2 minutes before IV insertion. Hand-held audio players with auto-reverse, new batteries, and headphones were used. Audio players were sanitized with a soft cloth and phenolic cleanser and placed in clear plastic bags before each use. Headphones were placed over the surgical caps covering participants’ ears to prevent the transmission of organisms. Volume was adjusted according to participant comfort. Venous cannulation without lidocaine was performed by a registered nurse as described previously. PROCEDURE FOR NO PAIN MANAGEMENT STRATEGY. No additional information was provided to participants who selected the no pain management option. Venous cannulation without lidocaine or guided imagery was performed by a registered nurse as described previously. All catheters were successfully inserted on the first attempt. Within 1 minute after IV insertion and securement, the study investigator returned to collect and record the remaining measures: (1) satisfaction with pain management choice, (2) pain perception and satisfaction with IV insertion, and (3) patient involvement in pain management decisions.
Table 2. Information for Patients—Guided Imagery Advantages of Guided Imagery Easy to use Helps to relax you Takes no additional time May decrease pain during IV insertion IV, intravenous.
Disadvantages of Guided Imagery Helps some people, not all May make you feel sleepy or disconnected May not be useful for hearing impaired persons Headphones may be uncomfortable
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Data Analysis
likelihood of type II error (assuming no difference when a real difference exists).
Study data were entered into a Microsoft Office Excel 2007 (Redmond, WA) spreadsheet and imported into Minitab 16 (State College, PA) for analysis. Data analysis was partitioned into four topical areas: (1) sample demographics, (2) satisfaction with pain management choice, (3) pain perception and satisfaction with IV insertion, and (4) patient involvement in pain management decisions. Descriptive statistics (frequencies and means), the Z-test, and Pearson’s c2 (categorical variables), and analysis of variance (continuous variables) were used to compare differences in outcomes based on pain management choice. There were no missing data. Alpha was set at 0.05 to protect against type I error (assuming a difference when one doesn’t really exist). Post hoc power analyses were conducted to address the
Table 3. Sample Demographics Characteristics Sex Female Male Race Black/African American White/Caucasian Mixed/inter-racial Education Less than high school diploma High school diploma Some technical school or college Technical school or college degree Graduate degree Relationship status Married/partnered Not married/partnered Income ($) 5,000-20,000 20,000-35,000 35,000-50,000 50,000-100,000 .100,000
N
%
19 11
63.3 36.7
1 28 1
3.3 93.3 3.3
3 14 8 3 2
10.0 46.7 26.7 10.0 6.7
18 12
60.0 40.0
7 2 6 13 1
23.3 6.7 20.0 43.3 6.7
Mean Age (y) Income (US$)*
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Findings Demographics, Past IV Experience, and Pain Management Choice A total of 30 of the 31 patients approached for participation agreed to take part in the study. The patient who declined participation noted that he was feeling too ill and ‘‘just wanted to get his surgery over with.’’ A total of 13 (43.3%) of the 30 participants chose intradermal lidocaine for pain management, 13 (43.3%) chose guided imagery, and 4 (13.4%) elected to forego a pain management strategy before IV insertion. With the exception of average annual income, personal characteristics did not differ among participants who chose lidocaine, guided imagery, or nothing to manage pain on IV insertion (Table 3). Participants who chose no pain management strategy before IV insertion (mean: $58,750; standard deviation [SD]: $27,724) reported the highest annual income, followed by participants who chose lidocaine (mean: $46,923; SD: $21,020) and those who chose guided imagery (mean: $30,962; SD: $16,942; F 5 3.68, P 5 .038). All participants had previously experienced IV insertion. A total of 31% (4/13) of lidocaine participants, 23% (3/13) of guided imagery participants, and none of the no strategy participants reported a fear of needles. None of the no strategy participants compared to 30.0% (Z 5 1.97, P 5 .048) of the guided imagery and 30.8% (Z 5 2.40, P 5 .016) of the lidocaine group reported a fear of needles. Fear of needles did not differ among lidocaine and guided imagery participants (Z 5 0.440, P 5 .657). Mean pain tolerance on a scale ranging from 0 5 no tolerance for pain to 10 5 extremely high pain tolerance did not differ among the three groups (lidocaine: 6.4, SD: 2.4 vs guided imagery: 6.4, SD: 2.3 vs no strategy: 7.5, SD: 1.0; F 5 0.44, P 5 .650).
SD
57.2 17.2 41,583 22,025
SD, standard deviation. *The midpoint of each income range was used to calculate average income.
Satisfaction With Pain Management Choice All (100%) lidocaine, guided imagery, and no pain management strategy participants (1) felt that they made an informed pain management choice and (2) that the choice was easy to
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make. All participants also felt they (1) were aware of their pain management options, (2) knew the advantages and disadvantages of both lidocaine and guided imagery, and (3) had enough information about their options before making their choice. Pain Perception and Satisfaction With IV Insertion As shown in Table 4, mean ratings of pain on IV insertion using a 0 to 10 point scale were low for all the three groups (lidocaine: 0.46, SD: 1.55; guided imagery: 2.69, SD: 1.55; no strategy: 2.75, SD: 0.50), although pain was significantly higher among guided imagery and no strategy participants than lidocaine participants (F 5 11.20, P 5 .000). Participants in all three groups equivalently agreed/strongly agreed that the nurse starting their IVs was concerned about their comfort. All (13/13) lidocaine participants compared with 77% (10/13) of guided imagery and 75% (3/4) of no strategy participants were ‘‘very satisfied’’ with their IV insertion. No participants in any group reported being unsatisfied (ie, not at all satisfied). A total of 85% (11/13) of lidocaine, 62% (8/ 13) of guided imagery, and 50% (2/4) of no pain control strategy participants reported that the current IV insertion was better than past IV insertions. No (0/13) lidocaine, 15% (2/13) of guided imagery, and 25% (1/4) of no pain control strategy participants reported that it was worse. All lidocaine
(13/13), 77% (10/13) of guided imagery, and 50% (2/4) of no pain control strategy participants expected to make the same pain management choice in the future. Importance of Patient Involvement in Pain Management Decisions One-hundred percent of the participants who chose lidocaine or no strategy for controlling pain on IV insertion, and 92.3% of the participants who chose guided imagery, liked being involved in the decision about IV pain management (Table 5). On average, lidocaine, guided imagery, and no pain control strategy participants equivalently agreed that being offered options for IV pain management was somewhat to very important (F 5 0.30, P 5 .720; Table 5). Participants in all three groups equivalently reported that involving patients in pain management decisions on IV insertion is, on average, very important (F 5 0.16, P 5 .856; Table 5). Approximately 70% to 100% of participants in the three study groups felt that pain management decisions should be made by patients and clinicians together, not clinicians or patients alone.
Discussion The primary purpose of this exploratory inquiry was to add to the body of knowledge about patient preferences for pain management during IV
Table 4. Pain Perception and Satisfaction With IV Insertion Parameters
Lidocaine
Guided Imagery
Pain on IV insertion, mean (SD)* 0.46 (1.13) 2.69 (1.55) Nurse was concerned about my comfort, 4.62 (1.12) 4.46 (0.66) mean (SD)y Satisfaction with IV insertion, % Not at all satisfied 0.0 0.0 Fairly satisfied 0.0 23.1 Very satisfied 100.0 76.9 Comparison to past IV insertions, % Better 0.0 0.0 Worse 0.0 15.4 About the same 15.4 23.1 Expect to make same choice next time 5 yes, % 100.0 76.9
No Pain Control Strategy
Statistic
P Value
2.75 (0.50) 5.00 (0.00)
F 5 11.20 F 5 0.59
.000 .560
0.0 25.0 75.0
c2 5 28.78
.000
0.0 25.0 25.0 50.0
c2 5 12.49
.002
c2 5 67.96
.000
IV, intravenous; SD, standard deviation. *0 5 numeric rating scale ranging from 0 5 no pain at all to 10 5 worst pain ever experienced. y 1 5 strongly disagree, 2 5 disagree, 3 5 neutral, 4 5 agree, 5 5 strongly agree.
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Table 5. Importance of Patient Involvement in Pain Management Decisions Parameters
Lidocaine
Guided Imagery
Liked being involved in the decision about IV 100.0 92.3 pain management, % Importance of offering pain management 2.62 (1.12) 2.85 (0.69) options before IV insertion, mean (SD)* Importance of involving patients in pain 3.00 (0.91) 3.00 (0.58) management decision, mean (SD)* Who should make pain management decision, % Clinician only 23.1 0.0 Patient only 7.7 23.1 Patient and clinician together 69.2 76.9
No Pain Control Strategy
Statistic
P Value
100.0
c 5 0.41
.816
2.50 (1.00)
F 5 0.30
.720
2.75 (1.26)
F 5 0.16
.856
0.0 0.0 100.0
c2 5 79.41
.000
2
IV, intravenous; SD, standard deviation. *1 5 not at all important, 2 5 somewhat important, 3 5 very important, 4 5 extremely important.
insertion. Study participants were provided with information about three options before IV insertion and asked to choose an option consistent with their preference: (1) intradermal lidocaine, (2) guided imagery, or (3) no pain management, which is consistent with the traditional standards of care. The most important finding in this study is that only 4 of 30 (13.4%) participants chose the traditional standard of care, no pain management strategy, before IV insertion. When given a choice, most participants (n 5 26, 86.6%) desired a pain control strategy. Equal proportions chose intradermal lidocaine (n 5 13, 43.3%) and guided imagery (n 5 13, 43.3%). Regardless of pain management choice, study participants were demographically similar (with the exception of income), all had previous experience with IV insertion, and did not differ based on pain tolerance. Ninety-two to 100% of participants in all three study groups said that they liked being involved in the decision about ways to minimize pain before IV insertion. Participants in all three groups believed that being offered options to manage IV insertion pain is very or extremely important. When asked who should decide how to minimize pain associated with IV insertion, 70% to 100% of participants in the three study groups felt that pain management decisions should be made by patients and clinicians together, not clinicians or patients alone.
An additional observation from this study was that the mean pain ratings on IV insertion on a 0 to 10 point scale were very low for all three groups, although pain was significantly higher among guided imagery (2.69) and no strategy (2.75) participants compared with lidocaine (0.46) participants. Furthermore, most participants in all three groups were ‘‘very satisfied’’ with their IV insertion and agreed that the nurse starting the IV was concerned about their comfort. More than 75% of the participants who chose lidocaine or guided imagery expect to make the same pain management choice in the future, compared with only half of those who chose no pain control strategy. The lack of information on whether patients desire to be involved in pain management decisions during IV insertion was the catalyst for this study.15 A number of studies comparing the effectiveness of various techniques for managing IV insertion pain have been conducted,18-21,31-44 but very few studies have addressed the more fundamental questions of whether patients desire pain management for IV insertion and want to be included in pain management decisions. After participating in a study examining pain and anxiety on IV insertion, 70% of health care providers reported that they would always desire local anesthetic for IV insertion both for themselves and their patients.33 Nonetheless, there is strong resistance to change. Brown45 reported that only a third of registered nurses consistently offered patients intradermal lidocaine to reduce fear and pain associated with IV insertion
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despite a hospital policy requiring this practice. Nurses believed that it made catheter insertion more difficult; was unreasonable to stick patients twice; and, contrary to existing evidence, did not believe that IV insertion caused enough pain to warrant an anesthetic.45 Providing choices to help decrease pain during IV insertion is a demonstration of empathic and holistic care, which may decrease the sense of vulnerability and lack of control experienced by patients. Including patients in decisions about their care may enhance satisfaction and well-being in an often confusing, foreign, and frightening health care environment. Collaborative relationships are enhanced by soliciting patient input during all phases of care and have been associated with better clinical outcomes.46 Jacobson22 recommended that low-cost, easy-to-use interventions such as guided imagery and music be made available to patients even if they do not significantly decrease pain perception because they may improve patient satisfaction and emotional and spiritual well-being. Limitations of the Study The sample size for this exploratory study was small and replication with a larger, more diverse, stratified sample is recommended. Randomization to groups was not possible because participant choices about pain management strategies were a key study outcome. Post hoc analysis revealed that statistical power to avoid false negatives (assuming no difference when a real difference exists) was only 13.7% for choice of pain management strategy. However, we were not testing differences in the choice of a strategy but rather differences in outcomes such as pain scores once a choice was made. Statistical power for pain scores on IV insertion ranged from 95.6% (lidocaine vs guided imagery participants) to 99.6% (guided imagery vs no strategy participants).
Nonetheless, replication studies should include more participants to test our findings. Participants were not asked if they had had IV pain management strategies in the past, which would have helped identify whether past choices influenced current choices. Finally, the amount of time available for listening to the guided imagery recording in a fast-paced preoperative unit may have been insufficient to achieve a state of relaxation necessary for the full effect to be achieved. Implications for Nursing Practice The approach to the patient undergoing a painful procedure such as an IV insertion should include a discussion about the available pain management options. The voice of the patient as measured on satisfaction surveys should be used to develop nursing interventions to ameliorate discomfort on IV insertion. Intradermal lidocaine injection21 and cognitive behavioral interventions are simple and inexpensive strategies that decrease pain and/or enhance patient satisfaction. Additional research is needed to identify why barriers to implementation of an evidence-based practice change exist and the interventions needed to overcome these obstacles.
Conclusion This study illustrates that patients have preferences for different pain management strategies during IV insertion and believe that they should be involved in decisions about pain management. Measurement of high-quality patient care may soon be defined in part by the provision of evidence-based information to patients and the opportunity for shared decision making. With the advent of computer accessible health care ratings to an increasingly sophisticated health care consumer, it is imperative that health care professionals embrace a patient-centered approach.
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PREFERENCES FOR PAIN MANAGEMENT DURING IV INSERTION 5. Gray BB. Changes fuel IV nursing specialty. Nurseweek. 1994;1:31. 6. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: A randomized controlled trial. Arch Intern Med. 1998;158:473-477. 7. O’Grady NP, Alexander M, Patchen Dellinger E, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recommendations Rep:1-26. 2002;51. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5110a1.htm. Accessed October 3, 2011. 8. Joint Commission on Accreditation of Healthcare Organizations, Joint Commission Accreditation Hospital. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2012. 9. American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain, 6th ed. Glenview, IL: American Pain Society; 2008. 10. McCaffery M, Pasero C. Pain Clinical Manual, 2nd ed. St. Louis, MO: Mosby, Inc.; 1999. 11. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, MO: Mosby Elsevier; 2011. 12. Moline BM. Pain management in the ambulatory surgical population. J Perianesth Nurs. 2001;16:388-398. 13. Aiello A, Garman A, Morris SB. Patient satisfaction with nursing care: A multilevel analysis. Qual Manag Health Care. 2003;12:187-190. 14. Wolosin RJ. Largest study of patient satisfaction ever conducted. Press Ganey Satisfaction Report. 2003;7. 15. Thompson AG. The meaning of patient involvement and participation in health care consultations: A taxonomy. Soc Sci Med. 2007;64:1297-1310. 16. American Nurses Association. Nursing: scope and standards of practice, 5th ed. Nursebooks.org; 2004. 17. American Nurses Association. Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing; 2001. 18. Beck RM, Zbierajewski FJ, Barber MK, Engoren M, Thomas R. A comparison of the pain perceived during intravenous catheter insertion after injection with various local anesthetics. AANA J. 2011;79:S58-S61. 19. Halm MA. Effects of local anesthetics on pain with intravenous catheter insertion. Am J Crit Care. 2008;17: 265-268. 20. Harris T, Cameron PA, Ugoni A. The use of precannulation local anesthetic and factors affecting pain perception in the emergency department setting. Emerg Med J. 2001;18:175-177. 21. Ales R, May D, Whitney L. A study comparing chloroprocaine with lidocaine for skin infiltration before intravenous catheter insertion. AANA J. 2007;75:255-258. 22. Jacobson AF. Cognitive-behavioral interventions for IV insertion. AORN J. 2006;84:1031-1048. 23. Tusek D, Church JM, Fazio VW. Guided imagery as a coping strategy for perioperative patients. AORN J. 1997;66: 644-649. 24. Tusek D. Guided imagery: A powerful tool to decrease length of stay, pain, anxiety, and narcotic consumption. J Invasive Cardiol. 1999;11:265-267.
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25. O’Connor AM. Validation of a decisional conflict scale. Med Decis Making. 1995;15:25-30. 26. O’Connor AM. Decisional conflict scale, 2nd ed. Ottawa, Canada: Hospital Research Institute; 1997. Available at: http:// courseweb.edteched.uottawa.ca/nsg6533/dcsweb.pdf. Accessed June 18, 2012. 27. O’Connor AM, Fiset V, DeGrasse C, et al. Decision aids for patients considering options affecting cancer outcomes: Evidence of efficacy and policy implications. J Natl Cancer Inst Monogr. 1999;25:67-80. 28. O’Connor AM, Rostom A, Fiset V, et al. Decision aids for people facing health treatment or screening decisions. BMJ. 1999;319:731-734. 29. O’Connor AM, Stacey D, Entwistle V, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2005;1:1-258. 30. Whelan T, Sawka C, Levine M, et al. Helping patients make informed choices: A randomized trial of a decision aid for adjuvant chemotherapy in lymph node-negative breast cancer. J Natl Cancer Inst. 2003;95:581-587. 31. Anderson S, Cockrell J, Beller P, et al. Administration of local anesthetic agents to decrease pain associated with peripheral vascular access. J Infus Nurs. 2010;33:353-361. 32. Brown D. Local anesthesia for vein cannulation: A comparison of two solutions. J Infus Nurs. 2004;27:85-88. 33. Brown J, Larson M. Pain during insertion of peripheral intravenous catheters with and without intradermal lidocaine. Clin Nurse Spec. 1999;13:283-285. 34. Burke SD, Vercler SJ, Bye RO, et al. Local anesthesia before IV catheterization. Am J Nurs. 2011;111:40-45. 35. Dickey J. Effectiveness of intradermally injected lidocaine hydrochloride as a local anesthetic for intravenous catheter insertion. J Emerg Nurs. 1988;14:160-163. 36. Kahre C, Fortune V, Hurley J, et al. Randomized controlled trial to compare effects of pain relief during IV insertion using bacteriostatic normal saline and 1% buffered lidocaine. J Perianesth Nurs. 2011;26:310-314. 37. McNaughton C, Zhou C, Robert L, Storrow A, Kennedy R. A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med. 2009;54:214-220. 38. Page L. How to start an IV without pain. Outpatient Surg Mag. 2004;5:40-45. 39. Palmon SC, Lloyd AT, Kirsch JR. The effect of needle gauge and lidocaine pH on pain during intradermal injection. Anesth Analg. 1998;86:379-381. 40. Peter DJ, Scott JP, Watkins HC, et al. Subcutaneous lidocaine delivered by jet-injector for pain control before IV catheterization in the ED: The patients’ perception and preference. Am J Emerg Med. 2002;20:562-566. 41. Windle PE, Kwan ML, Warwick H. Comparison of bacteriostatic normal saline and lidocaine used as intradermal anesthesia for placement of intravenous lines. J Perianesth Nurs. 2006;21:251-258. 42. Winslow EH, Jacobson AF. Clear benefit for lidocaine preparation of IV sites. Am J Nurs. 1997;97:20-21. 43. Zsigmond EK, Darby P, Koenig HM, et al. Painless intravenous catheterization by intradermal jet injection of lidocaine: A randomized trial. J Clin Anesth. 1999;11:87-94. 44. R€ ohm KD, Sch€ ollhorn TAH, Gwosdek MJ, Piper SN, Maleck WH, Boldt J. Do we necessarily need local anesthetics
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for venous cannulation? A comparison of different cannula sizes. Eur J Anaesthesiol. 2004;21:214-216. 45. Brown J. Registered nurses’ choices regarding the use of intradermal lidocaine for intravenous insertions: The chal-
LEVITT AND ZIEMBA-DAVIS lenge of changing practice. Pain Manag Nurs. 2002;3: 71-76. 46. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291:2359-2366.
PATIENTS REQUIRING INTRAVENOUS (IV) access are faced with the necessity of an invasive and uncomfortable procedure known as IV cannulation. Peripheral IV catheter insertion is one of the most frequent, painful, stressful, and dissatisfying invasive procedures performed on hospitalized patients.1-4 Approximately 25 million people in the United States and 90% of all hospitalized patients require IV catheter insertion.5,6 Moreover, although current guidelines are under scrutiny, most hospitals require that patients undergo an IV Francesca C. Levitt, MSN, RN-BC, ACNS-BC, is a Perioperative Clinical Nurse Specialist, St. Vincent Hospital Indianapolis, Indianapolis, IN; and Mary Ziemba-Davis is a Neuroscience Research Director, St. Vincent Hospital Indianapolis, Indianapolis, IN. Conflict of interest: None to report. Investigation was performed at St. Vincent Hospital Indianapolis, Indianapolis, IN, USA. Address correspondence to Francesca C. Levitt, St. Vincent Hospital Indianapolis, 2001 West 86th Street, Indianapolis, IN 46260; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2012.11.008
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site change every 72 to 96 hours to control infection and IV site complications.7 The Joint Commission standards8 endorsed by the American Pain Society9 require health care providers to assess and manage pain. The standard of care for managing pain associated with invasive procedures is to anticipate and ameliorate pain to the greatest degree possible.10,11 Pain management is a crucial component of good care and positively impacts patients psychologically and physiologically.12 Aiello et al13 found that nearly half of the variance in patient satisfaction with nursing care was attributable to patient-provider interactions. Wolosin14 demonstrated that patients want to: (1) have their personal circumstances and special needs taken into consideration while they are receiving care, (2) receive information about their care, and (3) have a say about treatment decisions. A qualitative study established patient interest in involvement in health care, ranging from basic needs for information to sharing or
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controlling health care decisions.15 Patients who desire to be involved in health care decisions want to be given options for participation.15 The American Nurses Association’s (ANA) Scope and Standard of Practice16 emphasize that nurses should collaborate with patients in their plan of care, treatment goals, and decisions related to the services rendered. The ANA’s Code of Ethics for Nurses with Interpretive Statements17 defines collaboration as providing necessary information for informed decision making. Involving patients in decisions about their care through deliberate and systematic sharing of evidence-based knowledge may give them a sense of control in an otherwise process-driven setting. Due in large part to advocacy efforts, patient involvement in decisions related to major health care issues such as cancer care and joint replacement has become more common. However, other care processes, from IV insertions to bath times, are still largely driven by providers who implicitly control day-to-day provisions of care.
Purpose The scarcity of evidence on patient preferences regarding pain management during IV insertion and patient desire for more information and involvement in pain management decisions15 led to this study. The purpose of our exploratory study was to add to the body of knowledge about patient preferences for pain management during IV insertion. Specific aims were to elucidate (1) patient desire to be involved in decisions about pain management, (2) whether patients have a preference for different pain management strategies, (3) patient satisfaction with the pain management choice, and (4) pain ratings and satisfaction with IV insertion. Intradermal lidocaine was offered as a pharmacologic pain management option because it is a proven anesthetic that decreases sensory perception of pain.18-21 Guided imagery was offered as a nonpharmacologic pain management strategy because it is well accepted by patients and has been shown to decrease preoperative pain and anxiety.22,23 Guided imagery has been shown to reduce stress, anxiety, and pain through relaxation, concentration, and body awareness. A calming voice combined with easy-listening
music guides the patient through an exercise, which may stimulate the release of endorphins and modify the perception of pain through distraction.24 Pain reduction is not predictable when using nonpharmacologic methods such as guided imagery; however, these techniques may make pain more bearable, improve mood, decrease distress, and give the patient a sense of control.8 No pain management strategy before IV insertion was offered as a third option consistent with traditional standards of care.
Materials and Methods Participants This study of hospital patients about to undergo surgical or nonsurgical procedures requiring an IV catheter was approved by an Institutional Review Board before data collection. The study was conducted at an 800-bed quaternary care referral hospital located in the Midwestern United States. Patients consecutively admitted to private procedural preparation rooms were greeted by the researcher (F.C.L.) and asked if they would be interested in participating in a research study on patient satisfaction with IV insertions. The researcher was not simultaneously working as nursing admission staff. Because this was an exploratory study, recruitment was capped at 30 volunteer participants. Participants were informed that they would choose among three different options for managing pain on IV insertion (intradermal lidocaine, guided imagery, or no pain management strategy) and answer some questions before and after IV insertion. Interested participants were screened to ensure that they were aged 18 years or older, could read and speak English, were able to provide informed consent, and could verbally rate pain and satisfaction on IV insertion. Pregnant patients, those who indicated a history of difficult IV insertions, those allergic to lidocaine, and those who took or received pain medications within 6 hours of hospital admission were excluded. Measures DEMOGRAPHICS. Participant sex, annual household income, highest grade completed in school,
PREFERENCES FOR PAIN MANAGEMENT DURING IV INSERTION
year of birth, relationship status, and race/ethnicity demographics were collected. Participants were asked if they ever had an IV (yes or no), whether they were afraid of needles (yes, no, or it depends followed by explanation), and pain tolerance (defined as the capacity to endure pain) on a numeric rating scale ranging from 0 (no tolerance for pain) to 10 (extremely high pain tolerance). Participants’ satisfaction with their pain management choice was measured using O’Connor’s25 decisional conflict scale (DCS) modified with permission. The unmodified 16-item DCS has demonstrated good reliability with test-retest coefficients exceeding 0.80 and internal consistency coefficients ranging from 0.78 to 0.89 in diverse test samples.26 Items included: I felt I made an informed choice (yes or no) The choice was easy for me to make (yes or no) I was aware of the options I had in this choice (yes or no) I felt I knew the advantages (pros) of using lidocaine (yes or no) I felt I knew the disadvantages (cons) of using lidocaine (yes or no) I felt I knew the advantages (pros) of using guided imagery (yes or no) I felt I knew the disadvantages (cons) of using guided imagery (yes or no) I had enough information about my options (yes or no) Perception of pain on IV insertion was measured on a numeric rating scale anchored by 0 (no pain at all) and 10 (worst pain ever experienced). Agreement with the statement ‘‘I think the nurse who inserted my IV was very concerned about my comfort during the procedure’’ was rated on a five-point Likert scale (strongly disagree, disagree, neutral, agree, or strongly agree). Three-point Likert scales were used to measure participant satisfaction with IV insertion (not at all satisfied, fairly satisfied, or very satisfied) and comparison of this IV insertion to past IV insertions (better, worse, or about the same). Whether or not participants expected to make the same decision the next time they need an IV (yes or no followed by why or why not) also was measured.
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Four-point Likert scales (not at all important, somewhat important, very important, or extremely important) were used to measure participant views on the importance of (1) being offered different options to manage pain on IV insertion and (2) involving patients in the decision about how to manage pain on IV insertion. Opinions on who should decide how to manage pain during IV insertion—the clinician starting the IV, the patient, or the clinician and patient together—also were assessed. Procedure On completion of the informed consent process, demographic and past IV experience questions were asked of participants, followed by presentation of the three options for pain management before IV insertion—intradermal lidocaine, guided imagery, or no pain management strategy. Decision aids (informational materials on lidocaine and guided imagery; see Tables 1 and 2) were provided because they have been shown to increase patient knowledge of medical issues and satisfaction with decision making.27-30 Lidocaine was defined as a traditional anesthetic or ‘‘numbing agent’’ used to dull pain associated with IV insertion. Guided imagery was defined as a relaxation technique, which uses a directed daydream to provide a feeling of temporary escape, detachment, sleepiness, and/or relaxation. Participants were informed that the guided imagery audiotape used for this study contained easy listening music in the background and the voice of a person guiding them through a daydream. The advantages and disadvantages of lidocaine and guided imagery were presented to participants (Tables 1 and 2). Face validity of written information about lidocaine and guided imagery, respectively, was verified by three anesthesiologists and the creator of the guided imagery audio tape. After learning about pain management options, participants changed into a hospital gown and were prepped for their procedure in the customary fashion. Before IV insertion, participants chose either lidocaine, guided imagery, or no pain management strategy. Registered nurses with 10 or more years of experience and trained in the
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Table 1. Information for Patients—Lidocaine Advantages of Lidocaine May decrease or eliminate the pain of IV insertion Blocks the pain impulse to the brain Has been safely used for years Recommended by anesthesiologists Takes 30-60 seconds to work
Disadvantages of Lidocaine Requires extra stick with small needle Briefly feels like a pinprick or bee sting or burn Extremely rare allergic reactions May make vein harder to see Adds about 1 minute to insertion process
IV, intravenous.
intradermal lidocaine technique started the IVs. The study investigator was not present at the time of IV insertion. PROCEDURE FOR INTRADERMAL LIDOCAINE. After ascertaining no allergy to lidocaine, washing hands, and donning clean gloves, 0.2-mL lidocaine without epinephrine (1%) was drawn into a tuberculin syringe from a dated multidose (30 mL) vial after cleansing the stopper with an alcohol pad. The 25-gauge needle was replaced with a 30-gauge needle expressing any air. A tourniquet was applied to the participant’s arm and the venipuncture site was selected. After topical cleansing of the IV insertion site with chlorhexidine and adequate time to allow the solution to dry, a small wheal (0.05 mL) of 1% lidocaine was injected intradermally (bevel up 1/4 to 1/3 cm) into the skin lateral to the vein. Allowing 30 seconds for full effect, the vein was stabilized, and a 20-gauge safety catheter was inserted directly into the vein through the skin wheal. After confirming proper catheter placement via blood return, 1 L of lactated ringers solution (or prescribed fluid) was connected to the catheter at a keep-open rate. The IV was secured with a transparent dressing, taped to the extremity, and documented in the medical record.
PROCEDURE FOR GUIDED IMAGERY. The guided imagery audiotape was started by the study investigator 2 minutes before IV insertion. Hand-held audio players with auto-reverse, new batteries, and headphones were used. Audio players were sanitized with a soft cloth and phenolic cleanser and placed in clear plastic bags before each use. Headphones were placed over the surgical caps covering participants’ ears to prevent the transmission of organisms. Volume was adjusted according to participant comfort. Venous cannulation without lidocaine was performed by a registered nurse as described previously. PROCEDURE FOR NO PAIN MANAGEMENT STRATEGY. No additional information was provided to participants who selected the no pain management option. Venous cannulation without lidocaine or guided imagery was performed by a registered nurse as described previously. All catheters were successfully inserted on the first attempt. Within 1 minute after IV insertion and securement, the study investigator returned to collect and record the remaining measures: (1) satisfaction with pain management choice, (2) pain perception and satisfaction with IV insertion, and (3) patient involvement in pain management decisions.
Table 2. Information for Patients—Guided Imagery Advantages of Guided Imagery Easy to use Helps to relax you Takes no additional time May decrease pain during IV insertion IV, intravenous.
Disadvantages of Guided Imagery Helps some people, not all May make you feel sleepy or disconnected May not be useful for hearing impaired persons Headphones may be uncomfortable
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Data Analysis
likelihood of type II error (assuming no difference when a real difference exists).
Study data were entered into a Microsoft Office Excel 2007 (Redmond, WA) spreadsheet and imported into Minitab 16 (State College, PA) for analysis. Data analysis was partitioned into four topical areas: (1) sample demographics, (2) satisfaction with pain management choice, (3) pain perception and satisfaction with IV insertion, and (4) patient involvement in pain management decisions. Descriptive statistics (frequencies and means), the Z-test, and Pearson’s c2 (categorical variables), and analysis of variance (continuous variables) were used to compare differences in outcomes based on pain management choice. There were no missing data. Alpha was set at 0.05 to protect against type I error (assuming a difference when one doesn’t really exist). Post hoc power analyses were conducted to address the
Table 3. Sample Demographics Characteristics Sex Female Male Race Black/African American White/Caucasian Mixed/inter-racial Education Less than high school diploma High school diploma Some technical school or college Technical school or college degree Graduate degree Relationship status Married/partnered Not married/partnered Income ($) 5,000-20,000 20,000-35,000 35,000-50,000 50,000-100,000 .100,000
N
%
19 11
63.3 36.7
1 28 1
3.3 93.3 3.3
3 14 8 3 2
10.0 46.7 26.7 10.0 6.7
18 12
60.0 40.0
7 2 6 13 1
23.3 6.7 20.0 43.3 6.7
Mean Age (y) Income (US$)*
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Findings Demographics, Past IV Experience, and Pain Management Choice A total of 30 of the 31 patients approached for participation agreed to take part in the study. The patient who declined participation noted that he was feeling too ill and ‘‘just wanted to get his surgery over with.’’ A total of 13 (43.3%) of the 30 participants chose intradermal lidocaine for pain management, 13 (43.3%) chose guided imagery, and 4 (13.4%) elected to forego a pain management strategy before IV insertion. With the exception of average annual income, personal characteristics did not differ among participants who chose lidocaine, guided imagery, or nothing to manage pain on IV insertion (Table 3). Participants who chose no pain management strategy before IV insertion (mean: $58,750; standard deviation [SD]: $27,724) reported the highest annual income, followed by participants who chose lidocaine (mean: $46,923; SD: $21,020) and those who chose guided imagery (mean: $30,962; SD: $16,942; F 5 3.68, P 5 .038). All participants had previously experienced IV insertion. A total of 31% (4/13) of lidocaine participants, 23% (3/13) of guided imagery participants, and none of the no strategy participants reported a fear of needles. None of the no strategy participants compared to 30.0% (Z 5 1.97, P 5 .048) of the guided imagery and 30.8% (Z 5 2.40, P 5 .016) of the lidocaine group reported a fear of needles. Fear of needles did not differ among lidocaine and guided imagery participants (Z 5 0.440, P 5 .657). Mean pain tolerance on a scale ranging from 0 5 no tolerance for pain to 10 5 extremely high pain tolerance did not differ among the three groups (lidocaine: 6.4, SD: 2.4 vs guided imagery: 6.4, SD: 2.3 vs no strategy: 7.5, SD: 1.0; F 5 0.44, P 5 .650).
SD
57.2 17.2 41,583 22,025
SD, standard deviation. *The midpoint of each income range was used to calculate average income.
Satisfaction With Pain Management Choice All (100%) lidocaine, guided imagery, and no pain management strategy participants (1) felt that they made an informed pain management choice and (2) that the choice was easy to
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make. All participants also felt they (1) were aware of their pain management options, (2) knew the advantages and disadvantages of both lidocaine and guided imagery, and (3) had enough information about their options before making their choice. Pain Perception and Satisfaction With IV Insertion As shown in Table 4, mean ratings of pain on IV insertion using a 0 to 10 point scale were low for all the three groups (lidocaine: 0.46, SD: 1.55; guided imagery: 2.69, SD: 1.55; no strategy: 2.75, SD: 0.50), although pain was significantly higher among guided imagery and no strategy participants than lidocaine participants (F 5 11.20, P 5 .000). Participants in all three groups equivalently agreed/strongly agreed that the nurse starting their IVs was concerned about their comfort. All (13/13) lidocaine participants compared with 77% (10/13) of guided imagery and 75% (3/4) of no strategy participants were ‘‘very satisfied’’ with their IV insertion. No participants in any group reported being unsatisfied (ie, not at all satisfied). A total of 85% (11/13) of lidocaine, 62% (8/ 13) of guided imagery, and 50% (2/4) of no pain control strategy participants reported that the current IV insertion was better than past IV insertions. No (0/13) lidocaine, 15% (2/13) of guided imagery, and 25% (1/4) of no pain control strategy participants reported that it was worse. All lidocaine
(13/13), 77% (10/13) of guided imagery, and 50% (2/4) of no pain control strategy participants expected to make the same pain management choice in the future. Importance of Patient Involvement in Pain Management Decisions One-hundred percent of the participants who chose lidocaine or no strategy for controlling pain on IV insertion, and 92.3% of the participants who chose guided imagery, liked being involved in the decision about IV pain management (Table 5). On average, lidocaine, guided imagery, and no pain control strategy participants equivalently agreed that being offered options for IV pain management was somewhat to very important (F 5 0.30, P 5 .720; Table 5). Participants in all three groups equivalently reported that involving patients in pain management decisions on IV insertion is, on average, very important (F 5 0.16, P 5 .856; Table 5). Approximately 70% to 100% of participants in the three study groups felt that pain management decisions should be made by patients and clinicians together, not clinicians or patients alone.
Discussion The primary purpose of this exploratory inquiry was to add to the body of knowledge about patient preferences for pain management during IV
Table 4. Pain Perception and Satisfaction With IV Insertion Parameters
Lidocaine
Guided Imagery
Pain on IV insertion, mean (SD)* 0.46 (1.13) 2.69 (1.55) Nurse was concerned about my comfort, 4.62 (1.12) 4.46 (0.66) mean (SD)y Satisfaction with IV insertion, % Not at all satisfied 0.0 0.0 Fairly satisfied 0.0 23.1 Very satisfied 100.0 76.9 Comparison to past IV insertions, % Better 0.0 0.0 Worse 0.0 15.4 About the same 15.4 23.1 Expect to make same choice next time 5 yes, % 100.0 76.9
No Pain Control Strategy
Statistic
P Value
2.75 (0.50) 5.00 (0.00)
F 5 11.20 F 5 0.59
.000 .560
0.0 25.0 75.0
c2 5 28.78
.000
0.0 25.0 25.0 50.0
c2 5 12.49
.002
c2 5 67.96
.000
IV, intravenous; SD, standard deviation. *0 5 numeric rating scale ranging from 0 5 no pain at all to 10 5 worst pain ever experienced. y 1 5 strongly disagree, 2 5 disagree, 3 5 neutral, 4 5 agree, 5 5 strongly agree.
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Table 5. Importance of Patient Involvement in Pain Management Decisions Parameters
Lidocaine
Guided Imagery
Liked being involved in the decision about IV 100.0 92.3 pain management, % Importance of offering pain management 2.62 (1.12) 2.85 (0.69) options before IV insertion, mean (SD)* Importance of involving patients in pain 3.00 (0.91) 3.00 (0.58) management decision, mean (SD)* Who should make pain management decision, % Clinician only 23.1 0.0 Patient only 7.7 23.1 Patient and clinician together 69.2 76.9
No Pain Control Strategy
Statistic
P Value
100.0
c 5 0.41
.816
2.50 (1.00)
F 5 0.30
.720
2.75 (1.26)
F 5 0.16
.856
0.0 0.0 100.0
c2 5 79.41
.000
2
IV, intravenous; SD, standard deviation. *1 5 not at all important, 2 5 somewhat important, 3 5 very important, 4 5 extremely important.
insertion. Study participants were provided with information about three options before IV insertion and asked to choose an option consistent with their preference: (1) intradermal lidocaine, (2) guided imagery, or (3) no pain management, which is consistent with the traditional standards of care. The most important finding in this study is that only 4 of 30 (13.4%) participants chose the traditional standard of care, no pain management strategy, before IV insertion. When given a choice, most participants (n 5 26, 86.6%) desired a pain control strategy. Equal proportions chose intradermal lidocaine (n 5 13, 43.3%) and guided imagery (n 5 13, 43.3%). Regardless of pain management choice, study participants were demographically similar (with the exception of income), all had previous experience with IV insertion, and did not differ based on pain tolerance. Ninety-two to 100% of participants in all three study groups said that they liked being involved in the decision about ways to minimize pain before IV insertion. Participants in all three groups believed that being offered options to manage IV insertion pain is very or extremely important. When asked who should decide how to minimize pain associated with IV insertion, 70% to 100% of participants in the three study groups felt that pain management decisions should be made by patients and clinicians together, not clinicians or patients alone.
An additional observation from this study was that the mean pain ratings on IV insertion on a 0 to 10 point scale were very low for all three groups, although pain was significantly higher among guided imagery (2.69) and no strategy (2.75) participants compared with lidocaine (0.46) participants. Furthermore, most participants in all three groups were ‘‘very satisfied’’ with their IV insertion and agreed that the nurse starting the IV was concerned about their comfort. More than 75% of the participants who chose lidocaine or guided imagery expect to make the same pain management choice in the future, compared with only half of those who chose no pain control strategy. The lack of information on whether patients desire to be involved in pain management decisions during IV insertion was the catalyst for this study.15 A number of studies comparing the effectiveness of various techniques for managing IV insertion pain have been conducted,18-21,31-44 but very few studies have addressed the more fundamental questions of whether patients desire pain management for IV insertion and want to be included in pain management decisions. After participating in a study examining pain and anxiety on IV insertion, 70% of health care providers reported that they would always desire local anesthetic for IV insertion both for themselves and their patients.33 Nonetheless, there is strong resistance to change. Brown45 reported that only a third of registered nurses consistently offered patients intradermal lidocaine to reduce fear and pain associated with IV insertion
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despite a hospital policy requiring this practice. Nurses believed that it made catheter insertion more difficult; was unreasonable to stick patients twice; and, contrary to existing evidence, did not believe that IV insertion caused enough pain to warrant an anesthetic.45 Providing choices to help decrease pain during IV insertion is a demonstration of empathic and holistic care, which may decrease the sense of vulnerability and lack of control experienced by patients. Including patients in decisions about their care may enhance satisfaction and well-being in an often confusing, foreign, and frightening health care environment. Collaborative relationships are enhanced by soliciting patient input during all phases of care and have been associated with better clinical outcomes.46 Jacobson22 recommended that low-cost, easy-to-use interventions such as guided imagery and music be made available to patients even if they do not significantly decrease pain perception because they may improve patient satisfaction and emotional and spiritual well-being. Limitations of the Study The sample size for this exploratory study was small and replication with a larger, more diverse, stratified sample is recommended. Randomization to groups was not possible because participant choices about pain management strategies were a key study outcome. Post hoc analysis revealed that statistical power to avoid false negatives (assuming no difference when a real difference exists) was only 13.7% for choice of pain management strategy. However, we were not testing differences in the choice of a strategy but rather differences in outcomes such as pain scores once a choice was made. Statistical power for pain scores on IV insertion ranged from 95.6% (lidocaine vs guided imagery participants) to 99.6% (guided imagery vs no strategy participants).
Nonetheless, replication studies should include more participants to test our findings. Participants were not asked if they had had IV pain management strategies in the past, which would have helped identify whether past choices influenced current choices. Finally, the amount of time available for listening to the guided imagery recording in a fast-paced preoperative unit may have been insufficient to achieve a state of relaxation necessary for the full effect to be achieved. Implications for Nursing Practice The approach to the patient undergoing a painful procedure such as an IV insertion should include a discussion about the available pain management options. The voice of the patient as measured on satisfaction surveys should be used to develop nursing interventions to ameliorate discomfort on IV insertion. Intradermal lidocaine injection21 and cognitive behavioral interventions are simple and inexpensive strategies that decrease pain and/or enhance patient satisfaction. Additional research is needed to identify why barriers to implementation of an evidence-based practice change exist and the interventions needed to overcome these obstacles.
Conclusion This study illustrates that patients have preferences for different pain management strategies during IV insertion and believe that they should be involved in decisions about pain management. Measurement of high-quality patient care may soon be defined in part by the provision of evidence-based information to patients and the opportunity for shared decision making. With the advent of computer accessible health care ratings to an increasingly sophisticated health care consumer, it is imperative that health care professionals embrace a patient-centered approach.
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