developing postoperative pain management: utilising the promoting action on research implementation...

Original Article

Developing Postoperative Pain Management:Utilising the Promoting Action on ResearchImplementation in Health Services (PARIHS)Framework

Donna Brown, RGN, PGDipHP, MA, Brendan McCormack, DPhil(OXON), BSc(HONS)

ABSTRACTBackground: The development of acute pain services (APS), education programmes, and protocols

assumed an expectation that health care professionals would integrate evidence into everyday practice.However, research evidence into pain management would suggest that this is not the case.

Approach: Through a review of the literature, the authors aim to (1) explore the factors that havea significant influence on getting evidence into practice (using the PARIHS model as a guide) and (2)examine the relevance of these factors to postoperative pain practices.

Findings: The need to assist clinicians with developing a greater awareness of the competing andcomplex influences that surround pain management practices is outlined.

Recommendations: There is a necessity to adopt a systematic, rigorous, and multidimensionalapproach to pain management issues, utilising the PARIHS framework as a guide, to improve painpractices.

Worldviews on Evidence-Based Nursing 2005; 2(3):131–141. Copyright ©2005 Sigma Theta Tau International

KEYWORDS evidence, context, facilitation, culture, pain management, knowledge

BACKGROUND

Postoperative pain management has been described asa high priority in the surgical ward setting, but it is

high-volume, high-risk, problem-prone, and high-cost interms of surgical ward activity (Idvall et al. 1999). Cen-tral to the delivery of safe patient care and efficacious painmanagement is clinicians’ ability to formulate accurate clin-ical assessments and develop appropriate strategies to ad-dress them (Tanner et al. 1987). It has been proposed that

Donna Brown, Acute Pain Control Sister/Research Nurse, Royal Hospitals Trust, Belfast,UK. Professor Brendan McCormack, Director of Nursing Research & Practice Devel-opment, Royal Hospitals Trust, Belfast, UK; Institute of Nursing Research/School ofNursing, University of Ulster, Belfast, UK; and Adjunct Professor of Nursing, Faculty ofMedicine, Monash University, Victoria, Australia.

Address correspondence to Donna Brown, RGN, PGDipHP, MA, Nursing Develop-ment Centre, 3rd Floor, Bostock House, Royal Victoria Hospital, Grosvenor Road,Belfast, UK BT12 6BA; [email protected]

Submitted 17 February 2005; Accepted 9 May 2005Copyright ©2005 Sigma Theta Tau International1545-102X1/05

nurses have a duty to deliver clinically effective care basedon the best possible evidence available and in accordancewith the individual needs of the patient (Department ofHealth 1997, 1999). However, achieving these goals by im-plementing change, getting evidence into practice, and/orimproving the quality of patient care is complex.

This literature review is a second article aimed at explor-ing the empirical evidence available for an ethnographicstudy into pain management practices with older peopleadmitted for colorectal surgery. The first article identifiedhow health care professionals contribute to the assessmentand control of postoperative pain in older people (Brown2004). The evidence from both articles is being used tounderpin and inform an action research study currentlyunderway.

INTRODUCTION

Within the United Kingdom’s National Health Service, thearrival of clinical governance and development of organisa-tions such as the National Institute for Clinical Excellence

Worldviews on Evidence-Based Nursing �Third Quarter 2005 131

Utilising the PARIHS Framework to Develop Postoperative Pain Practices

(NICE) has entrenched the themes of evidence-based prac-tice and clinical effectiveness. Such a drive is reflected inother developed countries around the world. There hasbeen a realisation, by policymakers and service deliverymanagers, that the increase in available research evidence,dissemination of guidelines (evidence), followed by an ed-ucation package has not led to automatic integration ofevidence into practice, as expected (Camiah 1997; Para-hoo 2000; Twycross 2002). It would appear that much re-search has little or no impact on practice (Boore 1995; Hunt1996). Transforming research into practice has revealed it-self to be a challenging task requiring “intellectual rigourand discipline as well as creativity, clinical judgement andskill, organisational savvy and endurance” (Horsley et al.1983, cited in Kitson et al. 1996).

Over the past decade, the theme of getting evidence intopractice has gained momentum. Drawing upon practicedevelopment, quality improvement, and research projects,research and practice development teams have accrued awealth of experience and knowledge about implementingand changing practice (for example, Royal College of Nurs-ing 1990; Dobson et al. 1999; Ferlie et al. 1999; NationalHealth Service [NHS] Centre for Reviews and Dissemina-tion 1999; McCormack & Wright 2000). Analyses of thefindings demonstrate that practice tends to be disorderedand challenging. Implementation and change are compli-cated processes because they involve individuals, teams,and organisations (Rycroft-Malone et al. 2002). For thisreason, they are not readily represented by early linear orlogical models (such as Haines & Jones 1994; NationalHealth Service Executive 1996).

Taking into account that implementing research intopractice is “complex, messy and demanding” (Rycroft-Malone et al. 2002, p. 38), Kitson et al. (1998) devel-oped a conceptual framework that was subsequently builtupon by Rycroft-Malone et al. (2002). The Promoting Ac-tion on Research Implementation in Health Services (PAR-IHS) framework acts as a map of the factors that need tobe taken into account when implementing evidence intopractice. This multidimensional framework is composed ofthree key elements derived from research, practice develop-ment, and quality improvement work; these are evidence,context, and facilitation. Each of the elements has beenfurther divided into subelements arranged along a low-to-high continuum of descriptors. It is argued that successfulimplementation occurs when the evidence is robust andmatches professional consensus and patient needs (highevidence); the context is receptive to change with sympa-thetic cultures, strong leadership, and appropriate evalua-tive systems (high context); and when there is appropriatefacilitation of change, with input from skilled external andinternal facilitators (high facilitation; Kitson et al. 1998).

Since publication of the PARIHS framework, refinement,validation, and clarity of the key elements (evidence, con-text, and facilitation) have been ongoing. To achieve con-ceptual clarity of the framework, the meaning of context(McCormack et al. 2002), the role and function of facilita-tion (Harvey et al. 2002), and the issues relating to evidence(Rycroft-Malone et al. 2004) have all been explored morefully.

AIMS

The aims of this review are (1) to explore the factors thathave a significant influence on getting evidence into prac-tice and (2) to examine the relevance of these factors topostoperative pain assessment and management.

METHOD

A literature search was conducted using CINAHL andMEDLINE electronic databases, reviewing studies from1980 to 2004. The terms pain (including assessment, post-operative, surgery, acute, management, services), evidence,evidence-based, practice, knowledge, utilization, barriers,facilitation, and context were meshed and merged. Subse-quently, 90 papers were identified as relevant to the focusof this article, and these abstracts were read. Royal Collegeof Nursing online resources were also utilised, and searcheswere supplemented by a hand search of subject-relatedjournals. This highlighted a further 10 papers. Using thethree key constructs of the PARIHS framework (evidence,context, and facilitation) as a guide to analyse the papers,58 papers were selected and read. The papers reviewedincluded theoretical discussions and qualitative and obser-vational studies. To support this literature, familiar painmanagement documents and texts were also included.

DISCUSSION OF FINDINGS

EvidenceNursing, as a practice, is a socially organised body of knowl-edge, with sets of skills and styles of relating to other prac-tices and to science and technology (Benner 2000). Expertpractitioners are required to respond to “patients as per-sons, respecting their dignity, caring for them in ways thatpreserve their personhood, protect them in their vulnera-bility, help them feel safe in a somewhat alien environment,comfort their families and preserve the integrity of close re-lationships” (Benner et al. 1997, p. 16; Nolan et al. 2001;Dewing 2004; McCormack 2004b). With this being thecase, nurses have struggled with the relationship betweenresearch and actual practice (Bloomfield & Hardy 2000).

132 Third Quarter 2005 �Worldviews on Evidence-Based Nursing


Research evidence, particularly in the form of ran-domised controlled trials (RCTs), has tended to assumepriority status in providing “gold standard” solutions tothe delivery of health care. However, RCTs do not alwaysaddress the complex clinical issues and problems that mayarise, and practitioners need to look toward other researchdesigns and paradigms, as different sources of evidence maybe valued in different ways by clinicians (Rycroft-Maloneet al. 2002). Upshur (2001) argues that as practice is rarelyconstant, definitive studies are few, and to apply the notionthat research evidence has the “ultimate” answers couldlead to confusion or, in some cases, may even be harmful(DiCenso et al. 1998).

Good “evidence,” therefore, involves more than RCTsand systematic reviews. To improve patient care, nursesmust use a number of different sources of evidence to makea clinical decision. This is likely to include clinical opinion,patient experience, and research evidence (Rycroft-Maloneet al. 2002). Bucknall (2003) and Booth et al. (1997) con-cur by suggesting that although research evidence is fun-damental to improvements in the delivery of patient care,unaided (by other forms of evidence) it may not be suffi-cient to inform practitioners’ decision making. Evidence,therefore, should not be interpreted in terms of researchevidence alone. Rather, evidence needs to be consideredas knowledge (Rycroft-Malone et al. 2004), defined as “anawareness or familiarity gained by experience, a person’srange of information, a theoretical or practical understand-ing of a subject” (Concise Oxford English Dictionary 1997,p. 753). Arguably, the term knowledge more aptly reflectsthe multiplicity of sources that practitioners draw upon tomake clinical decisions. Fundamentally, evidence needs tohave been subjected to scrutiny and found to be robust andcredible, regardless of the source from which it has beendrawn (McCormack 2004a).

The PARIHS framework not only incorporates evidenceas empirical research, but also includes factors such asthe patient’s experience and the clinical experience of theindividual nurse caring for the patient. In a further de-bate concerning the nature of evidence, Rycroft-Maloneet al. (2004) suggest utilising characteristics of knowledgegenerated from four different types of evidence base: re-search; clinical experience; patients, clients, and carers;and local context and environment. The experienced nurseshould be someone who can assess new situations on thebasis of similar past experiences and appropriately ap-ply evidence-based nursing interventions (Wallace et al.1997)—in line with the patient’s wishes. Consequently, ac-complished practice must encompass both skill and in-formation, blended with insight, understanding, wisdom,and critique (Goding & Edwards 2002). Exploring thefour sources of evidence and observing how they are in-

tegrated into daily clinical life may offer valuable insightsinto nurses’ decision-making practices.

Studies offer limited insight into nurse/patient interac-tions relating to pain management. Some researchers haveemployed Likert-type scales to measure nurses’ and pa-tients’ ratings of the intensity of pain (Field 1996; Harmer& Davies 1998). Others have used individual nurse in-terviews (Sjostrom et al. 2000), simultaneous patient andnurse questionnaires (Dahlman et al. 1999; Idvall et al.1999; Idvall 2004), focus groups (Nash et al. 1999), or acombination of approaches (Briggs & Dean 1998). Whilstthese studies highlight the inconsistencies that exist be-tween nurses’ and patients’ interpretations of pain, they donot adequately explore the total pain experience or the di-versity of factors within the clinical setting that may affectnurses’ decision making.

Attempting to address this shortfall, Idvall et al. (1999)developed a questionnaire, which they suggested mightbe a useful guide to the strategic and clinical indicatorsto achieving high-quality outcomes in postoperative painmanagement. They found that in several important aspectsof pain management, “both the patients and nurses assessedthe quality of care to be lower than the nurses’ assessmentof what was considered possible to effectuate in clinicalpractice” (Idvall 2004, p. 162). This led Idvall to question,“What is realistic in clinical practice?” Questionnaires is-sued to patients and nurses revealed a discrepancy betweenwhat nurses considered to be realistic to do and that whichthey actually thought they had done. In addition, the studyfound that enough nurses were on duty, they were knowl-edgeable, and there was strong evidence for the actionsassessed. Idvall concluded that applying research evidencefor postoperative pain into clinical practice is problematicand complex.

That pain management practices are problematic wasfurther evidenced by Brown and McCormack (2005). Fol-lowing the analysis of data obtained through observationof ward practice, patient interviews, and the distribution ofthe Nursing Work Index – Revised (NWI-R) questionnaire(Aiken & Patrician 2000), they identified three overarch-ing themes that contribute to suboptimal pain manage-ment. Pain assessment practices, knowledge/insight andstrategies to cope with episodes of uncontrolled pain, andorganisation of care, along with ward culture, were identi-fied as having an inhibitory effect on pain management inolder people.

Observational studies of pain have rarely been con-ducted in the clinical setting (Manias et al. 2002). Thoseundertaken (Fagerhaugh & Strauss 1977; Thomas et al.1998; Willson 2000; Brown & McCormack 2005) haveonce more found discrepancies between actual and po-tential pain relief. However, most researchers tend to



concentrate on patient observation and do not address theissues surrounding nurses’ assessment and managementof pain. Neither is there “accountability for the environ-mental context at the time of observation” (Bucknall et al.2001, p. 270). Willson (2000) attempted to address thisresearch “gap” in her observational study of patients fol-lowing fractured hip repair. Her study highlights the en-vironmental and situational factors that influence nurses’decision making in the administration of analgesia. Maniaset al. (2002) also adopted a clinical observational approachto investigate nurse–patient interactions associated withpain in postsurgical patients. They identified four barriersto effective pain management: nurses’ responses to inter-ruptions of activities relating to pain; nurses’ attentivenessto patient cues of pain; nurses’ varying interpretations ofpain; and nurses’ attempts to address competing demandsof nurses, doctors, and patients.

The observational component of Brown and Mc-Cormack’s study supported these findings (Brown &McCormack 2005). They highlighted that “medicinerounds” constituted the primary period of time the nursingstaff allotted for pain assessment and analgesic administra-tion. However, nursing staff experienced multiple interrup-tions from both medical and nursing colleagues during thistime. This led the authors to conclude that interruptionscan have a significant negative impact upon pain manage-ment, as nursing/medical colleagues’ requests are priori-tised over administering analgesia. Thus, findings from theevidence demonstrate that there are a significant number ofcompeting and complex influences that need to be takeninto account when attempting to understand issues sur-rounding getting pain management evidence into practice.Clearly, programmes must address not only knowledge en-hancement but also the wider complex of influences onpain and pain assessment (Manias et al. 2002).

ContextContext, within the PARIHS framework, refers to “the en-vironment or setting in which the proposed change is to beimplemented” (McCormack et al. 2002, p. 97). The subele-ments of context incorporate culture, leadership, and eval-uation. Clarity concerning decision-making processes, pat-terns of power and authority, information and feedbackmechanisms, and active management of competing priori-ties are all clearly defined boundaries within context. Priorto introducing and sustaining change, there is a need to de-velop an understanding of established values and beliefs, asmany diverse and conflicting cultures operate within an or-ganisational context (Chin 1985; McCormack et al. 2002).Often the nature of the environment or setting in whichthe proposed change is occurring is a key determinant ofits success (McCormack et al. 2002).

Ashworth et al. (1992) state that “health care hierar-chies are not structured in a simple, unitary fashion, butinvolve an intricate matrix of inter and intra professionalorderings of status. In such a context, it is almost inevitablethat patients will experience their situation as lacking sta-tus, as any degree of assertiveness is likely to be felt aspresumptive” (p. 1436). This factor is evidenced in Brownand McCormack’s ethnographic study (Brown & McCor-mack 2005), which sought to gain insight into the problemsof analgesic administration from the patient perspective.Pain assessment and the “medicine round” were particularsources of frustration for older patients who had chronicpain. For example, one patient stated that he was unable tomaintain his “normal” analgesic routine because it did notfit in with the existing medicine round regimens. Whenhe tried to negotiate with nursing staff members, he foundthat he became isolated from them, as there were no mecha-nisms in place for patients whose needs fell outside currentanalgesic practices.

While this patient presented with the most complex ofpain management problems, compared to the other patientswho were interviewed, the example raises issues that areworthy of consideration. “Bargaining” for adequate anal-gesia highlights the possibility that patient characteristicscan have an influence on communication. Willson’s ethno-graphic study (Willson 2000) supports the view that ten-sions can result as a consequence of poor communicationbetween patients and nurses. Whilst exploring factors thatnurses take into account when considering administrationof analgesia, Willson found that nurses preferred to con-form to customary analgesic practice rather than discussanalgesic requirements with patients. In her study, whenone older patient requested stronger than prescribed anal-gesia, three days postoperatively, the nurse questioned thepatient’s requirement. Willson suggested that this createda situation whereby the patient’s own assessment of painwas doubted.

Inadequate pain assessment (McCaffery & Beebe 1989;National Confidential Enquiry into Perioperative Deaths1999; Yarnold 1999) and/or insufficient professionalknowledge (Lander 1990; Field 1996; Carr 1997) havebeen repeatedly blamed for poor pain management. How-ever, ethnographic studies suggest that this may be toosimplistic a view. Willson (2000) demonstrated that work-ing shifts, organisation of patient care, time, customaryanalgesic practices, and communication both with pa-tients and the multiprofessional team all impact on nurses’pain management decisions. In support of these find-ings, Manias et al. (2002) identified four major themeswithin the ward culture that led to inadequate pain man-agement practices. Additionally, Brown and McCormack(2005) originally identified 31 factors that impacted upon



person-centred pain management practices with older peo-ple. Re-examining the data revealed commonalities be-tween the items, which subsequently allowed the threemain themes of (1) pain assessment and practice, (2)knowledge/insight and strategies to deal with episodes ofuncontrolled pain, and (3) organisation of care to be de-veloped. Manias et al. (2002) contend that “the apparentdifferences between nurses’ and patients’ pain estimates arelikely to be the consequence of multiple and complex in-fluences that are difficult to quantify” (p. 733). Arguably,these studies emphasise that one of the major themes aris-ing from context is culture.

CultureCulture has been defined as “how things are done aroundhere” (Drennan 1992, p. 3) and essentially manifests it-self through the values, beliefs, and assumptions embed-ded within organisations (Bate 1994). However, there maybe many cultures in any context, and it is imperative togain insight into the “culture of a practice context” if a sus-tainable approach to getting research into practice is to beachieved (McCormack et al. 2002, p. 98).

Since the introduction of acute pain services (APS), in-spired by Ready et al. (1988), it is argued that there hasbeen an improvement in doctors’ and nurses’ attitudes topain management (Pasero & Hubbard 1991; Nielson et al.1994; McLeod et al. 1995). Atkinson et al. (1999) proposethat positive changes in practice and attitude toward painmanagement may be attributed to education, role mod-els, familiarity with analgesic techniques through “handson” experience, and institutional support. These findingshave recently been substantiated in a study by Barton et al.(2004), who sought to assess the impact of APS on nursesand midwives. This was achieved by distributing a 29-itempain knowledge and attitudes questionnaire to 600 nursesand midwives. The authors concluded that nurses and mid-wives who were unaware that their organisation had APSdisplayed significantly lower scores on knowledge relat-ing to pain management, and particularly to the analgesicchoices they made.

Pain management studies (Cartwright et al. 1991;Wheatley et al. 1991; MacKintosh & Bowles 1997) tendto concentrate on audit findings and descriptions of howpain services have been introduced into individual hospi-tals. Clinical audit does not require the rigorous controls ofresearch and is not designed to establish the relationshipbetween the process of care and patient outcome (Don-abedian 1988). Therefore, these papers can only assumethat there is a direct link between the introduction of APSand changes in staff attitudes and knowledge. They becomelimited by their concentration on audit findings and fail-ure to examine the influence of knowledge and beliefs onclinicians and how this might impact on the pain manage-

ment that patients receive (Clarke et al. 1996; Carr 1997;Mackintosh & Bowles 1997). Neither do they address theinfluence that members of APS (and in particular the paincontrol nurse) may have on the prevailing organisationalculture.

Some hospitals possess organisational characteristicsthat support nurses to use their expertise, knowledge, andskills effectively to provide quality patient care. Such organ-isations have gained a reputation for recruiting and retain-ing staff and have been termed “Magnet hospitals.” Magnethospital research (Aiken 1984, 1989; Johnson 2000; Tross-man 2002) has demonstrated that nurses want to be valued.Valued not in terms of monetary marketing strategies, butrather they want to be recognised for their expertise and au-tonomy in the decision-making processes concerning theirpatients, and they want to be respected and appreciated byphysicians and management teams.

It has been proposed that autonomy, control, and nurse–physician relationships are codependent in a clinical prac-tice environment (Grindel et al. 1996; Hoffart & Woods1996). Additionally, these factors have been identified asfundamental characteristics of Magnet hospitals (Aiken etal. 2000; Aiken & Patrician 2000)—important for bothpatient outcomes and for nurses themselves (Budge et al.2003). In relation to pain management, Manias et al. (2002)found that relationships among health care professionalswere important to enable nurses to clarify patient needs andorganise the work environment. Exploring these issues fur-ther, Brown and McCormack (2005) distributed the NWI-R questionnaire (Aiken & Patrician 2000) and identifiedinconsistencies between the observation of practice andquestionnaire responses. Scores for autonomy and controlover practice displayed positive responses, and nurses per-ceived they had good working relationships with medicalstaff. Hence, it may be deduced that many of the attributesto promote good pain management practices were present.What remained elusive was why nurses did not fully utilisetheir autonomy, control over practice, and good workingrelationships with medical staff to discuss difficult painmanagement issues. The authors postulated that nursingstaff members may have been indeterminate in their knowl-edge or skills relating to pain management. Alternatively,good working relationships may have existed only becauseof the nurses’ willingness to prioritise the doctor’s wishesover those of the patient. Ultimately, discussions should beindividualised to address patient’s needs, but equally theyshould “involve a process whereby healthcare profession-als and patients work together to negotiate effective prac-tices and behaviours for pain assessment and management”(Manias et al. 2002, p. 732). However, further attentionneeds to be given to empowering relationships amongnurses and between doctors and nurses and the rest of themultidisciplinary team.



Senge (1990) suggests that employees are more likelyto participate in an organisation when they feel valued andhave choices. Such a context requires an emphasis to beplaced on manager–employee relations and decentraliseddecision making. Consequently, leaders have a significantrole to play in the transformation of cultures (Rycroft-Malone et al. 2002).

LeadershipLeadership, the third subelement of context within thePARIHS framework, gives rise to clear roles, effective team-work, and effective organisational structures (Kitson etal. 1998) and essentially encompasses knowing how tomake visions become reality (Kitson 2001). Hurst (1997)suggests that prior to the late 1990s, critical analysis ofthe theory and practice of clinical nursing leadership waspoorly developed. However, in recent years, there has beena reawakening of clinical leadership research, and the needfor strong leaders to have greater political awareness andinfluence over health care policy has become a recurringtheme (Cook 2001).

Currently, leadership style reflects a move away fromdictatorial approaches to more transformational or facili-tative styles (Bass & Avolio 1990). Transformational lead-ers motivate others to perform to their full potential, overtime, by influencing a change in perception and providing asense of direction (Bass & Avolio 1990). Such leaders whopossess the ability to inspire and challenge staff to achievea shared vision are fundamental in transforming culturesand ultimately shaping the context to be changed (Rycroft-Malone et al. 2002). Mintzberg (1975) proposes thattransformational leaders require emotional intelligence;rationality; motivational skills; empathy and inspirationalqualities; and the intellectual qualities of strategic sensing,analytical skills, and self-confidence in public presentation.Additionally, in the clinical setting, they are required toguide practice and actively promote the implementation ofstrategies to develop questioning reflective practitioners toimprove care.

The APS model (i.e., coordination/daily management,education, audit, and research of the service) has assumed apragmatic approach to pain management and offered somedirection and leadership in an area that had been identifiedas deficient. MacKintosh and Bowles (1997) propose thatthe clinical nurse specialist (CNS), in APS, promotes goodpractice, has increased awareness of what good pain man-agement entails, and influences members of the medicalstaff who “are now willing to listen to advice given by theAPS and prescribe accordingly” (p. 36). Indeed, Thomp-son et al. (2001) found that nurses’ valued the advice orguidance derived from a CNS. They propose that the CNShas the ability to harness multiple approaches to chang-ing practice and influence the clinical audit agenda, clini-

cal teaching, mentorship, or role modelling. Additionally,Atkinson et al. (1999) suggest that “members of the APSare important role models and catalysts in changing prac-tice and attitudes towards postoperative pain managementat an institutional level” (p. 13). The ability to utilise mul-tiple approaches is more successful than single approachesfor bringing research knowledge into clinical practice (Beroet al. 1998). Arguably the CNS could fulfil the role of thetransformational leader. However, this is an area that re-quires further research.

EvaluationMeasurement generates evidence on which to base prac-tice and is a part of the evaluation or feedback process thatdemonstrates whether or not changes to practice are ap-propriate, effective, and/or efficient (Rycroft-Malone et al.2002). However, measurement of outcomes in the clini-cal setting can be complex. Evaluation literature suggeststhat evaluation designs are required to embrace a range ofquestions (Owen & Rogers 1999; McCormack & Manley2004) and research methods that can be grouped withinquantitative and qualitative methodologies (McCormack2004a). Arguably, this does not subscribe to the search for“objective truth” that dominates evaluation methodologyand determines a research programme’s worth. However,evaluation, as opposed to the term measurement, embracesa broader feedback process and reflects the complexity oforganisational systems and the multiple realities of stake-holders. It is proposed that contexts that rely on broad andmultiple sources of information and evidence of effective-ness, as well as harder outcomes, tend to be those that aremore receptive to change (Rycroft-Malone et al. 2002).

Fundamental to evaluating the efficacy of pain man-agement strategies is the issue of quality assurance. Un-fortunately, quality is an abstract and subjective concept;therefore, the processes of care that are the most importantparts of quality are inevitably difficult to measure (Don-abedian 1980). Effective pain management is a quality is-sue and relies on both the efforts of the clinical nurses aswell as the involvement of nurse managers (Bucknall et al.2001). For this reason, Malek and Olivieri (1996) suggestthat essentially pain management should become a part ofstaff performance appraisals. Researchers (Pawson & Tilley1997; Quinn-Patton 1997) further suggest that evaluationframeworks are required to reflect the complexity of organi-sational systems and the multiple realities of stakeholders.Therefore, central to evaluation is the development of aculture that embraces peer review, user-led feedback, andreflection on practice (McCormack et al. 2002).

FacilitationFacilitation may be described as “a technique by which oneperson makes things easier for others” (Kitson et al. 1998,



p. 154). However, the purpose of facilitation appears to varythroughout the literature. Facilitators may be required tofocus on a particular task (task-based facilitation), suchas arranging education sessions for individuals or teams,or can encompass different modes, providing a range oftechnical, practical, and emancipatory support during aprocess of change (Titchen 2000; Garbett & McCormack2002). The adoption of more complex, holistic processesseek to enable individuals/teams to analyse, reflect, andchange their attitudes, behaviours, and ways of working(holistic facilitation; Rycroft-Malone et al. 2002). Thus thefacilitator works with other practitioners assisting themto change the context of the environment and in makingsense of the evidence being implemented (Harvey et al.2002).

Whilst facilitation is surrounded by complex issues andconceptual difficulties, Harvey et al. (2002) have clarifiedsome defining characteristics of facilitation through a con-cept analysis. The authors propose that facilitators are gen-erally appointed to the role and may be internal or external(or encompass a combined internal/external approach) tothe organisation in which the change is being implemented.The role is about helping and enabling rather than telling orpersuading. Additionally, Heron (1989) suggests that thefacilitator’s role is to give meaning to group discussions.This may necessitate facilitation style changing from be-ing directive to working collaboratively, depending on thecontext and developmental stage of the group. It is also sug-gested that the role of the facilitator is dependent upon thegoal to be achieved. Thus, if a facilitator has a singular goal,the role may be to provide practical help and support. How-ever, where the focus is based upon developing and empow-ering teams/individuals, then there is an additional empha-sis on the enabling aspects of facilitation. The aim of thefacilitator is to work democratically and collaborativelywith clinical staff members to enable them to review theirskills, values, and beliefs and evaluate their practice (Kitsonet al. 1996).

Having developed a clearer understanding of the is-sues, the facilitator’s role then concerns itself with assistingthe individual and/or clinical team to focus on the issuesand, with renewed insight, develop appropriate changestrategies (Titchen 2000). Given the broad focus of thefacilitation concept, a wide range of skills and attributesare therefore needed to fulfil the role effectively (Harveyet al. 2002). It appears that the key to successful facilita-tion is to match the purpose, role, and skills to the needsof the changing situation. How this may be best achievedremains unclear, as currently there is no available evi-dence relating to facilitation and pain management, in theliterature.

IMPLICATIONS FOR PAIN MANAGEMENTRESEARCH

It is recognised by those who coordinate acute pain servicesthat there is a need to improve pain management practices(Rawal 2002; Powell et al. 2004). As those in APS struggleto overcome organisational and attitudinal barriers, issuessurrounding the role of service members have become acentral theme. Brown and McCormack (2005) identifiedstrict adherence to protocols and the abdication of respon-sibility and accountability, in the presence of significantpain management problems and APS, to be restrictive anddisempowering to nursing practice. Thus, whether it is theAPS role to provide direct care to patients, or if they are a re-source for knowledge utilisation and the promotion of bestpractice, is hotly debated (Audit Commission 1997; Rawal2002; Werner et al. 2002). Clearly, there is a need to addressthe problems experienced by APS and consider strategies(such as the empowerment of ward staff) that could lead tothe successful treatment of postoperative pain. However,this would require a significant change in culture (Brown& McCormack 2005).

Values and beliefs underpin how things are done in anorganisation and will, therefore, impact on all aspects ofpatient care, including pain management. Much of theresearch surrounding pain management throughout theUnited Kingdom has concentrated on pain assessment andnurses’ knowledge. However, for more than a decade, thosein APS have put education at the forefront of their agenda,suggesting that additional factors may be contributing tothe problem. In their exploratory study of pain manage-ment practices with older people, Brown and McCormack(2005) identified three themes that have an inhibitory ef-fect on pain management in older people. They are (1) painassessment practices, (2) knowledge/insight and strategiesto cope with episodes of uncontrolled pain, and (3) organ-isation of care. In addition, ward culture and patient bar-riers impact upon ineffective pain management practices.Each theme, to a greater or lesser extent, is dependent onthe other and encompasses the three key elements of thePARIHS framework. The authors concluded that improvingpain management practices requires health care profession-als to reflect on reactions, values, and beliefs surroundingpain and examine how these have the potential to influ-ence the care provided. Consequently, there is a need for afocused, collaborative, interdisciplinary approach to chal-lenge current pain management practices and implementchange.

Arguably “learning organisations,” characterised by be-ing more conducive to facilitating change by creatinglearning cultures that pay attention to individuals, group



processes, and organisational systems (Senge 1990), arekey. Learning in and from practice may be achieved onlyif better practice environments are created. However, be-fore a hospital attempts to change patient care delivery,it is important for the organisation to understand the pa-tient outcomes that are sensitive to nursing interventionsand to examine the relationship between nurse staffing andoutcomes (Potter et al. 2003). There is a growing acknowl-edgement that successful interventions must deploy mul-tiple strategies, targeting aspects of the individual, the or-ganisation, its culture, and characteristics of the message,simultaneously (Kitson 2001). Thus, examining the avail-able literature, and in particular considering the findingsof Brown and McCormack (2005), it would appear thatthe three key constructs from the PARIHS framework (ev-idence, context, and facilitation) are vital to getting evi-dence into practice. Ultimately, successful implementationof pain management evidence into practice may not be de-pendent only on the aforementioned factors, but also onthe facilitator’s ability to lead changes in practice throughaction research.

RECOMMENDATIONS FOR PRACTICEAND FUTURE RESEARCH

Adopting a systematic approach by utilising the PARIHSframework has been advantageous in guiding the focusand structure of this article. The three key constructs(evidence, context, and facilitation) have identified theneed for the following:

� For health care professionals to draw upon clinicalopinion, patient experience, and research evidenceto develop person-centred pain practices.

� To obtain clarity relating to the many diverse andconflicting cultures that operate within the organisa-tional context—exploring further the way in whichthese cultures impact upon pain management andclinicians’ decision-making practices.

� To explore leadership issues—clarifying the role ofthe CNS and if or how CNS influence impacts uponpain management practices.

� To assist individuals and/or teams to focus on painmanagement issues and develop appropriate changestrategies through facilitation.

� To adopt a systematic and rigorous approach to ac-tion research, utilising conceptual frameworks (suchas PARIHS) as a guide to improve pain managementpractices.

AcknowledgmentsThe authors are grateful to the Royal Hospitals Trust Mul-tidisciplinary Research Fellowship Scheme for the research

grant that has enabled this work to be undertaken. The re-search currently underway is funded through the NorthernIreland Department of Health, Social Services and PublicSafety (DHSSPS) Doctoral Fellowship Scheme.

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