This study’s findings shed new light on the utilization of non-pharmacologic interventions for adult patients undergoing turning procedures within hospital environments. Notably, these interventions were observed to be employed more frequently than opioid pre-medication. The most prevalent non-pharmacologic methods included employing a calming voice, providing patients with information, and guiding them in deep breathing exercises. Furthermore, the application of these interventions was linked to specific clinical characteristics, such as the patient’s diagnosis and level of care, alongside certain demographic factors.
A significant observation was the frequent use of non-pharmacologic interventions, with 93% of patients receiving at least one, and 26% benefiting from five or more. Existing literature offers limited data on the frequency of non-pharmacologic interventions for procedural pain, with studies on acute pain suggesting less frequent use. However, this study, known as Thunder II ®, presented a more comprehensive list of non-pharmacologic interventions, potentially contributing to this variation. It’s also plausible that non-pharmacologic interventions are more commonly applied for procedural pain compared to acute pain. This increased usage in procedures may stem from the consistent presence of a nurse, who can initiate or guide patients in techniques like deep breathing during these moments. Another contributing factor could be the predictable and relatively short duration of procedures, particularly turning, making the integration of these interventions more feasible.
The study raises concerns about the infrequent use of analgesic pre-medication. The unpredictable timing of turning, often requiring two individuals, might limit nurses’ opportunities for timely pre-medication. Consequently, when patients experienced pain during turning, both patients and caregivers might have resorted to alternative pain management strategies. The underutilization of medication is a significant issue, especially considering the pain levels reported by patients during turning. Enhanced nursing awareness and a focus on prioritizing pre-medication whenever possible could be crucial in reducing pain associated with this routine procedure. Moreover, exploring the combined effectiveness of pharmacologic and non-pharmacologic interventions during turning procedures presents a promising avenue for optimal pain management, warranting further investigation.
The interventions most frequently employed during turning encompassed calming voice, providing information, deep breathing, gentle touch and hand holding, distraction techniques, pillow splinting for support, and humor. These methods are generally straightforward to implement, requiring minimal equipment or specialized training. Conversely, interventions necessitating equipment and/or training, such as Transcutaneous Electrical Nerve Stimulation (TENS), music therapy, and guided imagery, were less frequently utilized. These findings align with the realities of busy acute and critical care settings, where ease of application is paramount.
Interestingly, the non-pharmacologic interventions extensively studied for efficacy do not entirely align with those most frequently used in this study. For instance, a substantial body of research focuses on music therapy for procedural pain. Yet, music was used in only 1.9% of cases in this study. Calming voice, gentle touch, pillow splinting, and humor, which were among the most frequently used interventions, have limited or no existing research on their effectiveness for procedural pain. While this study did not assess the efficacy of these interventions, identifying their prevalence and predictors of use lays a crucial groundwork for future research endeavors.
Among the frequently used interventions in this study, only information provision and deep breathing have been evaluated in prior research. Lang and colleagues (2005) investigated the link between pain intensity and providing information about potential painful sensations, such as “sharp” or “stinging,” during interventional radiology procedures. Intriguingly, patients informed about expected pain or noxious stimuli reported higher procedural pain intensity scores compared to those who were not pre-warned. In another study, Puntillo and colleagues (2004) examined the addition of sensory information to pharmacologic analgesia for chest tube removal. Sensory information described anticipated sensations like aching, sharp, or stinging. The study found no significant differences in pain intensity and distress between patients receiving sensory information with analgesia versus those receiving analgesia alone. These studies suggest that information alone may not effectively alleviate procedural pain.
Deep breathing’s effectiveness in procedural pain management has been assessed in two studies. Friesner and colleagues (2006) discovered that patients performing deep breathing exercises (inhaling through the nose and exhaling slowly through pursed lips) alongside opioids experienced a significant reduction in pain intensity scores during chest tube removal compared to those receiving only opioids. In a randomized clinical trial by Lang et al. (2000), patients undergoing percutaneous vascular and renal procedures were assigned to a self-hypnosis group (instructed to close eyes, breathe deeply, and focus on a floating sensation) (n=82). This group reported consistent procedural pain levels, contrasting with increased pain in attention control (n=80) and standard care groups (n=79). This indicates that hypnosis interventions including deep breathing might lessen procedural pain. However, as the hypnotic intervention combined eye closure and focus on floating sensations, the isolated impact of deep breathing remains unclear. Nonetheless, both studies offer some evidence that deep breathing could help ease procedural pain.
Considering the efficacy of the most frequently used non-pharmacologic interventions highlighted in this study, the evidence is varied. There is a lack of data on calming voice effectiveness; information may be ineffective or even detrimental to pain management; while deep breathing shows potential in pain alleviation. It is important to note that all this data pertains to procedures other than patient turning. Given the limited research, the generalizability of findings across different procedures is uncertain. Randomized controlled trials are essential to determine the effectiveness of various non-pharmacologic interventions, leading to the development of evidence-based guidelines for specific procedures like patient turning.
This study also explored demographic and clinical characteristics influencing the use of calming voice, deep breathing, and information interventions, when considered with other factors. Logistic regression analyses indicated that clinical factors generally had a greater impact on non-pharmacologic intervention use than demographic factors. Age, as a demographic variable, was not a predictor, suggesting that while age is inversely related to reported pain levels, it was not associated with non-pharmacologic intervention use during turning. Among clinical characteristics, critical care settings and pain intensity during turning consistently increased the likelihood of patients receiving these three non-pharmacologic interventions. The setting-related finding might be attributed to greater nursing experience and improved nurse-patient ratios in Intensive Care Units (ICUs). Critical care nurses often possess more experience and manage fewer patients, potentially allowing more time for turning procedures and greater comfort and skill in applying multiple interventions. Patient pain intensity may also drive non-pharmacologic intervention use; nurses aware of a patient’s pain during turning might proactively respond with readily available non-pharmacologic strategies. Similarly, patients experiencing pain during turning might self-initiate interventions like deep breathing.
Despite these novel findings, this study has limitations. Combining data from patient, nurse, and other responses obscures who initiated interventions and whether provider type influences intervention success. However, the study prioritized capturing overall non-pharmacologic intervention use in this exploratory phase over identifying the performer. The observational design prevents evaluating the effectiveness of the non-pharmacologic interventions for turning. The positive association between pain and non-pharmacologic intervention use highlights this limitation. Another limitation is the convenience sample, not random, which could introduce selection bias and limit generalizability. However, the large sample size across numerous units in multiple hospitals is a strength.
While the large, multi-site sample enhances generalizability, it can also lead to statistical overpowering, potentially yielding significant results by chance. However, key findings like non-pharmacologic intervention frequency are purely descriptive and not influenced by statistical power. For univariate and logistic regression analyses, most significant findings surpassed a more stringent significance level (p<.01 or p<.001). A further sample limitation is its limited ethnic diversity, predominantly White (86.3%) with a small African-American group (7.1%). This ethnic distribution limits the findings’ applicability to Asian, Latino, and other diverse patient populations. Future studies should incorporate sampling strategies to ensure more ethnically diverse representation.
