Pain Management and Mid Range Theory

Mid Range Theory and Pain Management

 Mid Range Theory and Postoperative Pain ,Analgesia and Its Effects ,Individual Response to Therapy,Responsibility of Nurse and Other Health Care Providers,Research and Hypothesis about Theory,Critical Review,Why Pain Management is Important .

Mid Range Theory and Postoperative Pain 

    The theory of a balance between analgesia and side effects proposes that multimodal therapy, attentive care, and patient education contribute to a balance between pain relief and minimal side effects of analgesic medication (Good, 1998, 2004; Good & Moore, 1996). 

    Multimodal therapy consists of a combination of strong analgesics and pharmacological adjuvants (eg, nonsteroidal anti-inflammatory drugs) plus nonpharmacological adjuvants (eg, relaxation, music, guided imagery). 

    Attentive care means vigilance and consists of regular assessment of pain and side effects, plus identification of inadequate relief, intervention, reassessment, and reintervention. Patient education consists of patient teaching for pain management and mutual goal setting between the nurse and patient. 

    The three principles are proposed to result in more relief and less side effects than simply giving analgesic medication (Good, 1996, 1998, 2004). 

    The theory is based on the premise that a balance between analgesia and its side effects is the desired goal in acute pain. It is a new conceptualization of acute pain management compared to the previous notion of only giving analgesics (Moore, SM, 2004).

Analgesia and Its Effects 

    The theory of a balance between analgesia and side effects is the first integrated, prescriptive nursing theory for acute pain management in adults. Middle-range nursing theories are more useful in practice and research if they have empirical support. 

    Useful sources of mid-range theories are clinical practice guidelines that are based on research and consensus of interdisciplinary experts. Such guidelines can provide a jump start for empirically based theories and a body of scientific knowledge for practicing nurses. 

    The resulting knowledge then can be taught, used, and developed further. The acute pain management guidelines published by the Agency for Health Care Policy and Research (Acute Pain Management Guideline Panel, 1992) were the source that Good and Moore (1996) used to develop a mid-range pain management theory.

Individual Response to Therapy

    Although analgesic medication is the mainstay of pain therapy after surgery, especially at first, there are large differences in individual response to pain and analgesics. In addition, there may be a mind body effect from relaxation and soft music. These non-pharmacological modalities have been found to reduce the pain further. 

    Good and colleagues (1999) found that they reduced pain up to 31% more than patient-controlled opioids alone at ambulation and rest. The findings supported the integrated mid-range intervention theory.

Responsibility of Nurse and Other Health Care Providers

    The assumptions of the theory are practical. 

First, the nurse and physician must have current knowledge of pain management and collaborate to achieve relief. 

Second, the theory is expected to be applied with acute pain in situations in which systemic opioid analgesics or epidural anesthesia are prescribed and medication for side effects is administered as needed. 

Third, it is applicable to adults who have the ability to learn, set goals, and communicate symptoms (Good, 1998, 2004;Good & Moore, 1996). 

    This theory has not been directly applied to labor pain, cognitively impaired adults, or patients with special problems such as opioid tolerance, shock, trauma, or burns. However, other theories can be developed from the acute pain management guidelines or from other practice guidelines. 

    For example, Huth and Moore (1998) published an integrated prescriptive theory of acute pain management for infants and children which has been supported by research (Huth, Broome, & Good, 2004). Ruland and Moore (1998) published a mid-range theory of the peaceful end of life based on existing standards of care.

Research and Hypothesis about Theory 

    Articles about this theory contain examples of testable research concepts and hypotheses that can be deduced from it. In addition, this literature contains hypothetical cases that ground the theory in reality and illustrate its use with surgical patients and in clinical research (Good, 1998, 2004). 

    It has been republished in part in a textbook of theory development (McEwen, 2002), and practicing nurses taking graduate courses ask about its usefulness for research and practice.

    When the theory was created, it was based on empirical support for two of its three propositions and on a consensus of experts for the third one about patient teaching and goal setting (Acute Pain Management Guideline Panel, 1992; Good & Moore, 1996). 

    Since then, there have been research findings that support the effect of nonpharmacological therapies in providing additional pain relief when used with analgesics after surgery (Good & Chin, 1998; Good et al., 2001; Good et al., 1999; Roykulcharoen & Good , in press). 

    These studies took place in the US, Taiwan, and Thailand. The largest was a randomized controlled trial of 500 abdominal surgical patients in the US, which demonstrated that jaw relaxation, music, and the combination of both had a small to medium effect size compared to analgesics alone. 

    Supported by the National Institute of Nursing Research (NINR), the interventions were effective on postoperative days 1 and 2 and at ambulation and rest (Good et al., 1999). The same music as used in the US study had large effects after gynecological surgery in Kaohsiung, Taiwan (Good & Chin). 

    A test of a longer, whole-body relaxation technique resulted in a large effect size in postoperative abdominal surgical patients in Bangkok, Thailand (Roykulcharoen & Good). 

    A current randomized controlled trial, funded by NINR, is underway to study the effects of nonpharmacological interventions on side effects of opioids after surgery and also the effects of patient teaching for pain management (Good, Anderson, Albert, & Wotman, 2001-2005).

Critical Review

    Critical reviews of this theory have noted the clear theoretical and operational definitions given and the clarity and consistency in the use of concepts and prescriptive propositions, making it easy to test in randomized controlled trials (Moore, SM, 2004; Suppe, 1996). 

    The theory presents a comprehensive approach to clinical management of acute pain, yet with only three propositions it is fairly parsimonious, which is important when teaching it to others. It is reality based, as is evident in the assumptions, concept names, and principles; they are in terms that practicing nurses can easily understand and use. 

    The criteria for a theory in the middle range are met. It is narrow in scope because it is limited to acute pain. It is appropriate for testing because hypotheses can be deduced. Nevertheless, it is abstract enough to be useful in practice (Moore, SM).

Why Pain Management is Important 

    Pain management is important to quality of life. Surgical events are critical stressors in people's lives a few days when nursing interventions are key factors in preventing ongoing pain and in patients' satisfaction and memory of the event. Pain is a complex phenomenon because human response to pain varies greatly. 

    Pain management is central to good nursing care and relief calls for continual growth of prescriptive knowledge for practitioners. Mid-range theories that clearly and parsimoniously describe this knowledge for nurses can help meet this basic human need in our society.     

    Although more research on the theory is needed and encouraged, what is known thus far can be used to educate the next generation of nurses on management of acute pain.