Context Matters for Nurses Leading Pain Improvement in U.S. Hospitals

Background: Pain continues to be a problem in hospitalized patients. Contextual factors contribute to the success of pain quality improvement efforts. Aims: This paper describes nurse team leaders’ perceptions of organizational context and factors perceived to help and hinder the process of leading a unit-based improvement effort focused on pain. Design: Qualitative descriptive design. Setting: Interviews took place over the telephone. Participants: Nurses from 106 hospitals across the United States. Methods: Investigators interviewed 125 nurses leading a unit-based pain quality improvement project in partnership with the National Database of Nursing Quality Indicators. Lewin's Field Theory guided a thematic analysis. Results: Key contextual factors related to the amount of change in the health care environment and characteristics of the organization and providers. Helping forces included characteristics of nurses, teamwork, a culture of quality, opportunities for learning, pain management resources, and accountability for pain management. Hindering forces included: barriers to involvement, attitudes and relationships, lack of knowledge, and types of patients. Conclusions: Overcoming the pervasive barriers of constant change and lack of staff involvement while also capitalizing on the culture of quality and characteristics of the health care team may further enhance and sustain improvement efforts related to pain management of hospitalized patients. New models for influencing quality improvement could be strengthened with involving frontline staff in both planning and implementation of improvement efforts. Clinical Implications: Because of the diverse responses, it is recommended that each unit conduct a force-field analysis to guide successful implementation of improvement efforts.