Publications by authors named "Judy Watt-Watson"

66 Publications

Development and usability testing of HEARTPA♀N: protocol for a mixed methods strategy to develop an integrated smartphone and web-based intervention for women with cardiac pain.

BMJ Open 2020 03 9;10(3):e033092. Epub 2020 Mar 9.

Patient Advisor, Toronto, Ontario, Canada.

Introduction: More women experience cardiac pain related to coronary artery disease and cardiac procedures compared with men. The overall goal of this programme of research is to develop an integrated smartphone and web-based intervention (HEARTPA♀N) to help women recognise and self-manage cardiac pain.

Methods And Analysis: This protocol outlines the mixed methods strategy used for the development of the HEARTPA♀N content/core feature set (phase 2A), usability testing (phase 2B) and evaluation with a pilot randomised controlled trial (RCT) (phase 3). We are using the individual and family self-management theory, mobile device functionality and pervasive information architecture of mHealth interventions, and following a sequential phased approach recommended by the Medical Research Council to develop HEARTPA♀N. The phase 3 pilot RCT will enable us to refine the prototype, inform the methodology and calculate the sample size for a larger multisite RCT (phase 4, future work). Patient partners have been actively involved in setting the HEARTPA♀N research agenda, including defining patient-reported outcome measures for the pilot RCT: pain and health-related quality of life (HRQoL). As such, the guidelines for Inclusion of Patient-Reported Outcomes in Clinical Trial Protocols (SPIRIT-PRO) are used to report the protocol for the pilot RCT (phase 3). Quantitative data (eg, demographic and clinical information) will be summarised using descriptive statistics (phases 2AB and 3) and a content analysis will be used to identify themes (phase 2AB). A process evaluation will be used to assess the feasibility of the implementation of the intervention and a preliminary efficacy evaluation will be undertaken focusing on the outcomes of pain and HRQoL (phase 3).

Ethics And Dissemination: Ethics approval was obtained from the University of Toronto (36415; 26 November 2018). We will disseminate knowledge of HEARTPA♀N through publication, conference presentation and national public forums (Café Scientifique), and through fact sheets, tweets and webinars.

Trial Registration Number: NCT03800082.
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http://dx.doi.org/10.1136/bmjopen-2019-033092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064127PMC
March 2020

Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study.

BMJ Open 2019 03 1;9(2):e022995. Epub 2019 Mar 1.

Anesthesiology, Perioperative Medicine and Surgical Research Unit, Population Health Research Institute, Hamilton, Ontario, Canada.

Introduction: Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not.

Methods And Analyses: In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score.

Ethics And Dissemination: This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals.

Trial Registration Number: NCT01842568.
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http://dx.doi.org/10.1136/bmjopen-2018-022995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398732PMC
March 2019

[Interprofessional pain education-with, from, and about competent, collaborative practice teams to transform pain care].

Schmerz 2019 Feb;33(1):66-72

Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.

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http://dx.doi.org/10.1007/s00482-018-0352-0DOI Listing
February 2019

Just how much does it cost? A cost study of chronic pain following cardiac surgery.

J Pain Res 2018 8;11:2741-2759. Epub 2018 Nov 8.

Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada,

Objective: The study objective was to determine use of pain-related health care resources and associated direct and indirect costs over a two-year period in cardiac surgery patients who developed chronic post-surgical pain (CPSP).

Methods: This multicentric observational prospective study recruited patients prior to cardiac surgery; these patients completed research assistant-administered questionnaires on pain and psychological characteristics at 6, 12 and 24 months post-operatively. Patients reporting CPSP also completed a one-month pain care record (PCR) (self-report diary) at each follow-up. Data were analyzed using descriptive statistics, multivariable logistic regression models, and generalized linear models with log link and gamma family adjusting for sociodemographic and pain intensity.

Results: Out of 1,247 patients, 18%, 13%, and 9% reported experiencing CPSP at 6, 12, and 24 months, respectively. Between 16% and 28% of CPSP patients reported utilizing health care resources for their pain over the follow-up period. Among all CPSP patients, mean monthly pain-related costs were CAN$207 at 6 months and significantly decreased thereafter. More severe pain and greater levels of pain catastrophizing were the most consistent predictors of health care utilization and costs.

Discussion: Health care costs associated with early management of CPSP after cardiac surgery seem attributable to a minority of patients and decrease over time for most of them. Results are novel in that they document for the first time the economic burden of CPSP in this population of patients. Longer follow-up time that would capture severe cases of CPSP as well as examination of costs associated with other surgical populations are warranted.

Summary: Economic burden of chronic post-surgical pain may be substantial but few patients utilize resources. Health utilization and costs are associated with pain and psychological characteristics.
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http://dx.doi.org/10.2147/JPR.S175090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235323PMC
November 2018

Evaluating an Innovative eLearning Pain Education Interprofessional Resource: A Pre-Post Study.

Pain Med 2019 01;20(1):37-49

Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada.

Objective: The challenges of moving the pain education agenda forward are significant worldwide, and resources, including online, are needed to help educators in curriculum development. Online resources are available but with insufficient evaluation in the context of prelicensure pain education. Therefore, this pre-post study examined the impact of an innovative eLearning model: the Pain Education Interprofessional Resource (PEIR) on usability, pain knowledge, beliefs, and understanding of pain assessment skills including empathy.

Methods: Participants were students (N = 96) recruited from seven prelicensure health sciences programs at the University of Toronto. They worked through three multifaceted modules, developed by an interprofessional team, that followed a patient with acute to persistent postsurgical pain up to one year. Module objectives, content, and assessment were based on International Association for the Study of Pain Pain Curricula domains and related pain core competencies. Multimedia interactive components focused on pain mechanisms and key pain care issues. Outcome measures included previously validated tools; data were analyzed in SPSS. Online exercises provided concurrent individual feedback throughout all modules.

Results: The completion rate for modules and online assessments was 100%. Overall usability scores (SD) were strong 4.27/5 (0.56). On average, pain knowledge scores increased 20% (P < 0.001). The Pain Assessment Skills Tool was sensitive to differences in student and expert pain assessment evaluation ratings and was useful as a tool to deliver formative feedback while engaged in interactive eLearning about pain assessment.

Conclusions: PEIR is an effective eLearning program with high student ratings for educational design and usability that significantly improved pain knowledge and understanding of collaborative care.
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http://dx.doi.org/10.1093/pm/pny105DOI Listing
January 2019

Self-Management of Cardiac Pain in Women: A Meta-Summary of the Qualitative Literature.

Qual Health Res 2018 09 19;28(11):1769-1787. Epub 2018 Jun 19.

1 University of Toronto, Toronto, Ontario, Canada.

Symptom recognition and self-management is instrumental in reducing the number of deaths related to coronary artery disease (CAD) in women. The purpose of this study was to synthesize qualitative research evidence on the self-management of cardiac pain and associated symptoms in women. Seven databases were systematically searched, and the concepts of the Individual and Family Self-Management Theory were used as the framework for data extraction and analysis. Search strategies yielded 22,402 citations, from which 35 qualitative studies were included in a final meta-summary, comprising data from 769 participants, including 437 (57%) women. The available literature focused cardiac pain self-management from a binary sex and gender perspective. Ethnicity was indicated in 19 (54%) studies. Results support individualized intervention strategies that promote goal setting and action planning, management of physical and emotional responses, and social facilitation provided through social support.
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http://dx.doi.org/10.1177/1049732318780683DOI Listing
September 2018

Perspective: update on pain education.

Pain 2018 Sep;159(9):1681-1682

Anesthesiology & Pain Medicine, School of Medicine, Harborview Integrated Pain Care Program, University of Washington, Seattle, WA, United States.

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http://dx.doi.org/10.1097/j.pain.0000000000001297DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6106863PMC
September 2018

Self-Management Interventions for Women With Cardiac Pain: A Systematic Review and Meta-analysis.

Can J Cardiol 2018 04 19;34(4):458-467. Epub 2017 Dec 19.

Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Background: Cardiac pain is considered the primary indicator of coronary artery disease (CAD). Existing reviews lack appropriate numbers of women or sex-based subgroup analyses, or both; thus, the benefits of self-management (women with cardiac pain actively participating in their own care and treatment) remain uncertain.

Methods: Using methods described by the Evidence for Policy and Practice Information and Co-ordinating Centre at the Institute of Education, 7 databases were systematically searched to examine and synthesize the evidence on self-management interventions for women with cardiac pain and cardiac pain equivalents, such as fatigue, dyspnea, and exhaustion.

Results: Our search yielded 22,402 article titles and abstracts. Of these, 57 randomized controlled trials were included in a final narrative synthesis, comprising data from 13,047 participants, including 5299 (41%) women. Self-management interventions targeting cardiac pain in women compared with a control population reduced (1) cardiac pain frequency and cardiac pain proportion (obstructive and nonobstructive CAD), (2) fatigue at 12 months, and (3) dyspnea at 2 months. There was no evidence of group differences in postprocedural (percutaneous coronary intervention or cardiac surgery) pain. Results indicated that self-management interventions for cardiac pain were more effective if they included a greater proportion of women (standardized mean difference [SMD], -0.01; standard error, 0.003; P = 0.02), goal setting (SMD, -0.26; 95% confidence interval [CI], -0.49 to -0.03), and collaboration/support from health care providers (SMD, -0.57; 95% CI, -1.00 to -0.14).

Conclusions: The results of this review suggest that self-management interventions reduce cardiac pain and cardiac pain equivalents.
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http://dx.doi.org/10.1016/j.cjca.2017.12.011DOI Listing
April 2018

Self-management of cardiac pain in women: an evidence map.

BMJ Open 2017 Nov 25;7(11):e018549. Epub 2017 Nov 25.

Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Objective: To describe the current evidence related to the self-management of cardiac pain in women using the process and methodology of evidence mapping.

Design And Setting: Literature search for studies that describe the self-management of cardiac pain in women greater than 18 years of age, managed in community, primary care or outpatient settings, published in English or a Scandinavian language between 1 January 1990 and 24 June 2016 using AMED, CINAHL, ERIC, EMBASE, MEDLINE, Proquest, PsychInfo, the Cochrane Library, Scopus, Swemed+, Web of Science, the Clinical Trials Registry, International Register of Controlled Trials, MetaRegister of Controlled Trials, theses and dissertations, published conference abstracts and relevant websites using GreyNet International, ISI proceedings, BIOSIS and Conference papers index. Two independent reviewers screened using predefined eligibility criteria. Included articles were classified according to study design, pain category, publication year, sample size, per cent women and mean age.

Interventions: Self-management interventions for cardiac pain or non-intervention studies that described views and perspectives of women who self-managed cardiac pain.

Primary And Secondary Outcomes Measures: Outcomes included those related to knowledge, self-efficacy, function and health-related quality of life.

Results: The literature search identified 5940 unique articles, of which 220 were included in the evidence map. Only 22% (n=49) were intervention studies. Sixty-nine per cent (n=151) of the studies described cardiac pain related to obstructive coronary artery disease (CAD), 2% (n=5) non-obstructive CAD and 15% (n=34) postpercutaneous coronary intervention/cardiac surgery. Most were published after 2000, the median sample size was 90 with 25%-100% women and the mean age was 63 years.

Conclusions: Our evidence map suggests that while much is known about the differing presentations of obstructive cardiac pain in middle-aged women, little research focused on young and old women, non-obstructive cardiac pain or self-management interventions to assist women to manage cardiac pain.

Prospero Registration Number: CRD42016042806.
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http://dx.doi.org/10.1136/bmjopen-2017-018549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719283PMC
November 2017

A Pain Education Intervention for Patients Undergoing Ambulatory Inguinal Hernia Repair: A Randomized Controlled Trial.

Can J Nurs Res 2017 Sep 20;49(3):108-117. Epub 2017 Jun 20.

3 School of Nursing, McMaster University, ON, Canada.

Background Inguinal hernia repair is a common ambulatory surgery after which many patients experience moderate to severe post-operative pain. Limited research has examined the effect of education interventions to reduce pain after ambulatory surgery. Purpose This trial evaluated the effectiveness of an individualized Hernia Repair Education Intervention (HREI) for patients following inguinal hernia repair. Method Pre-operatively, participants (N = 82) were randomized to either the intervention (HREI) or the usual care group. The HREI included written and verbal information regarding managing pain and two telephone support calls (before and after surgery). The primary outcome was WORST 24-h pain intensity on movement on post-operative day 2. Secondary outcomes included pain intensity at rest and movement, pain-related interference with activities, pain quality, analgesics consumed, and adverse effects at post-operative days 2 and 7. Results At day 2, the intervention group reported significantly lower scores across pain intensity outcomes, including WORST 24-h pain on movement and at rest (p < 0.001), and pain NOW on movement and at rest (p = 0.001). Conclusion These findings suggest that the HREI may improve patients' pain and function following ambulatory inguinal hernia repair. Further research should examine the effectiveness of an education intervention over a longer period of time.
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http://dx.doi.org/10.1177/0844562117714704DOI Listing
September 2017

Impact of marital status and comorbid disorders on health-related quality of life after cardiac surgery.

Qual Life Res 2017 09 8;26(9):2421-2434. Epub 2017 May 8.

Faculty of Health Sciences, Institute of Nursing, Oslo and Akershus University College of Applied Sciences, Oslo, Norway.

Purpose: To explore associations between HRQL, marital status, and comorbid disorders in men and women following cardiac surgery.

Method: A secondary analysis was completed using data from a randomized controlled trial in which 416 individuals (23% women) scheduled for elective coronary artery bypass graft and/or valve surgery were recruited between March 2012 and September 2013. HRQL was assessed using the Health State Descriptive System (15D) preoperatively, then at 2 weeks, and at 3, 6, and 12 months following cardiac surgery. Linear mixed model analyses were performed to explore associations between HRQL, social support, and comorbid disorders.

Results: The overall 15D scores for the total sample improved significantly from 2 weeks to 3 months post surgery, with only a gradual change observed from 3 to 12 months. Thirty percent (n = 92) of the total sample reported a lower 15D total score at 12 months compared to preoperative status, of whom 78% (n = 71) had a negative minimum important differences (MID), indicating a worse HRQL status. When adjusted for age and marital status, women had statistically significant lower 15D total scores compared to men at 3, 6, and 12 months post surgery. Compared to pre-surgery, improvement was demonstrated in 4 out of 15 dimensions of HRQL for women, and in 6 out of 15 dimensions for men at 12 months post surgery. Both men and women associated back/neck problems, depression, and persistent pain intensity with lower HRQL; for women, not living with a partner/spouse was associated with lower HRQL up to 12 months.

Conclusion: Women experienced decreased HRQL and a slower first-year recovery following cardiac surgery compared to men. This study demonstrates a need for follow-up and support to help women manage their symptoms and improve their function within the first year after cardiac surgery. This was particularly pronounced for those women living alone.
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http://dx.doi.org/10.1007/s11136-017-1589-2DOI Listing
September 2017

The Pain Interprofessional Curriculum Design Model.

Pain Med 2017 06;18(6):1040-1048

Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.

Objective: Although the University of Toronto Centre for the Study of Pain has successfully implemented an Interfaculty Pain Curriculum since 2002, we have never formalized the process in a design model. Therefore, our primary aim was to develop a model that provided an overview of dynamic, interrelated elements that have been important in our experience. A secondary purpose was to use the model to frame an interactive workshop for attendees interested in developing their own pain curricula.

Methods: The faculties from Dentistry, Medicine, Nursing, Occupational Therapy, Pharmacy, and Physical Therapy met to develop the model components. Discussion focused on patient-centered pain assessment and management in an interprofessional context, with pain content being based on the International Association for the Study of Pain-Interprofessional Pain Curriculum domains and related core pain competencies. Profession-specific requirements were also considered, including regulatory/course requirements, level of students involved, type of course delivery, and pedagogic strategies.

Results: The resulting Pain Interprofessional Curriculum Design Model includes components that are dynamic, competency-based, collaborative, and interrelated. Key questions important to developing curricular components guide the process. The Model framed two design workshops with very positive responses from international and national attendees.

Conclusions: The Pain Interprofessional Curriculum Design Model is based on established pain curricula and related competencies that are relevant to all health science students at the prelicensure (entry-to-practice) level. The model has been developed from our experience, and the components resonated with workshop attendees from other regions. This Model provides a basis for future interventions in curriculum design and evaluation.
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http://dx.doi.org/10.1093/pm/pnw337DOI Listing
June 2017

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol.

JMIR Res Protoc 2016 Aug 1;5(3):e149. Epub 2016 Aug 1.

McMaster University, Hamiltion, ON, Canada.

Background: Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT-VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom.

Objective: Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT).

Methods: CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise-death, myocardial infarction, and nonfatal stroke- all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups.

Results: Study start-up is underway and usability testing is scheduled to begin in the fall of 2016.

Conclusions: Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.
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http://dx.doi.org/10.2196/resprot.5763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4999307PMC
August 2016

Patients' experiences of enhanced recovery after surgery: a systematic review of qualitative studies.

J Clin Nurs 2017 May 9;26(9-10):1172-1188. Epub 2017 Feb 9.

Diakonhjemmet University College, Institute of Nursing and Health, Oslo, Norway.

Aims And Objectives: To aggregate, interpret and synthesise findings from qualitative studies to further our knowledge regarding patients' pre- and postoperative experiences when participating in an enhanced recovery after surgery.

Background: Numerous quantitative studies have documented benefits of participation in enhanced recovery after surgery programmes. Randomised control trials show that enhanced recovery after surgery reduce patient morbidity and shorten hospital length of stay. However, we presently have only sparse knowledge regarding patients' experiences of participating in these programmes.

Design: A qualitative systematic review and meta-synthesis.

Methods: A systematic literature search of databases (Cinahl, Medline, PsycINFO, Ovid Nursing, and EMBASE) for qualitative studies published between 2000-2014 were undertaken. The identified studies were critically evaluated using the Critical Appraisal Skills Program, and patient experiences were synthesised into new themes by a team of researchers, using qualitative content analysis.

Results: Eleven studies were included. Upon analysis, four main themes emerged: information transfer, individualised treatment vs. standardised care, balancing burdensome symptoms and expectations for rapid recovery, and sense of security at discharge. Information helped patients feel secure and prepared for surgery. Patients reported being motivated to participate in their recovery process. However, this became challenging when they faced symptoms such as pain, nausea, and weakness. Professional support fostered a feeling of security that was important in helping patients continue their regimen, recover, and be discharged as early as planned.

Conclusions: Patients in enhanced recovery after surgery programmes desired more consistency between pre- and postoperative information. Important opportunities exist to improve symptom management and help patients feel more secure about recovery postoperatively.

Relevance To Clinical Practice: Nurses are in a unique position to improve communication of standardised regimens and enhance symptom management across the perioperative period. Clinical outreach, such as follow-up visits or phone calls, could target older adults who need additional assistance to meet enhanced recovery after surgery programme goals and derive benefit.
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http://dx.doi.org/10.1111/jocn.13456DOI Listing
May 2017

The quest of pain education leaders in Canada and the United States: a qualitative study.

J Adv Nurs 2016 Nov 19;72(11):2728-2737. Epub 2016 Jul 19.

Faculty of Nursing, University of Calgary, Alberta, Canada.

Aims: To determine key factors that stimulate and drive the ongoing interests of leaders in the field of pain to continue to work for change and to explore how they use their own experiences in their teaching.

Background: The assessment and management of acute and chronic pain remains a challenge and the pain education of pre-licensure/undergraduate health professionals (e.g. nurses, physicians, etc.) continues to be suboptimal. Understanding the motivations of pain leaders may provide insights to facilitate the future development of pain clinicians.

Design: A Narrative enquiry.

Methods: A purposeful sample of 17 Canadian and USA leaders in pain education participated. Data were collected between September 2012-January 2013 using recorded semi-structured telephone interviews. Transcripts were coded to provide storied experiences (themes).

Findings: Six themes were identified as a stimulus for pain leaders: An early pain experience, mentorship and circumstances, a personal shift in understanding, catalysts (institutional or political), recognition of barriers and a determination to improve. Their work towards change appeared to be motivated by their pain 'quest' where leaders embraced their personal experiences of pain, a need for social action and individual change.

Conclusions: Educational approaches for health professionals usually focus on the importance of knowledge, skills and attitudes to be competent in pain care. To inspire and educate young health professionals about pain management we suggest the development of future pain leaders may require a different approach that recognizes personal stories of pain, includes a local pain champion and incorporates a model of mentorship.
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http://dx.doi.org/10.1111/jan.13050DOI Listing
November 2016

Pain experiences of men and women after cardiac surgery.

J Clin Nurs 2016 Oct 15;25(19-20):3058-68. Epub 2016 Jun 15.

Faculty of Health Sciences, Institute of Nursing, Oslo, Norway.

Aims And Objectives: To compare the prevalence and severity of pain in men and women during the first year following cardiac surgery and to examine the predictors of persistent postoperative pain 12 months post surgery.

Background: Persistent pain has been documented after cardiac surgery, with limited evidence for differences between men and women.

Design: Prospective cohort study of patients in a randomised controlled trial (N = 416, 23% women) following cardiac surgery.

Methods: Secondary data analysis of data collected prior to surgery, across postoperative days 1-4, at two weeks, and at one, three, six and 12 months post surgery. The main outcome was worst pain intensity (Brief Pain Inventory-Short Form).

Results: Twenty-nine percent (97/339) of patients reported persistent postoperative pain at rest at 12 months that was worse in intensity and interference for women than for men. For both sexes, a more severe co-morbidity profile, lower education and postoperative pain at rest at one month post surgery were associated with an increased probability for persistent postoperative pain at 12 months. Women with more concerns about communicating pain and a lower intake of analgesics in the hospital had an increased probability of pain at 12 months.

Conclusion: Sex differences in pain are present up to one year following cardiac surgery. Strategies for sex-targeted pain education and management pre- and post-surgery may lead to better pain outcomes.

Relevance To Clinical Practice: These results suggest that informing patients (particularly women) about the benefits of analgesic use following cardiac surgery may result in less pain over the first year post discharge.
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http://dx.doi.org/10.1111/jocn.13329DOI Listing
October 2016

The impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery.

Eur J Cardiovasc Nurs 2017 01 7;16(1):18-27. Epub 2016 Jul 7.

7 Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Institute of Nursing, Norway.

Background: Relevant discharge information about the use of analgesic medication and other strategies may help patients to manage their pain more effectively and prevent postoperative persistent pain.

Aims: To examine patients' pain characteristics, analgesic intake and the impact of an educational pain management booklet intervention on postoperative pain control after cardiac surgery. Concerns about pain and pain medication prior to surgery will also be described.

Methods: From March 2012 to September 2013, 416 participants (23% women) were consecutively enrolled in a randomized controlled trial. The intervention group received usual care plus an educational booklet at discharge with supportive telephone follow-up on postoperative day 10, and the control group received only usual care. The primary outcome was worst pain intensity (The Brief Pain Inventory - Short Form). Data about pain characteristics and analgesic use were collected at 2 weeks and at 1, 3, 6 and 12 months post-surgery. General linear mixed models were used to determine between-group differences over time.

Results: Twenty-nine percent of participants reported surgically related pain at rest and 9% reported moderate to severe pain at 12 months post-surgery. Many participants had concerns about pain and pain medication, and analgesic intake was insufficient post-discharge. No statistically significant differences between the groups were observed in terms of the outcome measures following surgery.

Conclusion: Postoperative pain and inadequate analgesic use were problems for many participants regardless of group allocation, and the current intervention did not reduce worst pain intensity compared with control. Further examination of supportive follow-up monitoring and/or self-management strategies post-discharge is required.
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http://dx.doi.org/10.1177/1474515116631680DOI Listing
January 2017

An interprofessional consensus of core competencies for prelicensure education in pain management: curriculum application for nursing.

J Nurs Educ 2015 Jun;54(6):317-27

Background: Ineffective assessment and management of pain is a significant problem. A gap in prelicensure health science program pain content has been identified for the improvement of pain care in the United States.

Method: Through consensus processes, an expert panel of nurses, who participated in the interdisciplinary development of core competencies in pain management for prelicensure health professional education, developed recommendations to address the gap in nursing curricula.

Results: Challenges and incentives for implementation of pain competencies in nursing education are discussed, and specific recommendations for how to incorporate the competencies into entry-level nursing curricula are provided.

Conclusion: Embedding pain management core competencies into prelicensure nursing education is crucial to ensure that nurses have the essential knowledge and skills to effectively manage pain and to serve as a foundation on which clinical practice skills can be later honed. [J Nurs Educ. 2015;54(6):317-327.].
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http://dx.doi.org/10.3928/01484834-20150515-02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462171PMC
June 2015

Pain Assessment and Management in Canada: We've Come a Long Way but there are Challenges on the Road Ahead.

Can J Nurs Res 2015 Mar;47(1):9-16

Faculty of Nursing, University of Toronto, Ontario.

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http://dx.doi.org/10.1177/084456211504700102DOI Listing
March 2015

Pain characteristics and analgesic intake before and following cardiac surgery.

Eur J Cardiovasc Nurs 2016 Feb 5;15(1):47-54. Epub 2014 Sep 5.

Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Institute of Nursing, Norway.

Background: Cardiac surgery is a common intervention that involves several pain-sensitive structures, and intense postoperative pain is a predictor of persistent pain.

Aims: To describe pain characteristics (i.e. intensity, location, interference, relief) and analgesic intake preoperatively and across postoperative days 1 to 4 after cardiac surgery, and to explore associations between postoperative pain and demographic and clinical characteristics.

Methods: Four hundred and sixteen patients (24% women) undergoing elective coronary artery bypass grafting and/or valve surgery were enrolled in a randomized controlled trial. Data were collected using standardized measures including the Brief Pain Inventory-short form. A linear mixed model analysis estimated the impact of sex, age, body mass index, analgesic intake and preoperative pain on postoperative worst pain ratings in the previous 24 hours from postoperative days 1 to 4 prior to discharge

Results: Thirty-eight per cent of the cardiac surgery patients reported preoperative pain. Postoperative worst pain remained in the moderate to severe range for the majority of patients across day 1 (85%) to day 4 (57%), mainly around the chest incision area for the majority (70%). Mean oral morphine intake was 17 mg/24 h (day 1: 27mg; day 4: 10mg). Lower age, female sex, preoperative pain and analgesic intake had a statistically significant association with higher postoperative worst pain ratings.

Conclusion: Study findings demonstrated a high prevalence of moderate to severe pain after cardiac surgery and insufficient analgesic administration. Results indicated that patients were discharged from hospital with unrelieved pain and a potential risk for further postoperative complications.
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http://dx.doi.org/10.1177/1474515114550441DOI Listing
February 2016

Persistent postoperative nonanginal pain after cardiac surgery.

CMAJ 2014 Aug;186(11):855

Centre de recherche de Centre hospitalier de l'Université de Montréal (Choinière); Département d'anesthésiologie (Choinière), Université de Montréal; Montreal Heart Institute Research Centre (Choinière), Montréal, Que.; Faculty of Nursing (Watt-Watson), University of Toronto; Toronto, Ont.

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http://dx.doi.org/10.1503/cmaj.114-0057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119150PMC
August 2014

Content validity of the Toronto Pain Management Inventory-Acute Coronary Syndrome Version.

Can J Cardiovasc Nurs 2014 ;24(2):11-8

Background: Cardiac pain and/or discomfort arising from acute coronary syndromes (ACS) can often be severe and anxiety-provoking. Cardiac pain, a symptom of impaired myocardial perfusion, if left untreated, may lead to further myocardial hypoxia, which can potentiate myocardial damage. Evidence suggests that once ACS patients are stabilized, their pain may not be adequately assessed. Lack of knowledge and problematic beliefs about pain may contribute to this problem. To date, no standardized tools are available to examine nurses' specific knowledge and beliefs about ACS pain that could inform future educational initiatives.

Aim: To examine the content validity of the Toronto Pain Management Inventory-ACS Version (TPMI-ACS), a 24-item tool designed to assess nurses' knowledge and beliefs about ACS pain assessment and management.

Methods: Eight clinical and scientific experts rated the relevance of each item using a four-point scale. A content validity index was computed for each item (I-CVI), as well as the total scale, expressed as the mean item CVI (S-CVI/AVE). Items with an I-CVI > or = 0.7 were retained, items with an I-CVI ranging from 0.5-0.7 were revised and clarified, and items with an I-CVI < or = 0.5 were discarded.

Results: I-CVIs ranged from 0.5-1.0 and the S-CVI/AVE was 0.90, reflecting high inter-rater agreement across items. The least relevant item was eliminated.

Conclusions: Preliminary content validity was established on the TPMI-ACS version. All items retained in the TPMI-ACS version met requirements for content validity. Further evaluation of the psychometric properties of the TPMI-ACS is needed to establish criterion and construct validity, as well as reliability indicators.
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July 2014

Patients' perceptions of joint replacement care in a changing healthcare system: a qualitative study.

Healthc Policy 2014 Feb;9(3):55-66

Department of Anaesthesia, Faculty of Medicine, University of Toronto, Toronto, ON.

Background: Ontario has introduced strategies over the past decade to reduce wait times and length of stay and improve access to physiotherapy for orthopaedic and other patients. The aim of this study is to explore patients' experiences of joint replacement care during a significant system change in their care setting.

Methods: A secondary analysis was done on semi-structured qualitative interviews that were conducted in 2009 with 12 individuals who had undergone at least two hip or knee replacements five years apart at a specialized orthopaedic centre in Ontario, Canada. Interview transcripts were coded and then organized into themes.

Results: Although the original study aimed to capture participants' experiences with changes in anaesthetic technique between their first and second joint replacements, the participants described several unrelated differences in the care they received during this period. For example, participants had difficulty obtaining a referral to an orthopaedic surgeon from their family physician. They also noted that the hospital stay and in-hospital physiotherapy they received were shorter after the second joint replacement surgery. They identified guidance from physiotherapists as an important component of their recovery, but sometimes had difficulty arranging physiotherapy after hospital discharge following their most recent surgery.

Conclusions: The changes described between the first and second joint replacements provide the participants' perspective on the impact of policy changes on wait times, reduced lengths of hospital stay and physiotherapy access. The impact of these policy changes, often made in an attempt to improve access to care, had an unintended and detrimental effect on participants' perceptions and experiences of the quality of care provided.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999571PMC
February 2014

Current challenges in pain education.

Pain Manag 2013 Sep;3(5):351-7

LS Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.

SUMMARY The continuing high prevalence of pain, both acute and persistent, is a public health problem. Improving pain curricula for health professionals is essential if we are to change the current ineffective practices related to pain prevention and management. An important question for all educators is whether our graduates are sufficiently competent in pain knowledge and skills to give appropriate pain care. In addition, deficiencies in our current education approaches need to be examined, including the key challenges that limit our moving the pain agenda forward. Limiting factors considered in this article include issues related to regulatory system requirements, curriculum priorities and resources, faculty qualifications and the need for collaboration with clinicians, traditional beliefs about patients and opportunities for interprofessional learning. Recent innovative advances are discussed related to curriculum resources, development of core pain competencies and creative learning models, including interprofessional ones. Suggested approaches to advocating for pain education changes are also included.
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http://dx.doi.org/10.2217/pmt.13.39DOI Listing
September 2013

Test of a Process Evaluation Checklist to improve neonatal pain practices.

West J Nurs Res 2015 May 27;37(5):581-98. Epub 2014 Feb 27.

University of Toronto, Ontario, Canada.

The Evidence-Based Practice Identification and Change (EPIC) strategy is a multifaceted knowledge translation intervention. Although the intervention promoted evidence-based practice, the process of delivering the intervention components is not well understood. The purpose of this study was to determine the construct validity of the Process Evaluation Checklist developed for monitoring the fidelity of implementing the intervention to improve neonatal pain practices (i.e., documentation of ordering and administration of sucrose). A case study design was used. A research practice council in a single Neonatal Intensive Care Unit implemented the intervention. The Process Evaluation Checklist was used to record adherence in carrying out the intervention components. A significant improvement in the documentation of sucrose orders (p = .002) and administration (p = .004) provided evidence of the construct validity of this intervention fidelity measure. Using this measure in different contexts over longer periods of time will further validate the Process Evaluation Checklist.
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http://dx.doi.org/10.1177/0193945914524493DOI Listing
May 2015

Prevalence of and risk factors for persistent postoperative nonanginal pain after cardiac surgery: a 2-year prospective multicentre study.

CMAJ 2014 Apr 24;186(7):E213-23. Epub 2014 Feb 24.

Background: Persistent postoperative pain continues to be an underrecognized complication. We examined the prevalence of and risk factors for this type of pain after cardiac surgery.

Methods: We enrolled patients scheduled for coronary artery bypass grafting or valve replacement, or both, from Feb. 8, 2005, to Sept. 1, 2009. Validated measures were used to assess (a) preoperative anxiety and depression, tendency to catastrophize in the face of pain, health-related quality of life and presence of persistent pain; (b) pain intensity and interference in the first postoperative week; and (c) presence and intensity of persistent postoperative pain at 3, 6, 12 and 24 months after surgery. The primary outcome was the presence of persistent postoperative pain during 24 months of follow-up.

Results: A total of 1247 patients completed the preoperative assessment. Follow-up retention rates at 3 and 24 months were 84% and 78%, respectively. The prevalence of persistent postoperative pain decreased significantly over time, from 40.1% at 3 months to 22.1% at 6 months, 16.5% at 12 months and 9.5% at 24 months; the pain was rated as moderate to severe in 3.6% at 24 months. Acute postoperative pain predicted both the presence and severity of persistent postoperative pain. The more intense the pain during the first week after surgery and the more it interfered with functioning, the more likely the patients were to report persistent postoperative pain. Pre-existing persistent pain and increased preoperative anxiety also predicted the presence of persistent postoperative pain.

Interpretation: Persistent postoperative pain of nonanginal origin after cardiac surgery affected a substantial proportion of the study population. Future research is needed to determine whether interventions to modify certain risk factors, such as preoperative anxiety and the severity of pain before and immediately after surgery, may help to minimize or prevent persistent postoperative pain.
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http://dx.doi.org/10.1503/cmaj.131012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986330PMC
April 2014

Improving pain practices through core competencies.

Pain Med 2013 Jul 3;14(7):966-7. Epub 2013 May 3.

The Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/pme.12130DOI Listing
July 2013

Core competencies for pain management: results of an interprofessional consensus summit.

Pain Med 2013 Jul 11;14(7):971-81. Epub 2013 Apr 11.

Department of Anesthesiology and Pain Medicine, School of Medicine, University of California, Davis, Sacramento, California 95817, USA.

Objective: The objective of this project was to develop core competencies in pain assessment and management for prelicensure health professional education. Such core pain competencies common to all prelicensure health professionals have not been previously reported.

Methods: An interprofessional executive committee led a consensus-building process to develop the core competencies. An in-depth literature review was conducted followed by engagement of an interprofessional Competency Advisory Committee to critique competencies through an iterative process. A 2-day summit was held so that consensus could be reached.

Results: The consensus-derived competencies were categorized within four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management. These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations, and care team models. A set of values and guiding principles are embedded within each domain.

Conclusions: These competencies can serve as a foundation for developing, defining, and revising curricula and as a resource for the creation of learning activities across health professions designed to advance care that effectively responds to pain.
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http://dx.doi.org/10.1111/pme.12107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752937PMC
July 2013

The ethics of Canadian entry-to-practice pain competencies: how are we doing?

Pain Res Manag 2013 Jan-Feb;18(1):25-32

University of Toronto, Toronto, Ontario, Canada.

Background: Although unrelieved pain continues to represent a significant problem, prelicensure educational programs tend to include little content related to pain. Standards for professional competence strongly influence curricula and have the potential to ensure that health science students have the knowledge and skill to manage pain in a way that also allows them to meet professional ethical standards.

Objectives: To perform a systematic, comprehensive examination to determine the entry-to-practice competencies related to pain required for Canadian health science and veterinary students, and to examine how the presence and absence of pain competencies relate to key competencies of an ethical nature.

Methods: Entry-to-practice competency requirements related to pain knowledge, skill and judgment were surveyed from national, provincial and territorial documents for dentistry, medicine, nursing, pharmacy, occupational therapy, physiotherapy, psychology and veterinary medicine.

Results: Dentistry included two and nursing included nine specific pain competencies. No references to competencies related to pain were found in the remaining health science documents. In contrast, the national competency requirements for veterinary medicine, surveyed as a comparison, included nine pain competencies. All documents included competencies pertaining to ethics.

Conclusions: The lack of competencies related to pain has implications for advancing skillful and ethical practice. The lack of attention to pain competencies limits the capacity of health care professionals to alleviate suffering, foster autonomy and use resources justly. Influencing professional bodies to increase the number of required entry-to-practice pain competencies may ultimately have the greatest impact on education and practice.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665434PMC
http://dx.doi.org/10.1155/2013/179320DOI Listing
April 2013