Care by districts nurses : management of patients with chronic-pain conditions, patient satisfaction and effects of pain advisers

Abstract: This thesis focuses on some aspects of primary health care in Sweden before and after the introduction of "pain advisers": the district nurses opinions regarding their knowledge, management and documentation of patients with chronic-pain conditions, the review of the district nurses documentation of these patients and these patients opinions of the care and their own well-being. Moreover, it focuses on patients satisfaction with the primary health care given by the district nurses (not only patients with chronic-pain conditions). In order to make a controlled study design for the four studies with the focus on chronic-pain conditions, a study area (SA, 5 PHCCs = primary-health-care centres) and a control area (CA, 7 PHCCs) were selected within the South-western Health-care Region in Stockholm. In the first study, before starting the education and introduction of the "pain advisers" in the SA, all 72 district nurses at the 12 PHCCs included were asked to fill in a questionnaire. The questionnaire was answered by 70 (97%) of the district nurses. The results showed that 85% of the district nurses met patients with chronic pain at least once a week and that no PHCC had any written information or policy on pain control. Many district nurses (27-69%) were dissatisfied with the present management of patients with chronic pain at their PHCCs, their own knowledge of pain control and their own documentation. Furthermore, their opinions regarding pain management varied depending on their satisfaction with their own management of the patients pain problems. In the second study, 32 (94%) district nurses in the SA answered a questionnaire before and 36 (97%) after the introduction of the "pain advisers". The corresponding figures for the CA were 38 (100%) and 27 (75%), respectively. According to the district nurses, several improvements were made after the training and introduction of five of them as "pain advisers" in the SA: e.g. more district nurses reported that pain policies now existed at the PHCCs, and they also reported an increased satisfaction with the routines regarding pain management at their PHCCs and an increased, individual, pain assessment of the patients. In the third study, the district nurses documentation of patients with chronic-pain conditions was reviewed. A total of 144 (56 SA, 88 CA) patients records were reviewed before and 104 (76 SA, 28 CA) after the introduction and support of "pain advisers". At the follow-up in 1998, a more detailed description of the chronic pain was found in the SA. In the fourth study, a total of 84 (34 SA, 50 CA, answering rate 67%) patients answered a study-specific questionnaire in 1996 and 60 (43 SA, 17 CA, answering rate 77%) patients in 1998. It revealed that the patients with chronic-pain conditions considered that the pain influenced their well-being to a rather great extent. However, the patients felt confirmed at the meeting with the district nurse, e.g. they felt believed, taken seriously and understood. The advice and recommendations and/or information and education received were also found to be of great value to these patients. After the introduction of "pain advisers" into the SA, the patients reported less pain as a result of the advice and recommendations. The patients also reported more knowledge with which to understand the pain as a result of the information and education. The fifth study investigated the patients satisfaction with the care given by the district nurses at home and at the PHCCs (not only patients with chronic-pain conditions). In order to collect the data, the questionnaire entitled "Quality of care from the patient's perspective" (QPP) was used and answered by 168 (62%) home-care (HC) patients and 264 (72%) outclinic (OC) patients. High satisfaction was in general reported although some areas were identified as being in need of improvements. HC and OC patients with poor, self-rated, physical health were identified as being likely to be dissatisfied with the care.