A middle-range theory of balance between analgesia and side effects comprises the eight intervention concepts cumulated in their prepositions and it predicts the outcome balance concept (Butts & Rich, 2013). The prepositions predict that the multimodal intervention, attentive pain management, and patient participation contribute to balance between analgesia and side effects. Reduction of severe pain, as well as control of medication side effects, are important for ethical, economic and humanitarian reasons(Butts & Rich, 2013).
Good M Marion is a faculty of Case Western Reserve University. She has worked closely with colleague Shirley M. Moore. They both developed the theory of balance between analgesia and side effects as the first integrative prescriptive middle-range pain management theory (Im, 2014). Their theory provides a broader and parsimonious overview than detailed guidelines of pain management. The theorist expects that practitioners apply the overall principles along with the detailed knowledge that is contained in adult acute pain guidelines and any other empirical evidence (Smith & Liehr, 2018). Good's theory is based on multiple control trials and decades of concentrated research on pain management (Butts & Rich, 2013). They have created hypotheses that can be tested and translated into practice guidelines. The theory provides a framework for nurses to structure pain management and provide good pain control outcomes while minimizing the side effects (Im, 2014).
Crucial References for Original and Current Work
Descartes first explained pain theory and the modern understanding is drawn from his 17th-century drawing (Smith & Liehr, 2018). Melzack who was a psychologist and a neurophysiologist published Gate Control Theory, which revolutionized the understanding of psychological components of pain (Im, 2014). Good and her colleagues in 1992 discussed the first proposition regarding multimodal intervention, which proposed that nurses use potent pain medication and pharmacological and nonpharmacological adjuvants to balance analgesia and side effects. The second proposition of attentive care, which was supported by 30-year research, showed that pain is inadequately treated and from the findings, regular assessments were not adequate to produce relief by themselves (Peterson & Bredow, 2013). The finding also indicated that through intervention, reassessment after a strategic interval as well as re-intervention through an increase of analgesic and or adding adjuvants are needed and should be continued until of satisfactory balance is attained (Smith & Liehr, 2018).
The third proposition on patient participation was supported by meta-analyses for patient teaching as well as the expert opinion for goal setting (Smith & Liehr, 2018). Findings indicated that patient teaching is key when improving outcomes is a priority and that patient teaching should include reporting pain, obtaining medication and use of a non-pharmacological adjuvant (Peterson & Bredow, 2013). The non-pharmacological adjuvant theory has been extended to other populations, for instance, studies by Lwandowski in 2004 among other scholars indicate that music reduces chronic pain, the pain of arthritis and that of labor and guided imagery reduced chronic pain (Peterson & Bredow, 2013).
The Phenomenon of Concern Addressed by the Theory
The theory addresses pain management especially with regards to acute pain. Good mainly focuses on acute pain and she implies that managing pain successfully is a complex process (Im, 2014). Good suggests that by limiting the scope of acute pain, much vulnerability in caring for patients with chronic pain, long-term opioid use, and diabetic neuropathy is eliminated (Butts & Rich, 2013).
Mid-range theory on Balance between Analgesia and Side Effect applies deductive reasoning. This is because it formulates the hypothesis that could provide an explanation for a particular problem, and then it proceeds to use observations to test the hypothesis (Im, 2014). Good developed the theory, to move away from the social concept of generalization that applies inductive reasoning. Her aim is to provide the outcome of good pain control and outcome of good pain control while minimizing the negative side effects that are associated with potent pain medication (Peterson & Bredow, 2013).
Description of the Major Concepts of the Theory.
The major concepts of the theory include multimodal therapy, attentive care, and patient education (Im, 2014). Multimodal therapy comprises a combination of strong analgesics and pharmacological adjuvants such as nonsteroidal anti-inflammatory drugs plus nonpharmacological adjuvants like relaxation, massage, and music. Attentive care means vigilance and comprises of regular examinations of pain and side effects, and identification of inadequate relief, intervention, re-examination, and reintervention. Finally, patient education consists of patient teaching for pain management and mutual goal setting between nurse and patient. Im (2014) proposes that these concepts result in more relief and less side effects than simply giving analgesic medication. These concepts are defined theoretically because the use of these definitions is from a wider theoretic concept. Thus, an operational concept could be developed from them.
Consistency with used of Terms
The author is consistent with the use of concepts and other terms in the theory because they are adequately used in the text, to explain the mid-range theory on balance between analgesia and side effect concept in their research
The concepts are interpreted explicitly, and it gives no room for uncertainty. The authors are very clear on their definitions of the concepts applied to explain the theory.
Relationships among Major Concepts
The concepts within the texts are highly interrelated as they are used adequately to explain the phenomenon in question. For instance, 'pain' is being interrelated with analgesia, side effects, pain relief, non-pharmacological adjuvant among others. These concepts bring out a clear understanding of the text and gives a clear explanation to the reader.
Assumptions of the Theory
Just like any other theory, it is based on assumptions. The major explicit assumptions include first, the physicians and the nurse collaborate to manage pain (Peterson & Bredow, 2013); second, medication for side effects are given as needed and third; the patient is adults with the ability to learn, set goals and communicate symptoms (Im, 2014). The implicit assumptions of the theory include the fact that systemic opioid analgesics agent or epidural opioid agents are indicated and that nurses have current knowledge of pain management. The theory is built on these assumptions as they form the basis of the clinical research that is undertaken by the theorists (Smith & Liehr, 2018).
Theories' Description of the Meta-Paradigm Concepts of Nursing
The main meta-paradigm concepts in nursing include human beings, environment, and health. These three concepts are interrelated and they affect nursing practice. The theory through the three concepts is developed within the concept of pain management (Peterson & Bredow, 2013). Humans experience pain, and health interventions through the use of opioids which are drawn from the environment are highly evident. Through proper pain management, the direct impact of pain on humans and indirect impact on the environment can be managed, through effective health interventions (Im, 2014).
The theory clearly states the main components of acute pain as management as multimodal assessment, attentive care as well as patient participation. These components correlate with the existing nursing processes that aim to assess, diagnose, plan, implement, and evaluate, concepts that are clearly understood by the clinicians. The theory is highly consistent as it focuses on pain management, and the main components of the theory support management of acute pain, and it suggests recommendations for practice that can be applied by nurses and clinicians.
Application Conclusion and Summary
How the Theory Would Guide Nursing Actions
The middle-range theory of the balance between analgesia and side effects is an invaluable resource for chronic pain management and acute pain among patients. It gives a framework for which pain can be assessed, intervened and brings out the concept of patient education (Alligood, 2014). The theory encourages pharmacologic and non-pharmacologic interventions for instance music which are highly overlooked. The theory encourages nurses to be more proactive in offering alternative pain relief methods. By following the three propositions of pain management as described in the theory, nurses can better manage pain among patients more effectively (Alligood, 2014).
Application in Nursing
This theory is highly applicable especially in nursing practice, mainly in pain management. The three propositions described by the theorists are highly practicable in nursing care and for a successful pain relief intervention; the three must be applied (Smith & Liehr, 2018). The theory has proven useful especially useful in postsurgical nursing units as the basis for post-operative pain management as its results have been proven to be concrete (Alligood, 2014). Use of non-pharmacologic adjuvants is becoming a popular intervention in pain management and the theory can be applied successfully for effective results.
Alligood, M. R. (2014). Areas for Further Development of Theory-Based Nursing Practice. MR Alligood (Ed.), Nursing Theory:Utilization & Application, 414-424.
Butts, J. B., & Rich, K. L. (2013). Philosophies and Theories for Advanced Nursing Practice. Jones & Bartlett Publishers.
Im, E. O. (2014). Situation-Specific Theories from the Middle-Range Transitions Theory. Advances in Nursing Science, 37(1), 19-31.
Peterson, S. J., & Bredow, T. S. (2013). Middle Range Theories.
Smith, M. J., & Liehr, P. R. (Eds.). (2018). Middle Range Theory for Nursing. Springer Publishing Company.
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