Spotlight on Research


Hip hip hooray! Transferable methods in hip pain managementUsing a qualitative research approach involving Flanagan's Critical Incident Technique (Flanagan, 1954), this paper reports on ambulance staff's experiences of managing pain in people with a suspected hip fracture. Notably the study was undertaken in Sweden where an ambulance crew comprises a pre-hospital emergency care nurse and an emergency medical technician (EMT), both of whom have to recertify every other year.Despite the differences in health care system, there appear to be some transferable elements in the findings, which should be of interest to UK paramedics, as treating elderly people who have sustained a hip fracture as a result of falling is a regular phenomenon.In total, 22 people participated (18 pre-hospital emergency care nurses, 4 EMTs) in individual, face-to-face interviews. Eligibility criteria included having worked for more than three years in the ambulance service, and participants must have had experience of managing patients with suspected hip fracture.During the interview, participants had to reflect on previous incidents where they were involved in the care and management of these patients and, in line with the approach used in Flanagan's Critical Incident Technique, they were required to discuss both the strengths and limitations of what happened during these encounters, in this case with a particular focus on management of the patients' pain.Although the introductory phase of the interviews was not recorded (presumably to help relax the participant), audio recording was undertaken from the point where the aim of the study was explained to the ambulance staff.Interviews were transcribed verbatim and data analysis was conducted using a variant of qualitative content analysis. In total, 51 incidents emerged from the 22 interviews.The authors give a good account of processes involved in their analysis, illustrating how they moved from a coding stage, through to the development of five sub-categories and, finally, to the identification of the following two main categories: i) care based on the individual patient's needs; ii) empowering the patient.‘Care based on the individual patient's needs’ reflects how ambulance staff, through clinical reasoning, tailored the management of pain relief to each individual patient and, perhaps unsurprisingly, this involved the following three sub-categories: ‘strategies of selecting pharmacological analgesia’, ‘strategies when moving the injured patient’, and, ‘choice of positioning of the patient on the stretcher’.There were many similarities to UK practice identified in these sub-categories, although the choice and available selection of analgesic agents reveals some differences. However, principles of pain assessment, management and consideration of the patients' needs during transportation appear to be similar between the two health care systems.The second main category that emerged in this study—‘empowering the patient’—included two sub-categories: ‘create conditions for patient participation’, and, ‘adaptation to the patient’. The first sub-category focuses on effective communication, emphasising the importance of keeping the patient informed as to what was happening and why, and engaging them in decisions around pain management, movement and positioning.‘Adaptation to the patient’ happened in different ways. In some cases it centred on assessment of their non-verbal communication, or listening to the patient's relatives or caregivers if the patient was incapable of verbal communication. Other examples given within this sub-category included giving patients the time they needed either to get maximum benefit from any administered analgesia, or to feel ready and safe to leave home.The authors identify some methodological limitations such as the use of reflection on past events during interviews, as participants may suffer from lack of recall of specific detail. Interestingly they identify that the two interviewers were also pre-hospital emergency care nurses and that this can be seen either as a strength as they had relevant, contextual knowledge about the ambulance service, or a limitation, in that there was the potential that their own experiences could bias their interpretation of the participants' narratives.Overall, the study's findings illustrate that participants attempted to individualise care based on patients' needs but that this was also influenced by the practitioners' own knowledge base and skills. So no different to UK practice in that sense—the main differences emerged in relation to choice of pharmacological interventions, and variations in moving and handling equipment. However, the principle of engagement of the patient, where possible, in decision-making about their care and management, is relevant for all ambulance staff. This study usefully highlights a need for further research to examine the issues and complexities surrounding the concept of patient empowerment within ambulance service settings.

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