Table 2

Reflexive case summaries

Case 1Case 2Case 3
Key personnel /staff engagementImprovements to pain management appeared to have been made by both nursing and medical staff. Evidence of commitment across the team. No single pain champion. Staff appeared to have more collaborative view of pain management, with less variation in attitude than other cases. All roles identified as important in pain management, with support for HCAs in undertaking assessment and identification of pain.One member of staff who had tried to improve pain management by changing the documentation to include pain scoring, was referenced as the ‘go to’ person within the ED for any changes or research but was very busy and difficult to access.
Staff were observed to advocate for patients when asked for analgesia, but were not proactive and there was less evidence of staff being encouraged to ask about pain than at site 1.
Nurses could not cannulate and HCAs did not perceive themselves to have a role in pain management.
There was no single individual identified as responsible for changes. Senior nurse was instrumental in encouraging nurse prescribing and PGDs for morphine in trauma.
Both nursing and medical staff had undertaken audits around pain management, and fed back results to the department.
Staff appeared engaged in improving pain management and were aware of problems, and the need to improve some of the structural issues such as inability to prescribe codeine at triage, and problems administering morphine for ambulance patients.
Organisational priorityEvidence of support between ED and Trust board regarding development of new ED. No issues regarding organisational support arose during fieldwork. Staff did not appear to be under too much pressure to meet 4-hour targets, despite struggling with exit block.
Evidence of changes being fine-tuned and altered when difficulties encountered.
Evidence of tensions within the relationship between the ED and the wider organisation. Significant talk about flow and ED staff clearly felt under pressure to meet targets. Staff appeared to feel disempowered and perceived a lack of commitment from the organisation in supporting changes aimed at improvements within their department.No issues regarding organisational support arose during the fieldwork. This may be due to there being fewer interviews and hours of observation undertaken at site 3 than sites 1 and 2.
ProfilePain management appeared to be integrated into the functions of the ED, with multifactorial initiatives having been embedded over past decade. Staff talked about pain management, were aware of processes for improving pain management and evidence of improvements having occurred. Patient information leaflets include reminders to take analgesia. Staff frequently discussed analgesia when discussing patient management plans.
Audits of pain management in triage undertaken every 2 years and results fed back to nursing staff.
Pain management was not well integrated into the work of the department, and there was less discussion around pain management than in other sites. Triage staff did not appear to be encouraged to ask about pain and questions regarding pain tended to be framed towards understanding whether analgesia had been taken, rather than asking whether analgesia was needed. Some nursing staff were unaware of the existence of PGDs for pain management, and the PGDs themselves were out of date.
Staff did not appear to be aware of their own performance regarding pain management and were unaware of any audits relating to pain management, although they were aware of complaints
Clinical audit of pain management had been undertaken 2 years previously and highlighted the need to improve documentation of pain and provision of analgesia at triage. Staff talked about the audit and were aware of changes that had been put in place to improve pain management.
Changes made during the course of the fieldwork appeared to impact on the profile of pain management, and to make the provision of analgesia easier. Staff appeared to be aware of the need to improve but changes were not yet embedded and there were suggestions that the ‘culture’ of pain management had not yet improved.
  • HCAs, healthcare assistants; PGD, patient group directive.