Exposing the complex realities of nursing unresponsive patients' pain in intensive care

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The experience of pain is individual and subjective and only accessible to another by means of communication. Consequently assessing and managing the pain of a patient can be one of the most complex and elusive objectives of nursing practice. This is particularly the situation when critically ill patients are unresponsive as uncertainty impacts on the nursing aim of providing consistent, quality pain care. For me, as an intensive care nurse, uncertainty seemed out of place in the technological world of intricate measurement in the intensive care unit. The research work presented within this thesis focuses on making sense of and dealing with this disparity. This study embraces both expressive and explanatory means of discovering and conveying knowledge. Nurses’ propensity for storytelling inspired the development of an original, eclectic narrative method; drawing on, and extending the work of a wide range of philosophers and theorists such as: Labov and Waletsky, Gee, Agar & Hobbs, Richardson, Mishler, Johnson and Mandler, Reason & Hawkins, Ricoeur and Hegel. The research processes are comprehensively detailed in order to make apparent the realities of undertaking such work, and of accommodating the delays created by ongoing life challenges. In addition, the thesis is presented in a way that increases its accessibility to nurses working in practice, balanced with the need to work within established academic processes and structures. While one still hopes for accurate measures of pain in unresponsive patients, the study identifies and discusses the few pain cues that nurses ‘see’, and the limited pain management options nurses ‘do’. Furthermore, the space between ‘seeing’ and ‘doing’, where nurses ‘think’ and ‘feel’, was filled with rich complexity. Stories emerged of: learning about pain, nursing intuition and ‘knowing the patient’, decision making, advocacy for patients, collaboration with doctors, emotional responses of feeling stressed, frustrated, anguished and inadequate, the nursing mandates of providing comfort, care and justice, distancing from or connecting with patients. The innovative narrative situatedness schema arising from this research offers a visual map of the interrelatedness of the study’s dialectic concepts. The narrative ideas of constitute/constitutive are juxtaposed with expression/explanation. Additionally, the philosophical views on epistemology/ontology, synthesised to ‘voice’, are dovetailed with Robbins’ pairs of human needs; certainty/uncertainty, significance/connection, and growth/contribution. Such complexity is contained within storytelling. The study promotes a new valuing of an old skill in highlighting the role of storytelling to further nursing practice development. This revealing of the complexity of nursing provides a major step towards the ongoing enhancement of patient care.
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