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Licensed Unlicensed Requires Authentication Published by De Gruyter July 1, 2017

Using education and support strategies to improve the way nurses assess regular and transient pain – A quality improvement study of three hospitals

Anna Peterson, Siw Carlfjord, Anne Schaller, Björn Gerdle and Britt Larsson

Abstract

Background and aims

Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication.

Methods

Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines.

Results

According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p < 0.001). For PS, corresponding numbers were 33% and 50% (p < 0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p = 0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p < 0.001).

Conclusions

After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief.

Implications

The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain.


DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.04.004.



Pain and Rehabilitation Centre and Department of Medical and Health Sciences, Linköping University, Linköping, SE-581 85 Linköping, Sweden.

  1. Funding: This study was supported by a grant from the research funds of the Östergöland County Council. The funder had no role in study design, data collection, data analysis, preparation of the manuscript, or decision to publish.

  2. Conflict of interest: None.

References

[1] Wadensten B, Frojd C, Swenne CL, Gordh T, Gunningberg L. Why is pain still not being assessed adequately? Results of a pain prevalence study in a university hospital in Sweden. J Clin Nurs 2011;20:624–34.10.1111/j.1365-2702.2010.03482.xSearch in Google Scholar

[2] Visentin M, Zanolin E, Trentin L, Sartori S, de Marco R. Prevalence and treatment of pain in adults admitted to Italian hospitals. Eur J Pain 2005;9:61–7.10.1016/j.ejpain.2004.04.004Search in Google Scholar

[3] Jabusch KM, Lewthwaite BJ, Mandzuk LL, Schnell-Hoehn KN, Wheeler BJ. The pain experience of inpatients in a teaching hospital: revisiting a strategic priority. Pain Manag Nurs 2015;16:69–76.10.1016/j.pmn.2014.05.007Search in Google Scholar

[4] Costantini R, Affaitati G, Fabrizio A, Giamberardino MA. Controlling pain in the post-operative setting. Int J Clin Pharmacol Therap 2011;49:116–27.10.5414/CP201401Search in Google Scholar

[5] Lewis KS, Whipple JK, Michael KA, Quebbeman EJ. Effect of analgesic treatment on the physiological consequences of acute pain. Am J Hosp Pharm 1994;51:1539–54.10.1093/ajhp/51.12.1539Search in Google Scholar

[6] Sinatra R. Causes and consequences of inadequate management of acute pain. Pain Med 2010;11:1859–71.10.1111/j.1526-4637.2010.00983.xSearch in Google Scholar

[7] Valat JP, Goupille P, Rozenberg S, Urbinelli R, Allaert F. Acute low back pain: predictive index of chronicity from a cohort of 2487 subjects. Spine Group of the Societe Francaise de Rhumatologie. Joint Bone Spine 2000;67:456–61.Search in Google Scholar

[8] Purser L, Warfield K, Richardson C. Making pain visible: an audit and review of documentation to improve the use of pain assessment by implementing pain as the fifth vital sign. Pain Manag Nurs 2014;15:137–42.10.1016/j.pmn.2012.07.007Search in Google Scholar

[9] Zoega S, Ward SE, Sigurdsson GH, Aspelund T, Sveinsdottir H, Gunnarsdottir S. Quality pain management practices in a university hospital. Pain Manag Nurs 2015;16:198–210.10.1016/j.pmn.2014.06.005Search in Google Scholar

[10] Idvall E, Ehrenberg A. Nursing documentation of postoperative pain management. J Clin Nurs 2002;11:734–42.10.1046/j.1365-2702.2002.00688.xSearch in Google Scholar

[11] Silva MA, Pimenta CA, Cruz Dde A. Pain assessment and training: the impact on pain control after cardiac surgery. Revista da Escola de Enfermagem da U S P 2013;47:84–92.10.1590/S0080-62342013000100011Search in Google Scholar

[12] Anwar ul H, Hamid M, Baqir M, Almas A, Ahmed S. Pain assessment and management in different wards of a tertiary care hospital. JPMA 2012;62:1065–9.Search in Google Scholar

[13] Chapman CR, Stevens DA, Lipman AG. Quality of postoperative pain management in American versus European institutions. J Pain Palliative Care Pharmacotherapy 2013;27:350–8.10.3109/15360288.2013.846955Search in Google Scholar

[14] Nworah U. From documentation to the problem: controlling postoperative pain. Nursing Forum 2012;47:91–9.10.1111/j.1744-6198.2012.00262.xSearch in Google Scholar

[15] Wells N, McDowell MR, Hendricks P, Dietrich MS, Murphy B. Cancer pain management in ambulatory care: can we link assessment and action to outcomes? Supportive Care Cancer 2011;19:1865–71.10.1007/s00520-010-1030-7Search in Google Scholar

[16] Ista E, van Dijk M, van Achterberg T. Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review. Int J Nurs Stud 2013;50:552–68.10.1016/j.ijnurstu.2012.11.003Search in Google Scholar

[17] Bourbonnais FF, Perreault A, Bouvette M. Introduction of a pain and symptom assessment tool in the clinical setting – lessons learned. J Nurs Manag 2004;12:194–200.10.1046/j.1365-2834.2003.00429.xSearch in Google Scholar

[18] Simons J, MacDonald LM. Changing practice: implementing validated paediatric pain assessment tools. J Child Health Care 2006;10:160–76.10.1177/1367493506062555Search in Google Scholar

[19] Zeppetella G. Impact and management of breakthrough pain in cancer. Curr Opin Support Palliative Care 2009;3:1–6.10.1097/SPC.0b013e3283260658Search in Google Scholar

[20] Zeppetella G, Ribeiro MD. Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev 2006:Cd004311.10.1002/14651858.CD004311.pub2Search in Google Scholar

[21] Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G. The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland. Eur J Pain 2009;13:331–8.10.1016/j.ejpain.2008.06.014Search in Google Scholar

[22] Haugen DF, Hjermstad MJ, Hagen N, Caraceni A, Kaasa S. Assessment and classification of cancer breakthrough pain: a systematic literature review. Pain 2010;149:476–82.10.1016/j.pain.2010.02.035Search in Google Scholar

[23] Rhiner MI, von Gunten CF. Cancer breakthrough pain in the presence of cancer-related chronic pain: fact versus perceptions of health-care providers and patients. J Supportive Oncol 2010;8:232–8.10.1016/j.suponc.2010.10.006Search in Google Scholar

[24] Rustoen T, Geerling JI, Pappa T, Rundstrom C, Weisse I, Williams SC, Zavratnik B, Wengstrom Y. How nurses assess breakthrough cancer pain, and the impact of this pain on patients’ daily lives – results of a European survey. Eur J Oncol Nurs 2013;17:402–7.10.1016/j.ejon.2012.12.002Search in Google Scholar

[25] Fitch MI, McAndrew A, Burlein-Hall S. A Canadian online survey of oncology nurses’ perspectives on the defining characteristics and assessment of break-through pain in cancer. Can Oncol Nurs J 2013;23:85–99.10.5737/1181912x2328591Search in Google Scholar

[26] Crawford CL, Boller J, Jadalla A, Cuenca E. An integrative review of pain resource nurse programs. Crit Care Nurs Quarterly 2016;39:64–82.10.1097/CNQ.0000000000000101Search in Google Scholar

[27] Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N. Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006;26:13–24.10.1002/chp.47Search in Google Scholar

[28] Yazici Sayin Y, Akyolcu N. Comparison of pain scale preferences and pain intensity according to pain scales among Turkish Patients: a descriptive study. Pain Manag Nurs 2014;15:156–64.10.1016/j.pmn.2012.08.005Search in Google Scholar

[29] de Rond M, de Wit R, van Dam F. The implementation of a Pain Monitoring Programme for nurses in daily clinical practice: results of a follow-up study in five hospitals. J Adv Nurs 2001;35:590–8.10.1046/j.1365-2648.2001.01875.xSearch in Google Scholar

[30] Zhang CH, Hsu L, Zou BR, Li JF, Wang HY, Huang J. Effects of a pain education program on nurses’ pain knowledge, attitudes and pain assessment practices in China. J Pain Symptom Manage 2008;36:616–27.10.1016/j.jpainsymman.2007.12.020Search in Google Scholar

[31] Phelan C. An innovative approach to targeting pain in older people in the acute care setting. Contemp Nurse 2010;35:221–33.10.5172/conu.2010.35.2.221Search in Google Scholar

[32] Ger LP, Chang CY, Ho ST, Lee MC, Chiang HH, Chao CS, Lai KH, Huang JM, Wang SC. Effects of a continuing education program on nurses’ practices of cancer pain assessment and their acceptance of patients’ pain reports. J Pain Symptom Manage 2004;27:61–71.10.1016/j.jpainsymman.2003.05.006Search in Google Scholar

[33] Ang E, Chow YL. General pain assessment among patients with cancer in an acute care setting: a best practice implementation project. Int J Evid Based Healthc 2010;8:90–6.10.1111/j.1744-1609.2010.00167.xSearch in Google Scholar

[34] Lewen H, Gardulf A, Nilsson J. Documented assessments and treatments of patients seeking emergency care because of pain. Scand J Caring Sci 2010;24:764–71.10.1111/j.1471-6712.2010.00774.xSearch in Google Scholar

[35] Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, Tanabe P. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain 2007;8:460–6.10.1016/j.jpain.2006.12.005Search in Google Scholar

[36] Erlenwein J, Studer D, Lange JP, Bauer M, Petzke F, Przemeck M. Process optimization by central control of acute pain therapy: implementation of standardized treatment concepts and central pain management in hospitals. Anaesthesist 2012;61:971–83.10.1007/s00101-012-2095-0Search in Google Scholar

[37] Pretorius A, Searle J, Marshall B. Barriers and enablers to emergency department nurses’ management of patients’ pain. Pain Manag Nurs 2015;16:372–9.10.1016/j.pmn.2014.08.015Search in Google Scholar

[38] Frank-Stromborg M, Christensen A, Do DE. Nurse documentation: not done or worse, done the wrong way – Part II. Oncol Nurs Forum 2001;28:841–6.Search in Google Scholar

[39] Samuels JG, Eckardt P. The impact of assessment and reassessment documentation on the trajectory of postoperative pain severity: a pilot study. Pain Manag Nurs 2014;15:652–63.10.1016/j.pmn.2013.07.007Search in Google Scholar

[40] Gordon DB, Rees SM, McCausland MR, Pellino TA, Sanford-Ring S, Smith-Helmenstine J, Danis DM. Improving reassessment and documentation of pain management. Jt Comm J Qual Patient Saf 2008;34:509–17.10.1016/S1553-7250(08)34065-3Search in Google Scholar

[41] Wengstrom Y, Geerling J, Rustoen T. European Oncology Nursing Society break-through cancer pain guidelines. Eur J Oncol Nurs 2014;18:127–31.10.1016/j.ejon.2013.11.009Search in Google Scholar

[42] Adamsen L, Tewes M. Discrepancy between patients’ perspectives, staff’s documentation and reflections on basic nursing care. Scand J Caring Sci 2000;14:120–9.10.1111/j.1471-6712.2000.tb00572.xSearch in Google Scholar

[43] Krebs EE, Bair MJ, Carey TS, Weinberger M. Documentation of pain care processes does not accurately reflect pain management delivered in primary care. J Gen Intern Med 2010;25:194–9.10.1007/s11606-009-1194-3Search in Google Scholar

[44] Steindal SA, Sorbye LW, Bredal IS, Lerdal A. Agreement in documentation of symptoms, clinical signs, and treatment at the end of life: a comparison of data retrieved from nurse interviews and electronic patient records using the Resident Assessment Instrument for Palliative Care. J Clin Nurs 2012;21:1416–24.10.1111/j.1365-2702.2011.03867.xSearch in Google Scholar

[45] World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013, 310:2191-4.10.1001/jama.2013.281053Search in Google Scholar

Received: 2016-11-10
Revised: 2017-01-30
Accepted: 2017-01-31
Published Online: 2017-07-01
Published in Print: 2017-07-01

© 2017 Scandinavian Association for the Study of Pain