beatleyweb.simmons.edu€¦ · Web viewThe results of the January 2016 Joint Commission Accreditation Review shed light on the need for a quality improvement strategy to improve compliance

Running head: PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION

Pain Assessment Education for Intermediate Care Orthopedic Nurses

to Improve Pain Score Documentation

Mary Anne Murphy Kenyon

PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION

Pain Assessment Education for Intermediate Care Orthopedic Nurses

to Improve Pain Scale Score Documentation


This manuscript is submitted to the faculty at Simmons College

in partial fulfillment of the requirements for the degree of

Doctor of Nursing Practice


Abstract

The results of the January 2016 Joint Commission Accreditation Review shed light on the need

for a quality improvement strategy to improve compliance with pain score reassessment

documentation for nurses working in the orthopedic unit of a large teaching hospital in Boston.

Following Lewin’s Theory of Change (Shirey, 2013), fifty-five nurses participated in a pretest

completing the City of Hope Knowledge and Attitude Survey Regarding Pain (KASRP) and

fishbone diagram exercise to unfreeze their current practice and explore barriers to

documentation compliance. After participating in a one hour, evidence-based educational

program guided by the International Association for the Study of Pain (IASP) Curriculum on

Pain for Nursing, the nurses completed the KASRP as a posttest. The aim of this quality

improvement project was to improve the pain assessment and reassessment practice, as

evidenced by improved and sustained pain scale score documentation that meets the Joint

Commission compliance expectation of ninety percent. Pretest and posttest scores reflect the

percentage of questions answered correctly. Results include an aggregated mean pretest score of

72.1042 and mean posttest score of 76.0209, t (54) = -3.722, p = .000. Quantitative statistical

analysis identified a positive correlation between the KASRP pretest-score and posttest-score (r

= -.362, n = 55, p = .01). The statistically significant improvement demonstrated that the nurses

were able to move and improve their knowledge about pain management following the

educational intervention. Weekly chart audits determined that staff were able to refreeze practice

and improve the pain score documentation compliance. Six months after completing this quality

improvement (QI) project, the pain score reassessment documentation compliance improved

from 65.75% to 83%. Further staff education is needed to sustain this improvement and future

work will include identifying solutions to overcome barriers to documentation.

III


Keywords: quality improvement, orthopedic, nursing, pain assessment, pain scale

©2018


ALL RIGHTS RESERVED

IV


Acknowledgements

Firstly, I would like to express my sincere gratitude to my advisor Prof. Eileen McGee PhD, for

the continuous support of my DNP work, for her patience, motivation, and immense knowledge.

Her guidance helped me in all aspects of reviewing, organizing and writing this manuscript. I

could not have imagined having a better advisor and mentor for my DNP study.

Besides my advisor, I would like to thank my committee: Maureen Fagan, DNP for her

insightful comments and encouragement, but also for her willingness to step in when I most

needed a supportive, caring, second reader – I am forever grateful.

My sincere thanks also go to my amazing Connors 7 staff, without their support it would not

have been possible to complete this project. Thank you for accompanying me on this journey,

your commitment to providing the safest care to our patients and families makes me proud. You

are my inspiration!

I want to thank three special colleagues, Kim, Mary & Sandy, for the encouraging discussions,

for the late night and early morning texting, celebratory meals, and for all the fun we have had

in the last four years. I treasure your friendship.

Last but not the least, I would like to thank my family: my husband, John and my children,

Ariel Dustin, Victoria, and Gabriela for unselfishly supporting me through these past four years.

Each of you has taught me so much about unconditional love and support, you each share in my

success and I am forever grateful. I could not have done this without each you

And I cannot forget the loving support of Stella & Nala who kept me company in the early

hours as I toiled at my computer…extra walks and bones for all

V


Dedication

For my dad, Martin C. Murphy

You are always on my mind,

I think you would be proud.

VI


Table of ContentsIntroduction.........................................................................................................................................1

Background.........................................................................................................................................2

Purpose Statement..............................................................................................................................6

Clinical Significance..........................................................................................................................7

Review of Literature..........................................................................................................................8

Historical Background.........................................................................................................11

Established Guidelines.........................................................................................................12

Nurses’ Attitudes and Education Related to Pain Management..........................................17

Pain Assessment Tools.........................................................................................................24

Economic and Societal Burden............................................................................................30

Recent Studies......................................................................................................................31

Summary...........................................................................................................................................35

Conceptual Framework....................................................................................................................36

Methods.............................................................................................................................................40

Design..................................................................................................................................40

Procedure.............................................................................................................................41

Setting..................................................................................................................................41

Participants...........................................................................................................................42

Intervention..........................................................................................................................43

Data Collection....................................................................................................................46

Data Analysis....................................................................................................................................46

Discussion/Implications...................................................................................................................53

Limitations........................................................................................................................................62

Conclusion.........................................................................................................................................62

Cost Analysis....................................................................................................................................65

Future Study......................................................................................................................................66

Human Subject Protection...............................................................................................................68

Plan for Dissemination.....................................................................................................................68

References.........................................................................................................................................70

VII


List of Tables

Table 1. Demographic survey results

Table 2. Post intervention audit data

VIII


List of Figures

Figure 1. Pre and post pain score documentation

Figure 2. EPIC MAR

Figure 3. EPIC pain documentation

Figure 4. Unidimensional assessment tools

Figure 5. Multidimensional assessment tools

Figure 6. Lewin’s Theory of Change

Figure 7. Fishbone diagram

Figure 8. Intervention timeline

Figure 9. Pain Score Assessment Documentation compliance

Figure 10. Pain Score Reassessment Documentation compliance

Figure 11. EPIC reassessment banner

Figure 12. EPIC, unit-view – pain compliance

Figure 13. EPIC dashboard at a glance

IX


List of Appendices

Appendix A. Email

Appendix B. Demographic survey

Appendix C. KASRP permission, tool and answers

Appendix D. IASP permission & tool

Appendix E. Pain Score Documentation audit tool

Appendix F. BWH IRB checklist

Appendix G. Simmons I

X


Introduction

Managing the acute pain associated with surgery is a challenge for most nurses. In the

specialty of orthopedics, the nurses are responsible for managing pain to enable patients to

fully participate in their physical therapy regime to restore functional mobility. The years of

clinical experience for nurses currently working in the Orthopedic Intermediate Care Unit at

a large teaching hospital in Boston ranged from less than one year to greater than twenty-six

years and their education preparation included diploma, associate degree, baccalaureate, and

masters’ degrees. Years of clinical experience and educational preparation may have

contributed to the variation seen in pain assessment, reassessment, and pain score

documentation practice. Regardless of the nurses’ years of experience or educational

preparation, regulatory and professional organizations have created guidelines for managing

pain and have identified a need for ongoing and life-long educational competency around

pain assessment and pain management (Academy of Medical-Surgical Nurses, 2012;

American Society of Anesthesiologists, 2012; Baker, 2017; Buvanendran et al., 2017; Chou

et al., 2016; Curtiss, 2001; Ferguson, 2016; Grinstein-Cohen, Sarid, Attar, Pilpel, &

Elhayany, 2009; Massachusetts Board of Registration in Nursing, 2017; National Institutes of

Health, 2015; Zahni, 2016).

Evidence based practice demonstrates how a comprehensive pain assessment can

inform pain management decisions (Apfelbaum, Chen, Mehta & Gan, 2003; Clarke et al.,

1996; Fink, 2000; Harvey et al., 2013; Kishner, Ioffe, Choo & Schraga, 2016). Reliable and

validated pain scale tools are readily accessible for nurses to use as decision aids.


In the orthopedic setting, multidimensional pain tools, such as the Functional Pain

Scale (FPS) or the Clinically Aligned Pain Assessment (CAPA©), are better suited to assess

pain compared to the antiquated, unidimensional pain scale tools, such as the Visual Analog

Scale (VAS) and the Numeric Rating Scale (NRS). Multidimensional pain scale tools shift

the pain assessment conversation between the nurse and patient, from identifying an

objective pain score to a bidirectional discussion that identifies the extent to which the

patient’s pain level interferes with the restoration of functional health, thus enabling the

bedside nurse to quantify the subjective description of pain (Schiavenato & Craig, 2010).

In March 2016, the Massachusetts governor, Charlie Baker signed the House Bill

3944, “An Act relative to substance use, treatment, education, and prevention,” which

aligned more closely with the Joint Commission (JC) established guidelines that defined best

practices for pain management in the setting of the opioid crisis. The clinical practices of the

target hospital demonstrated variations in the pain assessment and pain score documentation

that failed to meet the established standard. The aim of this project was to create and

implement a pain assessment educational program for the intermediate care orthopedic

nursing staff.

Background

Pain is a multidimensional experience, especially for the orthopedic population. Pain

negatively impacts the quality of life and decreases functionality. The primary rationale

behind most orthopedic pain management interventions aim at increasing functionality and

improving the quality of life. The current practice of assessing pain as the fifth vital sign

using a numerical rating scale only captures the pain during the time when the patient’s other

PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 3

vital signs are being assessed and fails to meet hospital and regulatory compliance (Ault,

2017).

In January of 2016, a JC accreditation visit to the target hospital reviewed pain

assessment, reassessment, and pain score documentation practices both before and after pain

medication administration in the orthopedic intermediate care unit. It was found that the

orthopedic unit did not meet the JC standards for pain assessment, pain management, and

pain score documentation. Soon after the JC visit, the staff received an email reinforcing the

hospital policy and JC standards about pain assessment, reassessment, and pain score

documentation. The staff was then directed to review the current policies and correct their

practices accordingly. In March of 2016, the JC standards and hospital pain management

policy were reviewed at a staff meeting and highlighted in the unit-based newsletter.

Between June and November of 2016, patient charts were audited for pain score

documentation compliance. A third party conducted the 2016 pain audits and reported the

data to the nurse director. The pain audit data revealed continued variance in pain score

documentation. Fifty-four patient records were audited for pre- and post-pain score

documentation between June 30, 2016 and November 28, 2016. The pre-pain score

documentation ranged from 71% to 100% compliance, while the post-pain score

documentation ranged from 56% to 92% compliance (Figure 1).


Figure 1: Pre- and Post-pain score documentation (percentages).

Prior to the 2015 implementation of an electronic health record (EHR), the bedside

nurses had documented pain assessments using a paper flow sheet at this large teaching

hospital in Boston. The paper flow sheet enabled the nurses to document pain scores every

two hours per hospital standard; however, the nurses were also able to batch their

documentation and back document pain assessment scores at the end of their shift. The

electronic medication administration record (EMAR) provided a visual reminder for pain

score documentation. The EMAR computer screen displayed a red triangle surrounding a

yellow face when the pain score documentation was due, and this icon remained on the

screen until the documentation was completed. With the implementation of EPIC, the visual

documentation reminders were lost, which may have influenced the decline in pain score

documentation compliance. Without visual reminders, it becomes essential that pain

assessment and pain score documentation become firmly embedded in clinical practice.

There is an abundance of articles and studies describing best practices for pain

assessment and reassessment, including the those that use evidence-based guidelines and pain

scale tools to facilitate assessment documentation; however, there are few published studies

regarding compliance with pain score documentation. Although pain is experienced by most

patients after a surgical procedure, the nursing education regarding pain management has not


kept pace with recommended changes in practice. The current pain assessment

documentation practice on the orthopedic intermediate care unit has not met or sustained the

JC compliance expectation of ninety percent.

The JC mandates that pain is assessed and reassessed after every pain intervention

and the efficacy of the pain intervention must be documented in a timely manner (Zahni,

2016, Ward, 2012). Pain assessment, reassessment, and pain score documentation audit data

demonstrated that there is wide variation in the nurses’ practice despite unit-based

communication regarding the importance of compliance. Surveying nurses’ attitudes and

skills regarding pain assessment and providing a comprehensive pain education program

based on an internationally supported curriculum developed specifically for the bedside

nurses’ practice may reinforce pain assessment expectations and improve compliance with

pain score documentation.

One barrier to accurate pain assessment documentation is the inherent design of the

electronic health record, EPIC. Current EPIC pain score documentation functionality defaults

to selecting a pain intensity indicator between 0 – 10 (Figure 2); however, nurses are

expected to assess the patients’ pain experience by documenting the characteristics of pain

using a pain flow sheet. EPIC provides several pain flow sheets to document the pain

assessment; furthermore, the hospital provides autonomy to the nurse to choose the most

appropriate pain scoring tool for documentation (Figure 3). This proposed the need for a

quality improvement project reset unit specific expectations regarding the documentation of

pain characteristics utilizing the functional pain flowsheet.


Figure 2. EPIC MAR.

Figure 3. EPIC pain documentation.

Despite established evidence-based practice initiatives, clear policy guidelines, and

almost a half century of published literature that describe problems persistent with the

undertreatment of pain, the orthopedic intermediate care unit remains out of step with the JC

and hospital compliance around pain assessment, reassessment, and pain score

documentation compliance.

Purpose Statement

The purpose of this quality improvement project was to improve and sustain the pain

assessment, reassessment, and pain score documentation in the orthopedic intermediate care

unit at a large teaching hospital in Boston to achieve ninety percent compliance by December

2017. This project explored the following question: did a targeted educational program


improve nurses’ knowledge regarding existing standards for pain assessment and

reassessment score documentation?

The aim of the educational intervention included: 1) improve bedside nurses’

knowledge about pain assessment, reassessment, and management, 2) improve compliance

and decrease variation with pre- and-post pain score documentation to more than ninety

percent, and 3) demonstrate sustained improvement of pain score documentation in all post-

operative joint replacement patients by December 2017, before the anticipated JC survey in

2018.

Clinical Significance

This proposed quality improvement project was relevant and necessary to address the

need for a practice change that would reset the clinical responsibilities of the orthopedic

nurse to effectively co-manage the patient’s pain experience. This project significantly

influenced the way nurses assessed, reassessed, and improved the pain assessment score

documentation.

In the United States, it has been reported that more than eighty percent of post-

operative surgical patients experience undertreated pain, which may be described as

moderate to severe impacted by the purposed lack of adequate pain management education

for nurses (Apfelbaum, Majali, Stomberg & Bergbom, 2010). The consequences of

undertreated pain include delayed healing, increased costs and resource utilization, slow

recovery and return to full functioning status, and decreased quality of life. Inadequately

managed pain leads to increased length of stay, poor recovery, and clinical outcomes, as well

as increased readmission rates (Schreiber et al., 2014, p. 475).


A hospitalization extended by one day due to undertreated pain cause significant

preventable costs that add to the overall economic burden of pain management. Evidence-

based practice and regulatory guidelines clearly define the practice expectation of the bedside

nurse regarding pain assessment, reassessment, and pain score documentation; however,

there is a call to action for formal pain management education to be offered to bedside nurses

on an ongoing basis to ensure competency in assessment skills and pain documentation

(Wells, Pasero, & McCaffery, 2008).

The pain assessment documentation practices followed by the orthopedic

intermediate care unit of the target hospital did not met the JC compliance expectation of

ninety percent. The JC mandates that pain is assessed and reassessed and requires that pain

interventions and their efficacy are documented in a timely manner (Zahni, 2016, Ward,

2012). The pain assessment, reassessment, and pain score documentation audit data

demonstrated that there is much variation in practices despite unit-based education and

communication regarding the importance of compliance. Surveying nurses’ attitudes and

skills regarding pain assessment and providing a comprehensive pain education program

based on an internationally supported curriculum developed specifically for the bedside

nurses’ practice reinforced pain assessment expectations and improved compliance with pain

score documentation.

Review of Literature

A literature search was conducted by accessing the Cumulative Index to Nursing and

Allied Health Literature database (CINAHL), Medline, and the National Center for

Biotechnology Information (NCBI), OVID, Pub Med, and the United States National Library

(NLM). These data bases were searched for English language articles published between


1975 and 2017 using the keywords pain assessment, postoperative pain assessment, pain

assessment guidelines, orthopedic surgery pain assessment, pain assessment tools, nurses’

attitude toward pain, nurses’ pain education, and acute pain assessment.

After reviewing more than one hundred and thirty articles, the following literature

review is organized around themes that impact pain management. The complexities of pain

assessment, reassessment, and pain score documentation take on different meanings and

characteristics in different clinical settings; therefore, for the purposes of this literature

review, pain assessment studies pertaining to patients with the following diagnostic criteria

were excluded: pediatric patients, non-verbal patients, patients with dementia, patients with

chronic pain, and palliative care patients.

Access to effective post-operative pain management is a basic human right in the

United States (Brennan, Carr, & Cousins, 2007). During the past twenty-five years, pain

management practices have become polarized between the undertreatment of pain and the

current national opioid epidemic believed to be fueled by liberal pain medication

prescriptions and inadequate pain medication monitoring. Throughout the early 1990’s, pain

management practices were scrutinized for being ineffective and failing to meet the needs of

many patients (Baker, 2017). In response to the growing concern for adequate pain

management guidelines, several regulatory agencies including the Centers Medicare,

Medicaid Services (CMS), and the JC called for legislative changes and practice guidelines

to address pain as a fifth vital sign (Ault, 2017; Curtiss, 2001).

During the first few years of the twenty first century, the medical community took a

closer look at established pain medication guidelines as an emerging opioid epidemic raised

concerns about public health gaps and ethical dilemmas about the adequate treatment of pain


(Schroeder et al., 2016; Briggs, 2010). Strassel (2009) identified 2128 published articles that

describe the epidemiology and associated cost of unmet pain needs. The common themes of

numerous studies and clinical practice guidelines regarding pain assessment documentation

identified problems associated with undertreated pain and the need for ongoing healthcare

provider education as necessary interventions to impact practice change (p. 559).

A comprehensive pain assessment is needed to describe the subjective complexities

of pain and empower the nurse to determine the most efficacious treatment plan for patients

with pain (Kishner et al., 2016, n.p.). The IASP (2014) defines pain as “an unpleasant

sensory and emotional experience” (p. 236). Pain management researchers agree that pain is

subjective and the gold standard for pain assessment is a self-reported pain status; however,

there was a scarce amount of data identifying the best tools to measure the patient’s

experience with pain (Bozimowski, 2012; Schiavenato & Craig, 2010). The JC set standards

for pain assessment for the hospitalized patient, which included ongoing, individualized pain

assessment, reassessment through legible documentation, and the use of reliable and valid

pain assessment tools, such as the Visual Analog Scale (VAS) and the Numeric Rating Scale

(NRS) (Breivik et al., 2008). Best practice for pain assessment ascertains the patients’

description of pain in terms of characteristics beyond intensity such as the interference with

functional abilities, sleep, and the quality of life. The best tools to measure pain must be

sensitive, accurate, reliable, easy to use, and must enable the nurse to gain valuable insight

into the patient’s unique pain experience (Breivik et al., 2008, p.17).

Despite extensive evidence-based guidelines, acute pain was often not adequately

assessed by healthcare professionals. Suboptimal pain relief was not the result of a lack of

scientific evidence, but the result of two common barriers: 1) inadequate pain assessment,


and 2) lack of pain management knowledge (Fink, 2000, p. 236). These practice guidelines

and standards reflect the national health care trends that require pain management to be

assessed to improve patient outcomes and guide clinical interventions. Knowledgeable and

skilled clinicians are critical to optimal pain management interventions, pain assessment,

reassessment, and documentation, which are the cornerstone of care. But these are limited by

the ability of healthcare professionals to listen to patients and legitimize their pain (Fink,

2000, Kishner et al., 2016).

Historical Background

Opium and cocaine use in the nineteenth century was virtually unregulated. Late in

the 1890’s, the Bayer Corporation advocated for cocaine and heroin to be made publicly

available as standard cough and cold remedies as part of their product line. In 1914, the

Harrison Narcotic Tax Act was put in place to regulate opium and cocaine use in the United

States (Clarke, Skoufalos, & Scranton, 2016, p. S-2). Physicians risked incarceration if they

prescribed or provided either of these substances to patients. It was not until 1997 that the

advocacy for better pain control led to the adoption of intractable pain standards that

quantified and established pain guidelines; however, these standards and guidelines was to

become fraught with their own limitations and unintended consequences (Clarke et al. 2016,

S-2).

In the early years of the twenty-first century, opioid pain medications were

considered the gold standard for pain treatment; however, from 1996 through 2008,

regulatory agencies, such as the American Society of Anesthesiologist (ASA), American

Pain Society (APS), JC, and the Centers for Medicare and Medicaid Services (CMS),

supported the use of opiate pain medications to manage acute and chronic pain as the fifth


vital sign (Curnutte, 2013, Lowes, 2016). In 2004, patient rights agencies pushed for

legislation to sanction providers who undertreated pain (Brennan, et.al, 2007). From 2001 to

2010, the JC and CMS tied hospital reimbursement to a provider’s performance and to

patient satisfaction with the postoperative pain management plan (Baker, 2017). Press Ganey,

HCAHP, Leap Frog, and Health Grade physician ratings further compounded the growing

opioid problem when they publicly identified physicians’ pain management practices, which

almost single handedly created an era of excessive opioid prescribing (Garcia, Angelini,

Thomas, Lenz, & Jeffrey, 2014).

In 2011, the Institute of Medicine (IOM) report, Relieving Pain in America, a

Blueprint for Transforming Prevention, Care, Education, and Research, called for a cultural

transformation in pain prevention, care, education, and research, which included professional

education and training regarding pain management practice for nurses (National Institute of

Health, 2015, p. 14) Although pain is the most common reason for persons to seek medical

care, professional education has not taught clinicians to completely understand pain and its

management principles. Accreditation and professional organizations and licensure boards

have made provisions and created guidelines for basic knowledge and assessment for staff to

assess pain in a culturally competent manner. The National Pain Strategy recommends the

development of a web-based pain education portal with up-to-date comprehensive and easily

accessible educational materials (National Institute of Health, 2015, p. 2).

Established Guidelines

Regulatory agencies and professional organizations have established pain assessment,

reassessment, and pain assessment documentation guidelines for frontline clinical staff.

There was consensus among regulatory agencies, such as CMS, Centers for Disease Control


(CDC), JC, Massachusetts Board of Registration for Nurses (MA BORN), that standards

should exist to guide clinical practice and compliance expectations. The IOM (2011)

recommended ongoing education regarding pain assessment and pain management to bridge

the gaps in current nursing practice and knowledge. The four pain principles guiding these

recommendations include: 1) effective pain management as a “moral imperative,” 2) pain

should be considered a disease with a distinct pathology, 3) a need for interdisciplinary

treatment approaches, and 4) the existence of serious problems with diversion and abuse of

opioid drugs (p. S-4). Regulatory guidelines ensure that health care workers are educated to

assess, reassess, and treat pain (Ferguson, 2013, Institute of Medicine, 2011).

A 2010 Executive Summary of the National Pain Strategy (NPS) highlighted the need

for a cultural transformation to reduce the burden of pain in the United States and identified a

need for significant improvements in pain assessment techniques and practices wherein much

of the responsibility for pain care rests with bedside clinicians who have not been sufficiently

trained in pain assessment and evidence-based management practices. Most nursing school

education has not given priority to pain assessment management skill acquisition in either the

undergraduate or graduate curriculum (NIH, 2015, p. 2).

The JC developed pain management standards that include clear guidelines about

pain assessment and reassessment that aim to reduce human pain and suffering. It has been

documented that failure to meet these standards may lead to increased length of hospital stay,

escalating health care costs, and a slower recovery (Grinstein-Cohen et al., 2009). Two JC

Standards specifically address pain management. Standard LD.04.05.17 required hospitals to

provide staff with educational resources to improve pain assessment, pain management, and

to monitor assessment. Standard PC.01.02.07 required hospitals to have written policies on


pain screening, assessment, and reassessment based on clinical practice guidelines and

evidence-based practices. There is an expectation that pain assessment and reassessment

documentation must to be clear, timely, and identify the efficacy of any improvement in pain

score after receiving pharmaceutical intervention (Buvanendran et al., 2017).

The implementation of these JC pain management standards are too often blamed as

the root of the current opioid crisis. From 2001 to 2006, there was a shift in the new

guidelines that encouraged organizations to establish pain assessment and treatments; these

guidelines mandated: 1) hospitals educate all licensed practitioners on pain assessment, 2)

patients have a right to pain management, and 3) assessment and management of pain and

documentation (Baker, 2017, n.p.).

Curtiss (2001) described pain management as an ever-evolving area for changes in

clinical practice. Beginning in January 2000, the JC provided a directive that added pain as

the fifth vital sign and mandated that healthcare organizations and clinicians make pain

assessment, reassessment, documentation, and pain management a priority (p. 28). To meet

these new regulatory mandates, the nursing profession became a pivotal stakeholder in the

field of pain assessment and pain management. It was also strongly recommended that

healthcare staff must have access to education and that reeducation must be established as

clinical competency standards to ensure that nurses had access to education to gain the skills

needed to meet these new practice guidelines (Curtiss, 2001, p. 29).

Stempniak (2016) acknowledged the unintended consequences of coupling patient

satisfaction with pain management practices and reimbursement, which have been trended by

consumer surveys such as the Hospital Consumer Assessment Healthcare Providers and

Systems survey (HCAHPS). In the early years of the twenty-first century, there was a


demonstrated increase in opioid prescriptions, and many suspected that excessive

prescriptions were written with the hope of raising HCAHP scores and preserving

reimbursement funding, often to the detriment of sound pain management practices (n.p.).

The best strategy for pain management is based on sound, reliable pain assessment and

reassessment observations that value both the subjective and objective bidirectional

conversations between healthcare providers and the patient.

The Massachusetts Board of Registration in Nursing (MA BORN) (2017) holds

nurses responsible and accountable for ensuring that patients receive appropriate evidence-

based nursing assessment and intervention. Nurses are encouraged to assess their own

attitudes and cultural biases to determine how their own experience with pain may be

impacted. The MA BORN requires nurses to use the nursing process to assess the patient’s

pain experience. Valid and reliable pain assessment tools are used to quantify pain. It is

essential that nurses have current knowledge and skills about pain assessment and

reassessment to enable the development of a comprehensive, individualized effective pain

management plan (Massachusetts Board of Registration in Nursing, 2017).

The current position of the MA BORN (2017) is to develop and implement pain

management interventions that are evidence-based. Documentation must be legible and

timely to ensure that the appropriate dose is administered. Assessments must be culturally

sensitive. Massachusetts General Laws (M. G. L.) c. 13 §§ 13, 14, 14A, 15, 15D to ensure

that nurses have access to educational opportunities to ensure knowledge about pain and pain

practices can be gained through basic undergraduate education, continuing education, and,

moreover, is appropriate to the scope of practice for professional licensure (Massachusetts

Board of Registration in Nursing, 2017).


Several professional organizations have defined similar practice guidelines for pain

assessment, reassessment, and pain assessment documentation. The Academy of Medical-

Surgical Nurses (AMSN) (2012) presented a position paper that describes the nurses’

responsibilities in relation to pain management. Nurses must collaborate with patients to

identify the best interventions to manage pain and suffering. The self-reported pain

experience was recorded as the most reliable indicator of pain. Pain assessment is required at

least every eight hours for the hospitalized patient, and pain reassessment is needed after

each pain treatment interventions to identify a change in pain level and to allow for adjusting

the treatment plan (n.p.).

In 2012, the American Society of Anesthesiologist (ASA), and the American Pain

Society (APS) commissioned guidelines on the management of pain to promote evidence-

based practice. The guidelines called for 1) safe and effective postoperative pain

management, 2) practicing changes to decrease adverse outcomes, 3) maintenance of

functional status, and 4) the enhancement of the patient’s quality of life (ASA, 2012).

Similarly, Chou et al. (2016) described thirty-two recommendations proposed by the APS

that discussed the management of pain. One of the recommendations, Recommendation 4,

states that “optimal pain management requires ongoing assessment to determine adequate

pain relief and monitor progress toward functional goals and functional recovery” (p. 135).

Recommendation 5 encouraged “the use of a validated pain assessment tool to track the

response of postoperative pain management interventions and adjust accordingly. The pain

scale should identify a change in pain status after a treatment” (p. 136).

Pain management expectations clearly identified in the Brigham and Women’s

Hospital (BWH) (2014) Pain Management Policy, 1.4.10 (formerly NCPM PAIN-00), state


that pain assessment should be documented within twenty-four hours of admission and that

reassessment is required before and after any pain intervention. A pain score tool, such as a

scale, appropriate to the patients’ cognitive ability, should be used as a decision aid to

quantify the pain assessment and enable documentation in EPIC (Brigham and Women’s

Hospital, 2017).

Nurses’ Attitudes and Education Related to Pain Management

Seminal research that investigated nurses’ attitudes and skills in the field of pain

assessment and pain management was conducted by Betty Ferrell and Margo McCaffery

more than forty years ago. It was Margo McCaffery who coined the phrase, “pain is whatever

the experiencing person says it is and exists whenever he says it does” in 1968 (McCaffery,

1968, p. 95).

According to a 2016 article published by the American Nurses Association, every

nurse is a pain management nurse, though additional pain education is optimal for nurses

(American Nurse Association, 2014). Pain management is complex; pain is often

undertreated, and there is a growing body of knowledge that states that if nurses had a more

structured formal education and access to more robust mentoring from a nurse in pain

management, practice may be more impactful (Bernhofer, Hosler & Karius, 2016). However,

there was concern that the time allotted or priority given to pain management education and

access to pain management educational resources for nurses was scarce in the workplace

(American Nurses Association, 2014). Yet despite advances in pain management, evidence-

based guidelines, and the development of pain management standards by many regulatory

agencies and professional medical organizations, many schools of nursing do not include


pain management education as part of the formal curriculum (Vargas-Schaffer & Cogan,

2014).

Nursing education fails to prepare nurses for clinical pain assessment and pain

management. Pain assessment, reassessment, and pain management in hospital patient care

units involve patients self-reporting their pain score and nurses interpreting this pain score to

guide them to administer the most appropriate pharmacological agent (Drake & Williams,

2017). Drake and Williams (2017) state that training nursing staff to use a pain scale tool to

quantify the patient’s experience of pain is not the same as training nursing staff to assess

pain (p. 12).

Even with clear standards and guidelines for pain assessment after pain medication

administration, a lack of compliance remains with pain scale score documentation in the

clinical setting. Published studies by Clarke et al. (1996), Wood (2008), Grinstein-Cohen, et

al. (2009), Briggs (2010), Schiavenato (2010), Borglin, Gustafsson, & Krona (2011), Cordts,

Grant, Brandt, and Mears (2011), Bozimowski (2012), Schreiber et al. (2014), Bernhofer et

al. (2016), Chatchumni, Namvongprom, Eriksson, & Mazaheri (2016), Drake & Williams

(2017) and Goodman (2017) provided insight into the complexities of pain management,

compounded by a lack of formal pain management training for nurses that are further

influenced by the nurses’ knowledge and attitudes.

Clarke et al. (1996) conducted a study that examined the knowledge, attitudes, and

clinical practices of 120 nurses regarding their pain management expertise. The nurses

represented their opinions about nurse practicing in nine diverse clinical units including two

orthopedic, three surgical, one medical, one medical oncology, and two surgical intensive


care units, in a large east coast urban teaching hospital. Nursing characteristics, education,

and clinical experiences were assessed by administering the KASRP survey, and the clinical

practice around the pain assessment documentation was studied using a pain audit tool (p.

19). There was a 53% return rate for the KASRP survey and the pain score interrater

reliability for audit data was reported as r = 0 .8 – 1.0 (p. 26).

The review of the KASRP survey responses demonstrated that the nurses were

practicing under a veil of misinformation that was negatively influencing their assessment

practices. Many nurses were practicing with inadequate and inconsistent knowledge

regarding pain assessment and pain assessment documentation (Clarke et al., 1996, p. 19).

Results demonstrated that the educational intervention had a positive impact on practice.

With a mean overall score of 62%, the KASRP results ranged from 41% to 92%. Data

showed that masters prepared nurses performed best at assessing pain with 74%, followed by

associate degree nurses at 62%, and baccalaureate trained nurses at 60% (Clarke et al., 1996,

p. 26). One limitation of this study was that the KASRP survey questions disproportionately

measured nursing knowledge regarding pain management in the oncology population, yet the

clinical areas included in this study represent medical surgical patient care units where nurses

may not have oncology expertise. The results were generalizable as the researchers

implemented this survey and education intervention across nine hospital units, and the results

were compelling enough to see this intervention added to the nursing orientation (p. 29).

Wood’s (2008) research study with pain concurred with the work of many other

researchers who proposed that the best clinical practice for optimal patient care was to train

nurses in the knowledge and skill of pain assessment and management; however, currently,

nurse education is lacking. The pain experience is multifaceted, and the nurses’ knowledge


skills and attitudes are often barriers that lead to poor documentation of the pain assessment

and reassessment (Wood, 2008).

Self-reported pain is the gold standard for pain assessment, and nurses are required to

translate subjective pain into objective pain scores, which requires the nurse to trust the

information the patient is describing, free of any bias and judgmental attitude. Often, nurses

report that they do not believe the patients’ self-reported pain; they offered clinical examples

of their observations of the patient lying in bed watching television and while reporting a

pain score of 10/10 or the patient is awakened from what appears to be a restful sleep and

report a pain score of 8/10 and falls back to sleep. The nurse’s attitude toward pain may not

be congruent with the patient’s self-reported pain score. This may lead to inconsistent pain

score documentation and result in the patient receiving a lower dose of pain medication at a

prolonged interval. The nurses’ interpretation of pain is subject to bias that may leave the

patient’s pain undermedicated (Briggs, 2010, Bernhofer et al., 2016, Chatchumni et al., 2016,

Cordts et al. 2011, Fink, 2000).

Despite a recent focus on pain management and the development of new standards of

post-operative pain management, Grinstein-Cohen et al. (2009) argued that patients have a

concern that nurses do not validate their fear of pain (p. 232). The challenge of appropriate

pain management is directly related to a nurse’s knowledge of pain assessment and

reassessment. Healthcare providers need comprehensive pain assessment education to

achieve better postoperative pain management. Pain management education should include a

review of a nurse’s knowledge and attitudes toward analgesics and the importance of pain

assessment and reassessment. Grinstein-Cohen et al. (2009) conducted a study of nurses’

attitudes toward pain management and found that eighty-percent of nurses admitted that they


are insecure about their knowledge of pain assessment and management and, thus, administer

lower doses at longer intervals due to their overestimated fear that patients will suffer

respiratory depression and future addiction (MA BORN, 2017). Adequate pain management

is impeded by a lack of formal education about pain assessment, reassessment practices and

knowledge of pain, all of which results in decreased compliance with assessment and

reassessment documentation (Grinstein-Cohen et al., 2009, p. 233).

Pain assessment is a core nursing skill and has historically been included as the fifth

vital sign. Pain is usually assessed every two hours upon admission after transfer to a new

patient care setting and after each pain treatment intervention (Wood, 2008). Briggs (2010)

described the importance of the pain assessment as a collaborative conversation between the

patient and nurse. The nurse’s role was clear; pain was assessed using a pain assessment tool

that enabled the nurse to validate the patient’s pain experience. Documentation of the pain

assessment was vital to monitoring progression toward comfort (p. 38).

The aim of Schiavenato’s published work in 2010 was to improve pain management

and focus on the importance of assessment and self-reported pain experience. Self-reported

pain often collides with nursing bias and errors and cause judgment (p. 667). Schiavenato

(2010) cautions that patients must accurately describe their pain to the clinician, and the

clinician must be fully present and actively listen to decrease skepticism around pain

assessment (p.673). The JC holds the patient-centered position that the patient is the source

of truth when it comes to describing their pain experience, and the nurses’ observation are

unidimensional; therefore, there is a need for decisional aides in the form of pain scale

scoring tools (p. 668). Pain assessment is a social transaction with a necessary feedback loop,

and pain must be assessed at rest and with activity (p. 670).


In a 2011 study, Cordts et al. utilized a survey tool and focus group setting to explore

the opinions of nurses and surgical residents regarding their experience with pain

management education. The setting for this study was a ten-bed inpatient orthopedic unit in

an academic medical center with a multidisciplinary team of nine nurses, twenty surgical

residents, and six physical therapists participated in a mixed methods survey for which they

met in focus groups and completed a survey specific to their respective clinical disciplines.

Focus group qualitative themes strongly suggest barriers to effective pain management across

disciplines, which include a lack of formal pain management education and a lack of

knowledge related to evidence-based pain management techniques (n.p.). Limitations of this

study included a small sample size of thirty-five participants and the limited scope of the

study because it was implemented in one clinical area in the hospital. In addition, the

opinions of this group may not be representative of all clinicians across the organization. The

nurses and surgical residents each described the one-time, two-hour education intervention as

less than memorable (n.p.).

Studies conducted by Schiavenato & Craig (2010) and Cordts et al. (2011) provided

the foundation for Bozimowski (2012) who concurred that an inadequate assessment of pain

is frequently identified as a significant barrier to adequate pain management; however, this

leads to much variation in practice. One barrier was the use of a unidimensional pain scale

scoring tool, which only enabled nurses to assess pain intensity that may not match the

patient’s reported score (p. 187). The two most commonly identified barriers to successful

treatment of pain was the nurses’ own beliefs that patients exaggerate pain and the nurses’

fear that patients will become addicted to opioids. Despite the existence of extensive pain

management guidelines, there remains a need for ongoing education and reassessment this


often does not occur (p. 189). In a 150-bed community hospital, Bozimowski interviewed

nurses to gain insight into their practices of predicting pain and their accuracy in correlating

with the pain scale scores and pain medication administration practices. Limitations

associated with this study include a small number of nonrandomized participants in a small

area county hospital reducing the possibility that the results could be generalized to other

clinical settings (p. 191). It was clear from this study that there are many complexities

associated with the art and science of pain management.

The work of Bernhofer et al. (2016) was parallel to the work of Cordts et al. (2011)

and Bozimowski (2012). A common assertion was that pain is a unique experience and no

two patients present have a similar clinical picture. Nurses with excellent pain management

knowledge and skills made better clinical decisions after pain assessment (p. 385). To prove

his hypothesis, Bernhofer et al. (2016) conducted a study that examined nurses’ influence on

pain management. In that qualitative study, twenty nurses in a large midwestern teaching

facility participated in face to face focus groups. Four themes about pain assessment practices

emerged from the focus groups: 1) it was important to understand the patient’s perspective,

2) pain education for the staff was important, 3) nurse must be self-aware, and 4) personal

values influenced pain assessment (p. 388). Eighty percent of the nurses participating in that

study provided responses to a questionnaire that confirmed that their first formal pain

education opportunity was in the workplace, where they stated that they wanted more

professional development opportunities going forward (p. 389). Limitations of that study

identified that a one-hour educational class was most likely not going to significantly change

clinical practice. One obstacle to consider was that the researchers taught the educational

class and hosted the focus groups, which may have increased the risk of bias (p. 390).


The concern associated with inadequate educational preparation of the nurses and the

inherent personal biases of nurses toward pain led Chatchumni et al. (2016) to investigate

pain assessment practices among surgical nurses in Thailand. The authors’ hypothesis was

that good patient observations and pain assessment documentation should increase a nurse’s

knowledge and skill in pain assessment and management. A cross sectional qualitative study

was conducted in Thailand in a 50-bed hospital in September 2013. This study was framed

by Benner’s theory (2001) that nurses move from novice to expert with mentoring and

training (n.p.). The researchers used Benner’s framework to develop a 45-minute educational

intervention to explore the nurses’ perception of pain where the nurses judged pain based on

appearance. The study described the incompatibility between what the nurse observed and

quantified as pain and what the patient reported as pain, further demonstrating the subjective

nature of the pain experience.

Pain Assessment Tools

Pain is complex and subjective, which makes for a measurement challenge (Younger,

McCue, & Mackey, 2009). Evidence-based practice demonstrates the importance of utilizing

a sensitive, valid, and reliable pain assessment tool to accurately monitor pain outcome

measures. Pain scale score tools are divided into two categories, unidimensional and

multidimensional. Unidimensional pain scale tools have been used for many years; however,

there has been a growing movement toward accepting the multidimensional pain scale score

tool, is believed to capture the complexities of pain better (Younger et al., 2009, p. 41).

According to Breivik et al. (2008) the unidimensional pain assessment tools fail to capture

the patients’ comprehensive pain experience, but the multidimensional pain scale tool allows

the bedside nurse to fully understand how pain interferes with a patient’s quality of life,


sleep, food patterns, and daily activities. To effectively understand a person’s pain

experience, the assessment should be dynamic and comprehensive. A valid and reliable pain

assessment tool should be used to monitor acute pain. Best practices encourage pain to be

evaluated at rest and during movement with a unidimensional pain score scale such as VAS

or NRS (p.17).

The most widely accepted unidimensional pain scales include the Numeric Rating

Scale (NRS) and the Visual Analog Scale (VAS) (Figure 4). The NRS is an assessment tool

that measures pain along a continuous line from zero to ten where zero correlates to no pain

and ten indicates the worst pain you can imagine. The NRS tool is validated for use in both

short- and long-term pain assessment due to the relative ease of use (Borglin et al., 2011).

Figure 4. Unidimensional tools 1.

The VAS is a unidimensional single item scale pain assessment tool that is widely used due

its simplicity and adaptability in most clinical settings and among most age groups. This pain

assessment tool easily fits into the nursing workflow, takes less than one minute to complete,

and requires minimal training to understand and administer. This tool’s reliability has been


demonstrated as r = .94, P < 0.001. (Hawkers, Mian, Kendzerska, & French, 2011, n.p.). The

primary limitations of the VAS pain tool are that it must be administered in person and that

the person and the patient must have the dexterity and mental capacity to draw a line on a

pain continuum.

Like the VAS, the NRS is a unidimensional pain assessment tool that requires

patients to rate pain on a scale of 0 to 10. The accuracy of the NRS has been reported to

reflect both pain and interference with functioning with a sensitivity of sixty-four percent and

a specificity of eighty-three percent, respectively (McCaffery & Pasero, 1999, p. 16). Krebs,

Carey, and Weinberger (2007) wrote that the NRS is simple to use, reliable and valid when

measuring pain intensity, can be administered verbally, takes less than one minute to

complete, requires minimal patient instruction to use, and demonstrates a high test and retest

reliability (p. 1457). One advantage of it is that it may be administered over the telephone

with a patient during a post discharge follow-up call. As pain assessment requires nursing

practice to be more sophisticated, the beside nurse is quickly outgrowing the NRS as a

reliable pain assessment tool as it only measures pain intensity and is unable to assess the

multidimensional characteristics of pain (Hawkers et al., 2011).

Multidimensional pain tools measure pain on multiple domains to assess the intensity,

quality, effect, and interference with function. One limitation of a multi-dimensional pain

tool is that it may ask the patient to report on too many items, thus making the tool

cumbersome and too lengthy to be used effectively in the clinical setting (Younger et al.

2009, p. 42). The Brief Pain Inventory (BPI) was an early attempt to provide a

multidimensional pain assessment tool for bedside nurses. The BPI is an eleven-item tool to

measure pain that interferes with functioning. Its shorter version is easy to administer and


assesses the seven domains of pain: general activity, mood, walking ability, work and

relation to people, sleep, and quality of life (Krebs et al., 2007, p. 1454). It takes between five

and fifteen minutes to complete this written pain assessment evaluation, which may be

cumbersome in the acute care setting (Kishner et al., 2016).

The most recent iteration of the multidimensional pain assessment tools includes both

the Clinically Aligned Pain Assessment tool (CAPA©) and the Functional Pain Scale (FPS)

(Figure 5). The CAPA and FPS demonstrate that pain is more than a number, alluding to the

NRS, and encourages nurses to utilize the information gleaned from the pain assessment to

interpret and apply the JC guidelines (Drew & Topham, 2014). With several valid and

reliable pain assessment tools in use in the clinical setting, it is important to ensure that both

subjective and objective pain perspectives are considered when patients and clinicians are

creating a pain management plan (Ault, 2017).

Figure 5. Multidimensional tools.

The CAPA© is structured around five domains: 1) Comfort (negligible to intolerant),

2) Change in pain (getting better to getting worse), 3) Pain control (inadequate to effective)


4) Functioning (cannot do anything to can do whatever I need to), and 5) Sleep (moderate

pain at night to slept well). One benefit of using the CAPA© is that a conversation between a

patient and a nurse can elicit valuable information that validates the patient’s individual pain

experience by contextual questions such as: “Was your last pain medication helpful to reduce

your pain?” (change in pain), or “Did your physical therapy session go better with the timing

of your pain medication?” (functionality) or “were you able to rest today?” (sleep) (Drew &

Topham, 2014). These questions enable the nurse to document the effectiveness of the pain

plan. Self-reported pain assessment is the gold standard, but the major disconnect is often

between what is reported and how a clinician applies this information in the clinical setting.

The multidimensional pain assessment adds to how context influences pain.

In 2012, the University of Utah conducted a pilot where the CAPA replaced the NRS,

and the Press Ganey scores increased from the 18th to 95th percentile, while the HCAHP score

increased from 45% to 98%. 55% of patients in the pilot study stated that they preferred the

CAPA and the nurse reportedly preferred the CAPA format of three to one over the NRS

(Wanner, Ransco, & Daniels, 2016, n.p.). Drew and Topham (2014) stated that pain is more

than a number because it encompasses functionality and effectiveness and the progress

toward a state of comfort. Engaging the patient in a meaningful conversation around pain and

how pain interferes with their daily life shifts the conversation from a subjective to an

objective pain assessment.

Newer multidimensional pain scale tools enable the nurse to assess and measure

multiple pain dimensions. The FPS was developed to assess pain in older adults by

measuring both subjective and objective pain and its interference with function. This tool has

been found to be valid and reliable in the geriatric population (Gloth, Scheve, Stober, Chow,


& Prosser, 2001). Like the CAPA, the FPS encourages patients and providers to engage in a

bidirectional conversation that creates a social transaction between the patient and the nurse

wherein the pain assessment process is ongoing, dynamic, and focused on the context of

functional status to guide pain management decisions (Drew & Topham, 2014). The FPS was

developed to assess pain in older adults who required both a subjective and an objective

assessment to fully understand the patient’s perceived pain tolerability and interference with

functioning. Like the CAPA©, the FPS assess pain on multiple domains.

Gloth et al. (2001) conducted a study with one hundred patients over sixty-five years

old. Ninety-four participants completed all phases of the study that aimed to determine the

reliability of the FPS compared to the VAS and the NRS. Reliability was tested using a test,

retest criteria, and the validity was established by comparing the FPS to the VAS and NRS.

Inter rater reliability demonstrated VAS r= .62, NRS r=.90, and the FPS r= .95; thus, the FPS

was determined to be reliable. The FPS responsiveness was deemed superior in

demonstrating pain changes better than the other tools (n.p.). In summary, unidimensional or

single dimensional tools are quick, simple, easily understood by the patient, fast to measure,

and do not increase nurse workload (Younger et al., 2009, p. 41).

Kishner et al. (2016) stated that pain assessment must be precise and systematic and,

thus, prefers the use of a multidimensional scale versus a single scale. The ideal pain measure

is accurate, reliable, valid, and useful. Single dimensional pain scales measure intensity and

are reproducible, but they oversimplify pain. They are best used when there is a clear

etiology of pain i.e. trauma, surgery. Multi-dimensional scales demonstrate how pain affects

activity and mood. This scale is useful to measure the complexity of pain, such as the

intensity, location, and interference (n.p.).


Economic and Societal Burden

Untreated pain contributes to poorer health outcomes, delayed restoration of

functional mobility, extended length of stay, and an avoidable increase in costs associated

with the surgical episode of care. In addition to contributing to an economic burden that

exceeds $180.8 billion per year, untreated pain has been attributed to misuse, abuse, and

overuse of prescription pain medications (Strassels, 2009, p. 556).

Schreiber et al. (2014) estimated that the financial impact of undertreated pain was

approximately $635 billion annually with Medicare assuming 25% of these expenses.

Healthcare organizations with evidence-based interventions related to pain management

demonstrated an average decrease of $1500 per day per inpatient stay (p. 475).

Ensuring that patients are satisfied with their pain management plan is an important

indicator trended by the patient satisfaction HCAHP survey, and suboptimal performance has

the potential to negatively impact hospital reimbursement. The University of Utah healthcare

system implemented a team-based approach to improve their HCAHP pain scores. After

historically low HCAHP scores (5%), the team administered a survey to the nurses to gain a

better understanding of their attitudes regarding pain medication, specifically the use of

opioids and their confidence in pain assessment techniques. From 2012 to 2015, the

HCAHPS scores improved dramatically; the increase in satisfaction scores was attributed to

the ongoing educational opportunities offered to staff, improved pain protocols, and a clinical

focus on assessment and reassessment (Wanner et al., 2016, Drew & Topham, 2014).


Cultural competence, as it relates to pain assessment, was first recognized as a public

health problem in older ethnic minority groups by Booker et al. in 2016. Ensuring quality of

pain assessment, reassessment, and documentation and measurement of compliance is a core

task and a mechanism by which disparities may be reduced. A comprehensive pain

management plan includes a method for comprehensive pain assessment and tools to

understand the characteristics of pain. It is equally important for nurses to be culturally

sensitive to be able to fully meet the pain treatment needs of all patients regardless of age,

ethnicity, gender, intellectual capacity, and culture of origin (Booker et al., 2016).

Recent Studies

Recent studies indicate that the implementation of the electronic health record has not

improved the documentation of pain assessment and reassessment. A study was conducted by

the research team of Song, Eaton, Gordon, Hoyle and Doorenbos in 2013 in the Washington

State healthcare system where nurses volunteered to allow their pain assessment and

reassessment documentation reviewed for accuracy and completeness. They studied the

documentation of pain management practices in patients hospitalized for cancer related care.

They found inconsistent documentation and reported that the assessment documentation was

suboptimal in 99.6 % of documented pain assessments that met all institutional guidelines,

which had required assessment at least every eight hours using a validated pain scale. The

researchers identified a lack of functional assessment and stressed on the need to complete a

thorough review of identified documentation barriers as next steps to practice improvement.

Samuels and Eckardt (2014) studied pain assessment and reassessment

documentation following the Joint Commission standards that clearly define the need for

pain reassessment if the patient’s condition changes or after the provision of a pain-relieving


intervention, such as medication (p. 653). The researchers questioned the effectiveness of

only documenting pain scores in conjunction with prn pain medication reassessment that

state that nurses are meeting vital components of a comprehensive pain management plan.

One of the suggested outcomes of this research was to eliminate prn medications and develop

a standardized around-the-clock practice of pain assessment aimed to capture the patient

experience during periods of rest and activity.

These researchers cited the barriers to pain reassessment documentation as the

nursing workarounds, such as back charting and variation used to document the electronic

health records, such as location and timeliness. The study concluded that once the

measurement and data coding issues are managed and standardized, the documentation

compliance will improve to meet the established guidelines.

With greater than 75% of the hospitals has adopted or is planning to adopt electronic

health record technology, the documentation provides increased opportunity to mine time-

specific pain management data, including pain assessment and reassessment documentation.

In the literature, there is a plethora of quality improvement and process improvement studies

reviewing pain assessment and reassessment documentation, and, yet, the compliance is not

consistent (Samuels & Bliss, 2012, p 316). Guided by the Joint Commission standards, many

hospitals have established processes to audit the pain documentation compliance. Samuels

and Bliss (2012) conducted a cross-sectional study to better understand inconsistencies in the

pain assessment documentation. The goal of that study was to identify trends that connected

the effectiveness of the pain assessment to patient satisfaction. Implications for practice were

supported by the perceived benefit that the EHR may provide a more reliable process for real


time documentation, improve the ease of retrieving benchmark data, and support process

improvement work.

In 2014, Jessica Latchman conducted a cross-sectional study with a sample of forty-

one senior nursing students pursing a baccalaureate in a large southeastern university school

of nursing. The nurses volunteered to complete the Nurse’s Attitude Survey (NAS) and Pain

Management Principles Assessment Tool (PMPAT). The NAS is a 25-item tool to gain

knowledge about nursing students’ attitudes toward pain management and the PMPAT is a

31-item multiple choice test to test pain management knowledge. The overall scores

indicated that baccalaureate prepared students near graduation had minimal knowledge about

pain management principles (Latchman, 2014, p. 13). This study confirmed what earlier

studies, such as Latchman (2014), Joint Commission (2016), Grinstein-Cohen et. al (2009),

Schiavenato et. al (2010), and Cordts et.al (2011), found; that nursing students do not receive

formal pain management education and may be underprepared to effectively manage pain in

hospitalized patients. Despite identifying pain management as a healthcare problem, few

strides have been made to ensure that healthcare providers are trained to adequately manage

pain in a variety of practice environments.

According to Diane Glowacki (2015), undertreated pain is seen as a national, if not

global, challenge, where the commonly held belief is that practitioner knowledge and

practices do not align, and the patient is left in a state of suffering. There are five domains of

pain management: physiological, sensory, affective, cognitive, and sociocultural. Often, pain

control remains elusive to the patient experiencing an acute episode. The American Pain

Society recommends that patients and their families would benefit from preoperative pain

education for the patient undergoing elective surgery and that trauma patients will benefit


from receiving patient education early and often during their hospital stay, including a multi-

media approach of written and visual patient education materials. Glowacki (2015)

acknowledged that one of the most important barriers to effective pain management is the

lack of attention to the subjective pain assessment—how the individual experienced pain and

suffering as well as previous experience with pain reliving modalities.

Provider education, or the lack thereof, is an important barrier to effective pain

management. In 2013, the American Nurse Credentialing Center (ANCC) estimated that

there were fewer than 1700 registered nurses in the United States who were certified in

advanced pain management techniques. Nursing schools, like medical schools, could benefit

from enhancing their educational curriculum to better meet this knowledge gap (Glowacki,

2015). As we move toward achieving improved patient satisfaction through elevated pain

management, the Hospital Consumer Assessment of Healthcare Providers and System

(HCAHPS) and National Databank of Nursing Quality Indicators (NDNQI) results suggest

that resources must be dedicated to improving healthcare education related to pain

management.

In 2016, the Joint Commission published a response to the growing opioid crisis and

the misinterpretation of earlier Joint Commission standards that suggested that pain be

treated as a fifth vital sign. The JC published clarifying statements regarding their pain

management guidelines, which mandate 1) all hospitals provide education to all licensed

independent practitioners on assessing and managing pain, 2) hospitals respect the patients’

right of pain management, and 3) expectations that hospitals create policies that identify pain

assessment and management practices (JC, 2016). Though the Joint Commission has been

connected, through historical context, to the opioid crisis that has led to the misuse, overuse


and abuse of pain medication, from 2016, they have continued to work to right the opioid

crisis and balance safe pain prescribing practices with patient pain satisfaction.

The JC has been an integral player in the fight against pain and opioid misuse. In

2008, they published a study conducted at the University of Wisconsin Hospital and Clinics

(UWHC). In 2005, the UWHC system identified inconsistent reassessing after pain

interventions as a significant clinical problem. After more than two years of daily pain audits,

repetitive educational efforts, and extensive leadership involvement, the researchers were

nearing a greater than 94.9% rate of pain reassessment documentation (p. 509). It is reiterated

throughout the study that safe effective pain management requires reassessment and

documentation after a pain-relieving intervention; however, there was inconsistent

compliance with pain assessment documentation.

Pain management guidelines were clearly defined, and pain was to be reassessed after

each pain treatment intervention and would include the patients’ goal for pain relief. Though

the UWHC study used an audit process that was labor intensive, daily pain audits, one-to-one

coaching, and ongoing counseling proved to be a strategy that made a significant impact on

practice change. Results identified overcoming documentation barriers and knowledge gaps

regarding pain knowledge as crucial steps to sustaining change.

Summary

Looking retrospectively, the current opioid crisis may be rooted in healthcare

practices around pain management that began more than one hundred years ago. Liberal pain

practices of the late twentieth century/early twenty first century fueled by pharmaceutical

company incentives and regulatory agencies threats of sanctions for undertreated pain pushed


practitioners to prescribe extensive amounts of pain medications without a mechanism to

closely monitor the effects of these mandates. Accountability and responsibility for pain

management has become decidedly absent in our healthcare system. “Pain is what the patient

says it is” (McCaffery, 1968, p. 95) may have landed the current healthcare system on a

slippery slope.

Regulatory agencies and professional organization have begun the work to right this

century old problem by establishing guidelines for best practice with respect to pain

assessment, reassessment, and documentation; yet, little has been done to change the nursing

school curriculum to include formal instruction for pain management. Technologies, such as

EPIC, has improved the nursing workflow by providing an easy to navigate electronic health

record in which to document a pain assessment. In addition, the transition from

unidimensional to multidimensional pain scale scoring tools further assisted the nurse in

documenting a comprehensive pain assessment.

Conceptual Framework

Lewin’s Theory of Change (Shirey, 2013) provided the framework for this quality

improvement project. Lewin is considered a pioneer in change practices and his work

emphasized the important role of change agents in enabling change (Mitchell, 2013) Kurt

Lewin began his work as a social psychologist who studied group dynamics and

organizational development to understand how change can happen. Lewin’s Change Theory

is based on a three-step design described as Unfreezing, Moving, and Unfreezing (Figure 6).


Figure 6. Lewin’s Theory of Change.

Wojciechowski, Murphy, Pearsall, and French (2016), Shirey (2013) and Mitchell

(2013), each highlighted Lewin’s work as a framework for transforming care when the three

stages are followed in a sequential order. In stage 1—Unfreezing, the need for change is

identified, barriers to change are discussed, and early adopters are recruited. In stage 2—

Moving, change begins when an intervention is identified and implemented. Stage 3–

Refreezing requires evaluation and monitoring after the intervention to determine if a change

took place, and strategies are put in place to ensure that the change is sustainable. Involving

the staff as primary stakeholders is invaluable to gain momentum for the planned change

(William & von Fintel, 2012).

The strength of Lewin’s Theory of Change is that it is practical, simple, versatile, and

easy to understand; characteristics that made this theory the best framework for this practice

the change initiative (Shirey, 2013, p. 70). Guided by Lewin’s Theory of Change, a quality

improvement project was introduced to the bedside nurses working on the intermediate

orthopedic care unit to improve pain score reassessment documentation. In phase one,

unfreezing, the nurses reviewed how current practices were out of step with pain

Stage 1Unfreezing

Review barriers to complianceReview baseline data

Stage 2Moving

create new processtrain staffpromote unit champions

Stage 3Refreezing

audit for changemonitor sustainability


management guidelines and discussed where the unit practices failed to comply with JC

compliance expectations and benchmark goals. The staff also discussed why a practice

change was necessary and identified what change might look like on this unit. The nurses

participated in the KASRP survey to identify gaps in the pain management knowledge,

attitudes, and practice. The second phase of this project aimed to move the nursing practice to

improve pain assessment and reassessment practices after providing a comprehensive

education program for all nurses working on the orthopedic unit. Phase three provided staff

with an opportunity to refreeze pain assessment, reassessment, and pain score documentation

practice to meet regulatory standards (Mitchell, 2013, Shirey, 2013). Practice expectations

were reset, and the practiced change was measured by auditing pain score documentation

practice, one, two, and three months after the educational intervention. Pain score audit data

monitored key performance metrics, which were then reported as aggregated unit data that

was shared with all staff. A process was developed to monitor sustainability, celebrate

successes, and provide coaching an additional training support as needed.

In June 2017, the nurses completed a short demographic questionnaire in addition to

the City of Hope Knowledge and Attitude Survey Regarding Pain (KASRP), which served as

a pre-test. The demographic survey included questions regarding gender, age, educational

preparation, pain education, number of years in current practice and current shift. The staff

were asked to rank how they spent their work shift to identify how tasks were prioritized.

The nurses were asked one open-ended question to understand, in their opinion, what barriers

that impacted their ability to complete required pain score documentation existed. The

demographic survey data is presented in Table One, and the responses to the open-ended


question regarding perceived barriers to documentation compliance were organized as a

fishbone diagram (Figure 7) and were discussed during the educational intervention.

Figure 7. Fishbone diagram: barriers to pain score documentation.

Practice expectations were reset, and the compliance was measured by auditing the

pain score documentation practice for three months after the educational intervention to

determine if a change took place. The pain score documentation audits were conducted

weekly from August through October 2017 to determine improved compliance. Pain audits

were completed in January 2018 to understand if the practice change had been sustained over

time. Sustainability efforts included celebrating incremental successes, tasking the unit-based

champions to provide coaching and support to their colleagues as well as delivering the

elbow support as needed.


Methods

Design

Pain, after orthopedic surgery, is an anticipated patient experience. To objectively

measure the subjective pain experience, the bedside nurse is required to follow policy and

established guidelines for pain assessment and reassessment. Pain assessment is evidenced by

a documentation of the pain score in the EHR. Established guidelines require the nurse to

assess pain quality, intensity, and characteristics, pre- and post-administering pain

medications, such as opioids. This quality improvement project was designed to explore

nurses’ knowledge and attitudes regarding pain and to provide education to improve

orthopedic nurses’ compliance with pain assessment, reassessment, and pain score

documentation compliance. To assess nurses’ general knowledge and attitudes regarding

pain, the KASRP survey was distributed to the nurses via an email link as a pre-test and post-

test in conjunction with educational intervention. The educational intervention followed the

IASP Curriculum for Nurses in Pain outline. Weekly post educational intervention pain score

documentation audits determined the success of this project.

The educational intervention qualified as a continuing education program meeting

criterion that includes fifty consecutive clock minutes in duration, written objectives that

were specific, attainable, and measurable with expected outcomes. The program content

intended to improve competency and included one or more of the following nursing science

and practices, nursing education, research in nursing, and healthcare; thus, the educational

intervention met the criteria for continuing education credit (MA BORN, 2017, p. 26). Each

nurse who fully participated in the educational intervention received one Continuing

Education Unit (CEU).


Procedure

Each nurse hired by June 1, 2017 to work on this intermediate care orthopedic unit

was invited to complete the City of Hope Knowledge and Attitude Survey Regarding Pain

(KASRP) two weeks before and two weeks after participating in an educational intervention

that followed the International Association for the Study of Pain (IASP) Curriculum on Pain

for Nurses. To determine if the educational intervention positively impacted the pain

reassessment score documentation practice, audits, in the form of a chart review, were

completed weekly from August through October 2017 and in January 2018.

The KASRP survey responses were collected and stored in the web-based, electronic

data system REDCap to protect the nurses’ identity and preserve anonymity. Each nurse

received an email containing a link to the KASRP survey and a six-question demographic

survey. The nurses were invited to complete the KASRP survey two weeks prior and two

weeks after participating in the educational intervention. Completion of the KASRP survey,

as a pre-test and post-test, and participation in the one-hour educational class served as

implied consent. The nurses had access to computers in the clinical area to enable them to

complete the survey in a timely manner. Classes were scheduled at the beginning of each

shift immediately after staffs arrived for work, and the staff also had the option to attend

class on their day off, with pay.

Setting

The setting for this QI project was a thirty-bed, intermediate care unit specializing in

the postoperative care needs of patients recovering from orthopedic surgery and/or

orthopedic trauma. On average, the orthopedic care unit of this target hospital admits and


discharges seventy-five patients per week with an average length of stay of thirty-six hours.

During the short length of stay, the average patient received approximately ten to twelve

doses of opioid pain medications. To minimize distraction from competing priorities on the

unit, time and resources were dedicated to this educational endeavor and the participating

nurses were relieved from direct care responsibilities to complete all aspects of this

intervention. The educational intervention took place in a conference room located adjacent

to the orthopedic unit that was well lit, ventilated, and had adequate chairs and tables to allow

note taking.

Participants

A convenience sample of sixty intermediate care orthopedic nurses received an email

inviting the nurses to participate in this quality improvement project. Nurses who met the

inclusion criteria were regularly scheduled full time, part time, and per diem nurses as well as

newly hired nurses who began unit-based orientation by June 14, 2017, in addition to the

travel nurses on assignment from October 2017. Hospital based float pool nurses, capstone

students, and nursing students present on this unit participating in a clinical rotation were

invited to be part of the educational sessions but were excluded from full participation and

were not counted as participants. A total of fifty-five nurses participated in the entire project:

five nurses were excluded due to a long-term leave, two nurses transferred off the unit before

the educational intervention, one opted out of participating in the educational intervention,

and one nurse did not complete the post-test survey (n=55). The participating nurses

represented an age range from 22 to 67 years, had years of experience from less than one

year to more than twenty-six years, and were from both genders. These nurses supported


patient care across twenty-four hours, seven days per week, and the majority have prepared

for a career in nursing with a baccalaureate degree or higher.

Intervention

Plan-Do-Study-Act (PDSA) methodology guided the intervention timeline that

organized this QI project (Figure 8).

Dates PDSA Intervention Results Action Step

6/18 – 7/4 Confirm IASP & KASRP permission

Transfer KASRP into REDCap

Send email to all nurses inviting participation in this project

Schedule nurses to attend class

Complete IASP curriculum class content

Reviewed the Fishbone diagram at during the June staff meeting

Permission have been received

IRB process complete

Educational content reviewed with clinical educator

Staff offered insight into the barriers to pain score documentation

Class schedule complete

Verify email addresses for bounce backs

Verify REDCap data base

Confirm staffing to cover the educational sessions

7/5 – 7/24 One-hour face to face educational sessions

Email post KASRP surveys as staff completed class

Update pain documentation audit tool design

Primary education Reviewed the

importance of pain assessment, guidelines and policy, scales, and EHR documentation

Backup plan for nurses on vacation to ensure unit staffing covered

EHR audit tool opinions reviewed with EPIC team

7/25 – 8/7 Collate KASRP post-test surveys

Create plan for random chart audits of pain score documentation

Great conversation and excitement in the education sessions

Update REDCap data base

Review KASRP pretest responses

8/8 – 8/29Month 1

EHR pain score documentation audits

o 5 random chartso Every Tuesday

8/8,15,22,29

Improvement in pain score documentation over baseline

Feedback provided to staff

Audit results shared in small group huddles weekly

Email staff with reminder to complete pain score


documentation9/5 – 9/26

Month 2 EHR pain score

documentation auditso 5 random chartso Every Tuesday

9/5, 12, 19, 26

improvement in pain score documentation

Feedback provided to staff

↑compliance with pain score documentation

Share audit results at staff meeting

Display pain audit success on the unit-based quality improvement bulletin board

Created laminated cards, re pain score documentation guidelines

Posted at each computer

10/3 – 10/31 Month 3

EHR pain score documentation audits


10/3, 10, 17, 24, 31

Audit data demonstrates improved compliance with pain score documentation

Share audit data in unit-based newsletter

Reviewed with Care Improvement Team

Met to discuss gaps with EPIC pain audit tool

1/02 – 1/30/18

Month 6

EHR pain score documentationAudits


1/02, 9, 16, 23, 30

Audit data demonstrates consistent pain score documentation practices with pre-score compliance higher than post score compliance

Discuss results with staff

Review barriers Consider planning

focus groups to discuss barriers

Review at mock JC survey

Figure 8. Intervention timeline.

In June 2017, all nurses who met the project inclusion criteria received an email with

a link to complete the KASRP pretest survey. Each nurse was assigned a unique ID code and

all survey responses were stored in REDCap to ensure anonymity and to provide easy

retrieval for analysis. The survey took approximately thirty minutes to complete online and

the nurses were asked to complete this survey prior to participating in the face-to-face


education program scheduled for July 2017. Nurses received a second email with a link to

complete a short demographic survey (Appendix B).

The KASRP survey (Appendix C) included twenty-two true/false and fifteen multiple

choice questions. The KASRP survey tool has been used in many research studies since the

late 1980’s and is a validated tool, considered reliable as a pre- and post-evaluation measure

for educational programs. The test-retest reliability was established (r>.80) by repeat testing

in a continuing education class of staff nurses (N=60). The internal consistency reliability

was established (alpha r>.70) with items reflecting both knowledge and attitude domains. A

passing score of 80% was considered acceptable and a score of less than 80% was considered

an indicator for further education regarding the pain experience (Ferrell & McCaffery, 2014).

In addition to completing the KASRP survey, groups of six to eight nurses

participated in a sixty-minute face-to-face interactive educational intervention that aligned

with the IASP Curriculum on Pain for Nursing (Appendix D). Attendance was tracked using

a paper sign-in sheet and the class time was monitored to ensure that the education sessions

were completed within the allotted sixty-minute time frame for both consistency between

classes and to maximize attention, as described by the Adult Learning Theory of Andragogy

(Cercone, 2008). Full participation by all the nurses met the criteria as one component of the

nurses’ annual competency for fiscal year 2017. All nurses participating in the pre-test

survey, educational intervention, and post-test survey received one continuing education unit

credit (CEU) awarded by the American Association of Colleges of Nursing (AACN).

Data Collection


Data was collected and analyzed for each phase of this QI project utilizing three

distinct tools: a demographic survey, the KASRP survey, and a chart review audit tool. The

short demographic survey revealed specific characteristics of the nurse staff working on this

intermediate care orthopedic unit. The KASRP survey data was collected as a pre-test and

post-test for the educational intervention. The KASRP data revealed the nurses’ knowledge

and attitudes regarding pain, pain assessment, pain management, and pain surveillance.

To measure a change in pain score documentation compliance, pain audits were

conducted every Tuesday beginning August 8, 2017 through October 31, 2017, and January

2018 using the current hospital pain audit tool (Appendix E). Charts for auditing were

identified using a random selection process where every sixth room was selected. On this

patient care unit, rooms were identified by even numbers from 706 to 776. For the post

intervention pain audits, Tuesday was the selected audit day as the unit census was

consistently 100%.

Data Analysis

The over-arching goal of this unit-based quality improvement project was to answer

the question: did the educational intervention result in increased and sustained compliance

with pain score documentation in EPIC? The data was calculated using Microsoft Excel and

the Statistical Package for Social Sciences (SPSS) version 22.0. For data analysis, the p

values were reported as statistically significant at p<0.05. Correlation analysis was run

between demographic variables and the percent of pre-test and post-test questions that were

answered correctly to determine if knowledge and attitude toward pain improved after an

educational intervention.


The KASRP survey results were analyzed using a t-test and other descriptive

statistical methods to identify improvement in the nurses’ knowledge and attitude toward

pain. The EHR pain score documentation was audited to determine if compliance improved.

Data was aggregated to reflect the performance of the nurses on the orthopedic unit of

the target hospital. Aggregated unit results were posted on the quality compliance bulletin

board, emailed to staff, and discussed at monthly staff meetings. Data specific to individual

nurses was not reported or identified publicly.

Prior to participating in an educational intervention, fifty-five nurses completed a

short demographic survey proving personal data regarding age, gender, education level, years

of experience, current work shift, and experience with specific pain education. Descriptive

statistics and a two tailed Pearson correlation was used to analyze the demographic survey

results. Pre-test and post-test survey results were compared against four demographic

variables. Gender was not analyzed against pre-test and post-test results due to the

disproportionate distribution of male nurses (n=3) to female nurses (n=52) on the

intermediate care orthopedic unit.

The demographic survey results revealed the characteristics of the nurses working on

the orthopedic unit. The composition of the nursing staff working on the orthopedic unit

revealed that 73% of the staff are under forty years old, 94% identified as females, 91% have

completed a BSN or higher, 60% have been working as a registered nurse for less than five

years and 45% stated their primary work schedule as a day shift /rotating nurse (Table 1).

Table 1 also reveals pre-test and post-test survey results, compared to the

demographic categories. Nurses aged twenty to twenty-nine (n=26) demonstrated the greatest


improvement in survey scores after the educational intervention, 71.30% to 76.71%, which is

a positive change of 5.41. The BSN nurses (n=46) demonstrated a modest improvement of

3.8% from pre-test to post-test (71.82% to 75.62%); however, nurses with an MSN (n=4)

demonstrated the greatest improvement from pre-test to post-test (68.6% to 80.4%).

Sixty percent of the nurses have been in professional practice for less than five years;

yet, despite being newer in clinical experience, these thirty-three nurses demonstrated a

consistent 5% improvement from pre-test to post-test. Staff responses describing their

primary work shift were split consistently across the three traditional shifts, day/rotating,

permanent evening, and permanent night. Forty-five percent identified as working day

shift/rotating though the majority of newer to practice nurses worked permanent night shifts.

Overall, the nurses working night shifts achieved the lowest on the pre-test score and, yet,

demonstrated the greatest improvement in posttest scores (69.56% to 75.68%).

Table 1

Demographics

Demographic variables N Mean pretest % correct

Mean posttest % correct

Change

Age20–29 years old30–39 years old40–49 years old50–59 years old60–69 years old

2614285

71.3170.7278.3875.3472.43

76.7175.4875.6877.0372.44

+5.41+4.76-2.71+1.70+.004

GenderMaleFemale

352

76.5771.85

70.2776.35

-6.30+4.51

EducationDiplomaAssociates DegreeBachelor of Science Master of Science

23464

82.4372.9771.8269.60

82.4372.0775.6280.40

0-0.9

+3.80+14.81

Years in Practice<1year 14 71.99 76.83 +4.96


1–5 years6–10 years11–15 years16–20 years21–25 years>25 years

1992038

72.2667.8771.62

n/a70.2777.70

77.5373.2777.04

n/a65.7777.71

+5.26+5.41+5.42n/a

-4.50+0.004

ShiftsDaysEveningsNights

251119

73.9472.3269.56

76.1176.4175.68

+2.16+4.10+6.12

TOTAL 55 72.10 76.02

A Pearson correlation was run to determine the relationship between the demographic

survey results and pre-test and post-test KASRP survey scores. There was a strong, positive

correlation between age and the nurse’s current years in the position, which was statistically

significant (r = .853, n = 55, p = .01). Further, there was a negative correlation between both

age and nursing education (r = -.397, n = 55, p = .01) and nursing education and the years in

current position (r = -.362, n = 55, p = .01).

As the age of the nurse increased, the number of nurses with a BSN or higher degree

decreased, which made sense because the requirement for hiring nurses is a minimum of

BSN degree. There is an inverse relationship between education and the years of practice, as

evidenced by the fact that 60% of nurses on this intermediate care orthopedic unit have less

than five years of clinical experience; however, 91% had earned a BSN and MSN degree.

The work shift and prior pain management education did not demonstrate statistical

significance in the pre-test and post-test scores.

The educational intervention provided opportunity for the nurses to gain knowledge

regarding pain assessment, reassessment, and documentation guidelines as well as consider

other professional development opportunities. To determine if participation in the


educational intervention improved the nurses’ knowledge and attitude regarding pain, the

pre-test and post-test KASRP survey scores were analyzed using a paired samples t test.

Statistical analysis demonstrates that there was a statistically significant improvement in the

survey responses measuring the pre-test and post-test scores following the pain education

course. The pre-test and post-test scores reflect the percentage of questions answered

correctly. Results include an aggregated mean pre-test score of 72.1042 and mean post-test

score of 76.0209, t (54) = -3.722, p = .000. Quantitative statistical analysis identified a

positive correlation between the KASRP pre-test and post-test scores (r = -.362, n = 55, p

= .01).

Thirteen out of the fifty-five participating nurses, representing 23.6% of the total

staff, achieved a passing score of 80% or greater on the KASRP pretest. Twenty-one nurses

achieved a score of 80% or greater on the KASRP post-test, representing 38.2% of the staff.

The highest achieving nurse was in her twenties, had completed a BSN, worked the

day/rotating shift, and had less than five years’ clinical experience; she achieved a pre-test

score of 86.49% and a post-test score of 97.30%.

Chart audits completed at one, two, three, and six months demonstrated that the

nurses were able to acquire and transfer this new knowledge to practice after participating in

a one-hour educational intervention. Table 2 displays compliance with the pain score

documentation before and after pain medication administration based on the established

guidelines. Five randomly selected patient EHRs were reviewed every Tuesday from August

8, 2017 to October 31, 2017 and every Tuesday in January 2018. The audit data identified the

number of pain assessments completed before administering pain medication and pain


reassessments completed thirty minutes after administering intravenous pain medication and

one hour after administering the oral pain medication.

The EHR audit was limited to prn pain medication administrations; patient-controlled

analgesia, epidural, or similar continuous pain medication infusions such as pain blocks as

well as transdermal pain medication and sustained release oral opioid analgesics were

excluded. Pain score documentation compliance improved each month beginning the month

after the nurses participated in the pain education intervention.

Table 2

Post Intervention audit data

Audit week Total number of

EHR audits

5/wk. on Tuesdays

Medications Total # opioid doses administered

% documented pain scores pre-

pain med administration

% documented pain scores

post-pain med administration

n % n %

August 20178/8/178/15/178/22/178/29/17

20 Dilaudid IVP/POFentanyl IVMorphine IVPNorco POOxycodone POTramadol PO

73 doses 64 87.67% 48 65.75%

September 20179/5/179/12/179/19/179/26/17

20 Dilaudid IVP/POMorphine IVPOxycodone POTramadol PO

86 doses 78 90.69% 66 76.74%

October 201710/3/1710/10/17

25 Dilaudid IVP/POMorphine IVP

72 doses 71 98.61% 62 86.11%


10/17/1710/24/1710/31/17

Norco POOxycodone PO

January 20181/2/181/9/181/16/181/23/181/30/18

25 Dilaudid IVP/POMorphine IVPOxycodone POTramadol

130 120 92.31% 109 83.85%

Control charts displayed EHR audit results documenting compliance variation. The

pain score assessment documentation compliance, before administering pain medication,

achieved the benchmark of 90% with a mean central limit of 90.20% (Figure 9). The

reassessment pain score documentation demonstrated additional variability with a mean

central limit of 76.17%, though the documentation compliance was sustained above 80%

from mid-October 2017 through January 2018. Despite trending in a positive direction, the

reassessment documentation continues to fall short of the 90% guideline established by this

large teaching hospital in Boston and the JC identified benchmark (Figure 10).

Figure 9. Pain score assessment documentation compliance.


Figure 10. Pain score reassessment documentation compliance.

Discussion/Implications

Accurate pain assessment and reassessment documentation is integral to a safe pain

management plan. The timely documentation of a patient’s response to a pain medication

intervention provides invaluable information to the patient’s care team especially in the

setting of the orthopedic care unit in the target hospital. The goal of this QI project was to

increase the orthopedic nurses’ knowledge related to opioid pain medications and improve

the pain assessment skill decrease variation in assessment and reassessment practice and

compliance with pain score documentation. Lewin’s Theory of Change was used as a

framework to guide change.

Demographic survey results and the fishbone exercise provided insight into

commonly held misconceptions and identified barriers that prohibited nurses from complying

with established guidelines and policy requirements for pain score documentation

compliance. Analyzing the demographic survey results and the KASRP pre-test responses

provided an opportunity to unfreeze the current state of pain score documentation and ready

staff to move forward with the required practice change.


The demographic survey results were analyzed in broad categories to preserve

individual anonymity. The results of the demographic survey revealed that more than sixty

percent of the current staff had been practicing for less than five years, held a BSN, worked

predominately on the day shift and rotated to off shifts including evening and nights, and

were between the ages of twenty and thirty-nine. Although these nurses completed a BSN

education, many described limited experience with pain management and pain assessment

prior to beginning as a newly licensed nurse (NLN). Many of the NLNs identified the time

they spent in senior mentorships and clinical interactions during their orientation as pivotal to

understanding how patients experienced pain and how the multidisciplinary care team

developed an individualized pain management plan of care.

Understanding the important relationship between the orientee and preceptor provides

valuable insight into how the NLN transitions from the role of student to independent

provider and highlights the importance of ensuring that the preceptor provides the best

experience for the NLN. Historical practice has often endorsed senior staff nurses as the

primary preceptors; however, the results of the QI project demonstrated that nurses with

more than twenty-five years’ experience scored the lowest on the KASRP pre-test and post-

test (77.70% to 77.71%), showing no appreciable difference after participating in the

educational intervention. These results are cause for pause and reconsideration that senior

staff may not be the best choice to assume the preceptor role.

Understanding the unique characteristics of the nursing staff, such as education, years

of experience, and exposure to pain education were helpful when developing the educational

intervention; however, it was the fishbone diagram exercise annunciated some of the system

problems that were perceived as barriers to documentation compliance. Barriers, such as


competing priorities, lack of time to document, voluminous pain medication administrations,

and quick patient turnover have been identified as activities that prohibit compliance with

pain score documentation. Other themes regarding barriers to timely documentation include

perceived staffing inadequacies, expansive geographical layout of the unit and assignments

not clustered in closer proximity, and comfort with documenting at the bedside. The staff

also discussed perceived problems with the EPIC platform, such as computer connectivity

speed and the fact that it takes four clicks to access the flow sheet screen to document the

pain reassessment.

When documentation was completed using a paper flow sheet, the staff could back

document and enter the pain assessment and reassement score at any time before their work

shift ended; however, with the EPIC system, pain assessment and reassessment scores are

time stamped when entered, and if the score is entered after the prescribed time interval

(thirty minutes after intravenous medication and one hour after oral pain medication), then

the pain score entry falls outside the guidelines and fails to meet compliance standards.

In addition to completing the KASRP survey, the staff nurses participated in a one-

hour educational class. Though the class followed the IASP curriculum, much of the content

was new to these orthopedic nurses. The IASP curriculum covers content from all areas of

pain management including acute, chronic, cancer, and pediatric pain. The participating staff

have extensive experience with acute, postoperative pain but expressed scant experience with

other areas. Though the staff stated they were frustrated with the length of the class and the

amount of content, they did feel that the class was a valuable experience and asked for future

access to the class perhaps in a HealthStream program where they could take their time to

review content at their leisure.


The nurses’ responses demonstrate strong basic clinical knowledge related to pain

assessment; however, there is evidence that the staff, across all demographics, overestimated

complications and risks, which may have influenced how they managed pain based on their

assessment and reassessment skills. The KASRP post-test results demonstrated significant

variation in responses. The survey answers to the multiple choice and true/false questions

ranged from 15.8% to 94% in the pre-test and 17.8% to 96% in the post-test.

Future pain education curriculum and presentation should be reviewed to meet unit

specific needs and should be generalizable for other care areas. It would be important to

review how the educational intervention may be customized and restructured to fit into a

shorter time frame to enable staff to receive the information in shorter sessions that can be fit

into their lunch session. It may have been helpful to have a second presenter in the room

during the education session to scribe conversations and comments that were missed during

the lecture. This may have been a missed opportunity to gather dynamic insight into the

statistic lecture setting.

New to practice nurses demonstrated the greatest improvement in knowledge in

almost all KASRP questions, from pre-test to post-test. Despite demonstrating a significant

improvement from pre-test to post-test, most nurses working permanent night shifts are

newer to clinical practice and have fewer educational supports and resources available to

them during their work hours. This group relies on the expertise of the senior night staff who

were not consistently high performers. The night staff expressed frustration with the lack of

onsite support at night, so, as we integrate a new clinical educator model with unit-based

champions, this will be a priority.


To determine if staff could transfer knowledge from the academic setting to bedside

care and refreeze practice, the EHR pain score reassessment documentation was audited, and

compliance was trended toward the benchmark goal of 90%. Pain audit results revealed some

improvement in the pain score documentation. Audit results in August closely resembled the

2016 baseline data with the reassessment compliance falling below 80%. The pain score

assessment documentation, prior to pain medication administration, was sustained at greater

than 85%, possibly due to an EPIC technology fix that moved the pain scale to the same

computer window where the nurses documented pain medication administration. The

proximity of pain medication administration and pain score documentation made the process

almost foolproof. Pain score reassessment documentation compliance continued to show

progress; however, the post intervention audit data and control chart demonstrated that the

reassessment documentation compliance continued to demonstrate practice variation, and the

process remained somewhat out of control.

Before implementation of an EHR in 2015, the nurses utilized work stations on

wheels loaded to document pain scores in the electronic medication administration record

(EMAR). The EMAR program provided visual reminders for nurses to enter pain

reassessment scores. When the pain reassessment documentation was due, a red triangle with

a smiley face within would appear beside the patient’s name. With the EPIC EHR

technology, the visual reminder is a banner that scrolls across the computer screen when the

RN logs in, to remind that a reassessment is due. In the current EHR technology, the nurse

must log on to a computer to see the visual reminder (Figure 11). The banner will be visible

to the nurse until the pain reassessment score is documented; however, the reassessment

reminder banner disappears whenever a healthcare provider enters a pain score in the


appropriate timeframe. Chart audits revealed that the reassessment reminder banner

disappeared when a pain score has been entered; however, the program does not differentiate

when a physical therapist enters a score, thus eliminating the reminder for the nurse to

document a pain reassessment score.

Figure 11. EPIC reassessment banner.

Despite identified documentation barriers, pain score reassessment documentation

improved in the months after the educational intervention. In August, September, and

October, the audit results were shared with the staff, posted on the quality bulletin boards

using graphs and charts that displayed trending progress. Laminated reminder cards were

affixed to each computer, and the updates were added to the unit-based newsletter. After

realizing steady improvement during the initial three months, the audit data from January

2018, six months after the educational intervention, revealed a slight decrease in the pain

score assessment documentation from 98.61% in October 2017 to 92.31%, and the pain score

reassessment documentation from 86.1% to 83.85%.

These results seem to be aligned with the outcomes of several studies such as Song

et.al (2015), Samuels et. al (2014), and Samuels et. al (2012), which cite persistent

inconsistencies in documentation of pain reassessments and identified the work-arounds


created by nurses to meet documentation compliance when forced to use an EHR. Studies by

Latchman (2014), the Joint Commission (2016), and the Joint Commission (2008) reported

the need for pain assessment education and curriculum review as the cornerstones of a

comprehensive nursing education. Research reported by Glowacki (2015) identified the need

for increased fundamental education, measurement, and improved attitude toward pain

management. Amid the current opioid scourge, healthcare professionals need to have a

renewed commitment to pain assessment education.

The 2008 Joint Commission publication reported the results of a study conducted at

the University of Wisconsin Hospital and Clinic (UWHC) where the pain reassessment

documentation was failing to meet the JC standards despite diligent auditing and education

practices. To realize a sustainable change in practice, the leadership at the UWHC committed

resources and staff to enable a process where every patient record was audited every day for

two years to ensure that pain assessment documentation achieved the greater than 90%

compliance. The chart audit process was an opportunity to speak with the staff one-on-one

each day. After two years, the hospital realized a significant improvement in pain

reassessment compliance, attaining and sustaining a rate that exceeded 99%.

Evidence in the literature concurred with the outcomes demonstrated in this unit-

based QI project, indicating a need for more frequent practice audits. The current practice

was to audit five random charts per month; however, successful practice was demonstrated

when the charts were audited more frequently, and one-on-one coaching was employed

simultaneously with the audits. Weekly audits, peer feedback, and one-on-one coaching lead

to a sustained practice change.


Daily auditing of each EHR, after each pain medication administration, would require

a significant investment of manpower; however, there may be an opportunity to collaborate

with the new Professional Development Managers (PDM) and the unit-based champions to

review pain assessment dashboards and provide peer to peer feedback more frequently than

the current audit practice of reviewing five charts per month. Sustainability efforts may

benefit from new technology being rolled out to the nurses in 2018, which will provide

quicker access to documentation flowsheets using the tap and go capability. To provide

elbow support to individual nurses, the PDM and nurse director have access to the EPIC unit

view to identify unit compliance at a glance (Figure 12). Individual nurse practice can be

viewed hour-to-hour and the PDM could initiate one-on-one coaching to improve compliance

(Figure 13). Unit champions will be developed to support peers, especially peers working off

shifts, such as evening, night, and weekend shifts.

Figure 12. EPIC unit view - pain compliance.

Figure 13. EPIC Dashboard at a glance.


After reviewing the KASRP pre-test and post-test responses and the EHR audits, it

was evident that the nurses could benefit from additional education opportunities. The

recommendation was to add pain assessment documentation education to the annual unit-

based competency day and unit-based orientation. The staff currently complete the Basic

Knowledge Assessment Tool (BKAT) assessment during central orientation; however, this

assessment tool does not assess knowledge of pain management. It is recommended that

newly hired nurses complete the KASRP survey as a screening tool to identify pain education

as a baseline assessment.

Limitations

This QI project analyzed data using quantitative statistics; however, a mixed method

analysis may have been beneficial to further explore the nurses’ knowledge and attitudes

regarding barriers to pain score documentation. The perspective of the staff gathered through

focus groups may have provided a more in-depth discussion regarding nurses’ perceptions

and capture workflow barriers impeding documentation compliance.

The pain assessment practice of individual nurses would be helpful when reviewing

compliance; however, studying individual nurses’ practice was out of the scope of this

project. Similarly, auditing five random medical records per week when there are more than

seventy-five patients admitted to this care unit per week may not be representative of the unit

practice. Auditing more frequently or more EHRs would provide a more accurate snapshot of

pain score reassessment documentation compliance but could not be accomplished with

current resources or within the identified time frame of this project.


Conclusion

A significant opioid crisis exists and persists despite legislative changes in provider

prescription restrictions, an aggressive media campaign to seek treatment and support, and a

reinforcement of pain assessment and reassessment within well established guidelines.

Pivotal to this practice change is the diligent engagement and timely assessment and

reassessment of pain documented in the EHR to facilitate a bidirectional communication with

the multi-disciplinary team regarding the most effective, safest pain management plan of care

for the individual.

This QI project was in response to the JC findings during a 2016 accreditation visit

where the orthopedic unit fell below the 90% pain score documentation standard required for

accreditation. Chart audits in the latter months of 2016 revealed persistent low performance

with pain reassessment documentation.

Supported by the underpinnings of Lewin’s Theory of Charge, this project was

examined in three phases, unfreezing where staff knowledge and attitude toward pain were

explored using the validated City of Hope KASRP survey. The survey was administered as a

pre-test and post-test in conjunction with an educational intervention aligned with the IASP

Curriculum on Pain for Nursing. The goal of this educational intervention was to review

expectations, improve knowledge, and to move practice closer to the established benchmark

identified as 90%.

Chart audits were completed to determine if the educational intervention caused a

change in practice that could refreeze practice, evidenced as sustained compliance with pain

score documentation. The result of this QI project demonstrates a statistically significant

change in knowledge and attitude from pre-test to post-test and a sustained changed in the


pain score documentation compliance though the resulting change remains below the 90%

benchmark.

The compliance with pain score reassessment documentation that chart audits

revealed continues to demonstrate variation. Data from the past six months the benchmark of

90% or greater has been attained and sustained for pain score assessment documentation;

pain score reassessment documentation, though trending closer to 90%, alludes the target

despite steadily maintaining scores in the 80th percentile. Further education is required to

reach this goal.

Previous studies by Latchman (2014), the Joint Commission (2016), Grinstein-Cohen

et. al (2009), Schiavenato et. al (2010), and Cordts et.al (2011) studied the effect of an on

single educational intervention on sustained practice change, and each found that the

overtime practice will revert to previous compliance.

With the implementation of the EHR, the practice auditing is believed to be less

cumbersome; however, while leading this project, it became obvious that the EPIC report for

pain assessment and reassessment documentation is flawed. The introduction of dashboards

to the staff may increase the peer-to-peer support with documentation compliance especially

during orientation, when preceptors and the newly hired staff review the documentation

together. Future work will concentrate on individual coaching to improve compliance.

As evidenced by previous studies conducted by Song et. al (2015), Samuels et.al

(2012), and Samuels et.al (2014), the nurses may benefit from continuing education to

demonstrate competency and confidence in pain assessment and reassessment, as evidenced

by the pain score documentation compliance sustained at >90%. For this QI project, the


documentation of a pain score is evidence that a pain assessment and reassessment has been

completed.

Nurses working in the adult acute care settings, such as postoperative orthopedic

education, require continued education around pain assessment and reassessment to create

sustainable practice. There are several published studies that support the need for continued

education regarding the knowledge gaps faced by nurses. Bernhofer et al. (2016) and

Bozimowski (2012) explored the connection between nurses’ perceptions about pain

management and nursing education. Nurses with excellent pain management knowledge

skills make better clinical decisions regarding pain assessment and pain management

(Bernhofer et al., 2016, p. 385).

Nurses are pivotal to safe and efficacious pain processes. They need dedication, skill

acquisition, and awareness to support, mentor, and teach peer-to-peer. In summary, this QI

project raised concerns that there is a need for additional staff education and one-on-one

support as well as more frequent auditing to maintain and sustain pain score reassessment

documentation compliance.

Cost Analysis

The cost of this project is budget neutral, as paper resources, the time for

interventions, REDCap data input activities, and the utilization of indirect time are within the

scope of work usually assigned to the unit-based practice committee, graduate student

assistance, and unit-based clinical educator and, therefore, budgeted to the patient care unit.

The educational program intervention was presented in a conference room adjacent to the

care unit, and this target hospital and the room were already equipped with all the technology


necessary to successfully offer an education opportunity. The unit also had more than thirty

available computers for staff to utilize to complete the KASRP survey online.

Calculations were performed to determine the return on investment (ROI) for this

project and identify the cost benefit of implementing this project. Fifty-five nurses

participated in a sixty-minute class; in addition, a total of sixty minutes was provided to each

nurse to complete the KASRP pre-and post-survey and the demographic pre-survey. The

average salary of nurses working on the intermediate care unit in June 2017 was $51.83 per

hour paid. Fifty-five nurses participating in a one-hour pain management class in-addition to

being paid for an additional hour to complete the pre-test and post-test surveys incurred the

expense of $5701.30 ($51.83/hr. x 2hrs x 55 nurses) during this educational intervention.

This project is important to ensure regulatory guidelines, and, moreover, when the guidelines

are followed, safe patient care is provided in a timely manner.

Delays in care and inadequate pain management may lead to extended preventable

hospital days. Room and Board for a one-day hospital inpatient stay in a semi private room at

this large Boston teaching hospital costs approximately $4000 per day (M Kenyon, personal

communication, July 17, 2017). If undertreated pain caused one patient to extend their

hospital stay by one extra day per week for one year, the cost was estimated to be $101,

296.00. The return on investment (ROI) for providing a comprehensive pain management

education session to nurses could create cost savings. The ROI for the cost training of the

nurse versus the cost of a hospital day is $4000(1) x 52/5701.30 = ROI of 36.48; therefore,

this QI project has the potential to provide substantial savings to the cost of an episode of

care.


Future Study

The opioid crisis is a particularly significant concern for nurses working in the acute,

postoperative orthopedic surgery, and orthopedic trauma milieu. This QI project highlighted

the need for ongoing staff education regarding pain assessment, reassessment, and pain score

documentation. Effective pain treatment is a collaborative process that begins with the

nurses’ documentation of the comprehensive pain assessment. There is an immediate need

for further study as to whether pain assessment is not done or not documented due to barriers

such as knowledge gap, computer access, competing priorities, nurses experience, and time

priorities.

Questions that were not answered correctly in the KASRP survey warrant a closer

review, and, most certainly, these incorrect responses will form the foundation of future

education endeavors. This orthopedic unit supports the existing multi-disciplinary

collaborative learning seminars for nurses, residents, and physical therapists; this would be

the ideal venue for a multidisciplinary discussion regarding pain.

Staff meetings, daily huddles, and unit-based newsletters provided an opportunity to

reinforce pain documentation compliance and explore solutions to documentation barriers.

Unit-based pain champions will be trained and supported to increase pain score

documentation audits and to provide support to enable the nurses to provide peer-to-peer

feedback in the moment.

The target hospital continues to explore opportunities for staff to gain experience and

knowledge regarding pain, such as participation in the hospital-wide Pain Committee and

attend Opioids Grand Rounds. Finally, the results of this project will be shared with the


technology support team with the goal of developing accurate EPIC pain reports to decrease

the burden of audits and improve reliability.

A future consideration is to maximize the technology that is already in use by the nurse

on the intermediate orthopedic care unit. One suggestion, to consider a voice recognition

software having the nurses dictate the pain assessment and smart data integration technology

to complete the transcription in the EHR record by opening the correct flowsheet, thus,

eliminating the burden of four clicks to get in to the health record. Voice recognition

documentation has been used in dictation for many years. It would be interesting to explore

its potential to enable nurses to use the voice recognition software to complete timely

documentation.

Human Subject Protection

After completing the Internal Review Board (IRB) checklist (Appendix F), the target

hospital determined that this QI project was exempted from the full IRB review because it

posed minimal risk to participants. The full IRB process was completed for the Simmons

College and the approval was granted (Appendix G). The email invitation to participate in

this QI initiative that the study participants received, and the completion of the survey served

as the nurses’ implied consent. The aggregated data was analyzed and reported for the

demographic survey results as well as the KASRP pre-test and post-test scores and pain score

documentation compliance in EPIC; however, the individual nurse compliance data was not

reported. All project data has been stored on a secure, password protected computer and the

deidentified paper audit forms have been stored in a locked file cabinet in the nurse director’s

office.


Plan for Dissemination

The results of each PDSA cycle were shared with the staff weekly to excite

momentum and enable staff to make immediate corrections in their documentation practices.

Kudos cards were distributed to early adopters to recognize best practice. There was an

interest to create a HealthStream online course for all registered nurses who wished to self-

select to participate in this professional development opportunity.

The intermediate care orthopedic unit hires approximately ten to fifteen NLNs who

annually support six clinical student groups per school semester and mentor nine capstone

students per semester; therefore, there is an interest to include an abbreviated version of the

educational intervention during post conference time. The educational content will be

included as part of the unit-based nurse orientation for this unit beginning January 2018.

This quality improvement project has been prepared in a written report, and a copy of

it was submitted to Simmons College, while the results were discussed at daily morning

huddles and presented at the multidisciplinary Orthopedic Care Improvement Team meeting.

Project results have been included as part of the 2018 Magnet Accreditation review at this

target hospital. Content and results will be created as a poster, which will be submitted for

inclusion at the annual National Association of Orthopedic Nurses in May 2019. In addition,

this project will be submitted to several peer reviewed nursing journals, such as Orthopedic

Nursing, Journal of Continuing Education, and Pain Management Nursing.


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Appendix A:

Date: July 1, 2017

Dear Connors, 7NS Nursing Staff

I am completing my Doctorate in Nursing Practice, and my project focus is pain scale score documentation compliance to ensure our practice is aligned with the Joint Commission standards.

Audit data from 2016 demonstrates much variability regarding pain scale score documentation on Connors 7NS. As opioid regulations continue to change in Massachusetts, this QI project enables the Connors 7NS staff to come together to review best practice and reset expectations.

6/30/1

6 - 7/1

/2016

7/6/1

6-7/8/1

6

7/11/1

6-7/14/1

6

7/25/1

6-7/28/1

6

8/1/2

016

8/10/2

016

10/16/1

6-10/17/1

6

10/22/1

6-10/23/1

6

11/3/2

016

11/27/1

6-11/28/1

60

20406080

100120

Pre and post pain scale score documentation

PrePost

Date of Pain Audit

Perc

enta

ge


Beginning on July 15, 2017 through August 15, 2017 all regularly schedule full time, part time and per diem nurses hired to work on Connors 7NS are invited and encouraged to participate in a unit-based quality improvement initiative to review pain assessment, reassessment and documentation standards

You will be asked to complete a fifteen-minute, on-line survey before and after participating in a one-hour comprehensive educational program which will be offered during your regularly scheduled work shift. Participating staff will be relieved from bedside duty for the duration of the program.

Privacy and confidentiality will be preserved and there is minimal risk of being identified by demographic information completed during the survey process. All survey data will be stored in RedCap and each nurse will have a unique identifier such as RN 00- RN 59. Your participation is voluntary, and you may choose not to participate without any penalty. If you choose to participate, you may withdraw at any time during the survey or class. Completing the survey will survey as your consent to participate.

There will be no direct benefit to you for participating. It is my goal to utilize any information gleaned from this QI project to improve nursing compliance with pain scale score documentation to meet the Joint Commission and BWH standard of 90%.

Thank you for considering participating in this quality improvement initiative

Sincerely

Mary Anne Murphy KenyonClick the link below to begin the surveyhttp://wwwredcap/knowldegeandattitudesurvey

Appendix B:

Supplemental Demographic Survey

RN NAME: _______________________________________________________________

1. Age 20 – 29 yrs.

30 – 39 yrs.

40 – 49 yrs.

50 – 59yrs

60 – 69 yrs.

2. Gender Male Female

http://wwwredcap/knowldegeandattitudesurvey


3. Highest Nursing School Education Diploma

Associates Degree

Bachelors in Nursing

Masters in Nursing

Other

4. Years in current position < 1 year

1 yr. to 5 yrs.

6 yrs. to 10 yrs.

11 yrs. to 15 yrs.

16 yrs. to 20 yrs.

21 yrs. to 25 yrs.

26 yrs.

5. Predominate scheduled shift Day shift

Evening shift

Night shift

6. Most recent pain education CEU program

Nursing school

Other


7. Rank the following activities by the amount of time you spend on each during your

scheduled shift:

1= activity that takes the least time, 5 = activity that takes the most time

_____ Providing personal care (toileting, bathing, feeding, dressing)

_____ Administering medications (assessing, dispensing, monitoring, teaching)

_____ Documentation

_____ Physiologic tasks including dressing changes, monitoring tubes/drains

_____ Assessment including reviewing labs, reviewing orders

8. Top 3 barriers to pain assessment documentation (open ended)

_____________________________________________________

_____________________________________________________

_____________________________________________________

Appendix C:









Appendix D:







Retrieved from: http://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2052


Appendix E:

Pain Assessment Audit Tool

WOS Pain Score DocumentationAudit date

MRN/ room #

PODDiagnosisService

Opioidsaudited

# pain meds administered12a – 11:59p

# Pre pain med adm scores documented

# Post pain med adm scores documented


Appendix F:



Appendix G:


Documents

beatleyweb.simmons.edu€¦ · Web viewThe results of the January 2016 Joint Commission Accreditation Review shed light on the need for a quality improvement strategy to improve compliance