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
Mary Anne Murphy Kenyon
This manuscript is submitted to the faculty at Simmons College
in partial fulfillment of the requirements for the degree of
Doctor of Nursing Practice
Running head: PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
Keywords: quality improvement, orthopedic, nursing, pain assessment, pain scale
©2018
Mary Anne Murphy Kenyon
ALL RIGHTS RESERVED
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PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
Dedication
For my dad, Martin C. Murphy
You are always on my mind,
I think you would be proud.
VI
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
List of Tables
Table 1. Demographic survey results
Table 2. Post intervention audit data
VIII
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
Running head: PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 5
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 7
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).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 9
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
(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,
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 11
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 13
(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 ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 15
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).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 17
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 ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 19
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 21
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).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 23
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).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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,
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 25
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 27
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)
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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,
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 29
& 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.).
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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).
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 31
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 33
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 35
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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).
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 37
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 39
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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).
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 41
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 43
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
o 5 random chartso Every Tuesday
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
o 5 random chartso Every Tuesday
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 45
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 47
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 49
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 51
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%
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 53
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 55
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 57
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 59
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 61
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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 ASSSESSMENT AND PAIN SCORE DOCUMENTATION 63
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 65
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 67
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.
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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.
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 69
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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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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
PAIN ASSSESSMENT AND PAIN SCORE DOCUMENTATION 81
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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
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:
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Appendix D:
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Retrieved from: http://www.iasp-pain.org/Education/CurriculumDetail.aspx?ItemNumber=2052
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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
PAIN ASSESSMENT AND PAIN SCORE DOCUMENTATION
Appendix F:
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Appendix G:
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