What nurses’ work-arounds tell us about pain assessment

Survey of Nurses' Use of the Clinically Aligned Pain Assessment (CAPA) Tool

BACKGROUND

Limited research is available on tools for assessing pain and its effect on function in the acute care setting.

AIM

This research's purpose is to describe nurses' use of the Clinically Aligned Pain Assessment (CAPA) tool and their beliefs about its utility for assessing pain compared to the numeric rating scale (NRS) in a hospital where CAPA had been used for 6 years.

DESIGN

A cross-sectional self-report survey.

METHODS

Nurses (N = 110) from 13 adult inpatient units in an academic center participated in this survey describing frequency of CAPA and NRS use, CAPA domains documented, and how nurses asked about pain and distinguished between categories when coding for documentation. Beliefs about the tools' effectiveness were also reported.

RESULTS

Most nurses used CAPA routinely for assessments; almost half used the NRS at times. They believed both tools were effective for assessment, but CAPA was more effective to determine what intervention was needed. They also believed patient report using CAPA was more likely to match the nurse's assessment; a majority reported incorporating their observations into CAPA documentation. Most asked the patient about pain without using CAPA words, although many used the specific words. Practice varied in how nurses determined which category to select in the comfort domain and which domains were assessed routinely.

CONCLUSIONS

Although many nurses believed CAPA was effective, variation existed in how it was used to assess and document pain, increasing potential for inconsistent assessments and interpretations of pain and pain management.

Prescribing and Administering Opioid Doses Based Solely on Pain Intensity: Update of A Position Statement by the American Society for Pain Management Nursing

The foundation of safe and effective pain management is an individualized, comprehensive pain assessment that includes, but is not limited to, the intensity of pain if the patient is able to report it. An unforeseen consequence of the widespread use of pain intensity rating scales is the practice of prescribing specific doses of opioid analgesics based solely on specific pain intensity ratings. Many factors in addition to pain intensity influence opioid requirements. To date there is no research demonstrating that a specific opioid dose will relieve pain of a specific intensity in all patients or even in the same patient at different times. The official position of the American Society for Pain Management Nursing (ASPMN) maintains that the practice of prescribing doses of opioid analgesics based solely on pain intensity should be prohibited because it disregards the relevance of other essential elements of assessment and may contribute to untoward patient outcomes.

Medical-Surgical Patients' and Registered Nurses' Satisfaction and Comprehensiveness of Patient Assessment Using the Clinically Aligned Pain Assessment Tool

BACKGROUND

The pain experience is complex, and nurses are challenged to objectively assess and document patients' subjective reports of pain. There is a clear need for an assessment tool that is easy to use and provides meaningful, actionable information for patients and nurses.

AIMS

This study explored nurses' and patients' satisfaction with the Clinically Aligned Pain Assessment (CAPA) as well as nurses' charting.

SETTING AND PARTICIPANTS

A convenience sample of adult patients and nurses on four medical-surgical units in one community hospital.

METHODS

A quantitative, two-group comparison design between patients and nurses using questionnaires to determine satisfaction and a retrospective chart review to determine comprehensiveness of nurse charting.

RESULTS

No significant differences existed between patients' and nurses' responses to seven of eight satisfaction questions The median score for seven of eight questions was 5 (using a 6-point Likert scale with 1 = strongly disagree and 6 = strongly agree), which demonstrated more than 80% agreement (somewhat agree, agree, strongly agree) among both groups that CAPA was superior to the NRS, based on individual responses. The one significant difference (p = 0.03) revealed patients were more likely to respond "agree or strongly agree" compared to nurses regarding the nurse thoroughly addressing patients' needs using CAPA. Inter-rater reliability using CAPA was determined to be 89.5%, and a panel of clinical experts determined CAPA had strong content validity of 88.33%. In addition, 70.41% of nurses charted comprehensively using CAPA.

CONCLUSION

As a result, CAPA was determined to be convenient, accurate, and valuable in guiding intervention decisions.

The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review

BACKGROUND

Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes.

OBJECTIVES

To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children.

DESIGN

Systematic literature review.

DATA SOURCES

The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020.

REVIEW METHODS

We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded.

RESULTS

In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions.

CONCLUSIONS

Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.

∗Surgical patients' and registered nurses' satisfaction and Perception of Using the Clinically Aligned Pain Assessment (CAPA©) Tool for Pain Assessment

Pain management is a significant issue in all health care systems. Pain is often mismanaged because of lack of a comprehensive pain assessment. This often leads to inappropriate medication administration, inadequate pain relief, negative patient outcomes, and delayed discharges. There is an opportunity for developing a more comprehensive pain assessment. The Clinically Aligned Pain Assessment (CAPA©) pain tool was developed by the University of Utah.. It assesses 5 dimensions of pain: comfort, change in pain, pain control, functioning, and sleep. The purpose of the study was to determine if the patients and nurses were more satisfied discussing pain with CAPA© or the numeric rating scale (NRS) and words to describe pain, intensity, location, duration, and aggravating and/or alleviating factors (WILDA) tool. This study had a 2-group comparison design with mixed methods approach. One group comprised patients and the other group comprised nurses. There were 63 nurses and 95 patients enrolled in the study at two perioperative hospitals. The results demonstrated that the patients and nurses were more satisfied with using the CAPA© tool than the NRS/WILDA. The CAPA© tool allows for a more comprehensive way to assess pain which has the potential to create more effective treatments for pain, improve discharge time, and positive patient outcomes.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Introduction

Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.

Methods

We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.

Results

Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.

Conclusion

Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

Improving paediatric pain management in the emergency department: An integrative literature review

BACKGROUND

Children presenting to the emergency department continue to experience suboptimal pain management. While evidence-based pain management interventions are available to clinicians, effective and sustainable practice change is yet to be achieved. This practice gap requires a collaborative approach to knowledge translation targeting systems of care.

OBJECTIVES

The purpose of this review was to explore systems level change in the emergency department for improved paediatric pain management.

DESIGN

Integrative review.

DATA SOURCES

CINAHL, Embase, PubMed/Medline, Dynamed, Cochrane, Scopus, Prospero and Joanna Briggs Institute were systematically searched, and clinical guidelines and reference lists scanned.

REVIEW METHODS

Studies were screened and selected according to the inclusion criteria, and independently appraised for risk of bias. Integrative review methodology informed data extraction and synthesis, focused on organisational context and engagement, facilitation and implementation of practice change, key components of the pain management interventions, and evaluation.

RESULTS

Twenty studies met the inclusion criteria: 18 uncontrolled pretest-posttest and two pseudo-randomised design. Study populations ranged from children with a specific presentation, to all presenting children. All studies adopted a multifaceted approach to organisational change, bundling various interventions including pain assessment tools and management protocols, clinician education, nurse-initiated analgesia, feedback and family engagement. Four studies used local systems analysis to inform interventions and two studies applied an implementation framework. Time to analgesia was the most commonly improved primary outcome. Parent and child sensitive outcomes were assessed in five studies. Interventions that hold the most promise for optimised pain management if embedded in the workplace include nurse-initiated analgesia and family involvement at each stage of pain management in the emergency department.

CONCLUSION

The way forward is to respectfully engage all stakeholders-children, parents and clinicians-to collaboratively develop evidence-based, sustainable solutions aligned with the emergency department context. Guided by an implementation framework, future research designed to creatively translate evidence into practice and facilitate change at a systems level is a priority. Key to this solution is the integration of family involvement in pain management, considering child and family sensitive outcome measures. Effectiveness of new interventions should be evaluated in the short and long term to embed sustainable practice change. Frontline nurses are well placed to lead this transformation in paediatric pain management in the emergency department.

Assessment of pain in chronic wounds: A survey of Australian health care practitioners

Pain associated with chronic wounds can delay wound healing, affects quality of life, and has a major impact on physical, emotional, and cognitive function. However, wound-related pain is often under-assessed and may therefore be suboptimally managed. The aim of this study was to describe the assessment practices used to assess chronic wound pain by health practitioners in Australia. A structured self-administered questionnaire was posted to members of an Australian national wound care organisation, whose membership represents various health practitioners involved in wound management. A total of 1190 (53%) members completed the survey. Overall, wound pain assessment was most commonly conducted at every consultation or wound dressing change (n = 718/1173, 61%). Nurses were more likely to assess wound-related pain before, during, and after the wound dressing procedures compared with other health care practitioners. In contrast, podiatrists assessed wound pain only when the patient complained about the pain. The most common assessment method was simply talking to the patient (n = 1005/1180, 85%). Two-thirds of practitioners used a validated pain assessment tool. The most commonly used tool was the numerical analogue scale (n = 524/1175, 46%). In summary, these findings suggest that there is no consistent method for the assessment of wound-related pain, and there are substantial variations in how and when wound-related pain is assessed between different professions.

Quality Improvement Project: Replacing the Numeric Rating Scale with a Clinically Aligned Pain Assessment (CAPA) Tool

CAPA is a multifaceted pain assessment tool that was adopted at a large tertiary Midwest hospital to replace the numeric scale for adult patients who could self-report their pain experience. This article describes the process of implementation and the effect on patient satisfaction scores. Use of the tool is supported by the premise that pain assessment entails more than just pain intensity and that assessment is an exchange of meaning between patients and clinicians dependent on internal and external factors. Implementation of the tool was a transformative process resulting in modest increases in patient satisfaction scores with pain management. Patient reports that "staff did everything to manage pain" had the biggest gains and were sustained for more than 2 years. The CAPA tool meets regulatory requirements for pain assessment.

Improving School Nurse Pain Assessment Practices for Students With Intellectual Disability

School nurses are afforded minimal resources related to assessing pain in students with intellectual disability (ID) and have called for continuing education. The purpose of this study was to measure the effectiveness of an education program regarding best practices for assessing pain in students with ID. Educational sessions were presented to 248 school nurses. Pre-, post-, and follow-up surveys measured (1) difficulty school nurses face when assessing pain, (2) knowledge and use of pain assessment methods, and (3) intent to change and actual changes to professional practices. Participants experienced less difficulty assessing pain following the educational program. Almost all participants intended to change pain assessment practices, but large caseloads limited new practice adoption. Policy makers must consider population size and acuity when determining school nurse staffing. Trainings and other resources should be made available to school nurses in order to make pain assessments for students with ID more thorough and efficient.