Putting pain assessment into practice: why is it so painful?

Effect of six-week short-duration deep breathing on young adults with chronic ankle instability-a pilot randomized control trial

BACKGROUND

Chronic ankle instability (CAI) is the most common injury in youth sports, which leads to psychological stress from doubting their performance. Cost effective and easy to access tool to reduce the stress among this target group are desired. Therefore, the purpose of this study was to investigate the effect of adding on intervention with short-duration deep breathing (SDDB) alongside with conventional physiotherapy (CP) among young adults with chronic ankle instability (CAI).

METHODS

Total of 30 CAI participants attended physiotherapy, who were randomly assigned into control and experimental groups. The participants in the experimental group received combined intervention (SDDB + CP), and the control group received CP for 6 weeks. The effectiveness of interventions was assessed at 3 intervals with a battery of questionnaires (Visual Analog Score, Cumberland Ankle Instability Tool, Mindful Attention Awareness Scale, and Oxford Happiness Questionnaire) at the end of week 3, week 6, and week 12 as follow-up. A two-way repeated measures of ANOVA was applied to report the statistical significance at p < 0.05.

RESULTS

The results showed a better improvement in pain, balance, happiness, and mindfulness attention among participants in the experimental group, with a significant improvement in mindful attention over the time point as compared to the control group.

CONCLUSION

The findings provide insight into incorporating SDDB additions to the existing CP for better CAI management. Breathing techniques that improve attention and happiness play a vital role in CAI, which recommends the biopsychosocial approach in chronic injury rehabilitation.

TRIAL REGISTRATION

Current Controlled Trials using Clinical Trials Registry under ID number NCT04812158 retrospectively registered on 23/03/2021.

Video-Based versus On-Site Neonatal Pain Assessment in Neonatal Intensive Care Units: The Impact of Video-Based Neonatal Pain Assessment in Real-World Scenario on Pain Diagnosis and Its Artificial Intelligence Application

BACKGROUND

Neonatal pain assessment (NPA) represents a huge global problem of essential importance, as a timely and accurate assessment of neonatal pain is indispensable for implementing pain management.

PURPOSE

To investigate the consistency of pain scores derived through video-based NPA (VB-NPA) and on-site NPA (OS-NPA), providing the scientific foundation and feasibility of adopting VB-NPA results in a real-world scenario as the gold standard for neonatal pain in clinical studies and labels for artificial intelligence (AI)-based NPA (AI-NPA) applications.

SETTING

A total of 598 neonates were recruited from a pediatric hospital in China.

METHODS

This observational study recorded 598 neonates who underwent one of 10 painful procedures, including arterial blood sampling, heel blood sampling, fingertip blood sampling, intravenous injection, subcutaneous injection, peripheral intravenous cannulation, nasopharyngeal suctioning, retention enema, adhesive removal, and wound dressing. Two experienced nurses performed OS-NPA and VB-NPA at a 10-day interval through double-blind scoring using the Neonatal Infant Pain Scale to evaluate the pain level of the neonates. Intra-rater and inter-rater reliability were calculated and analyzed, and a paired samples t-test was used to explore the bias and consistency of the assessors' pain scores derived through OS-NPA and VB-NPA. The impact of different label sources was evaluated using three state-of-the-art AI methods trained with labels given by OS-NPA and VB-NPA, respectively.

RESULTS

The intra-rater reliability of the same assessor was 0.976-0.983 across different times, as measured by the intraclass correlation coefficient. The inter-rater reliability was 0.983 for single measures and 0.992 for average measures. No significant differences were observed between the OS-NPA scores and the assessment of an independent VB-NPA assessor. The different label sources only caused a limited accuracy loss of 0.022-0.044 for the three AI methods.

CONCLUSION

VB-NPA in a real-world scenario is an effective way to assess neonatal pain due to its high intra-rater and inter-rater reliability compared to OS-NPA and could be used for the labeling of large-scale NPA video databases for clinical studies and AI training.

Assessing Neonatal Pain with NIPS and COMFORT-B: Evaluation of NICU’s Staff Competences

Background

Pain is considered “the 5th vital sign” that should be regularly assessed in the neonatal intensive care setting. Although over 40 pain assessment tools have been developed for neonates, their implementation in everyday practice is challenging. Epidemiological studies demonstrate that pain is still underassessed and undertreated in European NICUs.

Purpose

To evaluate the interrater and intrarater reliability of the NIPS and COMFORT-B scales among the tertiary NICU's staff members 4 years after their implementation in local pain guidelines with no prior dedicated training.

Methods

Physicians and nurses were invited to evaluate 5 video recordings of infants hospitalized in the intensive care settings, using the NIPS and COMFORT-B scales. The assessment took part twice at a 3-month interval. Interrater reliability was calculated for both scales using Kendall's W coefficient of concordance and Krippendorff's alpha coefficient. Cohen's kappa was used to assess intrarater reliability.

Results

17 physicians and 19 nurses took part in the study. Interrater agreement for the COMFORT-B scale was above 0.8 for Kendall's W coefficient (p < .01) and above 0.667 for Krippendorff's alpha coefficient. Kendall's W coefficient for the NIPS scores ranged between 0.7 and 0.8 (p < .01). Krippendorff's alpha was above 0.667. Intrarater agreement for both the COMFORT-B and NIPS scales was 0.693 and 0.724, respectively.

Conclusions

Overall, the agreement between our staff members was moderately good for both scales. This is not enough to avoid inadequate pain assessment. More training is needed to improve NICU's staff competences in using pain scales.

Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study

The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

[Item Reduction to Improve Practicability of Neonatal Pain Assessment Tools - Comparison of NFCSshort and PIPP in Daily Clinical Practice]

HINTERGRUND

Trotz über 50 psychometrisch validierter Beobachtungsverfahren gibt es bisher keinen Konsens über das praktikabelste Schmerzassessment bei Neugeborenen. Die Items von NFCSshort und PIPP wurden mit der Schmerzeinschätzung der prozedurbeteiligten Behandler verglichen und es wurde evaluiert, ob eine Itemreduktion zu Gunsten der Alltagsanwendung möglich wäre.

MATERIAL UND METHODEN

52 Neugeborene wurden in unserer Beobachtungsstudie einer klinisch indizierten peripheren Venenpunktion unterzogen. Patient und Monitordaten wurden standardisiert auf Video aufgezeichnet. Die Schmerzintensität wurden durch sieben unabhängige Untersucher mittels NFCSshort und PIPP bewertet und hinsichtlich der Variabilität zwischen den Untersuchern verglichen.

ERGEBNISSE

Nur vier Items des PIPP (Herzfrequenz, Augenbrauenvorwölbung, zusammengekniffene Augen, betonte Nasolabialfalte) wiesen einen signifikanten Zusammenhang mit der geschätzten Schmerzhaftigkeit der Prozedur auf. Die Items 1 (Gestationsalter), 2 (Wachheitsgrad) und 4 (Sauerstoffsättigung) hatten bei keinem Untersucher Einfluss auf das Schmerzmessergebnis. Die Auswertung des NFCSshort zeigte bei zwei Untersuchern für das Item 1 (Vorwölbung der Augenbrauen) und bei einem Untersucher für das Item 2 (zusammengekniffene Augen) keine Einflüsse auf das Messergebnis.

DISKUSSION

Die Ergebnisse der Studie legen eine Kürzung des PIPP um drei Items nahe, da diese keinen Einfluss auf das Schmerzmessergebnis zeigten. Eine Reduktion des PIPP um das Item Gestationsalter erscheint fraglich, da es in weiteren Studien als bedeutsames Item bewertet wurde. Ein Verzicht auf das Item Sauerstoffsättigung geht mit einem geringeren Messaufwand einher. Eine weitere Kürzung der bereits gekürzten Version (NFCSshort) auf weniger als fünf Items ist auf Basis unserer Ergebnisse nicht zu empfehlen.

BACKGROUND

Despite more than 50 laboratory-evaluated measurement systems, there is no consensus on the most practicable pain assessment in newborns in daily practice. For this purpose, the items of NFCSshort and PIPP were compared to the pain assesment of the involved medical practitioner. The aim of the study was to evaluate whether an item reduction of the assesments in favor of everyday use is feasible.

METHODS

In 52 neonates of a paediatric ward venous blood collection was performed in this observational study. Cameras recorded patients and monitor in a standardized way. The pain intensity was assessed with NFCSshort and PIPP by seven independent observers. The ratings were compared for variability between observers.

RESULTS

Of the seven PIPP items, only four were significantly associated with procedural pain assessment for all seven observers (heart rate, brow bulge, eye squeeze, nasolabial furrow). For the NFCSshort, no significant association with procedural pain assessment was found for two observers for the item "brow bulge" and for one observer for the item "eye squeeze".

CONCLUSION

The results of the study suggest a possible reduction of the PIPP by three items. Disregarding item 1 (gestational age) appears questionable, since its impact as context variable has been proven repeatedly. The waiver of item 4 (oxygen saturation) is associated with less measuring effort. A further reduction of the already shortened version of the NFCS with ten items (NFCSshort, five items) is not recommended by our results.

Prevalence and factors associated with ulcer-related pain in persons with chronic leg ulcers-an explorative study

AIMS AND OBJECTIVES

The aims of this study were to explore the prevalence of background pain and identify demographic, clinical and psychosocial factors associated with moderate to severe background pain in persons with leg ulcers.

BACKGROUND

All chronic leg ulcers are potentially painful. Research indicates that 80% of persons with chronic leg ulcers experience wound-related background pain. However, studies on factors associated with pain have small samples and findings are inconclusive.

DESIGN

Exploratory cross-sectional study.

METHOD

This quantitative study recruited persons with chronic leg ulcers (N = 252) from two wound care clinics using consecutive sampling method. Data were obtained through screening interview, clinical examination and questionnaires. Logistic regression with stepwise backwards elimination was used to identify factors associated with moderate to severe background pain. The STROBE checklist for cross-sectional studies was used for reporting this study.

RESULTS

Background pain was reported by 64% of the participants. Inferential statistical analyses suggest that between 58% and 69% of persons with chronic leg ulcers suffer from this type of pain. Factors associated with moderate to severe pain were older age, female gender, reduced sleep quality and diminished health status. In the final model, reduced sleep quality increased the likelihood of having moderate to severe pain in persons with good health status while not in persons with diminished health status.

CONCLUSION

Ulcer-related background pain is common in persons with chronic leg ulcers. Older females reporting insomnia symptoms also had increased risk of moderate to severe ulcer-related background pain. These participants also perceived their health status to be better.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrates that ulcer-related background pain and associated factors needs more attention in clinical practice. Furthermore, nurses and other healthcare professionals should integrate biopsychosocial strategies to assess and manage ulcer-related background pain.

Effects of Pain-Reporting Education Program on Children's Pain Reports-Results From a Randomized Controlled Post-operative Pediatric Pain Trial

Objective: Accurate assessment of patients' pain is an essential part of adequate analgesic treatment. Although reporting pain is a complex task, limited-to-no instructions are provided to pediatric patients regarding this process. Our goal in this randomized parallel-group clinical trial (Clinicaltrial.gov study protocol number NCT04306679) was to evaluate if a training program designed to improve children's ability to understand and use pain scales in a post-surgical setting would affect their pain scores. Methods: Eligible children (aged 8-17), hospitalized for elective surgery and their parents were randomized into two groups. Pre-surgery the intervention group underwent a multi-media program aimed to teach and train how to report pain. The control group received standard pre-surgical instructions. Post-surgery, the children reported their pain on 4 pain scales. The primary outcome was the concordance between children's pain intensity scores reported on four pain scales, both in terms of within-child standard deviation and absolute difference. Results: Ninety-six children met inclusion criteria and completed the study. The trained subjects' pain reports had significantly (p = 0.002) lower within-subject standard deviation (0.41 ± 0.31) than the control group (0.67 ± 0.46). In line, regarding absolute difference, the concordance of children's pain reports was twice better in the trained group (mean difference of 0.43 ± 0.40) than in the control group (0.88 ± 0.70) (p < 0.001). Discussion: Our results suggests that children's ability to report pain is a skill that can be improved. Future studies should test the potential clinical impacts of educational interventions aimed to improve pain assessment in children and adults.

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.

A child in pain: A psychologist’s perspective on changing priorities in scientific understanding and clinical care

My research and clinical career followed a trajectory of increasing appreciation for the importance of social factors as determinants of pain experience and expression. The social contexts of children’s lives determine whether infants and children are exposed to pain, how socialization in family and ethnocultural contexts lead to pain as a social experience, comprised of thoughts and feelings as well as sensory input, how others shape pain experience and expression, less so for automatic/reflexive features than purposeful representations, and how other's appraisals of children’s pain reflect the observer's unique background and capacities for intervening in the child’s interests. A greater understanding of the social dimensions of pain, as reflected in the social communication model of pain, would support innovation of psychological and social interventions.

Topical Review: State of the Field of Child Self-Report of Acute Pain

OBJECTIVE

Children experience acute pain with routine and emergent healthcare, and untreated pain can lead to a range of repercussions. Assessment is vital to diagnosing and treating acute pain. Given the internal nature of pain, self-report is predominant. This topical review reflects on the state of the field of pediatric acute pain self-report, and proposes a framework for acute pain assessment via self-report.

METHOD

We examine self-report of acute pain in preschool-age children through adolescents, and we detail a three-step process to optimize acute pain assessment.

RESULTS

The first step is to decide between a pain screening or assessment. Several 0-10 self-report scales are available for pain screenings. Assessment requires specification of the goals and domains to target. Core criteria, common features, modulating factors, and consequences of acute pain provide a framework for a comprehensive pain assessment. Whereas there are some measures available to assess aspects of these domains, there are considerable gaps. Last, it is important to integrate the data to guide clinical care of acute pain.

CONCLUSIONS

Self-report of acute pain is dominated by single-item intensity scales, which are useful for pain screening but inadequate for pain assessment. We propose a three-step approach to acute pain assessment in children. However, there is a need for measure development for a comprehensive evaluation of the core criteria, common features, modulating factors, and consequences of pediatric acute pain. In addition, there is limited guidance in merging data found in multifaceted evaluations of pediatric acute pain.

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.

Assessment of Pain in the Newborn: An Update

Preterm and term neonate pain assessment in neonatal intensive care units is vitally important because of the prevalence of procedural and postoperative pain. Of the 40 plus tools available, a few should be chosen for different populations and contexts (2 have been validated in premature infants). Preterm neonates do not display pain behaviors and physiologic indicators as reliably and specifically as full-term infants, and are vulnerable to long-term sequelae of painful experiences. Brain-oriented approaches may become available in the future; meanwhile, neonatal pain assessment tools must be taught, implemented, and their use optimized for consistent, reproducible, safe, and effective treatment.

Assessment of pain in newborn infants

Hospitalized newborn infants experience pain that can have negative short- and long-term consequences and thus should be prevented and treated. National and international guidelines state that adequate pain management requires valid pain assessment. Nociceptive signals cause a cascade of physical and behavioral reactions that alone or in combination can be observed and used to assess the presence and intensity of pain. Units that are caring for newborn infants must adopt sufficient pain assessment tools to cover the gestational ages and pain types that occurs in their setting. Pain assessment should be performed on a regular basis and any detection of pain should be acted on. Future research should focus on developing and validating pain assessment tools for specific situations.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children

BACKGROUND

Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited.

AIMS

The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples.

DESIGN

Qualitative, descriptive design.

SETTINGS

Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use.

PARTICIPANTS/SUBJECTS

Nurses (N = 22) with ≥1 year experience caring for preverbal children.

METHODS

Individual, semistructured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment.

CONCLUSIONS

Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

General anesthesia, conscious sedation, or nothing: Decision-making by children during painful procedures

BACKGROUND

Following diagnosis, children with cancer suddenly find themselves in an unknown world where unfamiliar adults make all the important decisions. Children typically experience increasing levels of anxiety with repeated invasive procedures and do not adapt to the discomfort. The aim of the present study is to explore the possibility of asking children directly about their medical support preferences during invasive procedures.

PROCEDURE

Each patient was offered a choice of medical support on the day of the procedure, specifically general anesthesia (GA), conscious sedation (CS), or nothing. An ad hoc assessment tool was prepared in order to measure child discomfort before, during, and after each procedure, and caregiver adequacy was measured. Both instruments were completed at each procedure by the attending psychologist.

RESULTS

We monitored 247 consecutive invasive procedures in 85 children and found that children in the 4 to 7 year age group showed significantly higher distress levels. GA was chosen 66 times (26.7%), CS was chosen 97 times (39.3%), and nothing was chosen 5 times and exclusively by adolescents. The child did not choose in 79 procedures (32%). The selection of medical support differed between age groups and distress level was reduced at succeeding procedures.

CONCLUSIONS

Offering children the choice of medical support during invasive procedures allows for tailored support based on individual needs and is an effective modality to return active control to young patients, limiting the emotional trauma of cancer and treatment.

A phase III wait-listed randomised controlled trial of novel targeted inter-professional clinical education intervention to improve cancer patients' reported pain outcomes (The Cancer Pain Assessment (CPAS) Trial): study protocol

Background

Variations in care models contribute to cancer pain being under-recognised and under-treated in half of all patients with cancer. International and national cancer pain management guidelines are achievable with minimal investment but require practice changes. While much of the cancer pain research over the preceding decades has focused on management interventions, little attention has been given to achieving better adherence to recommended cancer pain guideline screening and assessment practices. This trial aims to reduce unrelieved cancer pain by improving cancer and palliative doctors’ and nurses’ (‘clinicians’) pain assessment capabilities through a targeted inter-professional clinical education intervention delivered to participants’ mobile devices (‘mHealth’).

Methods

A wait-listed, randomised control trial design. Cancer and/or palliative care physicians and nurses employed at one of the six participating sites across Australia will be eligible to participate in this trial and, on enrolment, will be allocated to the active or wait-listed arm. Participants allocated to the active arm will be invited to complete the mHealth cancer pain assessment intervention. In this trial, mHealth is defined as medical or public health practice supported by mobile devices (i.e. phones, patient monitoring devices, personal digital assistants and other wireless devices). This mHealth intervention integrates three evidence-based elements, namely: the COM-B theoretical framework; spaced learning pedagogy; and audit and feedback. This intervention will be delivered via the QStream online platform to participants’ mobile devices over four weeks. The trial will determine if a tailored mHealth intervention, targeting clinicians’ cancer pain assessment capabilities, is effective in reducing self-reported cancer pain scores, as measured by a Numerical Rating Scale (NRS).

Discussion

If this mHealth intervention is found to be effective, in addition to improving cancer pain assessment practices, it will provide a readily transferable evidence-based framework that could readily be applied to other evidence practice gaps and a scalable intervention that could be administered simultaneously to multiple clinicians across diverse geographical locations. Moreover, if found to be cost-effective, it will help transform clinical continuing professional development. In summary, this mHealth intervention will provide health services with an opportunity to offer an evidence-based, pedagogically robust, cost-effective, scalable training alternative.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001103257. Registered on 3 July 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3152-z) contains supplementary material, which is available to authorized users.

Implementation of paediatric pain care-bundle across South-West England clinical network of Emergency Departments and Minor Injury Units: A before and after study

INTRODUCTION

Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs).

METHODS

A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records).

RESULTS

The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01).

CONCLUSIONS

Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.

Self-Perceived Pain Assessment Knowledge and Confidence (Self-PAC) Scale for Cancer and Palliative Care Nurses: A Preliminary Validation Study

BACKGROUND

Pain is highly prevalent in all health care settings, and frequently poorly managed. Effective pain management is predicated on a continuous cycle of screening, assessing, intervening and evaluating. Identifying gaps in nurses' self-perceived pain assessment competencies is an essential first step in the design of tailored interventions to embed effective pain assessment into routine clinical practice, and improve patient reported pain outcomes. Yet, few validated instruments focus on the competencies required for undertaking a comprehensive pain assessment, with most focusing on clinician's pain management competencies.

AIM

To examine the validity of the 'Self-Perceived Pain Assessment Knowledge and Confidence' (Self-PAC) Scale.

DESIGN

Preliminary instrument validation.

SETTING

Two Australian cancer and palliative care services.

PARTICIPANTS/SUBJECTS

186 cancer and palliative care nurses.

METHODS

The Self-PAC Scale was administered to participants online. Factor Analyses, including Exploratory and Confirmatory, were applied to examine the structural validity, Cronbach's alpha was calculated for internal consistency. Criterion validity was investigated by comparing responses from experienced and non-experienced nurses.

RESULTS

Two components resulted with a single factor structure for pain assessment confidence and a two-factor structure for the knowledge of pain assessment. The factor loading for the subscales ranged from 0.653 to 0.969, with large proportions of the variances explained by the factors. Cronbach's alpha of the subscales ranged from 0.87-0.92 and significant difference in responses were found between experienced and non-experienced nurses.

CONCLUSION

Preliminary validation of the Self-PAC Scale suggests that it is a helpful instrument for assessing cancer and palliative care nurse' pain assessment competencies.

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.

The Rotterdam Elderly Pain Observation Scale (REPOS) is reliable and valid for non-communicative end-of-life patients

BACKGROUND

In palliative care, administration of opioids is often indispensable for pain treatment. Pain assessment may help recognize pain and guide treatment in non-communicative patients. In the Netherlands the Rotterdam Elderly Pain Observation Scale (REPOS) is recommended to this aim, but not yet validated. Therefore the objective of this study was to validate the REPOS in non-communicative or unconscious end-of-life patients.

METHODS

In this observational study, the primary researcher applied the REPOS, while both the researcher and a nurse applied the Numeric Rating Scale (NRS). If possible, the patient in question applied the NRS as well. The NRS scores were compared with the REPOS scores to determine concurrent validity. REPOS scores obtained before and after a pain-reducing intervention were analysed to establish the scale's sensitivity to change.

RESULTS

A total of 183 REPOS observations in 100 patients were analysed. Almost 90% of patients had an advanced malignancy; observations were done a median of 3 days (IQR 1 to 13) before death. Internal consistency of the REPOS was 0.73. The Pearson product moment correlation coefficient ranged from 0.64 to 0.80 between REPOS and NRS scores. REPOS scores declined with median 2 points (IQR 1 to 4) after a pain-reducing intervention (p < 0.001). Optimal sensitivity (0.81) and specificity (0.62) were found at cut-off score 3.

CONCLUSIONS

This study demonstrates that the REPOS has promising psychometric properties for pain assessment in non-communicative end-of-life patients. Its application may be of additional value to relieve suffering, including pain, in palliative care.

How Situational Context Impacts Empathic Responses and Brain Activation Patterns

Clinical empathy, which is defined as the ability to understand the patient’s experience and feelings from the patient’s perspective, is acknowledged to be an important aspect of quality healthcare. However, how work experience modulates the empathic responses and brain activation patterns in medical professions remains elusive. This fMRI study recruited one hundred female nurses, who varied the length of work experience, and examined how their neural response, functional connectivity, and subjective evaluations of valence and arousal to perceiving another individual in physical pain are modulated by the situational context in which they occur (i.e., in a hospital or at home). Participants with longer hospital terms evaluated pain as less negative in valence and arousal when occurring in a hospital context, but not in a home context. Physical pain perceived in a hospital compared to a home context produced stronger activity in the right temporoparietal junction (rTPJ). The reverse comparison resulted in an increased activity in the insula and anterior midcingulate cortex (aMCC). Mediation analysis indicated that reduced personal accomplishment, a symptom of burnout, breaks down the mediation effect of the putamen on context-dependent valence ratings. Overall, the study demonstrates how situational contexts significantly influence individuals’ empathic processing, and that perceiving reward from patient care protects them from burnout.

Highlights-

Differences in behavior ratings and brain activations between medical practitioners perceiving others’ pain in a hospital and at home.

-

Situational contexts significantly influence individual’s empathic processing.

-

Perceiving rewards from patient care protects medical practitioners from burnout.

-

Empathy is a flexible phenomenon.

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.

Nurses' perceptions of pain assessment and management practices in neonates: a cross-sectional survey

AIMS

This study aimed to describe pain assessment and management practices for neonates based on nurses' perceptions in neonatal intensive care units (NICUs).

DESIGN

A descriptive cross-sectional survey was conducted in Finland.

METHODS

Of all nurses (N = 422) working in the NICUs in the country's five university hospitals, 294 responded to a questionnaire. The data were analysed by statistical methods.

RESULTS

Nurses agreed that pain assessment is important, but over half of them reported being able to assess pain in a reliable way without using pain assessment scales. Physiological parameters and changes in neonate's behaviour were reported as routinely observed, but many specific facial expressions indicative of pain were less often observed. Only a few pain assessment scales were known, and they were not routinely used in clinical practice. Most nurses reported using physical methods and giving oral sucrose along with non-nutritive sucking. Counselling parents to continue breastfeeding or guiding them to use skin-to-skin care or music was rarely reported as used to alleviate infants' pain.

CONCLUSIONS

Educational interventions for nurses are needed to improve pain assessment and management practices in the NICUs. In addition, there is a need for national guidelines in order to ensure the equal treatment to all neonates.

Individual contextual factors in the validation of the Bernese pain scale for neonates: protocol for a prospective observational study

Background

The Bernese Pain Scale for Neonates (BPSN) is a multidimensional pain assessment tool that is already widely used in clinical settings in the German speaking areas of Europe. Recent findings indicate that pain responses in preterm neonates are influenced by individual contextual factors, such as gestational age (GA), gender and the number of painful procedures experienced. Currently, the BPSN does not consider individual contextual factors. Therefore, the aim of this study is the validation of the BPSN using a large sample of neonates with different GAs. Furthermore, the influence of individual contextual factors on the variability in pain reactions across GA groups will be explored. The results will be used for a modification of the BPSN to account for individual contextual factors in future clinical pain assessment in neonates.

Methods and design

This prospective multisite validation study with a repeated measures design will take place in three university hospital neonatal intensive care units (NICUs) in Switzerland (Bern, Basel and Zurich). To examine the impact of GA on pain responses and their variability, the infants will be stratified into six GA groups ranging from 24 0/7 to 42 0/7. Among preterm infants, 2–5 routine capillary heel sticks within the first 14 days of life, and among full-term infants, two heel sticks during the first days of life will be documented. For each heel stick, measurements will be video recorded for each of three phases: baseline, heel stick, and recovery. The infants’ pain responses will be rated according to the BPSN by five nurses who are blinded as to the number of each heel stick and as to the measurement phases. Individual contextual factors of interest will be extracted from patient charts.

Discussion

Understanding and considering the influence of individual contextual factors on pain responses in a revised version of the BPSN will help the clinical staff to more appropriately assess pain in neonates, particularly preterm neonates hospitalized in NICUs. Pain assessment is a first step toward appropriate and efficient pain management, which itself is an important factor in later motor and cognitive development in this vulnerable patient population.

Trial registration

The study is registered in the database of Clinical Trial gov. Study ID-number: NCT 02749461. Registration date: 12 April 2016.

Adherence to All Steps of a Pain Management Protocol in Intensive Care Patients after Cardiac Surgery Is Hard to Achieve

Purpose. To investigate adherence to our pain protocol considering analgesics administration, number and timing of pain assessments, and adjustment of analgesics upon unacceptably high (NRS ≥ 4) and low (NRS ≤ 1) pain scores. Material and Methods. The pain protocol for patients in the intensive care unit (ICU) after cardiac surgery consisted of automated prescriptions for paracetamol and morphine, automated reminders for pain assessments, a flowchart to guide interventions upon high and low pain scores, and reassessments after unacceptable pain. Results. Paracetamol and morphine were prescribed in all 124 patients. Morphine infusion was stopped earlier than protocolized in 40 patients (32%). During the median stay of 47 hours [IQR 26 to 74 hours], 702/706 (99%) scheduled pain assessments and 218 extra pain scores were recorded. Unacceptably high pain scores accounted for 96/920 (10%) and low pain scores for 546/920 (59%) of all assessments. Upon unacceptable pain additional morphine was administered in 65% (62/96) and reassessment took place in 15% (14/96). Morphine was not tapered in 273 of 303 (90%) eligible cases of low pain scores. Conclusions. Adherence to automated prescribed analgesics and pain assessments was good. Adherence to nonscheduled, flowchart-guided interventions was poor. Improving adherence may refine pain management and reduce side effects.

Intrauterine contraception insertion pain: nursing interventions to improve patient experience

AIMS AND OBJECTIVES

To examine factors which contribute to the individual's experience of pain in relation to intrauterine contraception insertion and determine evidence-based nursing strategies to best assess and manage this pain.

BACKGROUND

Nurses are increasingly involved in consultations regarding intrauterine contraception. However, concerns regarding painful or difficult insertion may inhibit uptake and discourage nurses from promoting or inserting intrauterine contraception.

DESIGN

Integrative review.

METHODS

Database searches of CINAHL, PubMed, Wiley Online Library and the Cochrane Collaboration for relevant literature. Eight papers met the inclusion criteria and were analysed using an integrative review process.

RESULTS

Physical causes and pharmacological interventions for insertion pain have been thoroughly investigated. Absence of previous vaginal delivery and anxiety may increase the likelihood of procedural pain. The literature fails to conclusively determine any universally effective prophylactic analgesia. Cervical anaesthesia may be beneficial in some cases and oral analgesia may relieve postprocedural pain. Distraction in the form of conversation, music or television can be effective in reducing anxiety.

CONCLUSIONS

A combination of physical, psychological and environmental factors contribute to the individual's pain experience. Nurses have the potential to make a significant impact on pain outcomes by demonstrating clinical expertise and creating a trustful environment. Giving reliable information, acknowledging the significance of anxiety and providing reassurance and distraction are effective pain reducing strategies. Research into nonpharmacological approaches is warranted, especially those which reduce anxiety.

RELEVANCE TO CLINICAL PRACTICE

Increasing uptake of long-acting reversible contraception is a public health goal. Providing effective pain management strategies to improve patient experience may encourage more nurses to recommend, or enhance their scope of practice to include, intrauterine contraception insertion.

The role of organizational context in moderating the effect of research use on pain outcomes in hospitalized children: a cross sectional study

Background

Despite substantial research on pediatric pain assessment and management, health care professionals do not adequately incorporate this knowledge into clinical practice. Organizational context (work environment) is a significant factor in influencing outcomes; however, the nature of the mechanisms are relatively unknown. The objective of this study was to assess how organizational context moderates the effect of research use and pain outcomes in hospitalized children.

Methods

A cross-sectional survey was undertaken with 779 nurses in 32 patient care units in 8 Canadian pediatric hospitals, following implementation of a multifaceted knowledge translation intervention, Evidence-based Practice for Improving Quality (EPIQ). The influence of organizational context was assessed in relation to pain process (assessment and management) and clinical (pain intensity) outcomes. Organizational context was measured using the Alberta Context Tool that includes: leadership, culture, evaluation, social capital, informal interactions, formal interactions, structural and electronic resources, and organizational slack (staff, space, and time). Marginal modeling estimated the effects of instrumental research use (direct use of research knowledge) and conceptual research use (indirect use of research knowledge) on pain outcomes while examining the effects of context.

Results

Six of the 10 organizational context factors (culture, social capital, informal interactions, resources, and organizational slack [space and time]) significantly moderated the effect of instrumental research use on pain assessment; four factors (culture, social capital, resources and organizational slack time) moderated the effect of conceptual research use and pain assessment. Only two factors (evaluation and formal interactions) moderated the effect of instrumental research use on pain management. All organizational factors except slack space significantly moderated the effect of instrumental research use on pain intensity; informal interactions and organizational slack space moderated the effect of conceptual research use and pain intensity.

Conclusions

Many aspects of organizational context consistently moderated the effects of instrumental research use on pain assessment and pain intensity, while only a few influenced conceptual use of research on pain outcomes. Organizational context factors did not generally influence the effect of research use on pain management. Further research is required to further explore the relationships between organizational context and pain management outcomes.

The clinimetric properties of the COMFORT scale: A systematic review

The COMFORT scale is a measurement tool to assess distress, sedation and pain in nonverbal paediatric patients. Several studies have described the COMFORT scale, but no formal assessment of the methodological quality has been undertaken. Therefore, we performed a systematic review to study the clinimetric properties of the (modified) COMFORT scale in children up to 18 years. We searched Central, CINAHL, Embase, Medline, PsycInfo and Web of Science until December 2014. The selection, data extraction and quality assessment were performed independently by two reviewers. Quality of the included studies was appraised using the COSMIN checklist. We found 30 studies that met the inclusion criteria. Most participants were ventilated children up to 4 years without neurological disorders. The results on internal consistency and interrater reliability showed values of >0.70 in most studies, indicating an adequate reliability. Construct validity resulted in correlations between 0.68 and 0.84 for distress, between 0.42 and 0.94 for sedation and between 0.31 and 0.96 for pain. The responsiveness of the (modified) COMFORT scale seems to be adequate. The quality of the included studies ranged from poor to excellent. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain. The included studies were clinically and methodologically heterogeneous, hampering firm conclusions. WHAT DOES THIS REVIEW ADD?: An in-depth assessment of the clinimetric properties of the COMFORT scale. The COMFORT scale shows overall an adequate reliability in providing information on distress, sedation and pain. Construct validity varies from good to excellent for distress, from moderate to excellent for sedation, and from poor to excellent for pain.

Postoperative pain assessment in children: a pilot study of the usefulness of the analgesia nociception index

BACKGROUND

The ability to perform objective pain assessment is very important in paediatric patients. The goal of this study was to investigate the relationship between the analgesia nociception index (ANI), which is based on the heart rate variability, and objective measurements of pain intensity in young or cognitively impaired children, after surgical or imaging procedures (control group) under general anaesthesia.

METHODS

On arrival in the recovery room and subsequently at 5-10 min intervals, the level of pain was rated using the FLACC pain scale (0-10). The ANI values (0-100; 0 indicating the worst pain) were recorded simultaneously. The area under the receiver operating characteristic curve (AUC) and grey zone approach were used to evaluate the performance of the ANI to detect patients with FLACC >4. Instantaneous ANI values were compared with ANI values averaged over 256 s periods of time.

RESULTS

All children in the surgical group (n=32) developed moderate-to-severe pain (FLACC >4). Children in the control group (n=30) exhibited minimal pain. Instantaneous ANI values were lower in children of the surgical group than in the control group [52 (sd16) vs 69 (16), P<0.001]. The AUC for the 256 s ANI recording period [0.94 (95% confidence interval 0.85-0.99)] was significantly higher than for instantaneous ANI (P<0.05). When measured for a period of 256 s, an ANI cut-off value of 56 (grey zone [58-60]) was most predictive of a FLACC ≥4.

CONCLUSIONS

The ANI may provide an objective measurement of acute postoperative pain, which is correlated with that measured on a FLACC scale in young or cognitively impaired children.

Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy?

This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.

Neonatal procedural pain can be assessed by computer software that has good sensitivity and specificity to detect facial movements

AIM

The difficulty in assessing pain during the neonatal period is one of the main obstacles for appropriate analgesia in intensive care units. The aim of this study was to develop and validate computer software to monitor neonatal facial movements of pain in real time.

METHODS

The software was developed in the Delphi integrated development environment and provides real-time image analysis during monitoring, based on image recognition of pain-related facial actions. To validate the software performance, facial images were obtained during the monitoring of 30 neonates who were subjected to painful procedures related to daily care management. Of the 5644 images identified and analysed by the software, 360 images - 12 per infant - were randomly selected and assessed by six healthcare professionals with experience of recognising neonatal pain.

RESULTS

The agreement between the examiners and the software assessment was excellent (κ = 0.975). The software exhibited 85% sensitivity and 100% specificity in detecting neutral facial expressions in the resting state and 100% sensitivity and specificity in detecting pain during painful procedures.

CONCLUSION

It is possible to assess neonatal procedural pain using computer software that has good sensitivity and specificity to detect facial movements.

Nurses' report of in-hospital pediatric pain assessment: examining challenges and perspectives

Pain is a symptom pediatric nurses commonly encounter in the hospital setting. Untreated pain can lead to adverse physiologic and psychological effects. This study examines in-hospital pain assessment methods nurses report using and assesses challenges, difficulties, and barriers nurses report to assessing pain in hospitalized children. Cross-sectional study of 82 pediatric nurses from all pediatric departments of a tertiary hospital in Israel. A self-report questionnaire was developed to examine how nurses assess children's in-hospital pain and barriers to in-hospital pain assessment. Nearly all nurses (90%) reported having enough knowledge to assess children's pain in the hospital, relying on child's self-report (86%) and being familiar with commonly used validated pain scales (90%). However, a majority (75%) reported not using pain scales recently and only half (58%) reported using an alternative method involving the child. Most nurses (86%) reported relying on their own overall impression of the child's pain and only a third (34%) reported involving the parents in their pain assessments. Nurses included comments stressing the importance of pain assessments and their frustration with the current validated measures available. This study adds to a growing body of literature demonstrating a gap between recommended pediatric pain assessment guidelines and reported practice, with nurses showing a resistance to relying on single-item or unidimensional measures to assess and evaluate the rich and complex pain experience. A multidimensional approach involving child self-report, parent report, and nurses' own overall impression based on clinical assessment skills of pain is discussed.

Development of a Management Algorithm for Post-operative Pain (MAPP) after total knee and total hip replacement: study rationale and design

BACKGROUND

Evidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described.

METHODS

In partnership with clinicians, and based on best available evidence, the aim of the Management Algorithm for Post-operative Pain (MAPP) project is to develop, implement, and evaluate an algorithm designed to support pain management decision-making for patients after orthopaedic surgery. The algorithm will provide guidance for the prescription and administration of multimodal analgesics in the post-operative period, and the treatment of breakthrough pain. The MAPP project is a multisite study with one coordinating hospital and two supporting (rollout) hospitals. The design of this project is a pre-implementation-post-implementation evaluation and will be conducted over three phases. The Promoting Action on Research Implementation in Health Services (PARiHS) framework will be used to guide implementation. Outcome measurements will be taken 10 weeks post-implementation of the MAPP. The primary outcomes are: proportion of patients prescribed multimodal analgesics in accordance with the MAPP; and proportion of patients with moderate to severe pain intensity at rest. These data will be compared to the pre-implementation analgesic prescribing practices and pain outcome measures. A secondary outcome, the efficacy of the MAPP, will be measured by comparing pain intensity scores of patients where the MAPP guidelines were or were not followed.

DISCUSSION

The outcomes of this study have relevance for nursing and medical professionals as well as informing health service evaluation. In establishing a framework for the sustainable implementation and evaluation of a standardised approach to post-operative pain management, the findings have implications for clinicians and patients within multiple surgical contexts.

Impact of a novel online learning module on specialist palliative care nurses' pain assessment competencies and patients' reports of pain: Results from a quasi-experimental pilot study

BACKGROUND

Pain is a complex multidimensional phenomenon moderated by consumer, provider and health system factors. Effective pain management cuts across professional boundaries, with failure to screen and assess contributing to the burden of unrelieved pain.

AIM

To test the impact of an online pain assessment learning module on specialist palliative care nurses' pain assessment competencies, and to determine whether this education impacted positively on palliative care patients' reported pain ratings.

DESIGN

A quasi-experimental pain assessment education pilot study utilising 'Qstream^©', an online methodology to deliver 11 case-based pain assessment learning scenarios, developed by an interdisciplinary expert panel and delivered to participants' work emails over a 28-day period in mid-2012. The 'Self-Perceived Pain Assessment Competencies' survey and chart audit data, including patient-reported pain intensity ratings, were collected pre-intervention (T1) and post-intervention (T2) and analysed using inferential statistics to determine key outcomes.

SETTING/PARTICIPANTS

Nurses working at two Australian inpatient specialist palliative care services in 2012.

RESULTS

The results reported conform to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Guidelines. Participants who completed the education intervention ( n = 34) increased their pain assessment knowledge, assessment tool knowledge and confidence to undertake a pain assessment ( p < 0.001). Participants were more likely to document pain intensity scores in patients' medical records than non-participants (95% confidence interval = 7.3%-22.7%, p = 0.021). There was also a significant reduction in the mean patient-reported pain ratings between the admission and audit date at post-test of 1.5 (95% confidence interval = 0.7-2.3) units in pain score.

CONCLUSION

This pilot confers confidence of the education interventions capacity to improve specialist palliative care nurses' pain assessment practices and to reduce patient-rated pain intensity scores.