Nursing documentation of postoperative pain management

Previous studies have shown that nursing documentation is often deficient in its recording of pain assessment and treatment. In Sweden, documentation of the care process, including assessment, is a legal obligation. The aim of this study was to describe nursing documentation of postoperative pain management and nurses' perceptions of the records in relation to current regulations and guidelines. The sample included nursing records of postoperative care on the second postoperative day from 172 patients and 63 Registered Nurses from surgical wards in a central county hospital in Sweden. The records were reviewed for content and comprehensiveness based on regulations and guidelines for postoperative pain management. Three different auditing instruments were used. The nurses were asked if the documentation concurred with current regulations and guidelines. The result showed that pain assessment was based mainly on patients' self-report, but less than 10% of the records contained notes on systematic assessment with a pain assessment instrument. Pain location was documented in 50% of the records and pain character in 12%. About 73% of the nurses reported that the documentation concurred with current regulations and guidelines. The findings indicate that significant flaws existed in nurses' recording of postoperative pain management, of which the nurses were not aware.     

Geriatric pain competencies and knowledge assessment for nurses in long term care settings

Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults. Geriatric Pain Competencies and Knowledge Assessment for Nurses in Long Term Care Settings.     

A pain monitoring program for nurses: effects on communication, assessment and documentation of patients' pain

Nurses need to be informed about the patient's pain to be able to take appropriate measures to alleviate pain. However, communication, assessment, and documentation of pain by nurses is often a problem for hospitalized patients. In this study we aimed to overcome the main barriers by developing, implementing, and evaluating a Pain Monitoring Program (PMP) for nurses. The PMP consists of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. We describe the effects of the PMP on communication about pain between nurses and patients and between physicians and patients, agreement between patients' pain intensity and nurses estimations of patients' pain intensity, and documentation about pain in the nursing records. Factors that might influence communication, assessment, and documentation are also discussed. The effects of the PMP were measured in a quasi-experimental design with a nonequivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Results of the control group showed that communication about pain between nurses and patients, agreement between patients' and nurses pain ratings, and documentation about pain in nursing records, remain inadequate. Patients' pain intensity and age were related to communication, assessment, and documentation. Communication and documentation is better in patients with moderate to severe pain than in patients with mild pain, and assessment is better in patients with mild pain. Older patients communicate less with nurses and physicians about pain, and nurses document less about pain in nursing records for older patients compared with younger patients. The PMP proved to be effective in improving nurses' assessment of patients' pain and documentation about pain in nursing records. Patients' pain intensity and care setting were related to the efficacy of the PMP. Communication about pain between patients and nurses, and between patients and physicians did not improve as a result of the PMP. Based on this study it can be concluded that in using a simple method such as the numeric rating scale, together with an education program, attention is focused in a systematic way on patients' pain complaints and creates a common language between patients and nurses. Because the PMP proved effective in a heterogenous population in multiple care settings, it is recommended to implement the PMP in nursing practice.     

Barriers to nurse-led pain management for adult patients in intensive care units: An integrative review

ObjectiveThis integrative review sought to identify and synthesise quantitative and qualitative evidence on barriers to pain management in adult intensive care units (ICUs).BackgroundPain is experienced by 58% of adult ICU patients, which leads to consequences such as decreased healing and delirium. Managing pain effectively is an integral part of the critical care nurse's role.MethodsAn integrative review was conducted based on Whittemore and Knafl's approach. Peer-reviewed research articles were sourced from five databases. Included articles were limited to those published in English and Arabic. The quality of included papers was evaluated using the Mixed Methods Appraisal Tool (MMAT). Identified barriers to pain management in adult ICUs were mapped onto the components of the COM-B model. The study was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsNine hundred and ninety-one papers were identified; 19 studies met the inclusion criteria. Seventeen studies focused on pain management from the perspective of nurses, whereas the remaining two focused on the perspectives of patients and nurses. Using the MMAT, two studies were rated 5 stars (out of 5), nine studies were rated 4 stars, seven studies were rated 3 stars, and one study was rated 2 stars. Lack of knowledge and skills was found to be psychological capability barriers, while nurse dependency on following doctor's orders, poor staffing levels, lack of pain assessment skills, and lack of education were barriers mapped to physical capability. Opportunity was represented by three barriers: inadequate documentation of pain and shortage of nurses were mapped to the physical opportunity, and poor communication to the social opportunity. Nurses' beliefs towards pain assessment were mapped to reflective motivation.ConclusionsThe findings of this study suggest that knowledge, nursing beliefs, insufficient numbers of nursing staff, lack of documentation, and lack of communication commonly affect pain management in adult ICUs.Prospero registrationCRD42020179913     

An Exploration of Pain Documentation for People Living with Dementia in Aged Care Services

BackgroundPain in people with dementia is a common occurrence. Providing evidence-based pain management for people with dementia in residential aged care services is imperative to providing quality care. However, it remains unclear from current research how various aged care staff (Registered Nurses (RNs), Enrolled Nurses (ENs), Personal Care Assistants (PCAs)) engage at specific points of the pain management pathway. With structural changes to the residential aged care workforce over the past two decades, understanding the relative contributions of these aged care staff to pain management practices is crucial for future practice development.AimTo investigate the quality and completeness of pain documentation for people living with dementia, and assess the extent to aged care staff are engaged in documentation processes.DesignA three-month retrospective documentation audit.Setting and ParticipantsThe audit was conducted on the files of 114 residents with moderate to very severe dementia, across four Australian residential aged care facilities.MethodsData was collected on each resident’s pain profile (n=114). One hundred and sixty-nine (169) pain episodes were audited for quality and completeness of pain documentation and the extent to which aged care staff (RNs/ENs and PCAs) were engaged in the documentation of pain management.ResultsTwenty-nine percent of pain episodes had no documentation about how resident pain was identified and only 22% of the episodes contained an evidence-based (E-B) assessment. At least one intervention was documented for 89% of the pain episodes, the majority (68%) being non-pharmacological. Only 8% of pain episodes had an E-B evaluation reported. Thirteen percent (13%) of episodes contained information across all four pain management domains (Identification/ problems, assessment, intervention and evaluation). Documentation by PCAs was evident at all points in the pain management pathway. PCAs were responsible for considerately more episodes of assessment (50% vs 18%) compared to nursing staff.Conclusion and Clinical ImplicationsDespite the high prevalence of pain in people with dementia in aged care settings, current pain management documentation does not reflect best practice standards. Future capacity building initiatives must engage PCAs, as key stakeholders in pain management, with support and clinical leadership of nursing staff.     

A comparative study of nurses' and elderly patients' ratings of pain and pain tolerance

The purpose of this study was to compare elderly patients' and nurses' ratings of pain and pain tolerance. Data were collected through structured interviews with the patients. The attending nurses completed a questionnaire after conducting a pain assessment. Independent of each other, patients and nurses were asked to rate on a VAS when pain should be treated (pain tolerance) and pain intensity. The VAS has been used both by patients and nurses. The initial selection consisted of 43 patients; however, 9% (n = 4) were unable to complete the VAS. These patients were not significantly older than those who completed the study (n = 39). The results shows that nurses tend to overestimate mild pain and underestimate severe pain. Nurses rated pain tolerance significantly lower than patients. The results also suggest that nurses with training beyond basic nursing education tend to assess patients' pain more accurately than those without additional training. For patients who reported that they had pain prior to hospitalization, the nurses' pain ratings showed a higher agreement than for those who reported that they did not have pain before being hospitalized. At the time of the interviews, 21% (n = 8) of patients felt that their pain was so great they needed treatment. Those patients also were recognized by the attending nurses as being in pain. To improve elderly patients' pain management, practicing nurses must collaborate with researchers to develop specific empirical research nursing knowledge within geriatric pain management. This research-based knowledge should be incorporated into nurses' clinical practice regarding pain management. Specific guidelines must be developed for the assessment, treatment, and documentation of elderly patients' pain.     

Stakeholder opinions on a transformational model of pain management in long-term care

Pain in older adults with dementia who reside in long-term care (LTC) facilities tends to be undertreated, despite important guidelines designed to ameliorate this problem. A group of public policy and geriatric pain experts recently concluded that existing guidelines are not being implemented because they fail to take into account policy and resource realities. The group published a set of more feasible guidelines that confront these realities (e.g., a recommendation for very brief pain assessments that can be conducted by nursing staff at least weekly). We asked stakeholders to provide opinions on the possibility of implementation of these guidelines within their LTC facilities. Our results support the feasibility of, interest in, and desirability of implementation. They also support an increased role for nurse leadership in LTC pain management. These results could be used to strengthen advocacy efforts for improvement in pain management.     

Influences of patient behavior on clinical nurses' pain assessment: implications for continuing education

Pain management is an important consideration in the promotion of patients' comfort. However, research continues to indicate patients' pain management is poor. The nursing literature cites nurses' lack of knowledge as a significant determinant of poor pain management practices. The impetus for this study arose from poor attendance by nurses at inservice sessions discussing pain assessment and management. Knowledge of existing nursing practice and accompanying beliefs and attitudes in relation to pain management is paramount in the development of relevant continuing education for registered nurses. The aim of this investigation was to study nurses' intention to treat pain in different patients. A 10-page questionnaire with eight different patient scenarios was distributed to 886 nurses across all clinical divisions of an acute tertiary facility. Results indicate knowledge deficits regarding optimum pain relief for patients. This article highlights the need for innovative teaching strategies and approaches in the clinical context to heighten nurses' awareness of their lack of knowledge of pain assessment and management.     

Portuguese nurses' knowledge of and attitudes toward hospitalized older adults

Portugal is impacted by the rapid growth of the aging population, which has significant implications for its health care system. However, nurses have received little education focusing on the unique and complex care needs of older adults. This gap in the nurses′ education has an enormous impact in their knowledge and attitudes and affects the quality of nursing care provided to older adults. A cross‐sectional study was conducted among 1068 Portuguese nurses in five hospitals (northern and central region) with the following purposes: (i) explore the knowledge and attitudes of nurses about four common geriatric syndromes (pressure ulcer, incontinence, restraint use and sleep disturbance) in Portuguese hospitals; and (ii) evaluate the influence of demographic, professional and nurses' perception about hospital educational support, geriatric knowledge, and burden of caring for older adults upon geriatric nursing knowledge and attitudes. The mean knowledge and attitudes scores were 0.41 ± 0.15 and 0.40 ± 0.21, respectively (the maximum score was 1). Knowledge of nurses in Portuguese hospitals about the four geriatric syndromes (pressure ulcers, sleep disturbance, urinary incontinence and restraint use) was found inadequate. The nurses' attitudes towards caring for hospitalized older adults were generally negative. Nurses who work in academic hospitals demonstrated significantly more knowledge than nurses in hospital centers. The attitudes of nurses were significantly associated with the hospital and unit type, region, hospital educational support, staff knowledge, and perceived burden of caring for older adults. The study findings support the need for improving nurses' knowledge and attitudes towards hospitalized older adults and implementing evidence‐based guidelines in their practice.     

Evidence‐based practice for pain management for cancer patients in an acute care setting

The purpose of this study is to implement an evidence utilization project using an audit and feedback approach to improve cancer pain management. A three‐phased audit and feedback approach was used. A 46‐bed oncology nursing unit in the university's cancer centre was selected as a research site. Nursing records extracted from 137 patients (65 for the baseline assessment and 72 for the follow‐up audit) were used to examine nurse compliance with four audit criteria derived from best practice guidelines related to the assessment and management of pain. We observed a significant improvement in compliance from baseline to follow‐up for the following criteria: documenting the side effects of opioids (2–83%), use of a formalized pain assessment tool (22–75%), and providing education for pain assessment and management to patients and caregivers (0–47%). The audit and feedback method was applicable to the implementation of clinical practice guidelines for cancer pain management. Leadership from both administrative personnel and staff nurses working together contributes to the spread of an evidence‐based practice culture in clinical settings. As it was conducted in a single oncology nursing unit and was implemented over a short period of time, the results should be carefully interpreted.     

Effect of a QI Intervention on Nursing Assistants’ Pain Knowledge and Reporting Behavior

BackgroundPain among long-term care residents is often underdiagnosed and inadequately treated. We examined the effect of a multimodal intervention on certified nursing assistants’ pain recognition knowledge and verbal reporting behavior. Secondarily, we examined pain documentation in a newly established pain log compared with pain verbally reported to nurses and documented in the electronic health record (EHR).DesignQuality improvement project using a pretest–posttest design.SettingA skilled nursing and rehabilitation facility in Southwestern Pennsylvania including two long-term care units and one transitional rehabilitation unit.Participants/SubjectsFifty-six nursing assistants.MethodsThe intervention was a face-to-face educational session with a training video and introduction of a new pain log used to document residents' pain. Pain knowledge was measured before and after the educational intervention. Multiple measures were used to examine nursing assistants’ pain reporting.ResultsNursing assistants’ pain knowledge improved (p < .001). There was no change in verbal pain reporting behaviors. The percent of pain episodes documented in the electronic health record that were reported to nurses varied by unit type (45% on the long-term care units vs. 100% on the rehabilitation unit) but remained unchanged postintervention. Pain logs were used more often on the rehabilitation than the long-term care units; use was low overall. Nursing assistant reports that nurses provided feedback on their reports of resident pain increased from 45% in week 1 to 75% in week 4.ConclusionsAlthough the multimodal intervention improved nursing assistants’ pain knowledge and their perceptions of the feedback they received from nurses when they reported pain, it had no effect on certified nursing assistants reporting of pain to nurses (per nurse report).     

Pain management practices with older adults on acute medical units

Persistent pain is a significant problem for older hospitalized adults and their health care team. A better understanding of the approach to pain management in the clinical setting will provide guidance for the development of improvements in clinical management. The purpose of this study was to determine the prevalence of pain and to examine the current state of pain assessment and management in older adults on the six acute medical units of an academic health sciences centre. Findings revealed that 70% of older patients were in pain, nurses had limited awareness of their patients' pain, documentation of pain assessment and management was lacking, and pain was under-treated. Utilization of practice guidelines related to management of persistent pain in older adults in acute care settings is recommended, and an approach to their implementation, including identifying and overcoming the barriers to such best practices, is warranted.     

Implementation of Sustainable Evidence-Based Practice for the Assessment and Management of Pain in Residential Aged Care Facilities

Pain is common in residential aged care facilities (RACFs). In 2005, the Australian Pain Society developed 27 recommendations for good practice in the identification, assessment, and management of pain in these settings. This study aimed to address implementation of the standards and evaluate outcomes. Five facilities in Australia participated in a comprehensive evaluation of RACF pain practice and outcomes. Pre-existing pain management practices were compared with the 27 recommendations, before an evidence-based pain management program was introduced that included training and education for staff and revised in-house pain-management procedures. Post-implementation audits evaluated the program's success. Aged care staff teams also were assessed on their reports of self-efficacy in pain management. The results show that before the implementation program, the RACFs demonstrated full compliance on 6 to 12 standards. By the project's completion, RACFs demonstrated full compliance with 10 to 23 standards and major improvements toward compliance in the remaining standards. After implementation, the staff also reported better understanding of the standards (p < .001) or of facility pain management guidelines (p < .001), increased confidence in therapies for pain management (p < .001), and increased confidence in their training to assess pain (p < .001) and recognize pain in residents with dementia who are nonverbal (p = .003). The results show that improved evidence-based practice in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce via this implementation program has shown improvements in staff self-efficacy and practice.     

Pediatric pain, tools and assessment

Inadequate pain assessment in children may lead to an underestimation of pain, and consequently, undertreatment in this population. This article provides an overview of pain assessment and describes specific measurement tools that can be used with infants, children, and adolescents. Nationally published practice guidelines and standards recommend pain assessment at regular intervals with age-appropriate tools. Pain assessment must be integrated into perianesthesia nursing practice, and nurses must develop competency in the assessment and treatment of pain in children.     

Lack of opioid administration in older hip fracture patients (CE)

As part of a multisite study funded by the Agency for Healthcare Research and Quality, the medical records of older adults with a hip fracture were abstracted for acute pain assessment and treatment practices. Of the 709 records reviewed, 8 patients did not have an opioid administered during the first 72 hours after admission to a non-intensive patient care unit. Using a case study approach, this article examines demographic characteristics, pain assessment, and analgesic administration for these 8 patients to illustrate specific practice problems that occur in managing acute pain in older adults. Pain intensity was documented infrequently. All 8 patients had a physician order for some type of analgesic, and 7 of the 8 had an order for an opioid analgesic. Yet none received an opioid during the first 72 hours of care on a general medical-surgical unit, and one patient received no analgesia of any kind. The medical records of these hip fracture patients indicate that acute pain was underassessed and undertreated. Provision of quality pain management will require that nurses address the specific practice behaviors identified in the article and correct problems where they exist. Key strategies that can be used to improve pain management practices include implementation of standardized assessment tools and pain flow-sheets, audit and feedback of pain management data with staff, use of pain management opinion leaders and change champions, and incorporation of research-based pain management practices into performance-evaluation criteria.     

广东省护士老年疼痛知识现状调查

目的：了解护士对老年疼痛知识的掌握现状及影响因素,为采取有效措施提高护士老年疼痛护理能力提供依据。方法：采用McCaffery设计的护士疼痛知识与态度调查表及Sloman等设计的护士老年疼痛知识问卷对广东省35家医院的护士进行调查。结果：1502名护士完成了问卷。护士基础疼痛知识及老年疼痛知识均缺乏,平均答对率分别为45.2%、52.9%。不同年龄、学历、职称、工作年限及护理不同比例老年患者的护士的基础疼痛知识、老年疼痛知识得分差异均无统计学意义,但肿瘤科护士及参加疼痛学习班者得分较高。结论：护士疼痛知识不能满足老年疼痛患者的需求,应强化对护士进行老年疼痛专题教育,提高老年疼痛循证护理实践能力,持续改进老年疼痛护理质量。