Educational Intervention to Strengthen Pediatric Postoperative Pain Management: A Cluster Randomized Trial

BackgroundPediatric postoperative pain is still undertreated.AimsTo assess whether educational intervention increases nurses’ knowledge and improves pediatric postoperative pain management.DesignCluster randomized controlled trial with three measurement points (baseline T1, 1 month after intervention T2, and 6 months after intervention T3).Participants/SubjectsThe study was conducted in postanesthesia care units at six hospitals in Norway. Nurses working with children in the included units and children who were undergoing surgery were invited to participate in this study.MethodsNurses were cluster randomized by units to an intervention (n = 129) or a control group (n = 129). This allocation was blinded for participants at baseline. Data were collected using “The Pediatric Nurses’ Knowledge and Attitudes Survey Regarding Pain: Norwegian Version” (primary outcome), observations of nurses’ clinical practice, and interviews with children. The intervention included an educational day, clinical supervision, and reminders.ResultsAt baseline 193 nurses completed the survey (75% response rate), 143 responded at T2, and 107 at T3. Observations of nurses’ (n = 138) clinical practice included 588 children, and 38 children were interviewed. The knowledge level increased from T1 to T3 in both groups, but there was no statistically significant difference between the groups. In the intervention group, there was an improvement between T1 and T2 in the total PNKAS-N score (70% vs. 83%), observed increase use of pain assessment tools (17% vs. 39%), and children experienced less moderate-to-severe pain.ConclusionsNo significant difference was observed between the groups after intervention, but a positive change in knowledge and practice was revealed in both groups. Additional studies are needed to explore the most potent variables to strengthen pediatric postoperative pain management.     

Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception

BackgroundOver 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses’ perception.AimsTo investigate nurses’ perception of pain management in HF patients.MethodsMembers of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.ResultsA total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.ConclusionsThe impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.     

Quality Improvement Initiative to Improve Postoperative Pain with a Clinical Pathway and Nursing Education Program

Background and AimsWe created a multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.DesignA multicomponent intervention to improve pain management in the immediate postoperative period with the goal of improving the quality of patient recovery.SettingsPain management education of postanesthesia recovery room nurses through a practical intervention has the potential to improve patient pain experience, especially in those with a history of opioid tolerance.Participants/SubjectsPostanesthesia recovery nurses/postanesthesia patients.MethodsThe intervention included two components: a clinical pain pathway on multimodal analgesia for both opioid-naïve and opioid-tolerant patients undergoing surgery and an educational program on pain management for frontline clinical nurses in the postanesthesia care unit (PACU). We measured the intervention's impact on time to pain relief, PACU length of stay, and patient satisfaction with pain management, as measured by self-report.ResultsPatient PACU surveys indicated a decrease in the percent of patients with opioid tolerance who required more than 60 minutes to achieve adequate pain relief (from 32.7% preintervention to 21.3% postintervention). Additionally, after the intervention, the average time from a patient's PACU arrival to his or her discharge criteria being met decreased by 53 minutes and PACU stay prolongation as a result of uncontrolled pain for opioid-tolerant patients decreased from 45.2% to 25.7%. The sample size was underpowered to perform statistical analysis of this improvement.ConclusionsAfter the combined intervention of a clinical pain pathway and interactive teaching workshop, we noted shortened PACU length of stay, reduced time to reach pain control, and improved overall patient satisfaction. Although we could not determine statistical significance, our findings suggest improved management of acute postoperative pain, especially for patients who are opioid tolerant. Because of the paucity of data, we were not able to conduct the analysis needed to evaluate quality improvement projects, as per SQUIRE 2.0. could be adopted by any institution.     

Ways of Reasoning Used by Nurses in Postoperative Pain Assessment

BackgroundPostoperative pain is a major concern of patients undergoing surgery. Pain assessment for patients undergoing surgery is a common requirement for surgical nurses and is the most important nursing approach to ensuring patient comfort.AimsThe purpose of this study was to identify the reasoning used by nurses when assessing postoperative pain in patients.MethodsPhenomenography was the research approach chosen to analyze the nurses’ experiences. This approach is used to acquire qualitative knowledge about the ways individuals experience the world.ResultsThe reasoning used by nurses in postoperative pain assessment was identified from two perspectives: the frames of reference used to interpret a patient's perception of pain and the strategic efforts used to assess the pain. An outcome space for the various categories of reasoning employed by the nurses with regard to postoperative pain assessment was constructed to determine how these categories were logically related.ConclusionsThese findings have the potential to lead to a diverse range of nursing education modalities related to the adoption of different focuses and actions in postoperative pain assessment.     

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm

BackgroundConducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions.PurposeThe aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm.Design & MethodsThe Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice.ResultsThe majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments.ConclusionsThe use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms “assume pain present” and “assume pain managed,” and to also improve the overall feasibility and effectiveness of the algorithm.     

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

BackgroundLimited research is available on tools for assessing pain and its effect on function in the acute care setting.AimThis 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.DesignA cross-sectional self-report survey.MethodsNurses (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.ResultsMost 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.ConclusionsAlthough 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.     

Improving Pain Reassessment and Documentation Rates: A Quality Improvement Project in a Teaching Hospital’s Emergency Department

IntroductionED pain score reassessment and documentation rates were drastically low according to sampled data from the St. Margaret Hospital Emergency Department, leading to difficult pain management encounters for clinicians. The purpose of this project was to improve pain score reassessment rates in ED patients who were discharged with extremity pain.MethodsThis project was an 8-month, pre-postinterventional (preintervention: September-November 2018, intervention: December 2018-January 2019, and postintervention: February-April 2019) quality improvement project that took place in a community hospital emergency department. Emergency nurses participated in 6 focus groups, allowing for the creation of focus group-themed interventions at the request of the nursing staff. Daily audits of pain reassessment and documentation rates for individual nurses took place during the month of January 2019. In addition, a weekly newsletter was created and reported the ED pain reassessment and documentation rates.ResultsAll patient encounters (581) were reviewed over the 8-month period. Baseline pain score reassessment and documentation rates were 36.2% (confidence interval, 30.3%-42.3%) in the emergency department. Pain reassessment and documentation rates increased to 62.3% (confidence interval, 56.8%-67.6%) during the 3-month postintervention period.DiscussionImplementing daily audits and weekly newsletters that created transparency of individual and group performances increased pain score reassessment and documentation rates.     

The effectiveness of the Pain Resource Nurse Program to improve pain management in the hospital setting: A cluster randomized controlled trial

BackgroundThe Pain Resource Nurse program is a widely disseminated, evidence-based, nursing staff development program, designed to improve pain management in hospitals. The program has shown promising results, but has never been tested with a rigorous research design.ObjectivesOur objective was to test the effectiveness of the Pain Resource Nurse program. Hypothesized outcomes included improvements in nurses’ knowledge, attitudes, and assessment practices, and in patients’ participation in decision-making, adequacy of pain management, pain severity, time spent in severe pain, pain interference, and satisfaction.DesignCluster randomized controlled trial.SettingA 650-bed university hospital in IcelandParticipants: The sample consisted of a) patients ≥18 years of age, native speaking, hospitalized for at least 24 h, alert and able to participate; and b) registered nurses who worked on the participating units.MethodsTwenty three surgical and medical inpatient units were randomly assigned to the Pain Resource Nurse program (n = 12) or to wait list control (n = 11). The American Pain Society Outcome Questionnaire and the Knowledge and Attitudes Survey were used to collect data from patients and nurses respectively. Baseline data (T1) for patients were collected simultaneously on all units, followed by data collection from nurses. Then randomization took place, and the Pain Resource Nurse program was instituted. Ten months later, follow up (T2) data were collected, after which the nurses on the control group units received the Pain Resource Nurse program.ResultsAt baseline, data were collected from 305 of the 396 eligible patients and at follow up from 326 of the 392 eligible patients, a 77% and 83% response rate respectively. At baseline, 232 of 479 eligible nurses responded and at follow-up 176 of the eligible 451 nurses responded, a 49% and 39% response rate, respectively. A nested mixed model analysis of covariance revealed that the intervention was successful in changing pain assessment practices, with pain assessment using standardized measures increasing from 13% to 25% in the intervention group while decreasing from 21% to 16% in the control group. None of the other hypothesized improvements were found.ConclusionsThe Pain Resource Nurse program was successful in improving nurses’ use of standardized measures for pain assessment. No effects were found on patient outcomes; pain was both prevalent and severe at both time points. Only minimal improvements were noted in response to this evidence-based staff development program. Changes in pain management practices remain a challenge in clinical settings.     

Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children

Background: The National Association of Emergency Medical Services Physicians’ (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed. Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations. Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record. Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02). Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.     

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.     

Impact of a Training Intervention on the Pain Assessment in Advanced Dementia (PAINAD) Scale in Noncommunicative Inpatients

BackgroundPublic hospitals in Catalonia (Spain) recommend using the Spanish version of the Pain Assessment in Advanced Dementia (PAINAD-Sp) scale for assessing pain in adult patients unable to self-report. However, since its inclusion in Catalonian nursing care plans in 2010, there have been no training programs for nurses, contributing to its current underuse.AimsThe aim of this study was to assess the impact of a nurse training intervention on the PAINAD-Sp scale in noncommunicative inpatients unable to self-report.DesignBefore-after study.SettingsTwo public hospitals in Catalonia (Spain).Participants/SubjectsFour hundred and one nurses participated in the training course and 219 patients received PAINAD-Sp assessments.MethodsWe used a before-after study design, evaluating the use of the PAINAD-Sp scale over two 6-month periods before and after an online training intervention for nurses in February 2017, in two public hospitals. Data were collected from patient records in each center. The primary outcome was the number of patients receiving PAINAD-Sp assessments during admission. Secondary outcomes were the number of assessments undertaken per patient during admission, the total (0-10) and item-specific (0-2) PAINAD-Sp score, and pharmacologic treatment administered.ResultsThere were 401 nurses who took part in the training program. Over the study period, 219 patients received PAINAD-Sp assessments: 29 in the preintervention period and 190 in the postintervention period (p < .001). Administration of analgesics and antipyretics decreased (p < .001) after the intervention, whereas use of hypnotic drugs and sedatives increased.ConclusionsTheoretical and practical training may be an effective way to improve nurses’ approach to identifying, assessing, and managing pain in patients unable to self-report.     

The Use of a Nurse-Initiated Pain Protocol in the Emergency Department for Patients with Musculoskeletal Injury: A Pre-Post Intervention Study

Background and Aim: As a common complaint of patients with traumatic injuries, pain remains undermanaged in emergency departments (EDs). Our aim was to evaluate the effects of a nurse-initiated pain management protocol in patients with musculoskeletal injuries in an ED in Iran.Material and MethodsThis pre-post intervention design study was conducted on 240 patients with orthopedic injuries selected through sequential sampling over two phases. The intervention consisted of case study sessions and the implementation of the nurse-initiated pain management protocol. The outcomes were assessed based on the Numeric Rating Scale (NRS) pain scores, the pain management satisfaction questionnaire, the nursing performance checklist and the waiting time evaluation form.ResultsThe mean pain intensity 30 and 60 min after triage and at discharge decreased significantly in the post-intervention group (p < .001). The patients' satisfaction with pain management (p < .01) and the nurses’ performance (p < .001) improved in the post-intervention group. Waiting time: there was a significant reduction in the post-intervention group from the end of triage by the nurse to the visit by the physician, and from patient’s arrival in ED to discharge or transferring, and also the time to initial analgesic.ConclusionsEducation based on case study and the implementation of the nurse-initiated pain management protocol resulted in a significant increase in multimodal analgesia administration and a reduction in pain intensity, an increase in patient satisfaction, an improvement in the triage nurses’ performance and the reduction of potential delays in pain management while maintaining the safety of patients with musculoskeletal trauma.     

A Multimodal Pain Management Strategy for Burn Patients

BackgroundAcute burn pain is difficult to manage, and poorly managed pain can lead to deleterious consequences such as post-traumatic stress disorder, prolonged recovery, chronic pain and long-term dependence on opioids. Understanding the role of nursing in promoting self-efficacy and minimizing opioid use is valuable. It is unknown whether strategic efforts aimed at enhancing patient self-efficacy will improve pain managment and lessen opioid requirements in the adult burn population.AimThe aim of this study was to examine the effect of a multi-modal, interdisciplinary pain management strategy on coping self-efficacy, pain scores, and opioid use in adult burn patients in the acute care setting.MethodA quasi-experimental pre-test/post-test design was employed in an American Burn Association (ABA) verified burn center in the Pacific Northwestern United States. Data were collected prospectively for a 6-month period on 44 burn patients. The comparison group received usual care (n = 28), and the intervention received a pain management protocol (n = 16). Coping self-efficacy was measured on admission and at discharge in both groups using the Coping Self-Efficacy Scale. Numeric pain scores and opioid use in morphine milligram equivalents were averaged for each participant. Burn nurse perceptions were gathered via an anonymous electronic survey post data collection in February 2021.ResultsThere were no significant differences in measured coping self-efficacy, pain scores, or opioid use between the intervention and comparison groups. A significant positive correlation was found between length of stay, size of burn, and coping self-efficacy and problem focused self-efficacy. Burn nurses reported increased use of nonpharmacologic adjuncts since protocol implementation.ConclusionNonpharmacologic adjuncts are more likely to be used consistently when protocolized. There is also evidence to support that certain aspects of self-efficacy may be enhanced during acute phase of burn care.