Evidence Based Practice for Pain Assessment

Yolla Abi Khattar Melissa Makhoul
Tsoler Pashayan
Vera Tavoukjian
Wael Riman

Introduction:

Pain is a sensation of discomfort that is subjective to each individual, and it is characterized by an unpleasant feeling that can be either physiological or psychological. Acute pain is a sudden feeling of pain, occurring for a short duration lasting less than 3 months and disappearing once the injury has healed. Nurses are the most health care providers present on the unit with patients; therefore, they are the main providers responsible to carry out pain assessment appropriately. Nurses are expected to intervene accordingly to a person’s self-reported pain, and work with the person to manage the pain appropriately. Hence, nurses are required to possess the competencies to assess and manage pain, including knowledge and skills in interviewing techniques, and the ability to do physical assessment and manage pain of individuals who don’t have the ability to self –report (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011, as cited in RNAO, 2013). It is evident that unrelieved or poorly managed pain is a burden on the person, the health care system and society (Lynch, 2011, as cited in RNAO, 2013). In fact, 50 to 75 % of postoperative patients do not attain sufficient pain relief (Huang et al., 2001; Chung & Lui, 2003, as cited in Bell & Duffy, 2009) and some providers underestimate the intensity of the pain for 50% of the cases (Helfand & Freeman, 2009). Therefore, this observed nursing practice gives rise to a PICO clinical question. In adult patients with acute pain, does utilizing a standard pain assessment protocol, in comparison to the current practice, affect the pain relief process?

Literature review:

Effective pain management is a person’s right. Hence, assessing pain, implementing interventions to alleviate it, and prevent it are priorities while caring for a person (Jarzyna et al., 2011, as cited in RNAO, 2013). The article written by Bell and Duffy (2009) inspects two important barriers that serve as obstacles for appropriate pain assessment, which are the beliefs and attitudes of patients and nurses, and time management. Research done by Sloman et al. reinforced that pain can be perceived differently in various cultures (as cited in Bell & Duffy, 2009). Regarding the nurses’ attitudes, a triangulated study performed by Schafheutle et al. found that 39.3 % of respondents stated that not having enough of time, enough staff on the units and being overwhelmed with work were major features contributing to unproductive pain assessment (as cited in Bell & Duffy, 2009). Regarding time management, an observational study was performed for random nurses that showed that interruptions, such as answering the telephones, participating in the multidisciplinary rounds, assisting other nurses and looking for things contributed in poor pain assessment practice. In addition, it was noted that nurses’ priorities were to get all tasks and activities done before the end of their shift rather than allowing time to interact directly with patients to assess their comfort and pain level (Manias et al., 2002, 2005, as cited in Bell & Duffy, 2009).

While assessing acute pain in adults patients, nurses have to be aware of the routine pain assessment, the choice of measure and the protocols. According to Helfand and Freeman (2009) study, there has been an agreement among most of the institutions that routine assessment of self-reported pain is the best measurement for pain assessment, since some providers underestimate the intensity of the pain for 50% of the cases. According to Helfand and Freeman (2009) study, no evidence was found that directly linked the timing, frequency, or method of pain assessment with outcomes or safety in medical inpatients. It was also noted that instituting routine pain assessment along with an educational component improved rates of assessment and treatment. The protocols in the institutions tend to guide the assessment and the management of pain; hence the assessment should be unified and accurate in order to intervene accordingly.

Pain is universal but it is a subjective experience. Hence, it is challenging to obtain adequate objective information about it. Many assessment tools are used to rate and assess pain, such as the Visual Analogue Scale, the Verbal Numeric Rating Scale, Verbal Description Scales, Facial Pain Scales, Brief Pain Inventory and McGill Pain Questionnaire (Helfand & Freeman, 2009). For the choice of measure, it must be simple to use by the health care providers, and easy for the patients to understand and able to respond to it (Helfand & Freeman, 2009). The Visual Analogue Scale for pain assessment is used universally, however its efficacy and reliability is put to question since it may bias the results. A randomized control trial was tested over forty healthy volunteers where they were induced by thermal laser stimulations. Pain was tested during different sessions using two different visual scales; the classical pain visual analog scale (unbearable pain/ no pain), and the pleasantness visual analog scale (very pleasant/ very unpleasant). And at same time, somatosensory evoked potentials were measured. Results showed that the thermal laser stimulations that were of low intensity were reported as painful on the visual analog scale of pain, whereas they were rated as pleasant on the visual analog scale of pleasantness. Meanwhile, following the low intensity thermal stimulation, the cerebral responses indicated the activation of only C-fibers which indicate the warm sensations that are not painful. Therefore the somatosensory evoked potential results matched with the pleasantness visual analog scale and not with the classical pain visual analog scale. This signifies that when healthy individuals rate the “no pain” using the classical visual analog scale of pain, they are more likely to rate the intensity of the stimulation and not their pain perception (Kemp, Despres, & Dufour, 2012)

EBP Process:

Observations

In hospital X, Y, Z pain assessment was observed being performed by RNs. However, in hospital X, RNs were not using a pain assessment tool to assess the pain, some were just asking if the patient was in pain or not, even though the Visual Analogue Scale was available on the floor, others for sedated patients, were squeezing the patient’s skin to check response to pain, in addition to assessment of facial expressions and vital signs (heart rate), meanwhile in hospitals Y and Z, RNs were mostly using the Numeric Rating Scale to assess for pain by asking the patient to rate the pain between 0-10, where 0 was explained to be the absence of pain and 10 to be the worst pain. In hospital X, some RNs were observed documenting the pain assessment by filling a pain flow sheet, while others were only seen to document pain assessment on the pain flow sheet if the patient was on Patient-Controlled Analgesia, meanwhile in hospital Y, RNs were observed to document pain assessment per shift basis, whereas in hospital Z, RNs documented pain assessment only after a pharmacological intervention. In hospitals X and Y, RNs were not reassessing pain after pharmacological interventions, while in hospital Z, RNs were observed to do so. In the three hospitals, RNs were observed to inform the physician if the patient was assessed to have pain.

Hospital Protocols:

Pain assessment protocols were taken from 3 hospitals: X, Y & Z. It is important to note that the 3 hospitals were similar in the method/system that they adopted: The American system. That is, one of the references from which the pain assessment protocol of hospital X was taken, was JCR, J.Caho, Joint Commission Resources (USA), 2003. The protocol was issued on 15/01/2011 and updated on 15/01/2013. On the other hand, hospital Y has the followings as main references: Joint Commission International standards, Hospital standards, 4th edition, January 2011, Care of patient, and 2006 Lippincott Williams & Wilkins, Inc., Volume 1 (4), August 2006, p. 20-28. The pain assessment protocol is issued on January 2011 and revised on March 2012. While the pain assessment protocol of hospital Z is based on the Joint Commission International Accreditation Standards for Hospitals-5th edition, JCAHO Pain Management Standards (CAMH 2002) and The Ministry of Public Health (MOH), (2003). The protocol was issued on December 2006 and revised on June 2014. We can note that some references are outdated thus the protocols should be often revised to keep them equivalent with the latest evidence based practice.

3 of the pain assessment protocols stress on that pain assessment should be individualized according to the patient’s age and beliefs, values and cultural considerations. Hospital Z adds that pain assessment should be part of patient handover report. Three of the protocols state that assessment of pain should be done: Post-procedure (or within 1 hour of admission), post pharmacological and non-pharmacological interventions, with routine vital signs assessment, at time of discharge, before any planned activities (physiotherapy, stress test, post-operative ambulation). Apart from the assessment of pain, reassessment is considered as a crucial aspect, to monitor the pain level, in the 3 hospital protocols. Hospital Y mentions that prior to reassessment nurses should always refer to the literature of the analgesic agent for its peak action period. In hospital Z when pain is identified (score 2 and above), DMS-MRM-Nursing Sheets-Scale is activated while in hospital Y when pain is identified (score three and above), pain assessment and interventions flow sheet is activated.

The scales used to assess the pain of adult patients with acute pain common in 3 hospitals is the numeric scale, where the patient is instructed to choose a number from 1 to 10 that best describes his current pain, where 0 refers to no pain while 10 refers to the worst possible pain. Another common pain assessment scale among the three hospitals is the Visual Analogue Scale, where the patient points out his/her pain level across a continuum with the extremities of no pain and worst pain. The FLACC (Face, Legs, Activity, Cry, Consolability) scale is used for critically ill, sedated and paralyzed, intubated and ventilated patients in ICU in hospital Y while it is used for children up to 3 years old in hospitals X and Z. In addition, Adult Nonverbal Scale is used for patients unable to report pain in hospital Z. Similar to the FLACC and Adult Nonverbal scales used in the 2 hospitals, hospital X uses the Behavioral rating scale (components: Face, Restlessness, Muscle tone, Vocalization, Consolability) for patients unable to self-report pain. Wong Baker Facial Grimace is a common scale in the 3 hospitals for patients who cannot communicate their pain, recommended for patients of 3 years of age and older in hospital X, while up to 7 years of age in hospital Y.

Guidelines:

According to the guidelines mentioned in Assessment and Management of Pain Clinical Practice Guidelines (Registered Nurses’ Association of Ontario, 2013), nurses should screen for the presence, or risk of, any type of pain upon admission, after a change in medical status and prior to, during and after a procedure. Nurses should also perform a comprehensive pain assessment using a systematic approach and appropriate, validated tools and using appropriate tools for persons unable to self-report. The nurses should take into consideration the person’s beliefs, knowledge and level of understanding about pain and pain management. Then, document the person’s pain characteristics. After implementing pain relieving measures, the guidelines state that re-evaluation is important and should be done by reassessment of the pain characteristics, and accordingly documenting the outcomes. There are some validated assessment tools, recommended to be used by the guidelines, and are the following: Faces Pain Scale Revised, Numeric Rating Score, Verbal Rating Score, Brief Inventory Short Form, and Behavioral Pain Scale (See Appendices).

Proposed Change/Recommendations:

Most of the nurses in the three hospitals were observed to be unfamiliar with the pain assessment protocol. Hence, it is recommended to implement frequent sessions for all nurses to inform them about the criteria of the protocol, identify any gaps, and train them accordingly. Additionally, supervision is essential on each floor to evaluate the effectiveness of these sessions. It is recommended by the guidelines that health-care professionals should participate in ongoing education opportunities to improve their knowledge and skills to be able to knowledgeably assess and manage pain (RNAO, 2013). Apart from hospital setting, the guidelines recommend that educational institutions include guidelines, assessment and management of pain into their curricula for registered nurses, and all health care providers programs to indorse evidence-based practice (RNAO, 2013).

It was noted that some of the hospitals’ pain assessment policies were established on outdated references. It is hence recommended that hospitals always update their policies and base them on up-to-date EBP guidelines. In addition, it is also recommended for hospitals to establish a model of care to support inter-professional collaboration for the active assessment of pain and declare pain assessment as a strategic clinical priority (RNAO, 2013). Another common observation was that the three hospitals still used the Visual Analogue Scale, which is not among the list of recommended validated pain assessment tools mentioned in the guidelines (RNAO, 2013) and research found it to be unreliable, since patients are more likely to rate the intensity of the stimulation and not their pain perception (Kemp, Despres, & Dufour, 2012).

The University of Zurich and ETH Zurich in Switzerland, invented a new method for accurate pain assessment: The Pain Mouse. It is an electronic pain assessment tool that offers credible evaluation, lessening missing data and unclear markings concerning pain. The device captures the clenching reaction to pain through a pressure sensor that is connected to a portable computer (Schaffner et al., 2012). PM is recommended to be used in the near future considering that it distinguishes different levels of pain, is less time consuming, more accurate and can be used for patients with limited physical activity and vision impairment compared to the Visual Analogue Scale (VAS) (Schaffner et al., 2012).

References:

Bell, L., & Duffy, A. (2009). Pain assessment and management in surgical nursing: a literature review. British Journal of Nursing, 18(3), 153-156. Retrieved April 4, 2015, from http://web.a.ebscohost.com.ezproxy.lau.edu.lb:2048/ehost/pdfviewer/pdfviewer?vid=6&sid=ff36c8fd-ed44-444c-8182-9487d39e913b%40sessionmgr4005&hid=4104

Helfand, M., & Freeman, M. (2009). Assessment and management of acute pain in adult medical ?inpatients: a systematic review. Pain Medicine, 10(7), 1183-1199. Retrieved April 10, 2015, http://web.ebscohost.com/ehost/detail/detail?vid=3&sid=7b1adb63-ced7-4486-94ef-4ecc54ddc64b%40sessionmgr111&hid=123&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=rzh&AN=2010437732

Kemp, J., Despres, O., & Dufour, A. (2012). Unreliability of the Visual Analog Scale in experimental pain assessment: a sensitivity and evoked potentials study. Pain Physician, 15(5), 693-699. Retrieved on April 10, 2015 from http://www.painphysicianjournal.com/2012/september/2012;15;E693-E699.pdf

Registered Nurses’ Association of Ontario (RNAO). (2013). Assessment and management of pain (3rd Edition). Toronto, ON: Registered Nurses’ Association of Ontario (RNAO). Retrieved April 4, 2015, from http://rnao.ca/sites/rnao-ca/files/AssessAndManagementOfPain_15_WEB-_FINAL_DEC_2.pdf

Schaffner, N., Folkers, G., Kappeli, S., Musholt, M., Hofbauer, G.F.L., & Candia, V. (2012). A new tool for real-time pain assessment in experimental and clinical environments. PLoS ONE, 7(11), art. no. e51014. Retrieved on April 10, 2015 from http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0051014