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Spring 5-17-2024

Pain Assessment and Reassessment Documentation

Improvements in Medical-Surgical Units
Alicia Espinoza
University of San Francisco, [email protected]

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Espinoza, Alicia, "Pain Assessment and Reassessment Documentation Improvements in Medical-Surgical
Units" (2024). Master's Projects and Capstones. 1673.
https://repository.usfca.edu/capstone/1673

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Pain Assessment and Reassessment Documentation Improvements in Medical-Surgical

Units

Alicia Espinoza, RN, CNL

School of Nursing and Health Professions, University of San Francisco

N670 ME-MSN Internship

Jennifer Zesati, MSN, RN

May 13, 2024

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Abstract

Problem Pain management is essential when providing quality care, and adequate documentation

of pain assessment and reassessment with administration of opioid pain medications by nurses is

necessary for patient safety and satisfaction. Context Nurses play a pivotal role in providing safe

and effective administration of opioid pain medication and documentation of pain assessments.

This quality improvement (QI) project aimed to increase opioid medication administration

assessment and documentation compliance rate for nurses to 90% or greater in two medical-

surgical units. Intervention A knowledge check survey was utilized to assess nurse understanding

of required data needed to document, and timing for documentation to meet compliance.

Interventions included visual reminders, informational posters, and instructions on how to access

individual compliance reports. Measures A post-intervention survey was used to collect nurse

feedback on effectiveness of interventions and to gather further suggestions. Quarterly compliance

rate data was obtained to identify if improvements in compliance rates were achieved. Results

Unit A scored 62% for pre-assessment compliance, and 90% for reassessment compliance. Unit B

scored 77% for pre-assessment compliance and 89% for reassessment compliance. Conclusions

Providing visual aids as reminders for completing pain assessment and reassessment

documentation and expanding nurse education on current self-compliance rates are useful for

increasing nurse documentation compliance rates in medical-surgical units. Further evaluation of

pain assessment and reassessment documentation compliance rates are required to identify

sustainability and opportunities for greater improvements.

Keywords: pain assessment, reassessment, documentation, quality improvement, medical-

surgical, compliance
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Pain Assessment and Reassessment Documentation Improvements in Medical-Surgical

Units

Pain, the fifth vital sign, is subjective and can be complex. In an inpatient setting, pain is

common and the need to address it should be a priority for healthcare providers. Pain can be

assessed in several ways, and effective pain management requires regular pain assessment often

using a self-reporting scale, when possible, to help identify the most appropriate intervention. In

fact, a structured pain assessment, often conducted by nursing staff, should be used to help

identify the type, and possible causes of a patient’s pain, and to help evaluate the effectiveness of

the intervention utilized (Cox, 2022). Additionally, for patient safety reasons, when using opioids

for treating pain, pain assessments are particularly important in preventing opioid-induced

ventilatory impairment, which is categorized by respiratory depression and a decreased level of

consciousness (Cox, 2022). Ultimately, pain assessments are important for identifying baseline

data to help evaluate interventions taken to treat pain, and adequate documentation helps aid in

the comprehensive treatment of a patient’s pain and creates better patient outcomes.

Problem Description

The quality improvement project focuses on two medical-surgical units at Hospital A in

the Bay Area. The patient population consisted of adults from diverse ethnic and racial

backgrounds and different socio-economic groups. It is important to acknowledge that patients

admitted to these medical-surgical floors were there for a wide array of medical issues that

ranged in level of acuity. The nurse-to-patient ratio on these floors is typically 1:4, but can

sometimes be 1:5 depending on patient acuity. Nurses are responsible for completing several

tasks in a fast-paced environment, while ensuring safe and efficient patient care. There are a total

of 100 nurses combined on both units. Pain assessments are conducted by nurses on the units
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every time before administration of pain medication. Specifically, for opioid pain medication

administration, according to hospital policy, required pain assessment documentation criteria

includes respiratory rate, oxygen saturation, pain score, and sedation scale. Additionally,

reassessments should take place within a required time frame after administration of medication

dependent on route administered. For intravenous (IV) medications reassessments are to be

conducted within 30 minutes, and for oral (PO) medications within 60 minutes.

Results from monthly data collected for pain assessment and reassessment documentation

compliance revealed unsatisfactory compliance rates in both medical-surgical units at Hospital

A. The baseline data indicated that compliance was consistently below the acceptable 90% rate,

with ratings at 69% on unit A and 70% on unit B for pain assessments at time of medication

administration, and 89% on unit A and 85% on unit B for reassessments. Based on the data, it

can be concluded that if pain assessments are not being documented, then they are not being

performed. This data poses a problem on the medical-surgical units at Hospital A regarding

adequate pain assessment and reassessment documentation that required further investigation to

identify the true root causes of the issue. It is imperative that adequate pain assessment

documentation be conducted for both patient safety, and satisfactory patient outcomes regarding

pain management.

Available Knowledge

PICOT Question

This quality improvement project aims to address the following problem/population,

intervention, comparison, and time (PICOT) question: “For nurses on a medical-surgical unit (P),

does education (I) about best practices for opioid medication administration assessment and

documentation, compared with no education (C), lead to increased pain assessment

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documentation compliance (O) over two months (T)?”. The PICOT question serves as a guide to

help find relevant literature that may be used and referenced to conduct the project. Additionally,

the PICOT question will aid in focusing the efforts of the intervention used to carry out the

improvement project.

Search Methodology

Led by the PICOT question, a literature review was conducted using the online search

method including CINAHL, Scopus, and PubMed databases. The most helpful keywords used to

find literature included pain, practices, nursing, education, pain assessment, and pain

documentation. Using the search criteria, over 200 articles resulted that related to the desired

topic of pain assessment documentation. Upon thorough analysis of the literature, a total of ten

articles were selected using the Johns Hopkins Evidence Appraisal Tool to categorize each by

level of quality (see Appendix A). The level of evidence of the ten articles chosen ranged to

include all levels and good quality (Dang & Dearholt, 2018). Out of the ten articles, two are

considered level I, two are level II, four are level III, one is a level IV, and one article is a level

V. Inclusion criterion consisted of publications within a range of the last ten years and a focus on

an adult population. Exclusion criteria included pediatric and neonatal populations. The focus of

the quality improvement project was to ensure adequate documentation of pain assessment using

the electronic medical record (EMR). The goal of the quality improvement project was to

improve nurse pain assessment documentation compliance rates.

Literature Review

Educational Interventions

To begin, a randomized controlled trial by Grommi et al. (2021), was conducted in

Finland where 50 Registered Nurses (RNs) were randomly assigned to an intervention and
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control group. The intervention group was exposed to a short 45 minute, 21 slide, educational

PowerPoint lecture related to pain nursing guidelines, and the control group was not. A pre- and

post-intervention knowledge check survey was administered to both intervention and control

groups. The result of the study showed no significant change in knowledge between intervention

and control group and, furthermore, indicated that the educational intervention proved ineffective

in improving documentation, as those in the intervention group had worse documentation skills

than those in the control group (Grommi et al., 2021). Although this study indicates that

providing education on pain assessment and management had no benefit on documentation, it is

important to consider that this study could prove beneficial when planning the type of education

to be provided to nurses, which may offer different results. Furthermore, a randomized controlled

trial performed by Gunnarsdottir et al. (2017), aimed to identify the effectiveness of the Pain

Resource Nurse program, an evidence-based educational course developed by experts on pain

management, on hypothesized improvements in nurse knowledge, attitudes and assessment

practices, adequacy of pain management and severity, and time spent in severe pain. The study

was conducted in a 650-bed hospital in Iceland where 23 inpatient medical and surgical units

formed the study sample. Twelve units were randomly assigned to receive the Pain Resource

Nurse program, and the remaining eleven units formed the control group. The study results

indicated that the only improvement after intervention of the Pain Resource Nurse program was

an increase in pain assessment documentation from 13% to 25% (Gunnarsdottir et al., 2017).

Ultimately, this study demonstrates that a well-developed educational program can be effective

in increasing pain assessment documentation rates.

Education in Conjunction with Dashboards and Audits

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Jungquist et al. (2020), discuss revisions to the American Society for Pain Management

Nursing (ASPMN) guidelines for opioid-induced advanced sedation and respiratory depression,

which states that patients receiving systemic opioids for pain management are at increased risk

for oversedation and respiratory depression. Therefore, it is recommended that hospital policies

and procedures reflect the need for all patients receiving opioids to be assessed before opioid

therapy and reassessed as needed (Jungquist et al., 2020). Similarly, Ho and Burger (2020),

performed a non-experimental study aimed at improving medication scanning and pain

reassessment rates in a 167-bed acute-care community hospital in Central California, which

highlights the importance of conducting assessments and reassessments prior to and post-pain

medication administration to help in identifying the appropriate therapy required for pain

management, and to reduce the risk of opioid-related respiratory depression and death. In the

study, a stakeholder meeting took place which provided feedback that guided three rapid Plan,

Do, Study, Act (PDSA) cycles that included interventions such as weekly dashboards for data

transparency, addressing documentation barriers, providing education, and developing non-

compliance user dashboards. The study determined that developing weekly audit dashboards

proved most effective in improving pain reassessment with a 29% improvement (Ho & Burger,

2020). These results reflect similar results from a quality improvement project performed by

Wissman et al. (2020), that took place in the emergency department of a 26-bed community

teaching hospital in Pittsburgh, Pennsylvania, where the goal was to improve pain reassessment

rates. The intervention included providing education on the importance of pain reassessment to

improve pain management, daily audits to provide constructive feedback, and weekly newsletters

that shared department-wide rates of pain reassessment. The results of this study showed a 26%
 8

increase in pain reassessment and documented rates from pre-intervention period to post-

intervention period (Wissman et al., 2020).

Comparably, Hogan et al. (2016), conducted a quasi-experimental study aimed at

assessing the effectiveness of education and a quality improvement (QI) program on pain

management in older adults in an urban academic emergency department that serves

approximately 60,000 adults annually. It was affirmed that incorporation of education, QI

techniques, and weekly reports detailing staff performance on timing of assessments and

reassessments helped improve average time to reassessment after analgesic from 86 to 65

minutes, and increased pain reassessment rates from 51.9% to 82.5% (Hogan et al., 2016).

Finally, Grommi et al. (2023), conducted a systematic review and meta-analysis of 23 articles

obtained from four data sources, and aimed to identify the effect of pain education interventions

on nurse’s pain management. The articles ranged in type of education intervention, intervention

duration, sample, and setting, with some articles lacking a control group. The result of the review

concluded that all educational interventions showed positive outcomes, with continuous auditing

and feedback for nurses resulting in the most effective change in pain management and

assessment practices (Grommi et al., 2023).Based on the results of these articles, they all suggest

that a combination of education on pain management and consistent feedback on pain

reassessment performance rates through dashboards or weekly compliance rate reports are

effective in improving pain reassessment and documentation rates.

Other Methods to Consider for Improving Pain Assessment Documentation

A cross-sectional study was conducted from 2006 to 2012 in an adult emergency

department at a public urban teaching hospital in Stockholm by Sturesson et al. (2016), with the

purpose of identifying the frequency of pain assessment documentation. The interventions

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throughout the study included education on pain assessment and documentation, standardizing

pain scale used, and creating visible reminders for pain assessments in the patient’s medical

records, none of which proved effective until pain assessment documentation became mandatory

and computerized in 2010, at which point pain assessment documentation improved (Sturesson

et al., 2016). It is, however, important to note that during the study there was no documentation

for reassessment of pain found.

A non-experimental observational study was conducted by Ross et al. (2017), to assess

pain reassessment workflow and recommend improvements in policies at a large military clinic.

The pain reassessment process was evaluated using the EMR to identify documentation

practices, and through observation of the clinic workflow. The results of the observations

revealed that out of 151 cases, the overall compliance of all requirements for pain reassessment

documentation was 28%. The project improvement team recommended that the pain

reassessment policy be reviewed and updated to better reflect the organizational goals and

objectives for pain management, as well as to provide a standardized template in the EMR for

better efficiency in pain reassessment documentation (Ross et al., 2017). The recommendations

serve as a guide for improvement in pain reassessment documentation that can be implemented

in other hospital settings that may result in successful increases in pain reassessment

documentation compliance.

Finally, a pilot study by Samuels and Eckardt (2014), gathered clinical documentation

from three community hospitals to examine the impact of pain assessment and reassessment

documentation on postoperative pain severity trajectories (PST). Based on the data collected, the

results of the study demonstrate that despite low adherence rate, reassessment within one-hour

after intervention resulted in more favorable PST (Samuels & Eckardt, 2014). The results of the
 10

study demonstrate that pain assessment and reassessment documentation are essential for

adequate pain management.

Summary of Literature

In summary, the literature states that pain assessments and reassessments are necessary

for patient safety as well as patient satisfaction regarding effective pain management.

Additionally, the literature suggests that education and methods to create accountability, such as

a visual dashboard or weekly notices of documentation compliance, can be effective in

improving pain assessment and reassessment rates. It is important to consider these points when

attempting to implement an improvement project regarding pain assessment documentation.

Rationale/Framework

Quality improvement in healthcare is essential to providing the best patient care, and

change theories serve as a framework to provide guidance on methods to implement

improvement changes effectively and efficiently. Roger’s five stage change theory includes:

knowledge of the change, persuasion towards the change, decision to adopt the change,

implementation of the change, and confirmation by continuing to use the change (McDonald et

al., 2004). Roger also acknowledges that change is more likely to occur when it aligns with the

current values and beliefs of the organization (McDonald et al., 2004). The medical field has

become a catalyst for change and welcomes it when proven to be effective and beneficial, a

concept that catapults Roger’s change model to success when utilizing it to promote change

among individuals in healthcare.

When introducing change to improve pain assessment and reassessment in a medical-

surgical unit, Roger’s five-step change method can be applied to help successfully implement the

desired change. After adequate analysis of the microsystem to understand the culture, values, and
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beliefs of the unit, a change recommendation will be identified by conducting extensive research

on best practices for reassessing pain. The knowledge about the desired change will then be

disseminated to all stakeholders in an effort to persuade the desired improvement

implementation. Once the change has received adequate support from stakeholders it will be

fully adopted and implemented into practice, at which point Plan Do Study Act (PDSA) cycles

will be utilized until the change proves effective to implement permanently. Finally, the change

will be confirmed by continuing to implement it, making it a part of the new workflow among

the microsystems. Ultimately, Roger’s change theory fits best to properly study and identify the

desired implementation that may work best for the medical-surgical microsystem by breaking

down the process of natural change step-by-step to ensure efficacy and improve documentation

of pain assessment and reassessment.

Ethical Considerations

This project meets the guidelines for an evidence-based quality improvement project. An

IRB review was not required. A statement of non-research determination (SONRD) form was

completed to validate this quality improvement initiative (see Appendix B) followed by a review

and approval by University of San Francisco School of Nursing and Health Professions clinical

faculty. The project described received no funding and the project group members declare no

conflict of interest for the project.

According to the American Nurses Association (ANA) Code of Ethics (2015), provision

2.1: Primacy to the patient’s interests, this provision emphasizes that each plan of care must

reflect the fundamental commitment of nursing to the uniqueness, worth and dignity of the

patient, and that nurses provide patients with the opportunity to participate in planning and

implementing care and support that is acceptable to the patient. This provision is particularly
 12

applicable to the project of improving pain assessment and reassessment documentation because

by carrying out adequate documentation of pain progression and encouraging patients to

participate in their treatment of pain, it creates a better opportunity to provide appropriate pain

management and individualize the care to each patient, ultimately creating better patient

outcomes. In addition, the Jesuit value of nurturing the whole person (mind, body, and spirit)

applies to the project because ensuring satisfactory pain assessment and reassessment

documentation guarantees that patients are being taken care of appropriately. Addressing a

patient’s pain is a way of healing and nurturing the whole person, as experiencing pain affects

almost every aspect of a person’s life, leading to impaired physical functioning, poor mental

health, and reduced quality of life, and contributes to substantial morbidity each year (Dowell et

al., 2022). Overall, it is essential that nurses understand the ethical implications associated with

proper documentation of pain assessment in providing patient care and apply the value of caring

for the whole person to successfully individualize every patient’s treatment.

Project AIM

The aim of this project is to increase nurse pain assessment documentation prior to

administration of opioid pain medication by 21% for unit A and 20% for unit B, and

reassessment documentation by 1% for unit A and 5% for unit B on the medical-surgical units to

reach an acceptable standard compliance rate of 90% or greater by the end of April 2024.

Successful attainment of this goal will better ensure patient safety by allowing accessibility to

data that can help guide appropriate individualized treatment methods for pain, while attempting

to eliminate any adverse effects that can result from opioid pain medication treatment.

Additionally, adherence to patient pain assessment documentation by nurses provides a method

to evaluate the effectiveness of patient specific treatment methods for pain to more efficiently
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help in identifying what methods work best for providing each individual patient proper pain

management. Ultimately, increasing compliance rates for pain assessment and reassessment

documentation in the medical-surgical units benefits both patients and providers by delivering

and maintaining a safe and effective form of pain management that can easily be accessed and

monitored.

Methods

Context

This quality improvement project took place at a hospital in the Bay Area. The

microsystem was assessed using the five Ps: Purpose, Patients, Professionals, Processes, and

Patterns. This project specifically focused on two medical-surgical units (unit A and unit B) of

Hospital A where the purpose is to provide care to a diverse patient population with a wide

variety of acute and chronic conditions, many of whom may be receiving opioid pain medication

to treat acute pain. The professionals that form part of the microsystem consist of clinical nurses,

nurse leaders such as charge nurses and managers, doctors, nurse assistants, unit secretaries,

pharmacists, case managers, social workers, and occupational and physical therapists. The

processes that take place include nursing assessments, education, medication administration, pain

management, obtaining and monitoring vital signs, and interdisciplinary communication and

patient advocacy to achieve the best patient outcomes. Finally, some patterns that characterize

the microsystem functioning consist of teamwork and collaboration, policies and procedures,

effective leadership, successful communication, and adequate time management.

Upon sufficient microsystem analysis, a Gannt chart containing a timeline of tasks to

complete for successful project implementation was created (see Appendix C). Additionally,

after critically observing the microsystem a fishbone diagram was utilized to visually recognize
 14

potential root causes to the identified problem of lack of pain assessment documentation (see

Appendix D). Moreover, a strengths, weaknesses, opportunities, and threats (SWOT) analysis

contains crucial information that was gathered based on microsystem analysis to consider while

identifying an appropriate intervention (see Appendix E). Finally, a cost benefit analysis was

produced to identify costs and potential savings as a result of the implementation of the

intervention (see Appendix F). All these tools were applied to support the organization, planning,

and effective execution of the proposed intervention for this quality improvement project.

Intervention

The intervention consisted of educational materials on workflow recommendations,

reassessment reminders, and compliance tracking tools. To begin, a knowledge check survey was

conducted to determine if there were any gaps in knowledge for nursing staff regarding proper

criteria and timing required to meet compliance for pain assessment and reassessment

documentation (see Appendix G). The survey consisted of a total of seven questions, five of

which were multiple choice answers, and two short answers. A total of 50 responses were

collected. The survey helped guide the direction of the intervention and helped determine that

reminders about timely pain assessment and reassessment documentation, as well as education

on more efficient workflow for documentation could potentially help increase compliance

ratings. Small reminder cards were placed on the computers used in patient rooms, as well as

some nursing station computers, along with flyers posted in staff bathrooms and breakrooms

containing information about pain assessment and reassessment compliance requirements which

includes pain score, sedation scale, oxygen saturation, and respiratory rate (see Appendix H).

Additionally, a comprehensive poster board was placed in both medical-surgical unit breakrooms

which contained more in-depth information regarding current compliance rates and goals,
 15

instructions for access to self-compliance reports, documentation criteria, timing for

documentation, and helpful tips (see Appendix I). The tools for the intervention were developed

by a group of six nursing students and were reviewed by the hospital nurse educator and the

medical-surgical unit managers, who provided feedback and approval for the materials to be used

and posted.

Study of the Intervention

Once implemented, the intervention required future studying to recognize any potential

changes that needed to be made. The Plan Do Study Act (PDSA) cycle was utilized to aid in

studying the implementation of the intervention and evaluating its effectiveness or need for

change (see Appendix J). When planning the intervention, the required criteria that meets pain

assessment and reassessment compliance was identified, the hospital policy was reviewed, and

quarterly data was examined. Next, the surveys collected, and observations made on the units

helped in obtaining baseline nurse knowledge data and studying the microsystem. For study,

quarterly data was compared to observations, past similar projects were studied, and a literature

review was conducted to determine best practices. Finally, education on workflow was

implemented, data was assessed through manual chart audits, and an evaluation of the

intervention was performed. Future PDSA cycles can be useful in making small changes in the

intervention as needed until proven to be effective. Additionally, a post-intervention survey for

nurses was used to assess the effectiveness of the intervention and obtain feedback for

improvement (see Appendix K). This survey helped in recognizing if nursing staff was satisfied

with the intervention and if any improvements in pain assessment and reassessment can truly be

attributed to the intervention. Moreover, manual chart audits were conducted for the first two

weeks of April 2024 to observe if compliance rate progress was made, and pain assessment and
 16

reassessment documentation compliance increased. Currently, a third-party data analyst is

responsible for gathering the data on compliance rates for pain assessment and reassessment and

creating monthly reports for all hospital units. Therefore, conducting manual chart audits allowed

for compliance rates to be calculated in real time according to the required documentation

criteria from the hospital policy. Further investigation may be warranted to ensure adequate

understanding of compliance requirements from both the data collection and nursing perspective.

Outcome Measures

This quality improvement project will measure success by tracking monthly pain

assessment and reassessment documentation compliance rate. The outcome measure for

compliance rate will be collected by a third-party data analyst. Compliance rate reports are

typically available at the beginning of every month and sent out via email to each unit in the

hospital. Every nursing staff member should receive these emails and have access to the reports

as soon as they become available. A compliance rate of 90% or greater is desired for initial pain

assessment and reassessment on both medical-surgical units at Hospital A.

Results

The quarterly results for April 2024 helped indicate if the project was successful in

increasing pain assessment and reassessment documentation compliance rates. According to the

results, unit A scored 62% for pre-assessment compliance, and 90% for reassessment

compliance. Unit B scored 77% for pre-assessment compliance and 89% for reassessment

compliance. Therefore, the compliance rates did in fact increase with the exception of unit A’s

pre-assessment score, which decreased by 7% from 69% to 62%. Although unit A’s pre-

assessment compliance rate decreased, the reassessment score was the only one that did meet the

goal of 90% compliance rate. Moreover, Unit B improved by 7% on pre-assessment and 4% on

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reassessment indicating overall improvements in compliance rates for both pain pre-assessment

and reassessment. Therefore, any increase in compliance rates could indicate that the

intervention may have been successful given the short period of time for implementation. As a

result, it can be determined that patients are being better monitored and assessed for pain by

nurses leading to improvements in pain management and patient safety.

Discussion

Summary

This quality improvement project was intended to bridge the gap between nurses

assessing for pain and adequately documenting their assessments. After conducting a

microsystem analysis, it was determined that there was a need to increase pain assessment and

reassessment documentation rates on two medical-surgical units in hospital A. An initial

knowledge check survey identified that there was not a gap in knowledge for nurses, rather there

were time constraints and workflow barriers identified. Therefore, the intervention focused on

providing nurses with visual aid reminders and suggestions for workflow improvements to help

increase compliance rate scores. Based on the quarterly data obtained for the month of April it

was determined that some improvements were made in compliance rates, which indicated that

the interventions were somewhat successful. Although unit A’s reassessment compliance rate

was the only one to meet the intended goal of 90%, it is important to acknowledge the overall

improvements in compliance considering that this project faced time constraints. Therefore, an

important lesson learned from this project was that timelines are important to create, keep track

of, and meet when facing time constraints. However, this can be difficult to accomplish when it

requires communication and collaboration with other sources such as unit leaders, third party

data analysts and busy nurses on the floors.

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Nevertheless, the success of this project can be attributed to the observations obtained

from conducting the microsystem analysis and the determination to help create improvements.

Additionally, some strengths of this project include the discovery of inconsistencies with pain

assessment documentation practices and hospital policy, as well as how the data is collected and

interpreted by the third party data analyst. This creates an opportunity to further investigate any

changes that may need to be made to the policy or data collection practices. Finally, this project

allowed for an educational moment for nurses to learn more about tools provided to track their

own compliance scores, which helps in providing nurse accountability for pain assessment

compliance performance.

Limitations

Although some improvements in compliance rates for pain pre-assessments and

reassessments were achieved, this improvement project faced some limitations. To begin,

resistance to change by nurses on the units was difficult to overcome. It was challenging to

achieve stakeholder buy-in to help improve pain assessment and reassessment documentation

compliance rates making it difficult to implement the desired teaching. Additionally, a lack of

communication with the third party data analyst created difficulties in identifying how and what

data specifically was gathered to obtain compliance rates. This was particularly important to the

success of this project given that there appeared to be prior inconsistencies with data collection

and hospital policy requirements. Further investigation and communication would be needed to

truly identify what, if any, informatics or policy changes would need to be made. Moreover,

considering the short amount of time given to implement and evaluate the effectiveness of the

intervention, this created a limitation as there was a missed opportunity to address any changes to

the intervention after implementation that may have been helpful for improving compliance
 19

rates. Finally, a lack of clarity on what criteria was required and what specific documentation

timing was needed to meet compliance for pre-assessment according to the hospital policy

contributed to a lack of success in improving pre-assessment compliance rate. The unclear policy

created confusion in providing nurse education on workflow recommendations for

documentation of pain pre-assessments which could have led to undesirable decreases in

compliance rate scores for unit A’s pre-assessments.

Conclusion

In conclusion, this quality improvement project focused on investigating the effectiveness

of providing visual reminders and education on access to self-report tools to improve pain

assessment and reassessment documentation rates for nurses in two medical-surgical units. Given

the time constraints faced by this project, it is unclear if the implementation of this project is

sustainable and generalizable. Further assessment would be required to evaluate the long-term

success of this project. Additional recommendations provided by nurses to consider for

improving compliance rates are to create informatic improvements such as implementing a hard

stop in the EMR for pain assessment criteria at time of medication administration. Furthermore,

better communication between unit leaders, data analysts, and nurses are encouraged to ensure

clarity of expectations regarding pain assessment and reassessment compliance. Ultimately, this

project demonstrated that providing reminders, keeping nurses accountable, and ensuring timely

feedback and clear communication can lead to improved pain assessment and reassessment

documentation compliance.
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https://doi.org/10.1111/jgs.14377

Jungquist, C. R., Quinlan-Colwell, A., Vallerand, A., Carlisle, H. L., Cooney, M., Dempsey, S.

J., Dunwoody, D., Maly, A., Meloche, K., Meyers, A., Sawyer, J., Singh, N., Sullivan,

D., Watson, C., & Polomano, R. C. (2020). American Society for Pain Management

Nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory

depression: Revisions. Pain Management Nursing, 21(1), 7–25.

https://doi.org/10.1016/j.pmn.2019.06.007

McDonald, K. M., Graham, I. D., Grimshaw, J. (2004). Toward a theoretic basis for quality

improvement interventions. Agency for Healthcare Research and Quality (US).

Ross, A., Feider, L., Nahm, E. S., & Staggers, N. (2017). An outpatient performance

improvement project: A baseline assessment of adherence to pain reassessment standards.

Military Medicine, 182(5), e1688–e1695. https://doi.org/10.7205/MILMED-D-16-00104

Samuels, J. G., & Eckardt, P. (2014). The impact of assessment and reassessment documentation

on the trajectory of postoperative pain severity: A pilot study. Pain Management

Nursing: Official Journal of the American Society of Pain Management Nurses, 15(3),

652–663. https://doi.org/10.1016/j.pmn.2013.07.007
 22

Sturesson, L., Lindström, V., Castrén, M., Niemi-Murola, L., & Falk, A.-C. (2016). Actions to

improve documented pain assessment in adult patients with injury to the upper

extremities at the Emergency Department – A cross-sectional study. International

Emergency Nursing, 25, 3–6. https://doi.org/10.1016/j.ienj.2015.06.006

University of San Francisco (n.d.). Our Jesuit roots. https://www.usfca.edu/who-we-

are/reinventing-education/jesuit-roots

Wissman, K. M., Cassidy, E., D’Amico, F., Hoy, C., Vissari, T., & Baumgartner, M. (2020).

Improving pain reassessment and documentation rates: A quality improvement project in

a teaching hospital’s Emergency Department. Journal of Emergency Nursing, 46(4),

505–510. https://doi.org/10.1016/j.jen.2019.12.008
 23

Appendix A

Johns Hopkins Evidence Appraisal Table

Journal Citation Evidence Type Sample, How Does Article Quality Other Highlights from
# Sample Size, Address Problem? of Article
Setting Evidence (consider including
limitations &
outcomes)
1 Grommi, S., Vaajoki, Systematic review 23 articles Based on the articles Level III / Limitations:
A., Voutilainen, A., & and meta-analysis regarding pain reviewed it could be B There exist confounding
Kankkunen, P. (2023). education concluded that a Good factors in all studies and
Effect of pain education interventions and combination of methods quality lacks a control group,
interventions on the effect on including nursing making it difficult to assess
registered nurses’ pain registered nurse’s education interventions, the studies and make direct
management: A pain management auditing of pain nursing comparisons. This also
systematic review and were thoroughly and documentation, and presents the issue of lack of
meta-analysis. Pain reviewed. Four feedback can be effective generalizability. Based on
Management Nursing, data sources were in improving pain the studies reviewed, it is
24(4), 456–468. used including management, assessment unclear if one particular
https://doi.org/10.1016/ PubMed, Scopus, practices, and patient method of intervention
j.pmn.2023.03.004 CINAHL, and satisfaction. directly correlates with
ERIC. improvements in pain
The review of articles management or pain
provides information on assessments.
successful interventions
that aim to improve Outcome:
assessment practices, Pain education
among other outcomes interventions and protocols
related to pain, which influenced pain
directly addresses the documentation, pain
problem. assessment, pain
reassessment, and patient
satisfaction.
 24

Pain education varied

among studies making it
unclear what methods, if
any, best provide
improvement, which makes
it difficult to replicate
results. Future well-
designed studies that can be
reproduced are needed for
RN’s and patients.
2 Grommi, S., Randomized control Central hospital in The intervention consisted Level I / B Limitations:
Voutilainen, A., trial Finland. 50 RNs of a 21-slide educational Good Long-term effects of
Vaajoki, A., & from three lecture implemented on a quality knowledge impacts were
Kankkunen, P. (2021). different single day. Nurses were limited, requiring a
Educating registered specialized asked to complete an replicate of this study with
nurses for pain surgical wards Acute Postoperative Pain a recommended larger
knowledge and were randomly Knowledge Test before sample.
documentation assigned to the education was
management: A intervention and provided and three Outcomes:
randomized controlled control groups. months after the The education lecture
trial. International intervention to assess for intervention proved
Journal of Caring knowledge retention. ineffective in changing
Sciences, 14(2), 919– Documentation auditing nurse knowledge and
929. was conducted changes to documentation
retrospectively. effectiveness resulted even
lower. The knowledge test
In the Intervention group and documentation audit
there showed a results were contradictory
knowledge increase from in that nurses that had low
pre- to post-knowledge scores on the knowledge
test. However, there were test implemented
no significant changes in documentation better than
knowledge of pain those with an average
management and score.
postoperative
documentation skills.
There also showed no
difference in knowledge
retention between
intervention and control
 25

groups. The results

indicate that the
intervention had no effect
on RN’s documentation
skills.
3 Gunnarsdottir, S., Cluster randomized 650-bed Data was collected Level I / B Limitations:
Zoëga, S., Serlin, R. C., control trial university simultaneously on all Good Some changes in the
Sveinsdottir, H., hospital in units on two days, a week quality clinical environment could
Hafsteinsdottir, E. J. Iceland. apart. Survey not be controlled such as
G., Fridriksdottir, N., questionnaires were then temporary merging of units,
Gretarsdottir, E. T., & Sample included sent to all nurses on which could have caused
Ward, S. E. (2017). The patients ages 18 participating units. Units contamination between
effectiveness of the and older, native were then randomized to conditions. There was a low
Pain Resource Nurse speaking, receive the Pain Resource response rate of nurses for
Program to improve hospitalized for at Nurse Program survey questionnaires.
pain management in the least 24 hours, (intervention) or control.
hospital setting: A and registered Ten months later follow- Outcomes:
cluster randomized nurses on up data was collected The Pain Resource Nurse
controlled trial. participating from patients and nurses Program successfully
International Journal units. 23 medical using the same protocol. improved pain assessment
of Nursing Studies, 75, and surgical units practices among those in
83–90. were randomly The Pain Resource Nurse the intervention group,
https://doi.org/10.1016/ assigned to the Program is an evidence- while those in the control
j.ijnurstu.2017.07.009 Pain Resource based educational course group saw a decrease in
Nurse Program in pain management with pain assessment practices.
(n=12) or wait-list a follow-up plan to
control (n=11). support Pain Resource
Nurses in their role.
Education includes nine
modules through slide
presentation.

The results of the study

indicated that
documentation of pain
assessment improved
from 13% to 25% on the
intervention units and
decreased from 21% to
16% on the control units.
 26

4 Ho, J., & Burger, D. Non-experimental Sierra View At baseline pain Level III / Limitations:
(2020). Improving study Medical Center reassessment rates were at B This study may not be
medication safety (SVCM) a 167- 41% and bedside barcode Good generalizable considering
practice at a community bed medication administration quality the amount of work that
hospital: A focus on bar acute-care (BCMA) was at 81%. The went into completing each
code medication community goal was to reach 90 and PDSA cycle and the
administration scanning hospital located in 95% compliance rate creation of the dashboards
and pain reassessment. Central respectively. and weekly updates sent out
BMJ Open Quality, California. by leadership.
9(3), e000987. Performing pain
https://doi.org/10.1136/ assessments and Outcomes:
bmjoq-2020-000987 reassessments is crucial to BCMA scanning rates
help determine the improved by 14% to a total
adequate level of therapy 98%, exceeding the goal of
and to achieve appropriate 95%.
pain management while Pain reassessments one-
also providing patient hour post-opioid
safety and reducing administration improved by
adverse effects related to 50% to a total of 91%
opioid use. compliance.
Improvement was sustained
Three rounds of PDSA over 17 months after
cycles were performed to implementation of both
help identify best projects.
interventions for
improving and sustaining
compliance. Ultimately,
visual dashboards which
included graphs depicting
level of compliance for
reassessments resulted in
a successful increase in
pain reassessment
compliance.
5 Hogan, T. M., Howell, Quasi-experimental Urban academic A study was conducted to Level II / B Limitations:
M. D., Cursio, J. F., study ED. Focused on identify if standardized Good The study was conducted at
Wong, A., & Dale, W. individuals aged education and continuous quality one hospital and in one
(2016). Improving pain 65 and older quality improvement for unit, limiting the results to
relief in elder patients experiencing staff in the ED resulted in that particular setting and
(I-PREP): An moderate to improved pain putting into question the
 27

emergency department severe pain. management and timing study’s generalizability.

education and quality Intervention of pain assessments and Additionally, observations
intervention. Journal of targets included reassessments. took place only during the
the American 14 attending weekday ignoring
Geriatrics Society, physicians, two Observations were differences that may occur
64(12), 2566–2571. advanced practice conducted to collect data. on the weekends.
https://doi.org/10.1111/ nurses (APNs) Interventions consisted of
jgs.14377 and 86 registered education reemphasis at Outcomes:
nurses. monthly meetings, The I-PREP intervention
answering questions and resulted in an improvement
receiving feedback, high in pain management among
performers sharing older adults in the ED and
success stories, and low improvement of timing of
performers receiving pain assessments and
advice, tips, and reassessments.
encouragement.
Columns were inserted in
the EMR that contained a
visual reminder about
patient pain scores. Best
practice alerts were
displayed for patients
requiring pain
assessments and
reassessments.
6 Jungquist, C. R., Clinical practice A 14-member Revisions to the 2011 Level IV / Limitations:
Quinlan-Colwell, A., guideline expert panel guidelines remained A No limitations noted.
Vallerand, A., Carlisle, reviewed and relatively unchanged. One High
H. L., Cooney, M., graded the key revision included quality Outcomes:
Dempsey, S. J., strength of multiparameter nursing The health care team should
Dunwoody, D., Maly, scientific assessment of respiratory ensure safe prescribing and
A., Meloche, K., evidence rate and quality, pulse use of opioids across all
Meyers, A., Sawyer, J., published in peer oximetry, and level of transitions of care.
Singh, N., Sullivan, D., reviewed journals sedation before opioid
Watson, C., & and revised the administration and at peak
Polomano, R. C. ASPMN effect.
(2020). American (American
Society for Pain Society for Pain
Management Nursing Management
guidelines on Nursing) 2011
 28

monitoring for opioid- existing

induced advancing guidelines.
sedation and respiratory
depression: Revisions.
Pain Management
Nursing, 21(1), 7–25.
https://doi.org/10.1016/
j.pmn.2019.06.007

7 Ross, A., Feider, L., Non-experimental N=151 patients Chart audits were Level III / Limitations:
Nahm, E. S., & observational study who received conducted to identify gaps B The military clinic’s EMR
Staggers, N. (2017). An Toradol between in pain reassessment Good may not be generalizable to
outpatient performance February 1 and documentation. Workflow quality other settings. Sample size
improvement project: A May 30, 2013. was observed including was relatively small, further
baseline assessment of Large military compliance of adequate questioning the
adherence to pain primary care pain reassessment generalizability of the
reassessment standards. outpatient clinic documentation and study. The clinic was
Military Medicine, barriers to proper encountering current
182(5), e1688–e1695. documentation. relocation, possibly
https://doi.org/10.7205/ resulting in workflow
MILMED-D-16-00104 Observations revealed changes. Recommendations
low overall pain were not actually carried
reassessment compliance out to identify
rates for the 30-minute effectiveness.
time requirement outlined
in the clinic policy, heavy Outcome:
patient load and relying Observations successfully
solely on memory, identified problematic areas
making it difficult to keep in need of improvement.
up with documentation, However, improvement
and lack of standardized recommendations were not
procedures in the EMR carried out requiring further
design and clinic investigation into whether
workflows. the recommendations
would result in success.
Recommendations
include creating a pain
reassessment template for
the EMR, standardization
of patient movement
 29

processes, and a
dashboard to show up-to-
date compliance
information.
8 Samuels, J. G., & Qualitative quasi- 3 community Pain severity trajectory Level II / B Limitations:
Eckardt, P. (2014). The experimental pilot hospitals and 146 (PST) can help clinicians Good Data entry may have been
impact of assessment study adult patients who identify best methods for quality compromised due to a large
and reassessment underwent a therapy. One way to amount of data needing to
documentation on the general, measure PST is through be imputed manually.
trajectory of orthopedic, or documentation of pain Reassessment
postoperative pain gynecological assessment and documentation errors may
severity: A pilot study. surgical reassessment post- have occurred but may not
Pain Management procedure with a medication intervention. have been accounted for
Nursing: Official hospital stay of 12 Reassessment within one leading to variations and
Journal of the hours or more. hour of intervention unreliability of data. This
American Society of resulted in more favorable study may not be
Pain Management PST and the association generalizable due to the
Nurses, 15(3), 652– between reassessment and differences in the nature of
663. PST may be most useful the unit's workflows from
https://doi.org/10.1016/ in determining future which the data was
j.pmn.2013.07.007 documentation policies collected.
and identifying effective
research. Outcomes:
The study revealed that
pain management
documentation (PMD) can
influence practice and
impact outcomes. Adequate
documentation can lead to
appropriate pain
management, and there
should be consistency in
what is being documented
to be able to pull that data
more efficiently, which has
the potential to assist in
future studies and research.
9 Sturesson, L., Cross-sectional From 2006 - 2012 The current protocol Level III / Limitations:
Lindström, V., Castrén, Study patients with states that nurses should B Only the documentation of
M., Niemi-Murola, L., wrist/arm be assessing a patient's pain assessment was
 30

& Falk, A.-C. (2016). fractures or soft pain using a pain rating Good studied, excluding the
Actions to improve tissue injuries in scale (NRS) and should quality observation of physical
documented pain an adult ED of a include documentation of assessments that may have
assessment in adult public urban pain assessment before occurred.
patients with injury to teaching hospital and after administering Results of this study may
the upper extremities at in Stockholm. analgesics. From 2002 - not be generalizable due to
the Emergency Individuals aged 2010 there were several the uniqueness of the
Department – A cross- 15 years and changes to the pain setting.
sectional study. greater are treated assessment and The extent to which triage
International at the ED. 120 administration protocol. nurses administer
Emergency Nursing, patient medical In 2010 pain assessment analgesics was unknown
25, 3–6. records per year became mandatory. leading to a potential gap in
https://doi.org/10.1016/ were utilized for Beginning in 2006, data.
j.ienj.2015.06.006 data collection. guidelines for pain
assessment began to be Outcomes:
implemented, but were Mandatory pain assessment
not properly being in the patient’s electronic
followed. It was not until medical record was a
2010, when pain successful intervention in
assessment became improving documentation
mandatory, that pain of pain assessment rates in
assessment the ED.
documentation improved.
However, there was no
documentation of
reassessment of pain
found despite
administration of
analgesics.
10 Wissman, K. M., Pre-post Community Baseline pain score Level V / B Limitations:
Cassidy, E., D’Amico, interventional hospital reassessment and Good The length of the post-
F., Hoy, C., Vissari, T., quality improvement emergency documentation rates were quality intervention period may
& Baumgartner, M. project department. Six 36.2% in the ED. Post- have been too short to
(2020). Improving pain focus groups of intervention rates determine a significant and
reassessment and emergency increased to 62.3% during sustainable improvement in
documentation rates: A nurses. the 3-month post pain score reassessment and
quality improvement intervention period. documentation. The
project in a teaching interventions only applied
hospital’s Emergency Three interventions were to the current staff that was
Department. Journal of implemented to improve available, therefore not
 31

Emergency Nursing, pain reassessment reaching every staff

46(4), 505–510. documentation including member potentially creating
https://doi.org/10.1016/ 6 focus groups of an gaps in education for staff.
j.jen.2019.12.008 average of 3 nurses to
identify any barriers and Outcomes:
provide education on the Pain reassessment and
importance of pain documentation rates
reassessment for increased by 26% by the
providing appropriate post intervention period as
pain management, daily the result of using
audits to provide education for focus groups,
immediate feedback and daily audits, and weekly
encouragement, and newsletter communication
weekly newsletters to to staff.
provide continuing
education and
department-wide rates of
pain reassessments for
comparison.

The interventions proved

successful in improving
pain reassessment
documentation rates in the
ED.
 32

Appendix B

Statement of Non-Research Determination

Project: Statement of Determination and Non-Research Determination

Form

Student Name: Alicia Espinoza

Title of Project: Improving Pain Assessment and Reassessment Documentation in
Medical-Surgical Units

Brief Description of Project

• Data that Shows the Need for the Project

Patient assessment and reassessment documentation compliance rates for two
medical-surgical units at a 244-licensed-bed hospital in the Bay Area prompted a
need for improvement from the January 2024 quarterly report indicating 89%.
With the acceptable compliance rate at 90%, current pain assessment and
reassessment compliance data remained inadequate.

• Aim Statement
By April 30, 2024, our mission is to improve nurses' pain pre and post-reassessment
documentation on the medical-surgical floor to reach a total of 90% compliance.

• Description of Intervention(s)
o Surveys on the current knowledge of pain assessment and reassessment of
hospital policy
o Investigating current policy and whether it aligns with current practice
o Education on the current policy
o Weekly newsletters
o Pain assessment reminders during huddles, as well as display of posters
and physical reminders on workstations

• Desired Change in Practice

The desired change in practice would include increased pain assessment and
reassessment documentation. Specifically, both units of the medical-surgical floors
would have a satisfactory rate of 90% or greater for both pre-and post-pain
assessment. In addition, the nurses would be more aware of the four specific criteria
of oxygen saturation, pain level, respiratory rate, and sedation level that are needed
 33

to fulfill the assessment requirement.

• Outcome measurement(s):
After the implementation of surveys, the QI team aims to examine the quarterly
annual rate provided by the nurse educator in mid-April to assess whether a
productive change in chart documentation for pre- and post-assessment was made.

To qualify as an Evidence-based Change in Practice Project, rather than a Research

Project, the criteria outlined in federal guidelines will be used:
(http://answers.hhs.gov/ohrp/categories/1569)

☐ This project meets the guidelines for an Evidence-based Change in Practice Project as
outlined in the Project Checklist (attached). Student may proceed with implementation.

☐This project involves research with human subjects and must be submitted for IRB
approval before project activity can commence.

Comments:

EVIDENCE-BASED CHANGE OF PRACTICE PROJECT CHECKLIST *

Instructions: Answer YES or NO to each of the following statements:

Project Title: YES NO

The aim of the project is to improve the process or delivery of care with x
established/ accepted standards, or to implement evidence-based change.
There is no intention of using the data for research purposes.
 34

The specific aim is to improve performance on a specific service or x

program and is a part of usual care. ALL participants will receive
standard of care.

The project is NOT designed to follow a research design, e.g., hypothesis x

testing or group comparison, randomization, control groups, prospective
comparison groups, cross-sectional, case control). The project does NOT
follow a protocol that overrides clinical decision-making.

The project involves implementation of established and tested quality x

standards and/or systematic monitoring, assessment or evaluation of the
organization to ensure that existing quality standards are being met. The
project does NOT develop paradigms or untested methods or new
untested standards.

The project involves implementation of care practices and x

interventions that are consensus-based or evidence-based. The project
does NOT seek to test an intervention that is beyond current science
and experience.

The project is conducted by staff where the project will take place and x
involves staff who are working at an agency that has an agreement with
USF SONHP.
The project has NO funding from federal agencies or research-
focused organizations and is not receiving funding for
implementation research.

The agency or clinical practice unit agrees that this is a project that will be x
implemented to improve the process or delivery of care, i.e., not a
personal research project that is dependent upon the voluntary
participation of colleagues, students and/ or patients.

If there is an intent to, or possibility of publishing your work, you and x

supervising faculty and the agency oversight committee are comfortable
with the following statement in your methods section: “This project was
undertaken as an Evidence-based change of practice project at X hospital
or agency and as such was not formally supervised by the Institutional
Review Board.”

ANSWER KEY: If the answer to ALL of these items is yes, the project can be considered
an Evidence-based activity that does NOT meet the definition of research. IRB review is
not required. Keep a copy of this checklist in your files. If the answer to ANY of these
questions is NO, you must submit for IRB approval.

*Adapted with permission of Elizabeth L. Hohmann, MD, Director and Chair, Partners
 35

Human Research Committee, Partners Health System, Boston, MA.

STUDENT NAME (Please print):

____Alicia Espinoza______________________________________
Signature of Student:

____ _____________DATE___3/8/2024_____

SUPERVISING FACULTY MEMBER NAME (Please print):

__________Jennifer Zesati _________________________________________________

Signature of Supervising Faculty Member _____

______________________________________________DATE____________
 36

Appendix C

GANTT Chart
 37

Appendix D

Fishbone Analysis
 38

Appendix E

SWOT Analysis
 39

Appendix F

Budget Analysis
 40

Appendix G

Knowledge Check Survey

41
42
 43

Appendix H

Small Reminder Cards and Flyers

Small Reminder Cards

Flyers
 44

Appendix I

Poster Board
 45

Appendix J

PDSA Cycle
 46

Appendix K

Post-Intervention Survey