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Keywords:

  • audit and feedback;
  • cancer pain;
  • evidence-based practice;
  • pain management;
  • practice guidelines

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

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


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Pain is the fifth vital sign[1] and is one of the most feared and burdensome symptoms experienced by most cancer patients.[2] According to a meta-analysis, the prevalence rates of pain in patients with cancer were 53% for all stages; 64% for advanced, metastatic or terminal stages; 59% for active treatment; and 33% for those in the curative treatment stages.[3] However, pain is underreported, under-diagnosed or under-treated in approximately half of all cancer patients. In addition, it has been pointed out that measurements of pain do not necessarily translate to appropriate pain management.[4, 5] This discrepancy has significant effects on loss of function and quality of life. Untreated and under-treated pain greatly interferes with general activity, mobility, relationships with others, ability to tolerate cancer treatment and enjoyment of life.[6, 7] Moreover, pain is associated with multiple symptoms, such as sleep disturbance, fatigue, depression, anxiety, prolonged hospitalization, as well as high health-care costs.[8, 9] Hence, optimal control of pain affects the physical, emotional and functional well-being of the patient. In addition, pain control and management are significant nursing-sensitive patient outcomes, as recognized by the Oncology Nursing Society.[10] Barriers to cancer pain management could include lack of education and skills among health-care professionals to adequately assess pain and follow clinical guidelines. In addition, reluctance to report pain and lack of structural supports, such as clinical decision support systems, could also lead to under-treatment of cancer pain.[11, 12] To effectively manage cancer pain, best clinical practice guidelines should be introduced and implemented.[13]

Audit and feedback is an important approach for implementing clinical practice guidelines and has shown a mixed but generally modest positive effect on implementing guidelines for quality of care across a wide variety of settings.[14-16] This approach ensures the collection and integration of data relevant to health-care provider performance to improve practice behaviours and clinical outcomes.[14-18] In the study by Dulko et al., an audit and feedback approach showed the improvement of nurse practitioners' adoption of clinical practice guidelines for cancer pain management.[19]

The Joanna Briggs Institute (JBI) is an international non-profit, membership-based, research and development organization at the University of Adelaide, Australia, that offers various educational programmes supporting evidence synthesis, transfer and utilization. The JBI Clinical Fellowship Program supports fellows in the exploration of strategies promoting evidence utilization. The fellowship programme consists of a 1-week intensive training residency, a 6-month project implementation period at the fellow's institution, followed by a second 1-week residency for wrap-up.[20] This research was conducted as part of JBI's Clinical Fellowship Program, with collaboration between the JBI and Yonsei University Health System in Seoul, Korea. JBI supported fellows by providing resources such as staff and web-based applications to facilitate the evidence utilization project.

The purpose of this study was to implement an evidence utilization project via an audit and feedback approach to improve cancer pain management. The specific aims were to (i) assess current practices of pain management in patients with cancer; (ii) implement changes in pain management practices in patients with cancer based on the best available evidence; and (iii) improve compliance of practice and documentation with best practice guidelines for pain management in patients with cancer.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Setting and samples

Yonsei University Severance Hospital is a university-affiliated, tertiary care hospital located in Seoul, Korea. It includes a specialized cancer centre with 132 beds. Severance Hospital has used electronic medical records (EMR) for nursing documentation since 2005. It should also be noted that Severance Hospital was preparing for its accreditation renewal from the Joint Commission International (JCI) when this study was formulated in 2010. One 46-bed oncology nursing unit at the cancer centre was selected as a study site. The sample consisted of nursing records related to the assessment and management of pain experienced by patients who were admitted to this unit.

Study procedures

The study was conducted from January to June 2010. Data were collected without identifiers, and all data were aggregated to maintain anonymity and confidentiality. The institutional review board at the College of Nursing of the university approved this study. The study procedures are outlined in Figure 1. Following JBI recommendations, the implementation process was divided into three phases, which are described in detail below.

figure

Figure 1. Project implementation process.

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Phase 1: Baseline audit

The major activities of Phase 1 included identifying a study topic, pertinent setting, sample, audit criteria, organizing a research team and conducting the baseline audit. We identified the topic of pain management because improving pain management was one of the essential JCI standards that the hospital was striving to meet.[21] Although the nursing department had developed and used a hospital policy for pain assessment and management, nurse managers agreed that some areas still needed to be assessed and improved.

After identifying cancer pain management as the study topic, the criteria used for pain management in patients with cancer were derived from the Scottish Intercollegiate Guidelines Network[22] and the American Pain Society.[2] Four criteria related to pain assessment and documentation, assessment and management of the side effects of opioids, and the education of patients and caregivers were chosen for this study. These areas were consistently identified in multiple guidelines. Table 1 shows each criteria and its corresponding key performance index.

Table 1. Audit criteria with corresponding key performance index
CriterionKey performance index
1. Completed pain assessments are stored in the patient's notes.Documented evidence that comprehensive pain assessments are stored in the patient's notes at least once during his/her hospitalization.
2. Health-care professionals use a formalized pain assessment tool to assess pain in patients with cancer.Documented evidence that nurses used a formalized pain assessment tool, such as Numeric Pain Intensity Scale, Wong-Baker Faces Pain Scale, or FLACC (Face, Leg, Activity, Cry, and Consolability) .
3. Documentation reflects that side effects of opioids have been assessed and managed as appropriate.Documented evidence that side effects of opioids, such as constipation, nausea/vomiting, sedation or respiratory depression, have been assessed and managed as appropriate.
4. Documented evidence that patients and their caregivers (if applicable) have been educated and given information regarding the management of pain.Documented evidence that nurses handed out educational leaflet to patients and/or caregivers.

Once the study topic was selected, we organized a research team that included a director of the nursing department, nurse administrators, a nurse manager for the study site, a nurse informatician, a research assistant, and the director and members of the Yonsei JBI Centre. The research team agreed that the study topic was an important and feasible set of criteria for data collection concerning pain management. To collect and analyse the audit data, we established a JBI Practical Application of Clinical Evidence System (PACES) programme, which is a web-based application used to assist in the audit process. We queried and extracted nursing documentation related to pain management from the EMRs to review against best practices criteria for 1 week at the beginning of the study.

Phase 2: Change implementation and feedback

The research team determined a plan for best practice implementation by identifying areas of low compliance, where changes in management strategies were needed, as well as gaps and barriers. This process was implemented using the JBI Getting Research Into Practice (GRIP) programme, a module of the PACES programme, to facilitate change management. The GRIP process enabled us to perform a situational analysis, action-planning and action-taking. In the situational analysis, potential gaps and barriers affecting the assessment and management of pain in patients with cancer were recognized. Barriers included a lack of nurse awareness of evidence-based practice (EBP), lack of pain management guidelines for assessing and documenting patient pain and addressing the side effects of opioids, lack of a convenient method for documenting pain assessment and management in the EMR, lack of educational materials for patients and caregivers, and the burden for nurses associated with participating in the study. The strategies and resources used to overcome these barriers are listed in Table 2, along with the actions taken to improve compliance with the audit criteria.

Table 2. Implementation of Getting Research into Practice
BarrierStrategyResource
  1. EBP, evidence-based practice; EMR, electronic medical records.

Staff nurses lack awareness and education of EBPTo provide educational sessions about EBP, including definition, concepts, steps, etc.Educational sessions
Training room
Computers
Educational materials
Staff nurses lack awareness of pain management guidelinesTo provide an educational session on practice guidelines of pain managementEducational sessions and materials
Training room
To create a practice manual and a poster to increase awarenessPractice manual
Poster
Staff nurses wish to have a convenient way of documenting pain assessment and management in EMRTo involve a nurse informatician to modify EMR for nursing documentationEducational sessions
A nurse informatician
To provide staff nurses EMR training for newly changed featuresModification of EMR
Computers
Hard copy of instructions for documentation in EMR
Lack of visually friendly educational materials for pain management for patients and caregiversTo create a poster and leaflet to inform patients and caregivers

A poster

A leaflet for patients/caregivers

Nurses' burden of participating in project

To provide positive feedback and encouragement to improve pain management practices and documentation

To provide a meal or refreshment during each educational session

To provide a certificate at the completion of EBP training

To make communication channels available

To minimize changes in EMR to incorporate current practice into the EBP project as much as possible

Research team members

Meals or refreshments

Certificate as a token of completing educational sessions

A nurse informatician

Conducting the study without the nurses having a thorough understanding of EBP would not be sustainable for practice nor would it help to facilitate the implementation of practices for change. The research team set up educational workshops, and Table 3 shows detailed information. The research team was interested in targeting two different groups of nurses: nurses in leadership positions and staff nurses. Two workshops were offered to nurse administers and managers to obtain hospital supports for the EBP project throughout the process. Staff nurses took four educational workshops: (i) introduction to EBP; (ii) formulation of clinical questions using a PICO format (population, intervention, comparison and outcome) and literature search; (iii) appraisal of EBP resources; and (iv) best practice for pain management for cancer patients. To encourage staff nurses' participation in educational workshops, we offered the same session twice per day, before the evening shift and after the day shift, which helped nurses to attend regardless of their shift. We provided meals and refreshments during educational workshops, and certificates were presented upon completion of the EBP workshops.

Table 3. Educational workshops of best practice for cancer pain management
TopicTopic contentMethodParticipantTime (h)
  1. CINAHL, Cumulative Index to Nursing and Allied Health Literature; EBP, evidence-based practice; EMR, electronic medical records; PICO, population, intervention, comparison and outcomes.

Introduction to EBP utilization projectSharing overview of EBP utilization project: purpose, process and outcomesPresentationNurse administrators1
Discussion
Introduction to research team membersQ&ANurse managers
Building teamwork and communication channelsNursing faculty
Nurse informatician
Introduction to EBPConcepts, purpose, process and implementation strategies of EBP in clinical practiceLectureStaff nurses2
Q&A
Formulation of clinical questions and literature searchDefining clinical problems in daily practiceShort lectureStaff nurses1
Group session
Formulating top 5 prioritized problems using the PICO formatDemonstration
Practise using computers
Selecting relevant databases (e.g. PubMed, CINAHL, Cochrane library)Q&A
Choosing search terms
Retrieving literature
Appraisal of EBP resourcesAppraising quality of EBP resourcesShort lectureStaff nurses1
Reviewing papers
Group session
Q&A
Best practice for pain management for cancer patientsComprehensive assessmentLectureStaff nurses1
Pharmacological/non-pharmacological interventionsDemonstration by a nurse informatician
Evaluation of pain-related outcomes
Documentation on newly changed EMR for pain
Dissemination workshopWrap-upPresentationNurse administrators1
Presentation of project findingsDiscussion
Evaluation of project processFeedbackNurse managers
Sharing dissemination plansQ&ANursing faculty
Nurse informatician
Staff nurses

The research team also developed a practice manual for cancer pain management, with contents derived from organizations with expertise in cancer pain management.[2, 22] The practice manual acted as a resource for nurses to conveniently look up practice guidelines throughout the work shift. We made a poster and posted it on the unit bulletin board informing patients and caregivers about the importance of their involvement in pain management and the types of information they should report to clinicians about their pain. We also created a leaflet about cancer pain management for nurses to give to patients and caregivers.

We also worked with a nurse informatician at Severance Hospital to modify the EMR structure for pain assessment so that nurses could more easily document the relevant items. During the first educational workshop, we employed a slide presentation and provided hard copies to staff nurses detailing how to document pain assessment in the newly modified EMR. Figure 2 shows a screen shot of the EMR after modifications were made. The notations ① and ② represent the list of formal pain assessment tools and observation timing, respectively, in drop-down lists. The research team leader and unit manager observed that nurses documented newly changed features of pain management in the EMR and provided informal feedback and encouragement for this documentation.

figure

Figure 2. A screen shot of the modified pain documentation menu.

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Phase 3: Follow-up audit

The research team conducted a follow-up audit at the end of the 1-month implementation period. We collected the data using the same methods used for the baseline audit process during the 1 week from May 24 to 30, 2010.

Data analysis

The compliance rate for each criterion of this study was calculated by dividing the number of times each criterion was met by the number of times each criterion was applicable, multiplied by 100. We used chi-square tests to compare the follow-up audit data to the baseline audit, and to assess changes in the compliance rate with the best practice criteria before and after implementation. Yates' correction was employed in cases of small cell sizes. An additional analysis included examining an average of a patient's pain intensity on nursing records that was self-reported using 0–10 numerical pain intensity scale, where 0 = no pain and 10 = worst possible pain.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Compliance for the four criteria is shown in Table 4 and was generally improved, except for one criterion (criterion 1) that was routinely checked for every patient before implementation of this study. The number of patients whose nursing records were included for this data analysis was a total of 137 patients, 65 for the baseline audit and 72 at the follow-up audit. The patients were different in each time because the data were collected in different time period, but the same nurses documented in both times. As nurses recorded their nursing actions multiple times during a patient's hospitalization, the sample size of nursing records varied from 11 to as many as 938. Criterion 1 had 100% compliance at both baseline and follow-up audits. Comprehensive pain assessment documentation includes intensity, location, quality, and provoking and relieving factors, along with time aspects of pain. This documentation was completed by nurses at least once right after each patient's admission. Rates of follow-up compliance with all other criteria were increased compared with baseline, and these results were statistically significant.

Table 4. Compliance with four evidence-based audit criteria from pre- to postimplementation of best practices for the management of cancer pain
CriteriaBaseline auditFollow-up auditχ2P-value
nNo. of yes responses (%)nNo. of yes responses (%)  
  1. †Yates' correction is employed. n, number of nursing records audited; No. of yes, number complied with a criterion.

1. Completed pain assessments are stored in the patient's notes.6565(100)7272(100)
2. Documentation reflects that side effects of opioids have been assessed and managed as appropriate.431(2)4840(83)60.124<0.001
3. Health-care professionals use a formalized pain assessment tool to assess pain in patients with cancer.690151(22)938706(75)454.43<0.001
4. There is documented evidence that patients and their caregivers have been educated and given information regarding the management of pain.110(0)1711(47)9.167<0.001

The finding showed zero compliance with one criterion at the baseline audit, ‘there is documented evidence that patients and their caregivers have been educated and given information regarding the management of pain’; compliance at the follow-up audit, however, improved to 47%. Two other criteria showed a noticeable improvement of compliance: the criterion of using a formalized pain assessment tool (criterion 3) and documenting the side effects of opioids (criterion 2). Additionally, pain intensity did not significantly differ between baseline audit and follow-up audit, which showed means of 2.41 (SD = 2.20) and 2.57 (SD = 2.30), respectively (t = 1.405, P = 0.160).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

As pain is one of the most critical symptoms experienced by patients with cancer, we implemented an evidence utilization study using an audit and feedback approach to improve cancer pain management. The results of the present study demonstrate that an audit and feedback approach to implementing clinical practice is effective in increasing compliance with established guidelines. We found that follow-up compliance rates with all the criteria were increased compared with those at the baseline audit. Completing a pain assessment at least once during a patient's hospitalization (criterion 1) showed 100% compliance at the baseline audit. This criterion has been reinforced by protocol and the JCI audit, especially at the time of admission. Although the baseline results show that nurses have had low rates of documenting the side effects of opioids (criterion 2), using pain assessment tools (criterion 3) and handing out informational materials (criterion 4), this does not necessarily indicate that nurses do not perform those actions in routine practice. After the baseline audit, we identified major gaps in nurses' awareness of EBP and practice guidelines for cancer pain management. To change nursing practices, the research team agreed that increasing nurses' awareness of the importance of these practices and pain documentation should be enhanced by providing two strategies: EBP education and an EMR environment for convenient charting. Although compliance rates of the four criteria were improved, pain intensity showed no significant reduction from baseline to follow-up audits, which is similar to the findings of a previous study.[19]

The educational workshops during the implementation phase provided staff nurses with opportunities to learn the concepts and major components of EBP. We generated educational materials (a poster and a leaflet), displayed them on a bulletin board, and distributed them to patients and families. Several barriers to the effective treatment of cancer pain have been identified among patients and caregivers, including reluctance to take pain medications due to fear of addiction and side effects, acknowledgement of higher level of pain indicating awareness of disease progression, and fear that if they use pain medicine now, it would not be given later.[6] Lovell et al. found that educational intervention consisting of a video and booklet reduced the average and worst pain scores.[23] Nurses should consider that questioning patients and caregivers about barriers to taking pain medications and educating them about pain management are essential to good clinical practice.

EMR modifications to document the side effects of opioids and the use of a formalized pain assessment tool allowed nurses to more accurately and conveniently chart patient information, which led to noticeable improvements in compliance rates. The research team developed sub-menus for pain intensity, location, quality, provoking and relieving factors, and time aspects of pain in EMRs for use when nurses make nursing diagnoses of ‘acute pain’ or ‘chronic pain’. We also created a drop-down list of formalized pain assessment tools, that is the Wong-Baker facial scale, numeric rating scale or FLACC (Face, Legs, Activity, Cry, and Consolability), so that nurses have a list from which to select.

Criterion 2 changed significantly from the baseline audit. There was an 83% increase in the documentation, assessment and appropriate management of the side effects of opioids. It is important to predict and monitor opioid side effects, including nausea, vomiting, constipation, drowsiness, respiratory difficulties and urinary retention, as these symptoms discourage patients from taking opioids, resulting in inadequate pain control. Nurses should consider effective approaches to managing the side effects of opioids by taking histories of past opioid use and adverse effects, dose changes, and educating and supporting patients and caregivers.

Criterion 3 improved significantly after implementing the formalized pain assessment tool (22–75%). These findings are consistent with those of prior studies demonstrating that nursing education for pain assessment and documentation resulted in an improvement in nurses' knowledge and attitudes about pain and nursing practices.[24, 25] These results could be due to increased nurse awareness of the necessity of pain assessment and management through educational workshops, as well as the convenience of the modified EMRs. This could increase the number of chances for health-care professionals and patients to communicate and discuss the control of pain using a formalized tool for detecting and reporting pain.

Criterion 4 relates to documented evidence about patient and caregiver education, and whether or not they were given information regarding pain management. Although the hospital prepares informational materials regarding pain management, and nurses routinely provide them to patients and family members, they often forgot to document the action. This criterion achieved 47% compliance compared with 0% at the baseline audit.

Audits and feedback are widely used to change the clinical practice behaviours of health-care professionals, as well as to encourage guideline adherence.[16, 17, 26-29] We identified several barriers to pain management, and then implemented strategies and provided feedback to nursing staff. The study adopted a top-down approach, as our EBP implementation study was formulated without input from staff nurses. EBP projects might be more sustainable when nurses identify EBP topics based on their own clinical questions and needs.

This study has some limitations. It was conducted in a single oncology nursing unit and was implemented over a short period of time. The duration of this study was not long enough to examine long-term effects on nursing practice. In addition, we did not collect information about patient outcomes. Further studies are needed to examine patient outcomes, such as pain intensity and amounts of pain medications dispensed, which could provide further evidence of the effectiveness of implementing EBP guidelines.

Despite these limitations, we believe that this study was successfully implemented for several reasons. First, we developed a partnership between the university and hospital that capitalized on each party's strengths. The partnership created during this study could lead to more evidence utilization projects within more nursing units. This study also systematically implemented clinical guidelines with international collaboration and close partnership between Yonsei University medical system and JBI.

Second, we attempted to solve the study problem with a structural rather than a local approach, as evidenced by the modification of the EMR. The use of a menu-driven list on the EMR that shows the items outlined in pain management guidelines serves as a reminder of documenting essential aspects of pain to nurses. The amount of documentation that nurses perform has increased dramatically as nursing documentation is critical to the accreditation process. EMRs should be designed to enhance nursing documentation, should be convenient and should accurately reflect nursing practice without missing important facets of patient care.

Lastly, we acquired practical knowledge and experience in conducting an evidence utilization project and identified individuals who showed an interest in EBP. Our hope is that we will cultivate more EBP champions who will spread the culture of EBP in their workplaces, and that this dissemination will eventually improve patient outcomes. We suggest that this study will contribute towards future expansion to an experimental study with a control group and a sufficient sample size to test differences, including patient outcomes using a repeated measures design.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The audit and feedback method used in the present study proved to be applicable to the implementation of clinical practice guidelines for cancer pain management. Through this process, nurses increased compliance with best practice guidelines for cancer pain management, which in turn led to an improvement in the quality of nursing care. To successfully incorporate best practice guidelines into clinical practice, a hospital should consider the allocation of financial resources, time and human resources. Leadership from both administrative personnel and staff nurses will create a synergy for the spread of EBP culture in clinical settings.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

We would like to thank the Australia-Korea Foundation for funding this study, and the Joanna Briggs Institute (JBI) and its staff members for their enormous efforts and assistance, especially Dr. Rie Konno and Dr. Aye Aye Gyi, Mr. Sandeep Moola, and the members of the Yonsei JBI Centre at the Yonsei University College of Nursing. We also greatly appreciate the staff nurses of Ward 36 at Severance Hospital, who enthusiastically participated in this study, and the director and administrators of the Nursing Department at Severance Hospital for their support. This study was partly supported by the Korean Research Foundation (2009-0067338).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
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