BRIEF REPORT

Improving Patient Satisfaction

With Better Pain Management
in Hospitalized Patients
Jennifer DeVore, DNP, AG-ACNP, Amy Clontz, MSN, Dianxu Ren, MD, PhD,
Leslie Cairns, DNP, CMSRN, and Michael Beach, DNP, ACNP

ABSTRACT
Pain is a common problem in hospitalized patients. Pain management needed improvement at an urban
level 1 trauma hospital unit as evidenced by below benchmark pain management Hospital Consumer
Assessment of Healthcare Providers and Systems scores. A quality improvement project was implemented
that consisted of an evidenced-based nursing education program and the development and use of an
evidenced-based pain management algorithm for nurses. After completion of the quality improvement
project, nurses showed significantly improved knowledge regarding pain management and pain scores
improved. A pain management quality improvement project improved staff knowledge and patient
satisfaction with pain management.

Keywords: hospitalized patients, pain algorithm, pain management, pain satisfaction

2016 Elsevier Inc. All rights reserved.

INTRODUCTION how to manage pain and adequate use of analgesics,

P
ain is one of the most common reasons that
Americans access the health care system; it
has a multitude of adverse consequences if
not
managed appropriately.1 Adverse consequences
associated with inadequate pain management are
often related to decreased ability to move and include
(but are not limited to) strong associations with
thromboembolic incidents and pulmonary
complications, increased intensive care unit or
2
hospital time, and chronic pain. Patients’ reports of
satisfaction are increasingly used in public reporting
and in pay-for-performance programs, such as the
when to assess pain, and misconceptions regarding
4
opioids and addiction. Educating health care staff
about pain management improves patient satisfaction
5
and results in better pain control. A thorough pain
assessment and consequent reassessment are
considered important factors in improving patient
satisfaction, as they give patients the sense that their
nurse has genuine concern about their pain and is
6
doing their best to decrease their level of pain. Pain
management satisfaction increases when patients
report that their nurse frequently asked about their
pain, cared about the answer, and had excellent
response time to complaints of pain.
7

Hospital Consumer Assessment of Healthcare Pro-
3
viders and Systems (HCAHPS) program. Therefore,
hospitals and clinicians must make appropriate pain
management a standard of care to receive the
maximum reimbursement from the Centers for
Patient education is an integral part of the
nursing profession. Patients who are educated about
pain management are empowered to become
actively involved in their treatment and care, which
in turn improves patient satisfaction and outcomes.
7

Medicare & Medicaid Services for health care
services provided.
Nurses are direct patient care providers and have
the greatest opportunity to improve patient satisfac-
tion with pain management. Barriers to effective pain
management include lack of nursing knowledge on
Yet, in one study, 46.8% of patients did not receive
7
information about pain management. Another
study, at a community hospital, showed that patients
on a unit with lower satisfaction scores were 52%
more likely to report that education about pain

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 management was with pain patient ratios academic hospital in
inadequate, compared management. The average around 1 western Pennsylvania
with only specific aims nurse to 4 patients. during the period
36% of patients included: (1) The unit is from June 2015
reporting inadequate develop an primarily a trauma through September
education on a unit evidence-based and toxicology unit 2015. Patients were on
with higher education program with hospital the hospital unit from
6
satisfaction scores. and algorithm for overflow from January 2015 through
The same study found nurses aimed at other medical December 2015.
that 67.2% of patients improving patient- services, such as
dissatisfied with pain reported satisfaction orthopedic and Design
management also with pain vascular surgery. This project utilized a
reported inadequate management pre- and post-survey
patient education. In a among hospitalized M design and a
similar study at Mount patients; (2) assess E prospective pre- and
Sinai Hospital, of the nursing knowledge T post-algorithm
patients who rated and beliefs H descriptive
their nurse “excellent” satisfaction O evaluation. The
in all regarding pain D project committee,
3 categories—(1) management S consisting of a nurse
frequently asked about before and after and nurse
pain; (2) cared about training practitioners,
the answer; and (3) S
interventions on developed an
had excellent response a
the evidenced- evidence- based
time to complaints of m
based algorithm; education program
pain—87% also rated p
(3) implement the and algorithm (see
their pain satisfaction l
nursing education Figure) on pain
as excellent; however, program and
e management and a
of the patients who evidenced-based All staff nurses pre-/post-educational
rated only 1 of these were employed on
pain management test and nurse survey.
categories as excellent, the trauma and
algorithm; and (4) The algorithm was
only 16% rated pain toxicology
evaluate monitored unit at developed using
satisfaction as evidence from the
8 satisfaction with a level 1 urban
excellent. pain management literature and
The purpose of using HCAHPS underwent an
this quality scores before and iterative process of
improvement project after the education review and revision
was to: (1) increase program and until the committee
the knowledge of algorithm achieved a consensus
hospital staff nurses implementation. on the final
concerning the algorithm. The
manifestations, STUDY project gained
complications, and ENVIRONMENT institutional approval
interventions relating This quality from the hospital’s
to unmanaged pain; improvement quality improvement
and (2) develop, project was committee. The
implement, and conducted on a pre-/post-educational
evaluate an monitored unit test contained 6
evidenced- based with 23 patient items, which consisted
algorithm to improve beds. Nurse-to- of multiple-choice
patient satisfaction
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and true/false questions.
The nurse survey consisted
of 3 items, which included
2 multiple-choice questions
and 1 open-ended question.

Intervention
Staff nurses participated in
an educational in-service
conducted on day and
night shifts between June 6
and July 17, 2015, and
were also introduced and
educated on the pain
management algorithm.
Nurses were educated on
the manifestations,
complications, and
interventions relating to
pain. Participants took a
pre- and post-educational
test and a survey during the
in-service sessions and were
also asked how often
nonpharmacologic pain
management modalities
were used. Participants
were instructed to use the
pain management
algorithm to manage pain.
Nurses participated in a
second posttest, which was
con- ducted on a non‒in-
service day to assess
retained education.

Measures
The nursing pretest and the
2 posttest educational
scores were analyzed using
descriptive statistics, as were
the 2 post-surveys. In the 2
post-surveys, open- ended
responses were analyzed for
repeating themes. Pre- and
post-project
implementation pain

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Figure. Evidenced-based pain management algorithm.

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HCAHPS scores were
also analyzed using
descriptive statistics.
Pain HCAHPS scores
during the months of
January, February,
March, and April 2015
were used as baseline
comparison data, which
were compared with
pain HCAHPS scores
during the months of
September, October,
November, and
December
2015. May 2015, the
month immediately
before project
implementation; June
and July 2015, the
months of the in-service
sessions; and August
2015, the month
immediately after
project
implementation, were
not used for data
analysis. This time
frame prevented
confounding by staff
performance
improvement in
anticipation of the
project.
Data Analysis
Pre- and posttest scores
were analyzed using a
2-tailed independent t-
test (SPSS, Inc.,
Chicago, IL) to
compare pretests
independently to both
the first and second
posttests.
RESULTS
A total of 23 nurses were
included in the
educational in- service.
e6 The Journal for Nurse Practitioners - JNP
All 23 completed the test and the survey. plugs or headphones
pre- and post- Eleven nurses from 65%, 70%, and
educational participated in the 82%. No significant
second posttest. Nurse change occurred in
test scores increased reported use of
significantly after the elevation/repositioning,
educational intervention back massage, or with
(P < .05). encouraging mobility.
Nurse pre/posttest There was increased
survey answers (either frequency
“All of the time,”
“Most of the time,”
“Some of the time,” or
“None of the time”)
had inconclusive
results
in response to the
question, “Are
you able to
manage patients’
pain?” Some
nurses reported
increased ability to
manage pain and
others reported
decreased ability to
manage pain after
project
implementation.
Survey responses
regarding the frequency
of use of some
nonpharmacologic pain
management in-
terventions had
increased frequency of
response to: (1)
“always” use of
promoting sleep
hygiene from
57% to 64% (pretest
and second posttest,
respec- tively); (2)
“sometimes” use of
ice/warm packs from
13%, 17%, and 27%
(pretest, posttest, and
second posttest,
respectively); and (3)
“sometimes” use of ear
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of response “never” plugs/headphones many areas on the HCAHPS scores was
use of relaxation likely had a greater unit such as the small, which may be
channel/music from impact on reducing break- room and explained by the
22%, 26%, and 36%. pain than other central nursing unit’s high nurse
The pain modalities. This station. turnover rate during
HCAHPS scores increase may The results of the project’s timeline.
before the project explain the this project are Continuity of this
implementation had reduction in use of similar to those of quality improvement
an average of 55.5% relaxation other published initiative was likely
and a median of channel/music. studies, which disrupted as nursing
59.9%. The pain Nurses also showed that staff left and newly
HCAHPS scores reported decreased nursing education hired nurses joined the
increased after the ability to manage on evidenced-based unit. Also, pain
project pain after project pain management management is
implementation with implementation. strategies improved complex and
an average of 62% One explanation is patient satisfaction. improving patient
and a median of that nurses became The results satisfaction may
61.5%. more self-aware of contribute to the require continual
the difficulty and growing quality improve- ment
DISCUSSION complexity of knowledge efforts by all staff
The evidenced-based managing pain. regarding the caring for patients.
pain management Another expla- importance of
educational program nation, however, nursing expertise in Limitations
significantly could be that some providing effective There are limitations
improved nursing nurses may have pain management to this investigation.
knowledge regarding viewed the for patients. The The sam- ple size was
the manifestations, algorithm as improvement in small and the project
complications, and laborious and a was conducted on a
interventions relating hindrance to 23-bed unit. This
to unmanaged pain. managing pain. small sample size, the
Pain HCAHPS scores This possibility high turnover rate of
improved after requires further the staff, and the
implementation of exploration, but is limited population of
the education beyond the scope hos- pitalized trauma
program and pain of the and toxicology
management algo- current study. patients all limit the
rithm, reflecting an This project did generalizability of the
improvement in not notably add to findings. Future
patients’ satis- faction the nursing projects should assess
with pain workload. It whether similar
management. consisted of brief, findings would be
Nursing use of 15-minute in- observed in different
nonpharmacologic services with e- patient populations
pain manage- ment mails sent to nurses and on a larger scale.
modalities increased in as reminders to use
some modalities and the pain CONCLUSION
decreased in others. management Quality improvement
The increased use of algorithm. projects bring
ice/warm packs, sleep Reminders were evidence into
hygiene, and ear also posted in practice. This project

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increased nurses’ knowledge
regarding pain
management. The nurses
then used this knowledge
to better manage their
patients’ pain and also
educated patients on pain
management as part of an
evidenced-based algorithm.
Nursing and patient
education and the use of an
evidenced-based algorithm
enhanced patients’
satisfaction with their pain
management, as reflected in
the improved HCAHPS
scores. Future projects
should address whether
similar findings occur using
the same algo- rithm or a
similar algorithm that can
be utilized by other
medical team staff
members. Medical team
members rather than nurses
alone, such as nurse’s aides
or advanced practice
providers, should also be
included in the educational
programs in
future projects.
The role and impact of
the nurse practitioner is
continually improving
patient care through the
development and
implementation of quality
improvement initiatives.
Nurse practitioners play a
key role in bringing
evidence-based research to
practice in order to provide
superior quality patient
care. For ACNPs who work
closely with the nursing
teams, this article provides
some contemporary ideas
about how to feasibly bring
evidenced-based practice

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0

to the bedside. This
study is different than
others found in the
literature because it
was a nurse practi-
tioner lead QI project
that implemented a
nurse- driven protocol.
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I
project were limited by n
c
the sample size; All authors are affiliated with .

however the positive the University of Pittsburgh

finding of increased in Pittsburgh, PA. Jennifer A
l
patient satisfaction DeVore, DNP, AG- l

suggests that the design ACNP, is a staff nurse in

of this QI project could the Acute Care Adult
r
i
have similar results if Gerontology Nurse g
h
utilized by other Practitioner Program. She can t
institutions on a larger be reached at
s

sample. I would devoreja18@gmail.com. r

entertain emails if any Amy Clontz, MSN, is a e
s
NPs are interested in trauma services nurse e
carrying on this type of practitioner at the University r
v
work. of Pittsburgh Medical Center. e
d
Dianxu Ren, MD, PhD, is .
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