Pain Assessment for Non-Communicative Patients

CHAPTER 1

1.0 Introduction

Whereas individuals experience pain at a subjective and personal level, observations by Witt et al (2016) indicate that pain cannot be measured through objective tests. Therefore, whenever possible, pain is measured through patient self-reporting, thus explaining the clinical definition of pain as whatever the experience the individual describes it is (Fallon et al, 2018). However, some patients are unable to verbally, in writing or in any possible way, self-report their experience of pain. The focus of this practice improvement project (PIP) is on pain assessment among patients who are unable to self-report pain. Thus, this PIP will dwell mainly on specific populations such as elderly patients with communication issues emanating from conditions such as dementia; toddlers and infants who are still not able to effectively communicate, as well as unconscious patients with deteriorated communication abilities. The project will focus on populations who are unable to communicate due to learning disabilities that hinder them from self-reporting their pain experiences, thereby impeding physicians’ ability to asses and manage the pains. Fundamentally, pain assessment and management are based on various ethical tenets within the practice of healthcare. Particularly, according to Tsai et al (2018), pain management draws its background from the ethical principles of non- maleficence and beneficence, which mean the duty to cause no harm and benefit the other respectively. Health practitioners must adhere to these ethical principles whenever they are managing pain or when providing comfort to various types of patients, including those with various vulnerabilities. Besides, the principle of justice within the patient care setting requires that practitioners must provide quality and humane care by respecting human dignity. Based on the principle of justice, patients should receive a compassionately delivered care regardless of their economic status, personal attributes and severity of the health problem. The groups that are unable to self-report pain undergo both physiological and psychological distress because if the pain is not detected early enough, it can lead to the damage of body tissues (Salam et al, 2015). Furthermore, if injury goes unnoticed, it might escalate to a fatal extent. Therefore, clinicians need to detect the existence and severity of pain as early as possible. With this regard, some researchers insist that patient pain self-reporting is the most reliable way of evaluating pain. However, if the patient is unable to self-report the pain, physicians should use alternative methods of pain assessment (Hush et al, 2018).

In a clinical care setting, the first procedure in pain management is its evaluation (Watterberg et al, 2016) using a reliable pain assessment tool. Such tools enable physicians to make the right decisions when developing pain management interventions for patients. Therefore, because pain evaluation is a fundamental element of effective nursing interventions, healthcare facilities should have effective and practical approaches to detecting, measuring and managing pain (Lichtner et al, 2016). Nosier et al (2016) observe various effects of pain on patients, including reduced quality of life, impaired sleep, reduced participation in social and recreational activities, poor eating behavior, reduced mobility and delayed healing. Furthermore, according to Elder et al (2016), patients may develop declined body function, depression, and agitation especially the elderly. The lack of pain detection is often reported among the elderly and other special patient groups such as children who cannot self-report pain. According to Daler & Biornsen (2015), it is highly likely that unreported pain may go untreated, creating more health complications for the patient, and consequently longer stay in the hospital. This paper is a proposal for a practice improvement project that aims to improve pain assessment among patients with communication difficulties.

Chapter 2

2.0 Background

2.1 Introduction

This chapter will present a background of the study by highlighting the existing literature on pain assessment in patients with communication a range of communication impairments and barriers for example, children may not have impairments but face barriers because of their lack of vocabulary. Pain assessment is a complicated affair considering the complexity that accompanies the perception of pain. According to Abbey et al. (2004), pain is a multifaceted and subjective phenomenon that is influenced by a variety of factors, including culture and past experiences. An individual, regardless of their health condition, can experience spiritual, social, or physical pain (Abbey et al., 2004). Thus, pain assessment denotes the recognition of the level of pain severity, which is important because it helps evaluate the effectiveness of pain management treatment (Bird, 2005). Under normal circumstances, pain assessment begins by asking the person how they feel about the pain because they are the only ones able to describe what pain they are experiencing. In more unfortunate situations, practitioners assess pain intuitively by observing the individual’s behavioural response to pain. According to Corbertt et al. (2014), the intuitive assessment of pain may result in a failure and should not be applied, especially in cases where the individual can provide information about their pain. There is an increasing interest in pain management, especially among patients with poor communication abilities and learning disabilities (Dowding et al., 2016). According to Feldt (2000), pain assessment is more complicated in people with severe communication disabilities because obtaining information from them may be difficult. Moreover, other problems with pain assessment may result from their unique attitude towards the pain (Gregory, 2017). For example, in the case of dementia patients, the belief that pain is part of aging may cause them to be reluctant to report pain (Coker et al. 2008). Furthermore, according to Gregory (2012), older adults may use words that deny pain but acknowledge aching, hurting, and discomfort.

2.2 Pain Assessment Tools

While patients with cognitive impairment, or those in acute conditions may completely not be able to communicate their experience of pain (Corbett et al. 2014), the patient’s experience with pain can also be conveyed non-verbally, such as through timbre speech, facial expression, and muscle tension (Sheu et al. 2011). Hence, when physicians ask patients about their pain, they also automatically observe these behaviours as it is not expected that the patient would appear relaxed and still report pain. This implies that the non-verbal cues are more important when assessing pain in patients who are struggling to convey their experiences with pain. Regardless of the patient’s communication abilities, they should be asked about their pain. Nevertheless, the less a patient can describe their pain, the more the physician should rely on the patient’s behaviour through observation (Abbey et al., 2004). The main rationale for the use of pain assessment tools is to quantify the intensity of pain. Abbey et al. (2004) assert that pain assessment tools rely on a uniform standard of assessing pain, thereby improving communication because the scores can be incorporated into charts for further interpretation and use. In acute care settings, self-report is the standard assessment technique for pain assessment, whereby the practitioners use questions and tools meant to evaluate the pain intensity (Sheu et al. 2011). Despite their widespread use in pain assessment, the tools have several shortcomings that have been pointed out in most pieces of literature. In most cases, pain assessment tools use questionnaires that assist in self-reporting pain severity (Gregory, 2017). Thus, according to Mohan et al. (2013), the tools require individuals to remember the painful events, understand the request for pain rating, and rate the pain. This implies that the use of pain assessment tools is not practically applicable to certain groups of patients, such as children and adults with severe communication challenges, cognitive impairment, language barriers, and poor conscious levels (Sheu et al. 2011). Increased levels of cognitive impairment, or even learning disabilities, individuals are less likely to give an accurate report of pain, and practitioners are less likely to assess and treat the pain (Gregory, 2017). Clark et al. (2004) observed that practitioners working in nursing homes for people with learning disabilities adopt a relationship-cantered pain assessment, which includes knowing the patient and using that relationship to understand the vital pain cues for that patient, then using them to assess the patient’s pain. The participants interviewed by Clark et al. (2004) et al. illustrated how knowing crucial pain cues for the individual patient triggered a change in behaviour that led to a successful pain assessment for the patient. Besides, McAucliffe et al. (2008) observed that it could take at most three months to have substantive knowledge of a patient’s pain cues. However, in some settings such as acute care settings, there is a lack of time to develop such a relationship with the patient (McAucliffe et al., 2008). All in all, existing literature suggests that assessing pain in non-communicative patients is a challenging affair that requires other sources of data apart from self-reporting such as behaviour observation, health history, and proxy reports (Ersek et al. 2010).

Ruder (2010) argues that behaviour observation is an important element of all pain assessments. However, according to the authors, behaviour observation remains to be the only option when patients are unable to communicate. With this regard, three behaviour have been identified as possible indicators of pain, namely facial expression (grimacing), changes in interaction (withdrawal or aggressiveness), verbalization, and body movements (rigid or tense), changes in mental status and changes in activities of living (American Geriatric Society, 2002). However, existing literature by Buffum et al. (2007) also indicates that these behaviours may also indicate the existence of other conditions such as thirst, hunger, depression, or anxiety, thus the need to complement them with other sources of information. According to Mohan et al. (2013), most pain assessment tools have been designed to incorporate most of these indicators. While most of the indicators may not be specific to pain behaviours, they play a vital role in identifying and assessing pain. This implies that the tools should be used consistently. But, according to Mohan et al. (2013), different care settings and populations shave different tools that are applicable to them. Thus, there are two main types of behavioural pain assessment tools; the first one whereby the practitioner is familiar with the patient and can detect any slight behavioural changes, and the second one whereby a tool is used assess more obvious pain behaviours and is used more frequently. According to Buffum et al. (2007), the behavioural tools of pain assessment can be used together with information from close relatives and family to help in the identification and assessment of pain that patients cannot report on their own. Consequently, there has been a rampant use of behaviour observation pain assessment tools, popular ones being the behavioural pain scale (BPS), the BPS was originally published in the French language and translated into Chinese Ahlers et al (2008), Swedish (Ahlers et al, 2010), Persian (Rahu et al, 2015), and English (Payen et al, 2001). It had three sections, namely upper limb movement compliance with mechanical ventilation, and facial expression. The total minimum score for the three parts is 3 for no pain and a maximum of 12 points for maximum pain. Due to its extensive use, a variety of studies have evaluated its reliability, validity, responsiveness, feasibility, and limitations.

With regards to reliability, three studies (Payen et al. 2001, Ahlers et al. 2008, and Rahu et al. 2015) conducted a test and retest evaluation of its reliability and found satisfactory results of reliability. All the studies found a satisfactory level of reliability (r = 0.50-0.84, p < 0.001). Furthermore, a variety of studies (i.e., Chanques et al. 2014; Feldt et al. 1998, Feldt 2000) has evaluated the tool’s internal consistency and found it to have a ranging score of 0.59-0.80 in the Cronbach’s alpha, signifying a moderate to high internal reliability. Studies by Chanques et al. (2014); Feldt et al. (1998), Feldt (2000) found an inter-rater agreement level of over 85%, which is statistically acceptable. Nevertheless, in a study by Covington-East et al. (2014), and inter-rater agreement of 82-91% was achieved when the patient felt no pain, while after oral care, the inter-rater agreement turned to 64-73% despite being 36-46% when the pain was stimulated by a change in position. There are several other observational tools that have been recommended for use in assessing pain among patients with severe communication challenges. For instance, the Checklist of Non-verbal Pain Indicators (CNPI) developed by Feldt (2000), the Pain Assessment IN Advanced Dementia (PAINADI) by Warden et al (2003) and the Abbey Pain Scale by Abbey et al (2004) are considered some of the most popular observational pain scales among physicians in the UK. The Abbey Pain Scale assesses pain based on six categories, including physical changes, physiological changes, body language changes, facial expression, and vocalization. It has a score of 0 to 24 and has been recommended by the British pain Society, British Geriatrics Society, and the Royal College of Physicians. Developed in the USA, the PAINAD assesses pain based on five observations, namely body language, facial expression, breathing, consolability, and negative vocalization (Warden et al., 2003). It scores pain levels on a scale of 0-10 based on a descriptive pain guide. Apparently, both the PAINAD and Abbey Pain Scale were developed for use in long-term care settings where patients with cognitive impairment are cared for by experienced staff who know their patients’ behaviours. Originally developed for the orthopedic setting, the CNPI measures pain based on six main aspects, namely verbal complaints restlessness, rubbing, bracing facial wincing, bracing, and non-verbal vocal complaints (Feldt, 2000). The CNPI measures the pain items in two scales: 0-representing, not present, and 1-representing present, either when the patient is at rest or on movement. The points are then summed to produce a maximum of 12 points. Researchers have weighed the pros and cons of pain scales and came up with interesting observations. For instance, Williamson & Hoggart (2005) commented that the most popular pain assessment tools, such as the visual analog scale (VAS) verbal descriptor scale (NRS) and the numerical rating scale (VDS) are easier to use have considerable levels of reliability and validity. While they did not recommend any specific pain scale (i.e., among VAS, NRS, and VDS) to be above the other, the authors argued that the most important thing is to compare the pain scores with the previous scores when for purposes of deducing the patient’s pain severity. In another small study by Gregory & Richardson (2014) aimed at identifying the most popular pain scale in North West England, it was found that VAS was the most popularly used scale.

Layman et al. (2006) emphasized the need for consistent use of a single pain scale that is known to everyone within a practice setting to avoid inconsistencies that may put the patient’s life in danger. In the study by Gregory & Richardson (2014), the participants reported to have used more than one scale, and none of them agreed that they would use more than one scale to assess pain in one patient. As recommended by Mohan et al. (2013), this implies a patient-centred approach whereby a scale suitable for a specific patient is chosen and used consistently. Pain scales are only designed to measure pain intensity as opposed to other features of pain, such as provoking factors, quality of pain, and duration of pain. However, scientific development has seen the emergence of other pain measurement tools such as the PQRST mnemonic for pain and assessment, which facilitates a more comprehensive measurement of pain (Gregory, 2017). Because pain measurement goes in hand with physiological observations, physicians prefer to conduct pain assessment when the patient is at rest. Nonetheless, according to Mohan et al. (2013), pain assessment scales are more effective when the patient can understand the scales and when the physician can conduct a careful interpretation of the scale readings.

2.3 Contemporary guidelines and protocols of pain assessment in infants

Existing research has highlighted various recommendations on pain assessment for patient groups with different communication problems. Considering that the proposed project focuses on behavioral pain assessment tools, it is monumental to explore existing literature on some of the literature’s recommendations on the use of such tools. Apparently, there had been shortage tools with strong validity and reliability that can be used to assess pain in patients with certain communication issues such as dementia patients, anno current research evidence indicating that the shortage is no more. Nonetheless, according to Severgnini et al (2016), some of the existing tools are somewhat unreliable because the underlying research that led to their development relied on smaller sample population. Therefore, if a behavioral indicator has few features, it may be feasible to use although the feasibility may reduce in case of patients with less obvious behaviors. On the flipside, tools with more comprehensive checklists may be have better sensitivity despite the likelihood of identifying pain in patients who may not be experiencing any pain. Therefore, behavioral pain assessment tools with high sensitivity may be more desirable but may be more effective if an evaluation is conducted to validate that pain is the underlying cause of the experienced behavior. The validity issue that accompanies the use of behavioral pain assessment tools make sit necessary for clinicians to review all the available tools to establish the most appropriate one to use in the particular care setting that they target to use it (Alwan et al, 2019). Furthermore, according to Gellinas (2016), clinicians should obtain data from quality improvement projects before using these tools, just to ascertain that they are the most appropriate for use. This recommendation explicitly justifies the need for the proposed quality improvement project, which seeks to review and identify the most appropriate pain assessment tool for patients with communication problems who cannot self-identify pain. Within this context, there are several suggestions made by researchers on how behavioral pain assessment. First, it is important to understand the process by which patients develop the inability to self-report, which depends on the level of illness severity or disease progression. For instance, Fillingim et al (2016) observe that sometimes patients have mental health issues such as dementia that adversely affects the patient’s ability to self-report pain. Particularly, dementia causes adverse damages to the central nervous system, thereby affecting the patients’ memory, language and cognitive abilities needed to communicate their experiences. Yet, even with such damages on their cognitive system, the patent may still experience pain akin to that experienced by patients with intact cognitive capabilities (Schuler et al 2004). However, according to Scherder et al (2005), such patients generally have reduced abilities to interpret the pain stimulus and how their response to that sensation occurs. Nonetheless, while patients with mild to moderate cognitive impairment can self-report pain, this ability reduces with illness progression, leading to an eventual inability to self-report. Literature also highlights some strategies that can be used to identify the potential cause of pain in patients with chronic illnesses such as dementia. For instance, when assessing pain (such as low back pain, history of arthritis or neuropathies) among older patients, clinicians can consider common causes of pain such as neurologic and musculoskeletal disorders and prioritize them (Grace et al, 2017). Besides, it is important to consider other acute pain related items factors such as skin tear, urinary tract infection or pneumonia, which could cause pain.

While the use of pain assessment tools are considered the first priority in behavioral pain assessment, clinicians are advised to observe patient behaviors such as vocalization, facial expression, changes in their interpersonal reactions, routine change and body movements to identify and categorize pain especially among older people (AGS, 2002). Ideally, some behaviors are typically common indicators of pain, to an extent that one does not need a tool to ascertain that the patient is in pain. For instance, according to Devlin et al (2018), groaning, rubbing a body part or facial grimacing may directly indicate that the patient is in pain. However, there are other less obvious observations such as restlessness, confusion, irritability, agitation and combativeness that may require a follow-up evaluation to ascertain their indication of pain (Merola & Mills, 2016). Therefore, patients may not always display behaviors that typically indicate pain, and that pain may be indicated in the most subtle ways. In most cases, clinicians have also been advised to use the approach of surrogate pain reporting, where the caregiver or family member assists in identifying and reporting the patient’s pain experience. In care settings that have a long-term trajectory, certified nursing assistants play a key role in recognizing and reporting the patient’s pain experience (Fisher et al 2002). This implies that nursing assistance should receive effective pain assessment training as part of the requirements for practice certification. However, it is highly likely that family care giver will have the most familiarity with the patient’s pain behavior, especially by noticing changes in the patient’s usual activity that may indicate the presence of pain (Friesen et al, 2017). Therefore, family caregivers play an important role in patient pain assessment, especially in care settings where clinicians may not have the patient’s history. Thus, in the proposed project, the researcher will identify and utilize opportunities for involving family caregivers by teaching them how to use behavioral tools in assessing pain in patients under their care. A comprehensive review of literature also reveals the use of analgesics as a pain assessment tool in patients who are unable to self-report pain. Ideally, according to Main (2016), this entails the use of previously obtained information from earlier assessments before selecting appropriate analgesics. For instance, in situations where there is no change in pain indicating behaviors or if pain persists clinicians can prescribe 500 to 1000 mg of acetaminophen taken after every six hours (Manfredi et al 2003). Furthermore, according to Manfredi et al (2003), opioids have been useful in confirming that patient’s agitation is as a result of pain, although when prescribing opioids, clinicians should reduce the dosing by 25% to 50%. There are seal reasons why physicians may prefer to use analgesic trial to validate the presence of pain before resorting to psychotic medications. For instance, Gellinas (2016), the use of analgesic will yield faster response compared to psychotic medications. Similarly, analgesic interactions have less serious adverse effects compared to psychotic medications, and it is less likely that the pain being assessed will not be obscured with the sedative properties of psychotic medications (Friesen et al, 2017). Therefore, the use of analgesics will contribute to a detection and treatment of pain. However, Schofield (2018) advises that clinicians may consider alternative psychiatric approaches such as changing doses of various pharmacological approaches if the patient’s behavior fails to improve with the use of analgesic trial.

2.3 Contemporary guidelines and protocols of pain assessment in unconscious persons

Pain assessment in unconscious persons is unique from the other groups despite following similar strategies such as self-reporting, exploration of potential causes of pain, observation of patient behavior and surrogate reporting. Whereas it may be completely difficult to receive self-reporting from unconscious patients, clinicians should try to get it. Ideally, as Schofield (2018) observes, unconscious patients have communication and cognitive limitations that makes it difficult to self-report their experience of pain. Therefore, clinicians should try and conduct a serial assessment of the patients’ ability to self-report before attempting this strategy (Simons et al 2003). With regards to identifying potential cause of pain, Gellinas (2016) asserts that such patients may experience pain as a result of traumatic injuries, invasive instrumentation, the patient’s existing medical condition and surgical procedures. Moreover, the patient may be undergoing pain after catheter removal, wound care or turning (Simons et al 2003). According to Schofield (2018), verbal adults can describe medical procedure-related pain using words such as stinging, sharp, awful, shooting or stabbing pain. Therefore, clinicians should assume that unconscious patients in pain also experience these sensations. Nevertheless, hidden infection, discomfort and immobility may cause pain in unconscious patients. When observing patient behavior, according to Schofield (2018), clinicians should look up to expressions such as grimacing, wincing and frowning, which are often expressions of pain by critically ill patients. The patients may also be immobile, have increase muscle tone and fidget, all which are signs of pain. Gellinas (2016) recommends against the use of behavioral pain assessment scale in pharmacologically paralyzed patients because they tend to be too flaccid to give a behavioral response to pain. Therefore, in the case of patients under relaxants, clinicians should assume the patient is in pain and administer analgesics. According to Schofield (2018), clinicians should also be aware that patients in critical conditions may display anxiety and fear related to being under an intensive care unit. Therefore, conducting an analgesic trial may be useful in differentiating pain behaviors from distress behaviors (Simons et al 2003). Schofield (2018) asserts that clinicians may be misled if they rely on vital signs as primary indicators of pain because the vital signs may be attached to the patient’s underlying physiologic conditions medications or homeostatic changes. Furthermore, there is a paucity of research supporting the use of vital signs as pain indicators. However, according to Foster et al (2003), the patient may display a temporary increase in behavioral and physiologic responses with a sudden increase in pain. This implies that any change in physiologic measures should be considered an indicator that there is need begin further pain assessment, while conversely, an absence of any increase in ital. signs should not be construed as an absence of pain.

Whereas no single behavioral pain assessment tool has shown any good results when used with unconscious patients, clinicians may use tools that have been tested and validated in other settings if they are appropriately applicable to the pain problem. However, according to Gellinas (2016), behavioral pain assessment tools should be tested first to ascertain that they are valid and reliable before using them in populations they were not originally meant for. Nonetheless, surrogate pain reporting can also be used in unconscious patients. According to family members, parents, and caregivers of critically ill patients can report their assessment of the patient’s pain experience (Simons et al 2003). However, this should also include a response to an intervention because it may be a cause of pain in critically ill patients. With regards to analgesic trials, according to Schofield (2018), clinicians may initiate analgesic trial if they suspect pain, particularly to verify the existence of pain. Furthermore, any ongoing treatment should consider the fact that unconscious patients have unique issues, and that the continuous use of sedatives, comfort measures and analgesics can help in relieving pain (Schofield, 2018). However, Schofield (2018) cautions that sedatives and paralyzing agents should not be used as an alternative for analgesics. Moreover, it is important to note that opioids cannot be used in unconscious patients because opioids prevent successful extubation; nonetheless, any suspected pain in unconscious patients should be treated immediately. However, recommendations by Gellinas (2016) indicate that clinicians should use fewer sedating approaches and agents such as anti-inflammatory drugs, epidural analgesia and patient-controlled analgesia when treating pain in unconscious patients. If the clinician is handling a patient with head injury, there should be a balanced use of opioids to avoid the risk of sedation. (Simons et al 2003).

2.4 Justification of the Project

To improve the practice of detecting pain among patients who are unable to self-report their pain experiences, this practice improvement project is proposed to improve the assessment of pain through non-verbal indicators among nursing patients who are not able to communicate their pain due to various health issues that impact on their ability to communicate. The main motivation for the author’s proposition of this project is an observation of difficulties in identifying and assessing pain with people with communication problems. The author, therefore, saw a need for non-verbal ways of identifying pain among patients to improve the quality of care and patient experience within the hospital care setting. Particularly, the author is proposing a behavioral pain assessment tool that will help in evaluating patient pain by observing the patients’ behaviors rather than relying on self-reporting. This project proposal will be presented in a logical and detailed manner. The PIP will be structured into several sections explaining different aspects of the proposed project including the improvement plan, the intervention, the ethical considerations, data analysis and the presentation of results. Ultimately, the quality improvement project proposal will identify and justify the process to be applied by a team of healthcare professionals based in a hospital will develop a suitable pain assessment tool to assist them in assessing pain through non-verbal communication.

Chapter 3

3.0 The Improvement

3.1 Introduction

Phillips and Simmonds, (2013) observed that in healthcare settings, practice improvements occur when the targeted cohort of practitioners identify, understand and embrace modifications aimed at enhancing service provision in new ways. Consequently, the care setting transits into an environment of quality, productivity and efficacy within any service provided, leading to improved satisfaction of both patients and caregivers (McSherry et al., 2012).

3.2 Project stakeholders

3.2.1 Patients and their Families

Patients and their families will play a central role in the proposed project because they are the main stakeholders as well as the patients. Affective identification and assessment of pain for the patient not only contributes to their physiological well-being but also helps in enhancing person-centered care where close attention is paid to the patient’ needs (Cea et al, 2016). Involving the patient and their families in decision-making during the pain assessment is an essential aspect in all care settings, particularly considering that patients are the main reason for the hospital’s existence. Here, patients will be involved in the observation and audit stages of the study, where the author will observe how nurses assess pain before and after the intervention to measure the effectiveness of the introduced pain assessment tool.

3.3 The Healthcare Professionals

Selected registered nurse practitioners within the hospital will also take part in the project. In detail, some of the practitioners expected to be part of the project include, the case managers, nurses, physicians, psychiatrists, nurses and general practitioners. Nurses and general practitioners are inherently under close interaction with the patients are responsible for identifying the patients’ health needs including pain-relieving. They are also responsible for availing any internal or external resources needed for pain management. Therefore, failure to have an effective behavioral pain assessment tool limits their ability to manage pain. While all these stakeholders will be involved in the project at different capacities, the change agent will select a team 10 of higher-ranking nurses to assist with the project execution. They will participate in on behalf of the other practitioners (i.e. sample) in executing the selected pain assessment tool from baseline to post-intervention audit stages.

3.4 The proposed Improvement

The necessity of this improvement was identified by the author during a placement as a student nurse in a brain injury hospital, where she noted the absence of an effective behavioral pain assessment tool. Upon identifying this practice gap, the author engaged her colleagues in a clinical reflection after which they resolved that the lack of an effective behavioral pain assessment tool was a problem considering the increasing number of patients admitted to the hospital with various brain injury issues. The main aim of the proposed PIP is to improve practitioners’ ability to use behavioral pain assessment tools for the assessment of pain among patients with communication difficulties by identifying effective behavioral pain assessment tools and educating practitioners on how to use such tools. To achieve this, the change agent will use a workshop style of training to introduce staff to a specific behavioral pain assessment tools and how to use them. The participants will then be asked to use and test the most effective tools from the ones they have been trained on for official adoption in the hospital. The entre process will be executed in phases as highlighted below:

Phase 1: Audit of current practice

The first step will be to audit the current pain assessment practice in a hospital for people with severe communication problems (e.g. Badby Park). The audit will consist of a checklist (Appendix 2) that examines whether the nurses use any pain assessment tool in their normal practice, whether there is a section of pain assessment in the patient’s care pathways and whether they use any pain medications on patients. It might be challenging to obtain a 100% nurses’ participation due to multiple roles that nurses play in a normal day of duty. In the event of a poor participation or collection of inadequate data, each nurse will be required to make a second attempt and gather enough baseline data. The audit of current practice will be conducted using various tools and approaches. For instance, each of the ten participants will observe and record practice related to pain assessment among patients in each ward during the measuring of initial signs, medication administration, and ward rounds. The observer will record whether each patient was asked about pain, and the data obtained from all the wards will be organized for further comparison between patients with intact communication abilities and those with poor communication abilities. This phase will be considered successful if the assessment outcome shall identify practice gaps within the wards, and if there was a use of wrong tools in conducting behavioral pain assessment, if there is insufficient pain assessment frequencies in the care pathway. These results will indicate a lack of effective pain evaluation tool in patients with poor communication abilities.

Phase 2: Focus Groups

The tools will be identified through an elaborate literature review. An examination of literature relating to communication difficulties and pain assessment will be conducted with the help of the hospital librarian. The literature review will target existing behavioral pain assessment tools, with the abstracts, inclusion and exclusion criteria of the literature materials evaluated before including the respective tools they represent. This will result into a variety of evidence-based tools to choose from. After developing a list if evidence-based tools, the change agent will lead the focus group into selecting one most appropriate tool to be implemented in the wards.

Phase 3: Training and Workshops

The third phase will be executed in two workshops involving all the ten nursing professionals. The workshops will mainly be meant to introduce the nurses to the selected pain assessment tool, how it works and the importance of pain assessment. Besides, the workshop will involve presentations on pain assessment when caring for a variety of patients with brain injury who are incapable of communicating their pains. The workshop facilitators will also create a session for receiving claims, issues and concerns concerning pain assessment for further discussion and clarification.

Phase 4: Examination and trial of the tools

After conducting the workshops, the change agent will develop and implement an implementation plan that would see the new tool implemented for two weeks before re-evaluation. The selected tool will be tested in all the wards. To effectively complete this exercise, each ward will be assigned a nurse responsible for the trial of the selected tool in their respective wards. Furthermore, the nurses assigned to each ward will play the role of explaining to other healthcare workers how to use the tool.

Phase 5: Re-evaluation

The next phase will be evaluation of the tool to identify its effectiveness. To do so, an evaluation sheet will be distributed to each of the ten nurses for gathering specific information about the tool’s effectiveness. Some of the questions to be included in the tool are the staffs’ demographic data, the ward type, professional background, and the extent to which they had understood the tools, whether they encountered any difficulties in using the tools and how long it took them to use the tool. Afterward, they will be asked to rate the tool in scale of one to ten and give any comments regarding the pain assessment exercise using the tools. In case a nurse’s evaluation sheet is filled before the end of the trial session, each nurse will receive a second round of evaluation sheets. This is to ensure that as much information is collected as possible to help with a better evaluation of the tool. Appendix 1 illustrates an example of the evaluation sheet. In the end, the evaluation sheets will highlight various ratings and participant’s opinions regarding each pain assessment tool. The change agent will then convene another focus group with the nurses to discuss the outcomes and hear their opinion of how the tool has changed their practice of pain assessment. One of the key themes that the committee will look out for in the findings include whether the tools were accepted by the participants. The findings of the evaluation process will be discussed in the focus groups. The discussion will take different dimensions including identifying any similar ratings among the nurses, or any other interesting data that would help in identifying an important element of the behavioral pain assessment tool. The discussion will also aim to build a consensus among nurses on the risks and safety precautions to take when using the new tool. After the discussion, the committee will draft an official memo to be distributed among all healthcare professionals in the hospital informing them of the newly adopted tool. The Memo will describe all the various steps and procedures to follow when using the tool, which will then be distributed to all the stakeholders, with copies distributed to all the wards. Furthermore, the change agent will have a discussion with the senior hospital staff for endorsement or suggestion for amendments. The project will use qualitative methods (focus groups) to measure practitioner’s views about how successful the assessments have been. Therefore, the expected outcome of the project includes:

All the cohort practitioners are responsible for caring of patients with communication problems will have a comprehensive understanding of the importance of non-verbal pain assessment tools and how to apply those tools in effectively assessing pain.

An elaborate audit and feedback program to ensure that all the practitioners in the cohort effectively use non-verbal pain assessment tools.

Chapter 4

4.0 Methodology

Research methodology stipulates the strategies and techniques used in executing the study to an extent of gaining conclusions are answers to the research question (Trochim, 2010). Furthermore, according to Perri and Bellamy (2012), research methods entails the structures and tools used in facilitating the achievements of research objectives. This section of the proposal identifies techniques, tools and strategies that will be used to execute the proposed practice improvement project. There will be detailed description of the actions taken in educating and implementing behavioural pain assessment tools proposed by the change agent. Moreover, this section will highlight the rationale for the selection of each research methodology.

4.1 Research Approach

Research approach defines the strategies and techniques used in collecting, analysing and interpreting data (Trochim, 2010). Data collection approaches include quantitative and qualitative approaches while data analysis approaches include inductive or deductive approaches. While quantitative approaches of data collection are conventionally used in the field of research because they produce more reliable and verifiable data, qualitative approaches have also gained popularity among many scholars (Topping, 2015). However, there are several disadvantages of quantitative research methods that the proposed study might encounter. For instance, according to Topping (2015), quantitative methods are notorious for combining different variables into a single measurement. Another disadvantage of quantitative research is that they give outcomes without giving enough information on what constitutes the outcomes, and this limits the researcher’s ability to implement improvements based on the research findings (Trochim, 2010). On the other hand, qualitative research methods entail the collection of subjective information such as narratives, experiences and perspectives from the participants (Pachico and Fujisaka, 2004). Qualitative approaches can be used to address the limitations of quantitative approaches. By use of qualitative approaches, researchers can capture aspects of data that cannot be captured quantitatively through numbers (Leeuwis et al., 2011). Based on the advantage of both quantitative and qualitative approaches, the proposed study will use a mixture of both to achieve its objective. In doing so, the author shall have enhanced the credibility of the PIP through combined approaches that complement each other to yield more reliable results. Indeed, as suggested by Bowling, (2009), the use of both qualitative and quantitative research approaches will contribute more benefits to the study credibility than when each approach is used on its own. The following are detailed rationales for the use of both qualitative and quantitative research approaches in the proposed PIP:

Quantitative research approaches will enable the statistical analysis of data to compare the effectiveness of the selected behavioural pain measurement tool by analysing their respective ratings from each participant.

Qualitative approaches (i.e. focus group) will be useful in collecting textual data from the cohort participants with regards to whether they have improved knowledge of behavioural pain measurements techniques, and whether they are satisfied with the selected pain assessment tool.

The use of mixed research approaches will satisfy the assertions by Bowling, (2009) that one research approach might not answer all the research questions within a single research topic.

4.2 Research Design

Bowling, (2009) observes that a study can either take quasi-experimental or experimental research designs. The proposed study will take quasi-experimental research design as opposed to true experimental design. This implies that the study will miss out on important advantages of true experimental research designs such as the use of random selection of participants thereby eliminating the effect of confounding factors on the results (DePoy et al., 2016). However, the selection of quasi experimental design as opposed to true experimental design will help eliminate some significant limitations of the latter design such as the challenge of designing the study because specific populations will have to be represented (DePoy et al., 2016). The proposed project will also entail a review of evidence on behavioural pain assessment tools and how they should be used in normal care settings. In doing so, the change agent will rely on emancipatory practice development and participatory action research methodology. This implies that the change agent will draw from the critical social science perspectives, which, according to Fontana (2004), entail emancipating and empowering the project’s target group and freeing them from cultural, political and social influences that may cause them to resist change. Therefore, the proposed project will be a motivation for the project stakeholders to change their lives by changing their perceptions (Fox et al, 2007) and educating them on culture and social systems while encouraging them to receive wisdom.

4.3 Sampling Method

The main aim of the propose PIP project is to improve the use of behavioral pain assessment tools in assessing pain among patients with communication difficulties. Therefore, the study will select a sample of 10 nurse participants from the target hospital to provide the necessary data. Berkwits (2011) argues that research sampling methods enable the selection of a subset of the entire population to facilitate a cheaper and more efficient achievement of research objectives. While these techniques include randomized and non-randomized sampling methods, probability and non-probability sampling, a combination of these methods can be used. The proposed project will rely on non-probability sampling method because of its capability of creating rich data necessary for achieving the research objectives. There are many non-probability sampling approaches that can be taken. However, the proposed project will rely on purposive approach because it provides a robust and impartial framework for selecting study participants. However, a significant disadvantage of purposive sampling that the project will have to deal with is the idea that the change agent will rely on personal judgment when selecting the participants and this may create researcher bias (Trochim, 2010). Melynk et al (2011) define stakeholders as the individuals, organizations, or groups who have a direct interest in an activity. For instance, in the proposed project, the stakeholders may include clinicians, researchers, patients and their families, as well as social workers. Nonetheless, the project will only involve a few most important stakeholders such as families, patients, general practitioners, medical officers, the hospital administration and physicians; and not community partners for purposes of adhering to its scope. Pain assessment after hospital discharge is also important. With the campaign towards reduced hospital stay to reduce the cost of treatment, there is a need to include other external stakeholders into the project. This justifies the inclusion of outpatient care services and community partners into the project. However, the proposed project will not include any outpatient care and community partners because the change agent is a student and is only required to involve about 15 participants.

4.4 Inclusion and Exclusion Criteria

The inclusion/exclusion criteria define the characteristics that study participants must meet before being included into the study (Trochim, 2010). In this case, the inclusion criteria for the proposed PIP study are nurses and healthcare practitioners who care for patients with communication difficulties. The exclusion criteria will be nurses and healthcare practitioners who do not handle patients with communication difficulties.

4.5 Change Implementation Methods

Within the health care context, according to Freshwater (2005) an individual might not be aware of any conflict such as acknowledging the contradictions between what is said about care practice and the actual reality about the care practice. With this regard, Freshwater (2005) observes that this conflict or misunderstanding exists before action and can motivate healthcare practitioners to change from their unconventional practice to the more desired and acceptable practice. Practice improvement is a continuous process initiates a change within evidence-based practice and creates an opportunity for the healthcare team to develop their skills. Therefore, according to Cioffi et al (2007), practice improvement should not only focus on an aspect of care but also focus on creating a positive change in the organizational culture and care settings. Furthermore, Galsson et al (2006) emphasized that practice improvement should entail a deliberate effort to create a feeling of empowerment among the staffs and enable achieve both individual and team development. In the proposed project, this will be achieved by involving the staff in the decision-making process, as well as allowing them participates in the project activities. The staff’s active involvement and participation will make a significant contribution to the project process and enhance its credibility. Against this backdrop, the change agent is of the opinion that involving the stakeholders during the project’s entire decision-making process will create in them a sense of ownership, which will then make them feel autonomous and have a sense of control over the change. Therefore, at the core of the project will be a democratic participatory system that empowers and emancipates the stakeholders, giving the ability to influence the processes that have a direct impact on their practice. The project will involve influential clinicians responsible for pain assessment. Apart from taking up the ownership of the project, they will play the decision-making role, leading to an enhancement of the change process. Meanwhile changing the pain assessment practice will also require other stakeholders who will play a crucial role in decision-making. Just like any other issue that could be studies within the hospital context, the behavioral pain assessment tool, as a clinical issue to be addressed with the proposed project involves various choices, priorities, and contexts that influence decisions made around it (Caughlin & Casey, 2001). Even within the hospital organization, each ward has its own socially constructed context that has specific meanings to everyone within the hospital organization. According to Manley & McCormack (2003), this implies that there is inherently a collection of force fields that are constantly moving and changing depending on the cultural, economic, historical, psychological and political factors. This necessitates the understanding of cultures or other factors within the organization – together with the individuals within the organization. Moreover, according to Powell et al (2009), it is important to acknowledge that change is complex especially when it is implemented in organizations with people from various cultural backgrounds because the change will go against the traditional professional beliefs, roles and assumptions.

Therefore, for the quality improvement to be successful, the change agent will need to facilitate the development of each staff, organizational attributes, and the teams. Effective facilitation requires shared decision-making, critical thinking equity, and leadership. Therefore, the change agent became the facilitator and used certain techniques such as critique, reflection, high challenge and collaboration to enhance high learning and create the desired change. Throughout the project, the change agent will allow discussions by organizing periodic workshops and discussions during which the team will collectively interrogate aspects of daily pain assessment practice and how they can be improved. To effectively implement change, the researcher will rely on the Plan, Do, Study, Act Model (PDSA) model. The PDSA model is a framework used in clinical quality improvement projects to ensure that the project because it facilitates the change agent to develop change ideas, influence their teams into embracing the idea, and measure the outcome of new idea implementation within various healthcare settings (Vordenberg et al, 2018). The PDSA model is considered an appropriate approach for the proposed project because it will create an opportunity for the researcher to change, revise, upgrade and add any aspect of the project whenever they are not working as expected. Moreover, according to Christoff (2018), the PDSA model eliminates unnecessary wastage of resources, especially in quality improvement projects such as the proposed one, whereby clinician will have to be trained and educated on how to use behavioural pain assessment tools. Therefore, by applying the PDSA change model, the change agent will continuously ask themselves three major questions, namely what direction is the project leading the organization, what changes will have to be implemented to improve the current practice, and how will the change be measured (Brecknerr et al, 2017). The following table illustrates how each element of the model will practically be applied in the project:

Chapter 5

5.0 Ethical Issues

This chapter concerns the ethical issues that might be faced during the project implementation and how they will be dealt with. Fundamentally, the ethical issues addressed in this chapter are based on the Nursing and Midwifery Council (2015) code of ethics, which all health practitioners in the UK must abide by during such projects. This project holds with high regards the different ethical considerations because they form part of the frameworks for ensuring the safety of participants (Kumar, 2011). O’Leary (2010) adds that ethical considerations are important parts of research that must be adhered to because they make up the moral principles upon which the wrong and right things about the research can be established. This implies that ethical considerations in the proposed project will entail items such as participant privacy, dignity, informed consent and confidentiality. Against this backdrop, the proposed PIP project raises various ethical issues that emerge from the relationships and familiarity between the researcher and the participants (Holloway and Wheeler, 2010). The change agent will be required to take various precautionary steps to protect the safety and well-being of the participants especially with regards to the qualitative elements of the project. Before the change agent gathers any data or information from the participants, all the participants will have to give informed consent because according to Cronin et al (2014), gathering such information without the informants’ consent is tantamount to fraud. Therefore, the change agent will ensure that any data or information gathered from the participants is voluntarily given after the participants have read and signed a consent form. Furthermore, to guarantee voluntary participation, all the participants will have an opportunity to withdraw from the project as and when they deem fit – at their own will. The change agent will do all things possible to ensure that no participant is exposed to any harm. Particularly, research participants are highly vulnerable to mental and emotional harm such as harassment, anxiety or embarrassment (Beauchamp and Childress, 2013). Therefore, the change agent in the proposed project will avoid such occurrences by conducting thorough scrutiny of the study process to ensure that there are no unethical practices such as the collection of unauthorized data, inaccurate data reporting as well as data usage.

With regards to the qualitative elements of the project, the change agent intends to observe the ethical principles of beneficence, justice, truthfulness, confidence and non-maleficence. According to Grove et al, (2013), the principle of beneficence stipulates that the researcher must always represent the best interest of the participants. This principle always corresponds with the principle of non-maleficence that require the researcher to not harm any participants., which entails making decisions that safeguard the participants’ safety (Perri and Bellamy, 2012). To adhere to these principles, the change agent will incorporate sensitivity into the study process and ensure effective data storage and dissemination. Impartiality refers to entails being fair and avoiding bias in the study process (Kumar, 2011). To achieve this, the change agent will not pass judgments or display any form of discrimination to any participant regardless of their age, gender, race, nationality or religion. Parahoo (2008) asserts that all the data collected from participants must be treated with confidentiality and stored in a manner that maintains the same. Therefore, in adherence to the UK’s Data Protection Act 1998, all data collected before and after the intervention will be securely stored in a data stick with password access. This will guarantee privacy to the participant information and ensure that any information is publicly shared only with their consent.

Chapter 6

6.0 Data analysis and results presentation

The study will rely on qualitative approaches (i.e. focus groups) to seek practitioner’s views about how successful the tool has been. Furthermore, the project participants will be asked to give their opinion, from a professional standpoint, on how the project implementation has been and if any areas need changes. On the other hand, quantitative approaches will be used to analyze the observation feedback given in the evaluation template (Appendix 1) whereby the average score of from each participant will be calculated to have an overview of the tool’s success rate. Qualitative data will be analyzed through inductive approaches while quantitative data will be analyzed through deductive approaches. Thus, the proposed PIP project will use both inductive and deductive data analysis approaches. Specifically, inductive approaches will entail the use of data analysis tools such as content analysis while deductive approaches will entail the use of tools such as correlation mean, median and mode.

Chapter 7

7.0 Dissemination

Research dissemination refers to ensuring that people access and make use of research findings in a manner that maximizes the study’s benefit as soon as possible. Well-disseminated research has four major characteristics namely stakeholder engagement, context, ability to utilize the opportunity, appropriate format and opportunistic. With regards to stakeholder engagement, Brownson et al (2018) argue that researchers must identify their target audience, keep in touch with them and engage them early enough from the project’s planning stage to completion. In the proposed project, the target audience would be nurses, physicians, general practitioners, patients and their families. Having identified these stakeholders early enough, the project will be able to create a kind of ‘waiting for an audience’ for the project results so that as soon as the results are out, they are shared. Well-disseminated research must also be in the correct format so that the target audience can easily understand the content (Brown, 2017). Here, the study will be organized into chapters, each chapter having an introductory and conclusion part so that readers can easily transition from one part to the other. Furthermore, the project write-up will have a plain-language abstract to facilitate easier understanding by the non-scientific audience. The change agent will also be opportunistic by developing partnerships and networks with other entities such as journal articles to facilitate dissemination. Here, the change agent will approach various pain management professional groups to assist in disseminating the project results and advocating for the implementation of the newly developed pain assessment tool. Meanwhile, the change agent will disseminate the project results based on the context of each target audience and make use of influential personalities and leaders within health organizations to help in disseminating the project findings.

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