Beyond the Pain Scale

Provider Communication and Staffing Predictive of Patients' Satisfaction With Pain Control

Judith Shindul-Rothschild, PhD, MSN, RN; Jane Flanagan, PhD, RN, ANP-BC; Kelly D. Stamp, PhD, ANP-C, RN, FAHA; Catherine Y. Read, PhD, RN

Disclosures

Pain Manag Nurs. 2017;18(6):401-409. 

In This Article

Discussion

In this study we found that higher staffing by nurses and hospitalists was associated with improvements in perceived pain control (Figure 1, Figure 2), whereas staffing by interns and residents was not. The aggregate variable "nursing staff FTE" was found to improve patient perception of pain control in the regression model (Table 2), but care in teaching hospitals, where residents and interns are on the front line, did not. These findings suggest that having consistent staff and higher numbers of nursing staff and hospitalists results in higher patient satisfaction with pain management than when more care is provided by rotating interns and residents.

It should be noted that in some institutions hospitalists are physicians, whereas in others they are nurse practitioners. Hospitalists are typically assigned to one unit and typically work consecutive days, often on a 5–7 on, 5–7 off rotation. Data obtained for this study do not indicate the professional role of hospitalists nor their scheduling patterns. However, given the improvement in patient perception of pain management with hospitalists, this finding needs further exploration to determine if this role has a multidisciplinary best practice approach.

Given that, poor pain control was associated with teaching hospitals and residents/interns in this study; medical education has a notable role in promoting patients' satisfaction with pain management. Phillips and Barker (2010) reported significant spikes in fatal medication errors when new residents and interns began their hospital training in July. A systematic review found medical students had limited understanding of effective pain treatment because of the absence of a comprehensive curriculum on pain management (Ung, Salamonson, Hu, & Gallego, 2016). In response to fragmented pain education in medical schools, the University of Washington School of Medicine revised their curriculum to introduce a 4-year integrated pain curriculum that substantially increased didactic and multidisciplinary clinical training (Tauben & Loeser, 2013).

Limited clinical experiences requiring coordination of multimodal treatment approaches for pain control may also contribute to a lack of appreciation among medical students for the importance of interdisciplinary collaboration (Ung et al., 2016). In 2015 a German pharmaceutical company brought together pain specialists from Europe and the United States to form a Pain Advisory Board to advance the management of acute pain (Meissner et al., 2015). The Pain Advisory Board issued key priorities to improve pain management including better education and training for the multidisciplinary team and the inclusion of an acute pain service consisting of a pain nurse, pain specialist, and clinical psychologist in every hospital (Meissner et al., 2015). In other reports from two academic health centers, a best practice that improved trauma patients' experience of pain control was the inclusion of the pain relief service in the orientation of new residents and implementation of a transdisciplinary team approach emphasizing mutual learning, training, and education (Gordon et al., 2014, Martin et al., 2012). The findings in our study confirm the need for further medical education on pain management and clinical experiences that reinforce the value of interdisciplinary collaboration.

Patients' self-reports of not being helped soon enough and poor nurse-patient communication underscore the importance of timely attention to reports of pain. Possible explanations for poor nurse-patient communication may be inadequate nurse staffing and the need for additional education on pain assessment and management. In either case, both become organizational issues that hospital administrators will need to address through improved nurse staffing as well as education and training on patient-centered communication. As noted earlier, nurses' daily rounding has been reported to improve communication, patient safety, staff responsiveness, and pain control (Daniels, 2016). Multimodal collaborative group meetings that foster communication about pain control plans with patients and families significantly improve patients' self-reports of pain management (Martin et al., 2012). Our findings are consistent with previous research highlighting the importance of adequate numbers of nursing staff, especially pain resource nurses, to provide expert consultation (Williams et al., 2012).

Limitations

The three states chosen for this study, California, Massachusetts, and New York, may not be representative of all hospitals in the Pacific, Northeast, or Mid-Atlantic regions. Although three covariates were entered into the model to account for the intensity of care, the data analyzed in this study did not account for comorbid medical diagnoses, psychiatric conditions, or socioeconomic factors that may also influence patients' satisfaction with pain management. HCAHPS is case mix adjusted; however, scores are not adjusted for type of specialty care or diagnosis, which have been found to be significantly associated with HCAHPS score (Thiels et al., 2016). Participation in HCAHPS is voluntary, and response bias may influence patients' perception of pain control. Observed differences in HCAHPS scores have been found to be sensitive to response rates (Siddiqui, Wu, Kurbanova, & Qayyum, 2014). Survey response rates for HCAHPS from 2011 to 2012 were 33% in Massachusetts and 30% in California and New York (HCAHPS, 2013c).

Implications for Nursing Practice and Research

Findings from this study support nurses as key contributors to patient satisfaction with pain control, a measure correlated with a positive impact on HCAHPS overall hospital satisfaction scores. The findings in this study also highlight the need for adequate numbers of nursing staff to achieve optimal patient satisfaction with pain management. Further research is needed to determine what factors contribute to better pain management and how residents/interns, nurses, and hospitalists can best work together to improve patients' satisfaction with pain control. Research priorities should center on potentially modifiable factors, such as hospital-specific policies and procedures, structure of the staff orientation, increased nurse staffing, and opportunities for interdisciplinary communication around pain management.

Interdisciplinary education aimed at improving patient assessment, provider-patient communication, and alternative pain control interventions are essential steps toward achieving improved patient satisfaction with pain control. There is a need for creative educational approaches that build cohesive pain management teams. Some nursing education programs have successfully used e-learning strategies to enhance knowledge of pain management (Keefe & Wharrad, 2012). Hospitals could adopt computer-based learning, but required pain management training modules completed in isolation could fail to achieve the desired outcome. A better approach would be through group simulation exercises. A team-based learning simulation exercise, ideally in multiple sessions, could be a powerful way for nurses, residents, physicians, and other members of the health care team to develop and share creative strategies for pain management and build collaborative relationships.

Patients in pain also want their health care providers to reduce suffering by introducing nonpharmacologic approaches and demonstrating more empathy and understanding (Pathmawathi et al., 2015). Meeting this challenge requires guidance, education, time, and commitment—and may be easier to achieve when clinicians are full-time professionals, such as nurses, who are better positioned to provide continuity of care.

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