Effectiveness of INROADS Into Pain Management, a Nursing Educational Intervention

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1 Effectiveness of INROADS Into Pain Management, a Nursing Educational Intervention Gregory D. Salinas, PhD, and Maziar Abdolrasulnia, PhD abstract Nurses play a critical role in managing a patient s pain, from initial evaluation to ongoing patient education. However, little information exists on current gaps in nurses knowledge and their pain-related decision making. To this end, an educational intervention the INROADS initiative was designed to improve the knowledge of nurses involved in patient management as well as to guide them toward practices that are consistent with currently available evidence. The results from an evaluation of this intervention show that nurses participating in the INROADS program were 52% more likely to make evidence-based care choices for their patients, compared with a control group of demographically similar nurses. The effect of this program may reinforce it as a model for the design of future interventions for pain management. J Contin Educ Nurs 2011;42(X):xxx-xxx. After a decade of standard setting and research on pain control (Lippe, 2000), health care practitioner assessment and management of patient pain continues to be inadequate (Pasero & McCaffery, 2004; Pasero, Paice, & McCaffery, 1999). Although evidence-based guidelines (Gordon et al., 2005) emphasize thorough patient assessment, prompt recognition of patient pain, frequent monitoring, multimodal analgesic therapies, and patient input, there are persistent gaps in nurses knowledge and practice in key areas of acute and chronic pain management. These gaps concern, first, reliable methods for assessing pain. For instance, the evidence suggests that when assessing a patient with pain, the patient s current diagnosis, health history, experience of pain, and concerns (e.g., fears about the adverse effects of analgesics) all must be documented and acknowledged with a standardized assessment tool (Davis & Walsh, 2004). Moreover, comprehensive patient assessment must be accompanied by an awareness that pain responses and analgesic needs vary significantly between patients (Dunwoody, Krenzischek, Pasero, Rathmell, & Polomano, 2008). Because of gaps in knowledge about appropriate and reliable assessment tools, nurses may not recognize pain promptly or may provide infrequent and inadequate pain relief. Second, there are gaps in knowledge and practice regarding the goals of analgesic therapy and challenges in measuring pain relief outcomes (Farrar, Berlin, & Strom, 2003). These gaps may contribute to the undertreatment Dr. Salinas is Director of Research and Quality and Dr. Abdolrasulnia is Executive Vice President, CE Outcomes, LLC, Birmingham, Alabama. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. INROADS Into Pain Management: Improving Nursing Response for Optimal Analgesics and Drug Safety was sponsored by the University of Kentucky College of Nursing and AccreditEd, and supported by an educational grant from PriCara, a Division of Ortho- McNeil-Janssen Pharmaceuticals, Inc., administered by Ortho-McNeil- Janssen Scientific Affairs, LLC. Support for the writing of this article was provided by Ortho-McNeil-Janssen Scientific Affairs, LLC. Presented in part at the American Society for Pain Management Nursing Conference, September 12-15, 2009, Jacksonville, Florida. The authors acknowledge the INROADS contributing faculty and thank them for their ongoing efforts to improve nursing education: Rosemary C. Polomano, RN, PhD, FAAN, Chair; Colleen Dunwoody, MS, RN-BC; Chris Pasero, MS, RN-BC, FAAN; and Debra B. Gordon RN-BC, MS, ACNS-BC, FAAN. The authors gratefully acknowledge the contributions of Alexandra Howson, MA, PhD, to the background and structure of this article. Address correspondence to Gregory D. Salinas, PhD, Director of Research and Quality, CE Outcomes, LLC, 107 Frankfurt Circle, Birmingham, AL greg.salinas@ceoutcomes.com. Received: July 21, 2010; Accepted: October 4, 2010; Posted: December 8, doi: /

2 of pain by limiting the likelihood of nurses implementing preemptive analgesic strategies (Dunwoody et al., 2008). Undertreatment is especially evident in the first 24 hours after surgery, which is characteristically a highrisk period for respiratory depression (Taylor, Kirton, Staff, & Kozol, 2005). Although nurses may fear causing harm to their patients by using opioids for postoperative analgesia (Pasero & McCaffery, 2002), this concern, accompanied by overestimation of addiction risk and persistent misconceptions about the appropriate use, safety, and efficacy of opioids (Grinstein-Cohen, Sarid, Attar, Pilpel, & Elhayany, 2009), may lead to undertreatment of pain in the postoperative period. Guidelines recommend that the respiratory status and level of sedation of patients being treated with narcotic analgesics should be monitored at least every 2 hours (Pasero & McCaffery, 2002). However, despite evidence of the beneficial outcomes of such vigilant monitoring, nurses continue to be reluctant to manage patients immediate postoperative pain with opioids (Grinstein-Cohen et al., 2009). Third, there are gaps in knowledge about the efficacy of analgesic treatment strategies. Because patient response to analgesic medications is unpredictable, it is considered inappropriate to prescribe a predetermined opioid dose based on pain intensity alone (Gordon et al., 2004). The literature increasingly supports multimodal therapies (American Society of Anesthesiologists Task Force on Acute Pain Management, 2004) that reduce the adverse effects of individual agents. Multimodal therapy is the combination of analgesic agents that exert at least two distinct actions on the mechanism of pain or the administration of a single analgesic agent via two routes (American Society of Anesthesiologists Task Force on Acute Pain Management, 2004), and it offers several benefits to patients. Multimodal therapy influences different pain pathways, and medications used in multimodal therapy synergistically affect peripheral nociception (Grinstein-Cohen et al., 2009). Moreover, multimodal therapy reduces the overall amount of opioid analgesic required, potentially limiting side effects and improving patient outcomes and satisfaction with care (Gordon et al., 2005). Finally, there are gaps in knowledge and practice concerning the frequency and effectiveness of monitoring the effect of pain relief. Poor monitoring can lead to unrelieved pain, which causes physiological stress, resulting in, for instance, tachycardia, hypertension, left ventricular dysfunction, hyperglycemia, and insulin resistance (Dunwoody et al., 2008), all of which can compromise patient recovery and lead to poor outcomes. Overall, knowledge gaps in pain management can lead to misrecognition of pain symptoms and undertreatment (Kalkman et al., 2003), which in turn contribute to clinical and patient outcomes that have the potential to impair quality of life, increase patient morbidity, and increase visits to health care providers (Ersek & Poe, 2003). Adverse clinical outcomes of unrelieved pain include increased cardiovascular demands, which could lead to myocardial infarction, immobility (and therefore thromboembolic and pulmonary compromise), reduced urine output, and decreased motility (nausea and vomiting) (Briggs, 2003). The intangible costs of inadequate pain management also include emotional upset and dissatisfaction for patients (Chung & Lui, 2003). BARRIERS TO OPTIMAL PAIN MANAGEMENT Because nurses spend more time with patients than any other health professional group, nurses clearly have a key role to play in the management of their patients pain. Their roles include evaluating and assessing pain, supervising medical therapy, educating patients, monitoring patient responses to pain management, and sometimes conducting nonpharmacological therapy. However, there are a number of barriers to nurses exercising their pain management roles effectively. For instance, nurses may give patients lower and less frequent doses of opioids because of fears that they will cause harm to patients (Pasero & McCaffery, 2002) by potentially triggering respiratory depression or addiction. Openended institutional policies, such as as needed dosing, are an additional barrier to effective nurse decision making about pain relief (Gordon et al., 2004), because as needed strategies rely on patients requesting pain relief. However, nurses may underestimate patient expectations for pain relief (Grinstein-Cohen et al., 2009), and there are many reasons why patients might not request pain relief, such as fear of being seen as a complainer or anxiety about the cost of medication (Briggs, 2003). Moreover, it is difficult for individual nurses to challenge institutional policies, although nurse managers are uniquely positioned to do so (Pasero et al., 1999), to champion evidence-based strategies that offer tailored, multimodal analgesic delivery supported by thorough patient assessment and continuous monitoring. Pain management by health care professionals, including nurses, could be improved by increasing their knowledge about pain assessment, treatment, and follow-up (Chung & Lui, 2003). However, little information exists on the gaps in current knowledge and practice patterns of nursing staff with regard to pain management. Consequently, in 2008, the University of Kentucky College of Nursing designed and implemented an educational intervention entitled INROADS Into Pain Management: Improving Nursing Response for Optimal 2 Copyright SLACK Incorporated

3 Analgesics and Drug Safety. This comprehensive, certified educational initiative provided nurses with the latest findings on the pathophysiological pathways of pain as well as practical and evidence-based approaches to the evaluation and management of patient pain. The overall goal of this intervention was to inform nurses and enable them to become more active pain managers in providing optimal care to their patients. This study examined the effectiveness of the intervention. The hypothesis was that participants in the intervention would have greater adherence to evidence-based recommendations for pain management compared with a control group and that this greater adherence would directly improve the care of patients receiving pain treatment. METHODS Educational Initiative and Learning Objectives INROADS Into Pain Management: Improving Nursing Response for Optimal Analgesics and Drug Safety consisted of 10 regional meetings and 1 satellite symposium. The regional meetings occurred from June to December 2008, and the satellite symposium took place in September Versions of this material can be found at The objectives of these meetings were to: Explain the physiological pathways of pain and the role of neurochemical mediators in pain processing. Review the pharmacology and therapeutic rationale for major classes of pain medications. Discuss multimodal therapy as a means to achieve effective analgesia and reduce side effects. Identify key factors for tailoring and delivering analgesic care to provide the safest, most effective therapy. The educational objectives and content of the intervention were reviewed to define a series of performance measures focused on pain management. Performance measures are individual evidence-based statements that outline the health care performance expectations associated with the content of an educational activity. Performance measures were used to frame questions related to case vignettes, which were presented in survey format to the program participants (who took part in at least one workshop) and a demographically similar control group. Case vignettes have gained considerable support for their value in predicting the practice patterns of health care practitioners. Results from research studies (Gould, 1996; Tomey, 2003; Van Eerden, 2001) showed that case vignettes provide a valid and comprehensive method to measure a nurse s process of care in actual clinical practice. Furthermore, case vignettes are more cost-effective and less invasive than other means of measurement. TABLE 1 DEMOGRAPHICS OF THE PARTICIPANT AND NONPARTICIPANT SAMPLES Degree Participants Nonparticipants Nurse practitioner 25.8% 18.3% Registered nurse 61.3% 71.0% Advanced practice registered nurse 12.9% 7.5% Other a 0.0% 3.2% Practice setting Hospital 63.3% 48.4% Pain clinic 23.3% 34.1% Family/general practice 1.1% 0.0% Outpatient surgery center 3.3% 2.2% University 2.2% 2.2% Long-term care facility 1.1% 1.1% Other b 5.7% 12.0% Mean years in practice (SD) Mean patients per week treated for pain (SD) Area of focus in pain management 24 (11) 20 (22) 32 (27) 36 (33) Acute 24.2% 9.7% Chronic 19.8% 30.1% Acute and chronic 53.8% 54.8% Critical care 2.2% 0.0% Other 0.0% 5.4% Note. a Other degrees include master of science in nursing and combinations of the categories shown in the table. b Other settings include ambulatory treatment center, cancer care clinic, home care, veterans hospital, etc. They remove observational bias and allow for control and manipulation of multiple variables in a way that is not feasible with observational methods (DeSanto- Madeya, 2007; Jones, 2008). Case vignettes for this study were designed in collaboration with clinical nursing experts to assess whether the diagnostic and therapeutic choices of participants were consistent with clinical evidence presented in the intervention. The case vignettes were also used to assess whether the practice choices of participants were different from those of the control group. Additional survey items were included to assess barriers to optimal pain management. These instruments were peer reviewed to ensure accuracy of the cases and

4 TABLE 2 PAIN MANAGEMENT Participants Nonparticipants Case 1: A 24-year-old woman fractured her right femur and pelvis in a motor vehicle accident. After open reduction and internal fixation of the femur fracture, she is admitted to the trauma unit and given the surgeon s maximum dose of patient-controlled analgesia. She continues to report a deep and aching pain (10/10), and although she appears slightly sedated, she demands more pain medication. What is the best first action to improve the patient s pain management plan of care? Increase the patient s patient-controlled analgesia dose. 5.4% 12.9% Add another analgesic medication with a different mode of action. a 86.0% 66.7% Switch to a different opioid. 8.6% 20.4% What is the greatest concern about the patient s recovery if pain is undertreated? Patient may fear painful situations in the future. 5.4% 24.7% Patient may have hypersensitization and chronic pain syndrome. a 89.2% 72.0% Patient may learn that living with pain is acceptable and not pursue future treatment. 5.4% 3.2% Which agent is most likely to achieve more pain control at home while reducing side effects? Short-acting opioid. 5.4% 19.4% Extended-release opioid. 8.6% 19.4% Opioid with a dual mode of action. a 32.3% 16.1% Combination of short-acting and extended-release opioid. 53.8% 45.2% Case 2: A 67-year-old man with a 20-year history of type 2 diabetes mellitus is admitted to the hospital for treatment of an infected foot ulcer of 6 months duration that has been complicated by osteomyelitis of the fourth and fifth metatarsal bones. He reports that his pain is 8/10 despite daily opioid use, including use of different agents over the last several months. He also has problems with constipation and occasional nausea. What is the appropriate first step in establishing an effective pain management plan? Use standard guidelines to start treatment, with orders based on pain intensity scores. 2.2% 10.8% Obtain a detailed medical history, including reasons for use and medication response. a 95.7% 84.9% Convert all opioid analgesics to a parenteral route. 1.1% 3.2% Double the long-acting opioid dose. 1.1% 1.1% What is the primary goal of analgesic therapy for this patient? Achieve clinically meaningful pain relief. a 86.0% 74.2% Eliminate all pain. 1.1% 2.2% Reduce pain transmission. 11.8% 19.4% Improve patient coping mechanisms. 1.1% 4.3% What is the likely benefit of treating the patient with an analgesic that combines multiple modes of action? Lowering the rate of gastrointestinal side effects. a 51.1% 36.6% Reduction in the development of tolerance. 47.8% 59.1% Not advised multiple medications would increase the risk of drug-drug interactions. 1.1% 4.3% Case 3: A 52-year-old woman diagnosed with fibroids is admitted from the postanesthesia care unit to the surgical floor after abdominal hysterectomy. She is receiving patient-controlled analgesia with intravenous fentanyl. Her pain is 8/10 on admission, and she is receiving oxygen by nasal cannula at 3 liters/minute. She is alert and oriented. Her medical history includes the following: obstructive sleep apnea refusing continuous positive airway pressure therapy, type 2 diabetes mellitus, chronic renal failure (early stage), and minor depression. She is a 1-pack/day smoker. She is obese and her body mass index is 38 kg/m 2. Twelve hours after surgery, her pain is 5/10. Her vital signs are stable. It is 11:00 p.m., and the patient is exhausted and finally comfortable enough to go to sleep. She asks that you not wake her during the night unnecessarily. How do you respond? Do not wake her and plan to assess diligently for respiratory depression. 17.6% 26.9% 4 Copyright SLACK Incorporated

5 Do not wake her, but insist that she continue to wear her oxygen by nasal cannula to prevent possible oxygen desaturation during the night. 5.5% 8.6% Inform her that you must awaken her at least every 2 hours during the night to assess for seda- 50.5% 35.5% tion levels and respiratory rate, pattern, and depth. a Awaken her every 4 hours for a full assessment, including vital signs, and rely on respiratory assessment every 2 hours in between. Which patient factors pose the greatest risk for adverse opioid events? 26.4% 29.0% Obesity, obstructive sleep apnea, chronic renal failure. a 82.8% 72.0% Type 2 diabetes, depression, chronic pain, obstructive sleep apnea. 5.4% 8.6% Smoking status, type 2 diabetes, depression, chronic pain. 3.2% 8.6% Chronic pain, smoking status, obesity. 8.6% 10.8% What is the best definition of multimodal analgesia? Same as polypharmacy. 2.2% 1.1% Using medication to treat two or more mechanisms of pain. a 97.8% 89.1% Using two different routes of administration for the same class of analgesic. 0.0% 9.8% Note. Significant differences between participants and nonparticipants (p <.05) are shown in bold type. a Evidence-based response. clinical relevancy of the content to daily practice. Survey instruments were ed and mailed to the participant group at least 30 days after the intervention. Surveys were then distributed by to a demographically similar group of nurses who did not participate in the initiative. The nurses in the nonparticipant group were selected at random from their professional association membership list. Statistical Analysis Data were analyzed using PASW (version 18.0) software (SPSS Inc., Chicago, IL). Data were first arrayed using frequencies. The t test was then used to test the differences between the mean evidence-based responses of the participants and those of the nonparticipants. Differences between the two groups are considered significant if the p value is.05 or less. An effect size was calculated to determine the amount of difference between the evidence-based responses of the participants and those of the nonparticipants. This effect size is calculated using Cohen s d formula (the difference in mean divided by the square root of the pooled standard deviation) (Cohen, 1988), and it is expressed as a non-overlap percentage, or the percentage achieved by participants that was not reflected in the evidence-based responses of the control group. Results Demographics Of the 527 nurses who participated in the INROADS program, a sample of 93 participants was collected (17.6% response rate). A sample of 93 nurses with characteristics similar to those of the participants was chosen for a control group (nonparticipants). Demographic features of the samples are shown in Table 1. Participant and nonparticipant samples were composed primarily of registered nurses practicing in hospitals or pain clinics. On average, both groups had been in practice for more than 20 years and saw more than 30 patients per week who need treatment for pain. More than half of the respondents from both groups reported that their main focus in pain management covered both acute and chronic pain. Participants were more likely to be in a hospitalbased setting and to focus on acute pain than the nonparticipant group. Clinical Cases To assess the quality of care in both the participant and nonparticipant groups, case vignettes were presented representing typical patients whom nurses might see in their daily practice. In the first case, a 24-year-old woman is admitted to the trauma unit after open reduction and internal fixation of the right femur. She reports severe pain (10/10), despite using maximum patient-controlled analgesia, and asks for more analgesic medication, despite being slightly sedated (Table 2, case 1). When asked about the best first action to improve this patient s pain, significantly more participants (86.0%) than nonparticipants (66.7%; p <.05) selected adding another analgesic medication with a different mode of action, a practice choice that is consistent with the evidence concerning multimodal strategies. Significantly more participants (89.2% compared with 72.0% of nonparticipants; p <.05) also indicated that their greatest concern related 5

6 TABLE 3 GREATEST BARRIERS TO OPTIMAL PAIN MANAGEMENT Health care team fear of contributing to addiction Patient/family fear of addiction Lack of familiarity with evidence-based best practices Patient communication barriers/cultural barriers Lack of adequate education in dealing with pain management Participants Nonparticipants 21.5% 17.2% 4.3% 5.4% 20.4% 15.1% 0.0% 4.2% 53.8% 58.1% to this patient s recovery, if the pain is undertreated, is the development of hypersensitization and chronic pain syndrome. When asked which agent should be used for this patient to take at home to achieve more pain control while reducing side effects, almost one third of participants (32.3% compared with 16.1% of nonparticipants; p <.05) selected an opioid with a dual mode of action. Again, this choice is consistent with the evidence concerning the benefits of multimodal strategies. The second case involved a 67-year-old man with type 2 diabetes mellitus who was admitted to the hospital with a foot ulcer complicated with osteomyelitis. He reports severe pain (8/10), despite daily opioid use. He currently has issues with constipation and occasional nausea (Table 2, case 2). When asked about the appropriate first step to establish an effective pain management plan, participants were significantly more likely to obtain a detailed medical history (95.7% compared with 84.9% of nonparticipants; p <.05), including information about reasons for opioid use and patient response to the medication, as part of their initial assessment. Participants were also significantly more likely to indicate that achieving clinically meaningful pain relief was the primary goal of analgesic therapy (86.0% compared with 74.2% of nonparticipants; p <.05). Further, more participants (51.1%) than nonparticipants (36.6%) reported that the likely benefit of treatment with a multimodal analgesic lowers the rate of gastrointestinal side effects, an important consideration, given the negative effect that reduced motility can have on patient outcomes. The third case involved a 52-year-old obese woman with a medical history of diabetes, obstructive sleep apnea, chronic renal failure, minor depression, and smoking one pack of cigarettes per day. The patient is admitted to the postanesthesia care unit after abdominal hysterectomy (Table 2, case 3). When asked how they would respond to a request not to wake her during the night, more participants (50.5%) than nonparticipants (35.5%) were likely to let the patient know that they had to wake her every 2 hours for proper assessment. Participants were also slightly more likely (82.8%) than nonparticipants (72.0%) to identify obesity, obstructive sleep apnea, and chronic renal failure as patient factors that pose the greatest risk of adverse opioid events. However, participant responses were not significantly different from those of nonparticipants for either of these questions. Finally, participants were significantly more likely (97.8%) than nonparticipants (89.1%; p <.05) to properly define multimodal analgesia as using medication to treat two or more mechanisms of pain. Assessing Barriers to Optimal Pain Management Even with the best education, clinicians often encounter difficulties implementing newly learned information in their practice. To assess the critical factors preventing implementation, the authors asked each respondent to select the greatest barrier faced by nurses in providing optimal pain management to their patients. Participants (53.8%) and nonparticipants (58.1%) indicated that their perceived greatest barrier is a lack of adequate education in dealing with pain management, followed by fear of contributing to a patient s addiction (participants 21.5%, nonparticipants 17.2%) and lack of familiarity with the best evidence-based practices (participants 20.4%, nonparticipants 15.1%) (Table 3). The authors also asked respondents to gauge their confidence in their ability to provide optimal pain management to patients. On a scale of 1 to 10, 81.5% of participants reported that they felt extremely confident in their ability, significantly greater than the number of nonparticipants (60.2%; p <.05). Program Effectiveness Using Cohen s d formula, the authors calculated the effect size to be 0.91, or 52% non-overlap between participants and nonparticipants. DISCUSSION Despite the development of pain management standards (Phillips, 2000), such as prompt recognition and treatment of pain (Gordon et al., 2004), assessment of pain via patient self-report (Grinstein-Cohen et al., 2009), and the use of multimodal strategies to treat pain (Gordon et al., 2005), pain management remains a sig- 6 Copyright SLACK Incorporated

7 nificant health care challenge (Dunwoody et al., 2008). As other research has found (Grinstein-Cohen et al., 2009), a primary barrier to effective pain management that was identified by both participants and nonparticipants in this study was the lack of educational support for nurses. In this study, nearly two thirds of the surveyed nurses indicated that lack of adequate education and little familiarity with evidence-based information directly contributes to the inability to manage patients with pain properly. Accordingly, the educational intervention reported in this study aimed to address a number of knowledge gaps for nurses that were identified in the literature, including appropriate methods to improve patient pain management, recognize potential problems in patient recovery when pain is undertreated, establish an effective pain management plan, understand the primary goal of pain therapy, and identify patient characteristics that increase the risk of adverse drug events. Patient pain is often undertreated and unrelieved because of a range of factors, especially in the immediate postoperative period, when acute pain is not only highly likely, but also likely to be severe (Chung & Lui, 2003). Variability in patients tolerance and expression of pain makes dosing difficult (Taylor et al., 2005), and nurses fear of doing harm to their patients by inducing respiratory depression through the use of opioid analgesics can contribute to unrelieved pain (Grinstein-Cohen et al., 2009). The data indicate that acquiring knowledge about dosing, pharmacologic pathways, and best first actions to address pain can enable nurses to recognize pain more promptly and take action to alleviate pain with multimodal strategies. Adherence to best practices in pain management can mitigate potential problems in patient recovery. The literature points to a range of complications that may ensue because of the physiological stress caused when pain is undertreated and unrelieved. Tachycardia, hypertension, and myocardial dysfunction may result from the release of catecholamines; cortisol and glucagon may alter fat and protein metabolism; and impaired immunity puts patients at risk for infection (Dunwoody et al., 2008). Further, unrelieved pain may alter fluid balance (leading to reduced urine output), reduce motility (leading to nausea and vomiting), and affect oxygen saturation (Briggs, 2003). In addition, it can increase the risk of thromboembolic and pulmonary events, such as deep venous thrombosis and pulmonary embolism, as well as the development of chronic pain (American Society of Anesthesiologists Task Force on Acute Pain Management, 2004). Such complications lead not only to poor patient outcomes, but also to patient dissatisfaction with care (Kalkman et al., 2003). Data analysis suggests, however, that when nurses are informed of the patient implications of unrelieved pain, they are better placed to implement preemptive analgesic strategies (Dunwoody et al., 2008), recognize pain promptly (Gordon et al., 2005), and manage patient pain more effectively and appropriately. New standards for patient assessment point to the value of taking a comprehensive patient history that includes information about the location, intensity, and onset of pain; what causes or relieves it; and the meaning of the pain experience to the patient (Grinstein-Cohen et al., 2009). Standardized patient pain assessment tools (of which there are now several) can help institutions to develop a shared vocabulary of pain that supports effective communication among all members of the multidisciplinary team (Davis & Walsh, 2004). Comprehensive patient assessment enables nurses to tailor pain therapies and set clinically meaningful pain therapy goals for the specific needs of patients, rather than relying on a uniform approach to pain relief, as well as use multimodal strategies to address different pain mechanisms (Gordon et al., 2004). Tailored pain therapies are best accompanied by continuous monitoring to ensure that the pain management strategy adopted has the desired outcome for individual patients (Davis & Walsh, 2004). This study shows that education about best practices in patient assessment can help nurses to tailor pain management therapies to the needs of individual patients that are supported by clear clinical goals, are monitored continuously, and are modified as required to ensure that the stated goals are achieved. Finally, a key barrier to effective pain management is nurses hesitancy about using opioid analgesics because of the potential for adverse effects, such as respiratory depression, addiction, and the development of chronic pain. A number of specific factors put patients at risk for adverse events (Pasero & McCaffery, 2002), such as age, gender, comorbidities (e.g., chronic obstructive pulmonary disease), and the use of certain drugs in addition to opioids (e.g., muscle relaxants). However, the study data indicate that if these risk factors are monitored closely, nurses can identify patient risk, relieve patient pain more effectively, and therefore minimize the potential for the complications of unrelieved pain. CONCLUSION The study data show that the INROADS intervention influenced participants compared with the control group. In particular, the 0.91, or 52% non-overlap, effect size indicates that the INROADS educational intervention was highly effective in enhancing nurses understanding of pain management for patients with acute and chronic 7

8 key points Pain Management Salinas, G. D., Abdolrasulnia, M. (2011). Effectiveness of INROADS Into Pain Management, a Nursing Educational Intervention. The Journal of Continuing Education in Nursing, 42(X), xxx-xxx. 1 Nurses play an important role in managing their patients pain, but little information is available on the current gaps in nurses knowledge and practice patterns. 2 Lack of education and lack of familiarity with best evidencebased practices continue to be barriers to optimal management of pain. 3 Multimedia educational initiatives can be highly effective in ensuring that nursing pain management follows evidence-based recommendations. pain. Generally, activities with effect sizes greater than 0.80, or 47% non-overlap, are considered large (Cohen, 1988). This score is competitive with some of the best activities compared in a meta-analysis by Cook et al. (2008). Participants who had the educational intervention were more likely than nonparticipants not only to identify the best management strategies, but also to apply these strategies to practice. In addition, participants were more likely to report a higher level of confidence in their ability to provide optimal pain management for their patients. Although a limitation of the study is that the survey instrument did not directly measure patient care, case vignettes offer value in predicting the practice patterns of health care practitioners (DeSanto-Madeya, 2007; Jones, 2008). Another limitation is that the design of the study used a multiple-choice format and did not allow respondents the opportunity to answer questions in any manner they chose. Consequently, further research is necessary to collect wider data about nurses current pain management practice. A further limitation is that, rather than using experimental design to identify the effect of the intervention on a particular group of individuals, the study compared participants with a group of demographically similar nurses, rather than comparing the same nurses before and after the activity. In addition, this study is cross-sectional; future longitudinal studies are needed to track the educational effect directly and observe whether practice patterns regress over time. In addition to showing the effect of the INROADS pain management intervention, the analysis also points to two key knowledge gaps that could benefit from further educational support. First, findings suggest a knowledge gap for both participants and nonparticipants about the use of opioids with multiple modes of action in reducing side effects (Table 2, cases 1 and 2). This gap suggests a need for further educational activities to enhance knowledge about the pathophysiology of pain pathways and the effect of analgesics. Second, there seems to be a knowledge gap concerning the appropriate counseling and management of a postoperative patient who prefers to be allowed to sleep, but needs to be monitored (Table 2, case 3). This finding points to a need for further educational interventions that address the importance of continuous monitoring in the first 24 hours of the postoperative period. In conclusion, nurses need more information and education on the best practices in pain management. The results of the current study suggest that compelling multimedia educational interventions, such as the INROADS program, can effectively address gaps in nurses knowledge about evidence-based strategies to manage patient pain. The nurses who participated in the INROADS program were 52% more likely to give their patients evidence-based care, compared with a control group of demographically similar nonparticipants. The effect of this program may reinforce it as a model for the design of future interventions that address pain management, and the findings suggest that such interventions have the potential to lay the groundwork for subsequent changes in clinical practice behavior and positively affect patient care. REFERENCES American Society of Anesthesiologists Task Force on Acute Pain Management. (2004). Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology, 100(6), Briggs, E. (2003). The nursing management of pain in older people. Nursing Standard, 17(18), 47-53; quiz Chung, J. W., & Lui, J. C. (2003). Postoperative pain management: Study of patients level of pain and satisfaction with health care providers responsiveness to their reports of pain. Nursing & Health Sciences, 5(1), Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Cook, D. A., Levinson, A. J., Garside, S., Dupras, D. M., Erwin, P. J., & Montori, V. M. (2008). Internet-based learning in the health professions: A meta-analysis. Journal of the American Medical Association, 300(10), doi: /jama Davis, M. P., & Walsh, D. (2004). Cancer pain: How to measure the fifth vital sign. Cleveland Clinic Journal of Medicine, 71(8), DeSanto-Madeya, S. (2007). Using case studies based on a nursing conceptual model to teach medical-surgical nursing. Nursing Science Quarterly, 20(4), doi: / Dunwoody, C. J., Krenzischek, D. A., Pasero, C., Rathmell, J. P., & 8 Copyright SLACK Incorporated

9 Polomano, R. C. (2008). Assessment, physiological monitoring, and consequences of inadequately treated acute pain. Journal of PeriAnesthesia Nursing, 23(Suppl. 1), S15-S27. doi: / j.jopan Ersek, M., & Poe, C. M. (2003). Nursing management of pain. In S. M. Lewis, M. M. Heitkemper, S. R. Dirksen, P. O Brien, J. Giddens, & L. Bucher (Eds.), Medical-surgical nursing: Assessment and management of clinical problems (6th ed., pp ). St. Louis, MO: Mosby. Farrar, J. T., Berlin, J. A., & Strom, B. L. (2003). Clinically important changes in acute pain outcome measures: A validation study. Journal of Pain and Symptom Management, 25(5), Gordon, D. B., Dahl, J. L., Miaskowski, C., McCarberg, B., Todd, K. H., Paice, J. A., et al. (2005). American Pain Society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Archives of Internal Medicine, 165(14), doi: / archinte Gordon, D. B., Dahl, J., Phillips, P., Frandsen, J., Cowley, C., Foster, R. L., et al. (2004). The use of as-needed range orders for opioid analgesics in the management of acute pain: A consensus statement of the American Society for Pain Management Nursing and the American Pain Society. Pain Management Nursing, 5(2), Gould, D. (1996). Using vignettes to collect data for nursing research studies: How valid are the findings? Journal of Clinical Nursing, 5(4), Grinstein-Cohen, O., Sarid, O., Attar, D., Pilpel, D., & Elhayany, A. (2009). Improvements and difficulties in postoperative pain management. Orthopaedic Nursing, 28(5), ; quiz doi: /nor.0b013e3181b579ec Jones, M. (2008). Developing clinically savvy nursing students: An evaluation of problem-based learning in an associate degree program. Nursing Education Perspectives, 29(5), Kalkman, C. J., Visser, K., Moen, J., Bonsel, G. J., Grobbee, D. E., & Moons, K. G. (2003). Preoperative prediction of severe postoperative pain. Pain, 105(3), Lippe, P. M. (2000). The decade of pain control and research. Pain Medicine, 1(4), 286. Pasero, C., & McCaffery, M. (2002). Monitoring sedation. American Journal of Nursing, 102(2), Pasero, C., & McCaffery, M. (2004). Comfort-function goals: A way to establish accountability for pain relief. American Journal of Nursing, 104(9), 77-78, 81. Pasero, C., Paice, J., & McCaffery, M. (1999). Basic mechanism underlying the causes and effects of pain. In M. McCaffery & C. Pasero (Eds.), Pain: Clinical manual (pp ). St. Louis, MO: Mosby. Phillips, D. M. (2000). JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. Journal of the American Medical Association, 284(4), Taylor, S., Kirton, O. C., Staff, I., & Kozol, R. A. (2005). Postoperative day one: A high risk period for respiratory events. American Journal of Surgery, 190(5), doi: /j.amjsurg Tomey, A. M. (2003). Learning with cases. The Journal of Continuing Education in Nursing, 34(1), Van Eerden, K. (2001). Using critical thinking vignettes to evaluate student learning. Nursing and Health Care Perspectives, 22(5),