title: Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review.
abstract: OBJECTIVE
  Pain assessment and reassessment is an essential part of the treatment of hospitalised patients and must be integrated in pain management protocols. Yet nurses' adherence to pain assessment recommendations is problematic. We sought to review the comparative evidence for implementation strategies aiming to improve nurses' adherence to pain assessment recommendations in hospitalised patients.
  
  
  METHODS
  Systematic review using the narrative method.
  
  
  METHODS
  PubMed (MEDLINE), CINAHL, Cochrane library and hand searching.
  
  
  METHODS
  Studies published since 1990, reporting implementation strategies that aimed to improve nurses' adherence to pain assessment recommendations in hospitalised patients were included. According to the Cochrane Effective Practice and Organization of Care group (EPOC) classification system, strategies were categorized as directed at: health professionals, organizations, financing, or regulations. Given the heterogeneity in strategies, samples, outcomes and settings, evidence from the studies was synthesized using a narrative approach.
  
  
  RESULTS
  From 743 initial citations, 23 studies were included. They reported a variety of implementation strategies, but only directed at health professionals and/or organizations. In seven studies, a single strategy was applied (e.g. education or feedback). The remaining 16 studies used multifaceted approaches. The effectiveness of the implementation strategies varied. In all studies but one, adherence rates had improved after implementation compared to the before measurement, by 9% up to 49%. These effects were measured at different time points after completion of the implementation, ranging from 2 weeks to 6 months. Half of the reviewed studies reported an adherence rate of 80% or higher after implementation activities; other reported rates ranging from 24 to 80%. In two controlled studies the adherence to pain assessment recommendations increased significantly when feedback was provided compared to no feedback. Sustained effects were reported in three studies.
  
  
  CONCLUSIONS
  Based on this systematic review we conclude that implementation strategies to improve nurses' adherence to pain assessment recommendations vary but generally address professionals and organizational aspects. Educational and feedback strategies are often used and seem largely effective. Due to the heterogeneity of the implementation strategies it is not possible to recommend one preferred strategy. The level of evidence for strategies to improve pain assessment recommendations is limited however, as well-conducted studies are lacking.
authors.affiliation: Intensive Care Unit, Department Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands. w.ista@erasmusmc.nl
authors.forename: Erwin
authors.initials: E
authors.lastname: Ista
authors.forename: Monique
authors.initials: M
authors.lastname: van Dijk
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
mesh_terms: D019983:Guideline Adherence; D006739:Hospital Administration; D006801:Humans; D010147:Pain Measurement