title: Evaluation of Evidence-based Nursing Pain Management Practice.
abstract: It is important to ensure that cancer pain management is based on the best evidence. Nursing evidence-based pain management can be examined through an evaluation of pain documentation. The aim of this study was to modify and test an evaluation tool for nursing cancer pain documentation, and describe the frequency and quality of nursing pain documentation in one oncology unit via the electronic medical system. A descriptive cross-sectional design was used for this study at an oncology unit of an academic medical center in the Pacific Northwest. Medical records were examined for 37 adults hospitalized during April and May 2013. Nursing pain documentations (N = 230) were reviewed using an evaluation tool modified from the Cancer Pain Practice Index to consist of 13 evidence-based pain management indicators, including pain assessment, care plan, pharmacologic and nonpharmacologic interventions, monitoring and treatment of analgesic side effects, communication with physicians, and patient education. Individual nursing documentation was assigned a score ranging from 0 (worst possible) to 13 (best possible), to reflect the delivery of evidence-based pain management. The participating nurses documented 90% of the recommended evidence-based pain management indicators. Documentation was suboptimal for pain reassessment, pharmacologic interventions, and bowel regimen. The study results provide implications for enhancing electronic medical record design and highlight a need for future research to understand the reasons for suboptimal nursing documentation of cancer pain management. For the future use of the data evaluation tool, we recommend additional modifications according to study settings.
authors.affiliation: School of Nursing, University of Washington, Seattle, WA.
authors.forename: Wenjia
authors.initials: W
authors.lastname: Song
authors.affiliation: Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA. Electronic address: lineaton@uw.edu.
authors.forename: Linda H
authors.initials: LH
authors.lastname: Eaton
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
authors.forename: Debra B
authors.initials: DB
authors.lastname: Gordon
authors.affiliation: Psychosocial and Community Health Nursing, University of Washington, Seattle, WA.
authors.forename: Christine
authors.initials: C
authors.lastname: Hoyle
authors.affiliation: Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA.
authors.forename: Ardith Z
authors.initials: AZ
authors.lastname: Doorenbos
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use*; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D000072716:Cancer Pain / Q000175:diagnosis / Q000451:nursing*; D003430:Cross-Sectional Studies; D017679:Cryotherapy; D004282:Documentation / Q000592:standards; D057286:Electronic Health Records; D055318:Evidence-Based Nursing; D005260:Female; D006358:Hot Temperature / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009859:Oncology Nursing; D059408:Pain Management / Q000451:nursing* / Q000592:standards; D010147:Pain Measurement; D056888:Patient Positioning; D055815:Young Adult
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid