Pain: a quality of care issue during patients' admission to hospital

Distortions to the passage of time during chronic pain: A mixed method study

BACKGROUND

A core aspect of the clinical assessment of pain is establishing how long pain has been present for. The reported length of pain can therefore influence diagnosis and treatment. Despite this, little is known about how chronic pain affects the passage of time.

METHODS

A mixed-methods cross-sectional study examined experiences of the passage of time in people identifying as living with chronic pain (n = 398).

RESULTS

Experiencing chronic pain slows the passage of time for most people. Greater pain intensity, rumination about pain, helplessness and identifying as disabled were associated with a greater slowing of the passage of time. Thematic analysis of responses to open-ended questions suggested that a slowing of time during pain was associated with (1) pain intrusion preventing activities which would otherwise enable time to pass quickly, (2) increased attention to time and (3) as sense that in retrospect, time throughout life was 'lost' to chronic pain.

CONCLUSION

Chronic pain causes widespread distortion to the passage of time. The slowing of time during pain means that periods of pain feel subjectively longer than periods without, exacerbating patient distress.

SIGNIFICANCE

This study examined how chronic pain impacts on the experience of time. Chronic pain substantially slowed the passage of time for most people, subjectively lengthening the period of time that pain lasted for, exacerbating distress. Given the importance of time processing in clinical assessments of pain, medication adherence and therapeutic interventions, these findings underscore the importance of raising awareness about altered temporal processing in patients and clinicians.

Quality of recovery after day care surgery with app-controlled remote monitoring: study protocol for a randomized controlled trial

BACKGROUND

The majority of surgical interventions are performed in day care and patients are discharged after the first critical postoperative period. At home, patients have limited options to contact healthcare providers in the hospital in case of severe pain and nausea. A smartphone application for patients to self-record pain and nausea when at home after day care surgery might improve patient's recovery. Currently patient experiences with smartphone applications are promising; however, we do not know whether remote monitoring with such an application also improves the patient's recovery. This study aims to evaluate the experienced quality of recovery after day care surgery between patients provided with the smartphone application for remote monitoring and patients receiving standard care without remote monitoring.

METHODS

This non-blinded randomized controlled trial with mixed methods design will include 310 adult patients scheduled for day care surgery. The intervention group receives the smartphone application with text message function for remote monitoring that enables patients to record pain and nausea. An anaesthesia professional trained in empathetic communication, who will contact the patient in case of severe pain or nausea, performs daily monitoring. The control group receives standard care, with post-discharge verbal and paper instructions. The main study endpoint is the difference in perceived quality of recovery, measured with the QoR-15 questionnaire on the 7th day after day care surgery. Secondary endpoints are the overall score on the Quality of Recovery-15 at day 1, 4 and 7-post discharge, the perceived quality of hospital aftercare and experienced psychological effects of remote monitoring during postoperative recovery from day care surgery.

DISCUSSION

This study will investigate if facilitating patients and healthcare professionals with a tool for accessible and empathetic communication might lead to an improved quality of the postoperative recovery period.

TRIAL REGISTRATION

The 'Quality of recovery after day care surgery with app-controlled remote monitoring: a randomized controlled trial' is approved and registered on 23 February 2022 by Research Ethics Committees United with registration number R21.076/NL78144.100.21. The protocol NL78144.100.21, 'Quality of recovery after day care surgery with app-controlled remote monitoring: a randomized controlled trial', is registered at the ClinicalTrials.gov public website (registration date 16 February 2022; NCT05244772).

Wearable transcutaneous electrical nerve stimulation (actiTENS®) is effective and safe for the treatment of knee osteoarthritis pain: a randomized controlled trial versus weak opioids

INTRODUCTION

Despite their poor tolerance, especially in the elderly, weak opioids (WO) remain commonly prescribed for patients with knee osteoarthritis (KOA). We compared the efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) device with WO for the treatment of moderate-to-severe, nociceptive KOA chronic pain.

METHODS

The study was a non-inferiority, multicentric, prospective, randomized, single-blind, controlled, 2-parallel groups Trial. A total of 110 patients with KOA were included (Kellgren-Lawrence radiographic grade ⩾2; American College of Rheumatology criteria), with chronic moderate-to-severe nociceptive pain (mean 8-day pain intensity (PI) ⩾ 4 on an 11-point numerical rating scale), in failure to non-opioid analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs). Patients with neuropathic pain were excluded. The co-primary endpoints were mean PI at 3 months (M3) and number of potentially treatment-related adverse events (TRAEs). Secondary outcomes included Western Ontario MAC Master University function subscale (range, 0-68), additional pain and quality of life measures, and responder rates.

RESULTS

The non-inferiority of W-TENS was demonstrated in both the per protocol (PP) and intent-to-treat (ITT) populations. At M3, PI in PP population was 3.87 (2.12) compared with 4.66 (2.37) [delta: -0.79 (0.44); 95% CI (-1.65, 0.08)] in W-TENS and WO groups, respectively. A planned superiority analysis showed a significant superiority of W-TENS over WO on PI at M3 (p = 0.0124). The number of TRAEs was significantly lower in the W-TENS group (n = 7) than in the WO group (n = 36) (p < 0.001). Other secondary outcomes also favored W-TENS.

CONCLUSION

W-TENS was more effective and better tolerated than WO in the treatment of chronic nociceptive KOA pain and offers an interesting non-pharmacological analgesic alternative in the management of KOA.Trial Registration: ClinicalTrials.gov: NCT03902340.

Patient satisfaction with pain relief following major abdominal surgery is influenced by good communication, pain relief and empathic caring: a qualitative interview study

Background

Monitoring and improving the quality of care is an ever increasing concern for health care organisations. Measuring the effectiveness of clinical outcomes is done by looking at specific markers of high quality care. Pain management is considered one of the markers of high quality care and satisfaction with pain management is a crucial and important quality assurance marker; yet, we know little about what contributes to a patient's decision about satisfaction.

Methods

A qualitative study drawing on phenomenological approach aiming to evaluate the perspective of patients experiencing post-operative pain. Patients undergoing major abdominal surgery were recruited from a Renal Transplant and Urology ward in the North of England, UK. Data were collected using in-depth semi-structured interviews and were analysed using Colaizzi's approach.

Results

Ten patients participated in the study and three themes emerged from the analysis. The findings of this study revealed that in order to achieve satisfaction with the management of pain, patient care has to include information delivery which is timely and adequate according to a patient's individual needs, nurses should have a caring attitude and pain should be well controlled.

Conclusion

Satisfaction with pain management is influenced by good communication and information transfer, appropriate pain management and an empathic presence throughout.

The association of patients' daily summarized self-rated "real-time" pain scores with physical recovery after major surgery - A repeated measurement design

Aim

To determine the associations of patients' documented self-rated pain with self-rated early postoperative physical recovery.

Design

Observational with repeated measures.

Methods

General and orthopaedic inpatients (N = 479) were during the period 2012-2015 screened for pain. Individual daily median pain scores at rest and during activity were based on 4-9 self-ratings on postoperative days 1 and 2, using the Numeric Rating Scale. Nine items reflecting physical recovery from the "Postoperative Recovery Profile" were used in a questionnaire.

Results

Associations between median pain scores on postoperative day 1 and physical recovery (fatigue, sleeping difficulties, bladder function, mobilization, muscle weakness and personal hygiene) the same day were found. Additionally, associations were found between median pain scores on day 1 and physical recovery (fatigue, sleeping difficulties, mobilization and muscle weakness) on day 2.

Evaluation of the pain intensity differences among hospitalized cancer patients based on a nursing information system

Evaluating the absolute difference in pain intensity and the percentage difference in pain intensity could facilitate an understanding of pain reduction among cancer patients during repeated hospitalizations. Examinations of the absolute differences in pain intensity and the percentage differences in pain intensity according to the worst pain intensity and last evaluated pain intensity before discharge are lacking. The aim of this study was to evaluate the absolute and percentage difference in pain intensities among cancer patients with moderate or severe pain from their 1st to 18th hospitalizations from 2011–2013. A population-based retrospective cohort study was conducted. Pain intensity was assessed using scales and was recorded in a nursing information system. The absolute and percentage difference in pain intensities were examined via the one-sample Kolmogorov-Smirnov test, and group differences in moderate or severe pain were evaluated with the Mann-Whitney U test. For moderate pain patients, the mean absolute difference in pain intensity was 1.52, and the percentage difference in pain intensity was 29.0%; both these values were significant. More significant changes in the absolute and percentage difference in pain intensities were associated with severe pain patients. Both the average absolute difference in pain intensity (3.09) and the percentage difference in pain intensity (38.5%) in patients with severe pain were significantly higher than the average absolute difference in pain intensity (1.52) and the percentage difference in pain intensity (29.0%) in patients with moderate pain. Cancer patients with moderate and severe pain experienced pain reductions of approximately 30% and 40%, respectively. Early pain management intervention in patients with severe pain is necessary to achieve an obvious analgesic effect, and the formula of the percentage difference in pain intensity should be incorporated into the nursing information system to alert clinicians for early detection of the effectiveness of cancer pain management.

Pilot Testing the Clinically Aligned Pain Assessment (CAPA) Measure

BACKGROUND

Pain is one of the most common symptoms experienced by patients in acute care hospitals and acutely ill patients experience both acute and chronic pain. Unrelieved pain can have a profound negative impact on individuals' functional status, well-being, quality of life, and satisfaction with care. For providers, managing pain can be challenging. While the numeric rating scale is widely accepted and used, it measures only pain intensity. CAPA® pain assessment offers an alternative approach in which providers have a conversation with patients about pain and how it impacts five key areas.

AIMS

The purpose of this pilot project was to evaluate provider and patient satisfaction with the CAPA® measure as compared to a numeric rating scale when evaluating patients' experience with pain.

DESIGN

A mixed methods qualitative design was employed.

SETTING

This study was conducted at a 247-bed community teaching hospital in Providence, RI.

PARTICIPANTS

The target sample included patients admitted to the study units and providers who delivered care to patients on the study units and used the numeric rating scale and the CAPA® method of assessment.

METHODS

In focus groups, nurses and physicians were asked about satisfaction with evaluating patients' pain with the numeric rating scale as compared to CAPA®. During a one-to-one interview, patients were asked to describe their impressions of the two assessment measures.

RESULTS

Nurses, physicians, and patients were satisfied that CAPA® effectively evaluated pain and provided more information about pain than the numeric rating scale.

CONCLUSIONS

CAPA® is recommended as a supporting assessment to evaluate patients' pain experience in acute care.

Burden of cancer pain in developing countries: a narrative literature review

Cancer pain is one of the most common, feared, debilitating, and often undertreated symptoms among cancer patients. It needs attention since it has a significant impact on the quality of life (QoL) of the patients. Also, since cancer has emerged as a major health problem in developing countries, there is a need to strengthen preventive strategies for effective cancer pain management and provide comfort to cancer patients. Nonetheless, various barriers limit developing countries toward optimal cancer pain management. To bridge the gap between adequate pain management and burden of cancer pain in developing countries, a comprehensive understanding of the limitations faced and the prevalence of cancer pain should be addressed. The aim of this literature review is to provide a deeper understanding on the factors associated with cancer pain as well as barriers toward optimal cancer pain management in developing countries. Some of the barriers addressed were administrative, judicial, economic, and professional barriers. Also, estimates on the prevalence of cancer pain and detrimental effects of pain on the QoL of cancer patients have been addressed. In summary, pain, which is one of the most debilitating symptoms of cancer, remains uncontrolled and undertreated in developing countries. It has a profound impact on the patient’s QoL and can have physical, psychological, and social consequences; therefore, it needs to be managed urgently and appropriately. Most importantly, optimal treatment of cancer pain should be highlighted as a priority in developing countries and concerted efforts should be made to eliminate different barriers discussed in this review for effective and humane care.

Advances in the pharmacological management of acute and chronic pain

Effective management of acute and chronic pain is an important aspect of nursing practice. Relieving patients' pain requires nurses to have an understanding of the latest evidence-based approaches, which will enable them to assess pain, implement appropriate management strategies and monitor their effectiveness. This article outlines the developments in evidence-based guidelines and recommendations for the pharmacological management of acute and chronic pain, including migraine, and in the use of analgesics such as opioids. It also discusses pain management in specific groups such as children and young people, and older people.

Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand

BACKGROUND

The objective of pain medicine education is to provide medical students with opportunities to develop their knowledge, skills and professional attitudes that will lead to their becoming safe, capable, and compassionate medical practitioners who are able to meet the healthcare needs of persons in pain. This study was undertaken to identify and describe the delivery of pain medicine education at medical schools in Australia and New Zealand.

METHOD

All 23 medical schools in Australia and New Zealand in 2016 were included in this study. A structured curriculum audit tool was used to obtain information on pain medicine curricula including content, delivery, teaching and assessment methods.

RESULTS

Nineteen medical schools (83%) completed the curriculum audit. Neurophysiology, clinical assessment, analgesia use and multidimensional aspects of pain medicine were covered by most medical schools. Specific learning objectives for pain medicine were not identified by 42% of medical schools. One medical school offered a dedicated pain medicine module delivered over 1 week. Pain medicine teaching was delivered at all schools by a number of different departments throughout the curriculum. Interprofessional learning (IPL) in the context of pain medicine education was not specified by any of the medical schools. The mean time allocated for pain medicine teaching over the entire medical course was just under 20 h. The objective structured clinical examination (OSCE) was used by 32% of schools to assess knowledge and skills in pain medicine. 16% of schools were unsure of whether any assessment of pain medicine education took place.

CONCLUSION

This descriptive study provides important baseline information for pain medicine education at medical schools in Australia and New Zealand. Medical schools do not have well-documented or comprehensive pain curricula that are delivered and assessed using pedagogically-sound approaches considering the complexity of the topic, the prevalence and public health burden of pain.

Pain control through selective chemo-axotomy of centrally projecting TRPV1+ sensory neurons

Agonists of the vanilloid receptor transient vanilloid potential 1 (TRPV1) are emerging as highly efficacious nonopioid analgesics in preclinical studies. These drugs selectively lesion TRPV1+ primary sensory afferents, which are responsible for the transmission of many noxious stimulus modalities. Resiniferatoxin (RTX) is a very potent and selective TRPV1 agonist and is a promising candidate for treating many types of pain. Recent work establishing intrathecal application of RTX for the treatment of pain resulting from advanced cancer has demonstrated profound analgesia in client-owned dogs with osteosarcoma. The present study uses transcriptomics and histochemistry to examine the molecular mechanism of RTX action in rats, in clinical canine subjects, and in 1 human subject with advanced cancer treated for pain using intrathecal RTX. In all 3 species, we observe a strong analgesic action, yet this was accompanied by limited transcriptional alterations at the level of the dorsal root ganglion. Functional and neuroanatomical studies demonstrated that intrathecal RTX largely spares susceptible neuronal perikarya, which remain active peripherally but unable to transmit signals to the spinal cord. The results demonstrate that central chemo-axotomy of the TRPV1+ afferents underlies RTX analgesia and refine the neurobiology underlying effective clinical use of TRPV1 agonists for pain control.

Effects of experimental pain induction on alcohol urge, intention to consume alcohol, and alcohol demand

Research suggests one determinant of alcohol consumption may be physical pain, but there is no empirical evidence that pain has a causal effect on drinking. Therefore, the primary aim of this study was to test experimental pain as a determinant of several alcohol consumption proxies: self-reported urge to drink, intention to consume alcohol, and alcohol demand. This study also was designed to test negative affect as a mediator of the effects of pain on alcohol use proxies. We hypothesized that participants randomized to experimental pain induction (vs. no pain) would report greater urge, intention, and alcohol demand, and that these effects would be mediated by increased negative affect. Participants were healthy undergraduates who were moderate-heavy drinkers (N = 61). Experimental pain was induced using a novel capsaicin-heat model intended to approximate key features of clinical pain. Results indicated that participants in the pain condition subsequently endorsed greater urge and intention to drink. Furthermore, these effects were mediated by pain-induced negative affect. We observed no effect of pain on alcohol demand. This is the first study to demonstrate a causal effect of acute pain on urge and intention to drink. Given the close association between alcohol consumption, urge and intention to drink, these findings suggest that pain may influence alcohol consumption, which can have implications for individuals with co-occurring pain and alcohol use disorder (AUD). Specifically, individuals with co-occurring pain and AUD may drink to alleviate pain-related negative affect. Therefore, improving pain-coping skills may enhance pain-management abilities, subsequently reducing coping-motivated drinking. (PsycINFO Database Record

Assessing and Managing Acute Pain: A Call to Action

: Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic.

Light-Emitting Diode Phototherapy Reduces Nocifensive Behavior Induced by Thermal and Chemical Noxious Stimuli in Mice: Evidence for the Involvement of Capsaicin-Sensitive Central Afferent Fibers

Low-intensity phototherapy using light fonts, like light-emitting diode (LED), in the red to infrared spectrum is a promising alternative for the treatment of pain. However, the underlying mechanisms by which LED phototherapy reduces acute pain are not yet well understood. This study investigated the analgesic effect of multisource LED phototherapy on the acute nocifensive behavior of mice induced by thermal and chemical noxious stimuli. The involvement of central afferent C fibers sensitive to capsaicin in this effect was also investigated. Mice exposed to multisource LED (output power 234, 390, or 780 mW and power density 10.4, 17.3, and 34.6 mW/cm², respectively, from 10 to 30 min of stimulation with a wavelength of 890 nm) showed rapid and significant reductions in formalin- and acetic acid-induced nocifensive behavior. This effect gradually reduced but remained significant for up to 7 h after LED treatment in the last model used. Moreover, LED (390 mW, 17.3 mW/cm²/20 min) irradiation also reduced nocifensive behavior in mice due to chemical [endogenous (i.e., glutamate, prostaglandins, and bradykinin) or exogenous (i.e., formalin, acetic acid, TRPs and ASIC agonist, and protein kinase A and C activators)] and thermal (hot plate test) stimuli. Finally, ablating central afferent C fibers abolished LED analgesia. These experimental results indicate that LED phototherapy reduces the acute painful behavior of animals caused by chemical and thermal stimuli and that LED analgesia depends on the integrity of central afferent C fibers sensitive to capsaicin. These findings provide new information regarding the underlying mechanism by which LED phototherapy reduces acute pain. Thus, LED phototherapy may be an important tool for the management of acute pain.

Assessment of post-operative pain management among acutely and electively admitted patients - a Swedish ward perspective

RATIONALE, AIMS AND OBJECTIVES

Swedish health care is regulated to involve the patient in every intervention process. In the area of post-operative pain, it is therefore important to evaluate patient experience of the quality of pain management. Previous research has focused on mapping this area but not on comparing experiences between acutely and electively admitted patients. Hence, the aim of this study was to investigate the experiences of post-operative pain management quality among acutely and electively admitted patients at a Swedish surgical department performing soft-tissue surgery.

METHODS

A survey study design was used as a method based on a multidimensional instrument to assess post-operative pain management: Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP). Consecutive patients at all wards of a university hospital's surgical department were included. Data collection was performed at hospital discharge.

RESULTS

In total, 160 patients participated, of whom 40 patients were acutely admitted. A significant difference between acutely and electively admitted patients was observed in the SCQIPP area of environment, whereas acute patients rated the post-operative pain management quality lower compared with those who were electively admitted.

CONCLUSIONS

There may be a need for improvement in the areas of post-operative pain management in Sweden, both specifically and generally. There may also be a difference in the experience of post-operative pain quality between acutely and electively admitted patients in this study, specifically in the area of environment. In addition, low levels of the perceived quality of post-operative pain management among the patients were consistent, but satisfaction with analgesic treatment was rated as good.

Using a New Measurement to Evaluate Pain Relief Among Cancer Inpatients with Clinically Significant Pain Based on a Nursing Information System: A Three-Year Hospital-Based Study

OBJECTIVE

Developing a new measurement index is the first step in evaluating pain relief outcomes. Although the percentage difference in pain intensity (%PID) is the most popular indicator, this indicator does not take into account the goal of pain relief. Therefore, the aims of this study were to develop a pain relief index (PRI) for outcome evaluation and to examine the index using demographic characteristics of cancer inpatients with clinically significant pain.

DESIGN

Retrospective cohort study.

SETTING

A national hospital.

SUBJECTS

All cancer inpatients.

METHODS

Pain intensity was assessed using a numerical rating scale, a faces pain scale or the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Tool. Using a nursing information system, a pain score database containing data from 2011 through 2013 was analyzed.

RESULTS

Cancer patients representing 93,812 hospitalizations were considered in this study. We focused on cancer patients for whom the worst pain intensity (WPI) was ≥ 4 points. PRI values of -62.02% to -72.55% were observed in the WPI ≥ 7 and 4 ≤ WPI ≤ 6 groups. Significant (P < 0.05) effects on PRI values were observed among patients who were > 65 years old, those who were admitted to the medicine or gynecology and those who had a hospital stay > 30 days.

CONCLUSION

This hospital-based study demonstrated that the PRI is an effective and valid measure for evaluating outcome data using an electronic nursing information system. We will further define the meaningful range of percentage difference in PRI from various perspectives.

Trends in Clinically Significant Pain Prevalence Among Hospitalized Cancer Patients at an Academic Hospital in Taiwan: A Retrospective Cohort Study

Clinically significant pain (CSP) is one of the most common complaints among cancer patients during repeated hospitalizations, and the prevalence ranges from 24% to 86%. This study aimed to characterize the trends in CSP among cancer patients and examine the differences in the prevalence of CSP across repeated hospitalizations. A hospital-based, retrospective cohort study was conducted at an academic hospital. Patient-reported pain intensity was assessed and recorded in a nursing information system. We examined the differences in the prevalence of worst pain intensity (WPI) and last evaluated pain intensity (LPI) of ≥ 4 or ≥ 7 points among cancer inpatients from the 1st to the 18th hospitalization. Linear mixed models were used to determine the significant difference in the WPI and LPI (≥ 4 or ≥ 7 points) at each hospitalization. We examined 88,133 pain scores from the 1st to the 18th hospitalization among cancer patients. The prevalence of the 4 CSP types showed a trend toward a reduction from the 1st to the 18th hospitalization. There was a robust reduction in the CSP prevalence from the 1st to the 5th hospitalization, except in the case of LPI ≥ 7 points. The prevalence of a WPI ≥ 4 points was significantly higher (0.240-fold increase) during the 1st hospitalization than during the 5th hospitalization. For the 2nd, 3rd, and 4th hospitalizations, there was a significantly higher prevalence of a WPI ≥ 4 points compared with the 5th hospitalization. We also observed significant reductions in the prevalence of a WPI ≥ 7 points during the 1st to the 4th hospitalizations, an LPI ≥ 4 points during the 1st to the 3rd hospitalizations, and an LPI ≥ 7 points during the 1st to the 2nd hospitalization. Although the prevalence of the 4 CSP types decreased gradually, it is impossible to state the causative factors on the basis of this observational and descriptive study. The next step will examine the factors that determine the CSP prevalence among cancer patients. However, based on these positive findings, we can provide feedback to nurses, physicians, and pharmacists to empower them to be more committed to pain management.

The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia

Background

Assessment and management of pain in patients with dementia is known to be challenging, due to patients’ cognitive and/or communication difficulties. In the UK, pain in hospital is managed through regular assessments, with the use of pain intensity scores as triggers for action. The aim of this study was to understand current pain assessment practices, in order to later inform the development of a decision support tool designed to improve the management of pain for people with dementia in hospital.

Methods

An exploratory study was conducted in four hospitals in the UK (11 wards), with observations of patients with dementia (n = 31), interviews of staff (n = 52) and patients’ family members (n = 4) and documentary analysis. A thematic analysis was carried out, structured along dimensions of decision making. This paper focuses on the emergent themes related to the use of assessment tools and pain intensity scores.

Results

A variety of tools were used to record pain intensity, usually with numerical scales. None of the tools in actual use had been specifically designed for patients with cognitive impairment. With patients with more severe dementia, the patient’s body language and other cues were studied to infer pain intensity and then a score entered on behalf of the patient. Information regarding the temporality of pain and changes in pain experience (rather than a score at a single point in time) seemed to be most useful to the assessment of pain.

Conclusions

Given the inherent uncertainty of the meaning of pain scores for patients with dementia, numerical scales were used with caution. Numerical scores triggered action but their meaning was relative - to the patient, to the clinician, to the time of recording and to the purpose of documenting. There are implications for use of data and computerized decision support systems design. Decision support interventions should include personalized alerting cut-off scores for individual patients, display pain scores over time and integrate professional narratives, mitigating uncertainties around single pain scores for patients with dementia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0233-8) contains supplementary material, which is available to authorized users.

Using the Electronic Health Record in Nursing Research: Challenges and Opportunities

Changes in the patient record from the paper to the electronic health record format present challenges and opportunities for the nurse researcher. Current use of data from the electronic health record is in a state of flux. Novel data analytic techniques and massive data sets provide new opportunities for nursing science. Realization of a strong electronic data output future relies on meeting challenges of system use and operability, data presentation, and privacy. Nurse researchers need to rethink aspects of proposal development. Joining ongoing national efforts aimed at creating usable data output is encouraged as a means to affect system design. Working to address challenges and embrace opportunities will help grow the science in a way that answers important patient care questions.

Reducing patient suffering through compassionate connected care

Patient experience continues to play an increasingly critical role in quality outcomes and reimbursement. Nurse executives are tasked with helping direct-care nurses connect with patients to improve care experiences. Connecting with patients in compassionate ways to alleviate inherent patient suffering and prevent avoidable suffering is key to improving the patient experience. The Compassionate Connected Care framework identifies strategies for meeting the challenges of connecting with patients and reducing suffering. Methods integrate clinical, operational, cultural, and behavioral aspects of care to target patient needs based on condition. Caregivers learn to better express empathy and compassion to patients, and nurse leaders are better equipped to engage nurses at the bedside.