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RWJ 08-273 – HSR&D Study

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RWJ 08-273
Measuring Care Quality and Pain Outcomes in Hospitalized Veterans
Stacey K Shaffer MSN BSN BS
VA Salt Lake City Health Care System, Salt Lake City, UT
Salt Lake City, UT
Funding Period: October 2008 - March 2010

BACKGROUND/RATIONALE:
Research to study the impact of nursing care on nursing-sensitive patient outcomes has been challenging. There is limited effectiveness research to link nursing care and pain. To better understand the relationship between nursing care and patient outcomes, we must be able to measure care quality and patient outcomes at the nurse-patient level. Reliable, valid, and sensitive measurement tools are needed to evaluate nursing care quality. VA Nursing Outcome Database goals support providing tools for 1) understanding clinical processes that are sensitive to nursing practices, and 2) influencing patient outcomes. VHA established pain management as a national priority in 1998. In spite of advances in pain assessment and management, studies reveal that pain is highly prevalent and inadequately managed in hospitalized patients including veteran populations. Preliminary work for this study was funded to develop and test a tool to measure the quality of nursing care and interdisciplinary care related to pain management. This tool was validated at three non-VA facilities focusing on hospitalized patients with cancer. This study is the first testing of this tool in a general medical/surgical sample of hospitalized veterans.

OBJECTIVE(S):
In a sample of hospitalized Veterans who are experiencing pain, our objectives are to: 1) examine the reliability and validity of the Pain Care Quality (PainCQ) surveys, and 2) test a measure of the quality of nursing care related to pain management that effectively predicts pain outcomes (through correlational analyses).

METHODS:
Pain Care Quality Surveys and the Brief Pain Inventory-SF were administered to 221 hospitalized veterans over a period of one year. Study design used a cross-sectional survey administered within two hours following the end of a nursing care shift. Demographic and clinical data were collected from patients and/or patient records. Inclusion criteria: 1) admitted to one of five inpatient units with length of stay of at least 24 hours; and 2) positive response to screening for the presence of pain during the past shift. Exclusion criteria: cognitively and/or physically unable to participate in an interview or complete a survey. The study design employed confirmatory factor analysis and correlational analyses.

FINDINGS/RESULTS:
221 veterans enrolled age 28 to 91 (Mean = 62.2), 92.8% male, 92.3% non-Hispanic White, 79% had a medical reason for hospitalization, 36.7% reported "cause of pain" as surgical (majority orthopedic), 39.4% (majority cardiac) as non-cancer disease-related. Fifty percent of subjects reported being in "frequent/constant" pain during the last shift; 23% reported being in severe pain frequently or constantly. Veteran PainCQ survey data from the 33 question version, (originally developed and validated in the oncology setting), were analyzed to confirm the best set of questions to measure the defined concepts that comprised quality pain care. The survey consists of two scales, Interdisciplinary Care measuring two factors,1) partnership with the healthcare team and 2) comprehensive interdisciplinary pain care and Nursing Care measuring 3 factors, 1) being treated right, 2) efficacy of pain management, and 3) comprehensive nursing pain care. Reliability of each factors was found to be >0.7 (range = 0.76 to 0.89). Model fit statistics were improved to meet established criteria and redundant questions eliminated which ultimately produced a 20 question VA PainCQ model survey.
The Brief Pain Inventory short form (BPI-SF) was used as a measure of pain outcomes which were correlated for both scales of the PainCQ survey. Within the PainCQ-Interdisciplinary scale, only the "degree of pain relief" outcome was significantly correlated (p=<0.003) with the "comprehensive interdisciplinary pain care" factor. Most of the correlations were weak with the Pain CQ-Interdisciplinary scale. Within the PainCQ-Nursing scale, the strongest significant correlations were with the "efficacy of pain management" factor where all p values were < .001 and the correlations were moderate in strength. The factor "being treated right" correlated significantly (p=0.001-0.012) with all outcome measure although correlations were low.

IMPACT:
Measuring quality of care from the patient's perspective is consistent with the national VHA Pain Management Directive and national trends to deliver patient-centered care and supports the VA Nursing Outcomes Database (VANOD) goals. Outcomes of this project documented unrelieved pain in this sample of hospitalizerd veterans. The project demonstrated that veterans can make judgments about their pain management while hospitalized, increasing the feasibility of application of this type of survey tool. The product of this research, the PainCQ tools, are short, valid and reliable surveys that could be disseminated for use in evaluation and improvement of quality of pain care in hospitalized veterans.

PUBLICATIONS:
None at this time.


DRA: Acute and Combat-Related Injury, Health Systems
DRE: Treatment - Observational, Prevention
Keywords: Nursing, Pain, Quality Measure
MeSH Terms: none

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