The Effects of a “Real-Time” Audit Nurse for Better Pain Assessment Documentation
Pain is an important clinical feature of many pathologic states of human beings which also doubles as the chief complaint of most patients at admission. Because of this, proper management of pain is at the heart of comprehensive patient care. Over the last decade, a philosophy that sees pain as the fifth vital sign has gained fame. Just like other vital signs, documentation of pain is key. Having one nurse to audit how pain has been documented over a given period of time will enhance the effectiveness of documenting pain (Esper & Walker, 2015). This paper is an analysis of the effect of having a nurse dedicated to having pain documentations audited in the shortest time possible.
Past research has shown that most documents prepared by nurses are variably flawed (Lindo et al., 2016). It is this flaws which necessitate a real-time audit into this documents so as to encourage the nurses to document their findings better. A real-time audit will definitely enhance the compliance of nurses to the documentation requirements of the facility (Nielsen, Peschel, & Burgess, 2014). This ultimately encourages responsibility among nurses thus improving the effectiveness of nursing activities. In terms of pain assessment documentation, proper documentation will improve pain management. Currently, there are no past research papers which document studies into the roles of audit nurses in pain assessment and management. According to Wang, Hailey, and Yu (2011), there has been little research to suggest the cons of or to critique use of a nurse to give a real-time audit of pain documentations.
There are many research papers about the importance of real-time audits in various clinical activities. Audits can be done by health workers in a particular department as part of self-assessment in the department. Authorities from outside can also audit documents with a view of assessing the effectiveness of health workers in a certain department of a hospital (Nielsen et al., 2014). An audit by a nurse on documents prepared by fellow nurses is an internal audit which seeks to improve effectiveness; in this case, the audit is aimed at ensuring comprehensive management of pain in all patients by the end of a nursing shift. Wang et al. (2011) note that the main challenge to such audits that has been identified is the work pressure owing to the inadequacy of staff. Having one member of staff dedicated to the audit process effectively reduces the number of staff running other activities (Nielsen et al., 2014). However, in my opinion, this can be dealt with. The nurse in charge only has to make sure that they dedicated the auditing process to the nurse who is likely to be least busy in the day according to the facility’s nursing schedule. This will ensure that all other nursing activities are progressing as planned while the audit is also going on.
This proposed practice will greatly enhance management of pain among hospitalized patients and is in line with the national guidelines for pain management. The current guidelines were developed by the American Pain Society and have five prongs (Nielsen et al., 2014). The first prong encourages prompt recognition and treatment of pain. Patients and their families should be involved in designing an individualized pain management plan. Thirdly, the guidelines look to improve pain management patterns. Reassessment and adjustment of the pain management plan as necessary is also encouraged. Finally, the guidelines demand monitoring of process and outcome of pain management (Nielsen et al., 2014). This is where a real-time audit nurse becomes relevant to the guidelines. The audit nurse is to look at pain documents to see what pain medications were given to which patients and how the patients’ pain was affected by the medication as per the pain reassessment reports.
Moreover, this proposed policy is in line with the Baccalaureate accreditation requirements for nurses, who must be competent in assessment and management of pain. Moreover, for health facilities to be accredited, they have to prove that they have enough capacity to handle patients in pain properly. This will include having adequate nursing staff, having proper strategies, and having the necessary equipment.
In addition, this proposed practice is directly in line with evidence-based practice (EBP). In current health practice, EBP is at the center of everything. In this practice, the nurse will have evidence of which analgesic works best for a particular patient before administering the drug (Hayter & Schaper, 2015). Moreover, the choice of the drug to be used will be in line with the pain history that the patient gave prior hence making the practice patient-centered. It is a practice that is likely to be taken up by nurses in most institutions. There are several reasons why I think nurses will like having one of them as a real-time auditor of pain assessment and reassessment documents as follows.
Firstly, having a nurse to audit the pain assessment and reassessment documents throughout a shift is in line with practice policies in most health facilities. As earlier alluded to, most health facilities are moving towards EBP. In this regard, this proposed practice will ensure that patients receive the most suitable analgesia for their pain and at the time they need it most. Moreover, most health facilities are moving towards internal assessments of their staff (Nielsen et al., 2014). This means that nurses in a facility have the chance to asses and correct each other where necessary. Having one nurse to audit documents prepared by fellow nurses in the same department will help the nurses in that department to assess the work of each other hence to aid them to improve (Hayter & Schaper, 2015). In addition, current nursing guidelines insist on individualization of care and patient-centered nursing practice. This proposed practice ensures real-time audit of assessment and reassessment results of individual patients so as to intervene at exactly the correct time. For this reason, the practice is likely to be popular among nurses. Finally, most facilities are embracing technology and electronic systems in practice. An audit of pain documentation can be done electronically. Software and electronic cues that alert the audit nurse when the pain level of a particular patient requires intervention can be designed to aid in the activity (Nielsen et al., 2014). Nurses are likely to take up a policy that utilizes technology with utmost ease.
Secondly, nurses are expected to care for patients holistically; alleviation of pain is an important aspect of holistic care. This strategy is likely to enhance the effectiveness of pain management in patients hence increasing the effectiveness of nursing practice (Esper & Walker, 2015). For visibly increasing their effectiveness, this strategy is likely to be popular among nurses.
Thirdly, the auditing process is not much work and can be done either by the lead nurse or another nurse who seems to have the least workload throughout the day. For this reason, nurses will definitely appreciate this strategy. Facility management boards will also take advantage of this strategy since it might not require them to employ new nursing staff. As Nielsen et al. (2014) put it, real-time auditing of pain assessment documents will effectively reduce workload as pain will be recognized and managed promptly.
The embrace of real-time auditing of pain assessment and reassessment documents will definitely enhance pain management and holistic patient care in a health facility. Proper pain management is key to ensuring patients recover properly from various disease processes, surgical procedures, and diagnostic procedures. Failure to manage pain properly can lead to various complications of mismanaged pain including poor wound healing and infection. Embracing this proposed strategy will, therefore, benefit not only the nurse but also the patient and the facility in general.
References
Esper, P., & Walker, S. (2015). Improving documentation of quality measures in the electronic health record. Journal of the American Association of Nurse Practitioners, 27(6), 308-312. Retrieved from https://dx.doi.org/10.1002/2327-6924.12169
Hayter, K. L., & Schaper, A. M. (2015). Improving pain documentation with peer chart review. Nursing 2015, 45(7), 58-63. Retrieved from https://dx.doi.org/10.1097/01.NURSE.0000463673.52336.80
Lindo, J., Stennett, R., Stephenson‐Wilson, K., Barrett, K. A., Bunnaman, D., Anderson‐Johnson, P., … Wint, Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 499-507. Retrieved from https://dx.doi.org/10.1111/jnu.12234
Nielsen, G., Peschel, L., & Burgess, A. (2014). Essential documentation elements: Quality tool for the emergency department nurse. Advanced emergency nursing journal, 36(2), 199-205. Retrieved from https://dx.doi.org/10.1097/TME.0000000000000020
Wang, N., Hailey, D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: A mixed‐method systematic review. Journal of Advanced Nursing, 67(9), 1858-1875. Retrieved from https://dx.doi.org/10.1111/j.1365-2648.2011.05634.x
