In order to get a better picture of the current practice, a chart audit was undertaken on one day in the organization. All charts were reviewed regardless of diagnosis or analgesia orders. This included 50 charts on both the medical/surgical unit and the complex continuing care unit. The second component of the audit was an interview with each patient regarding their satisfaction with pain management using questions adapted from the Ontario Hospital Report Series. The findings of the audit confirmed our hypothesis that while patients appeared to be satisfied with pain medication, documentation of nursing assessment and plan of care was not done correctly.  

A meeting of nurse leaders in the organization occurred and it was decided to create a group of front line nurse “experts” who would hold inservices for other staff regarding pain management issues and act as consultants with challenging patient cases. This model of “train-the-trainer” has been used successfully in our small rural hospital with other initiatives. When challenged with this opportunity, seven front line Registered Nurses volunteered to be trained as pain management experts. A literature review was completed by the nurse leaders to identify evidence based practice tools to be used in training. 

A paid one-day session was held in December 2006 for this group of nurses. At the beginning of the day, a pre-test was administered to assess current practice knowledge. Speakers at the event included a regional pain and symptom management expert, a pharmacist, a physician, senior vice-president of our organization and the in-house palliative care coordinator. Topics included: anatomy and types of pain, pain assessment with tools, communication with physicians, medications and dosages, professional practice issues including ethics, and hands-on practice with our pain medication infusion pumps, the Gemstar. A post-test was administered which showed a 50% improvement in knowledge over the day. 

The first assignment that the nurse experts were given was to teach and review the operation of the Gemstar pump with nursing staff. This occurred from mid-December to mid-January.  

A pre-test was administered to all full and part-time Registered Nurses and Registered Practical Nurses who work on the medical/surgical and complex continuing care units (approximately 70 staff members) in January 2007. 

The nurse experts conducted inservices with staff on all shifts using a case study format to enhance critical thinking skills. Small groups are formed to analyze the case and make suggestions for treatment. The case studies were created by the nursing leaders/administration and will be reviewed with the nurse experts prior to any teaching. The nurse experts also assist and guide staff in treating patients on the units and in communicating with physicians. These inservices and teaching opportunities will take place between February and May 2007.  

A post-test will then be administered to the same group who completed the pre-test in June 2007 in order to assess the effectiveness of the teaching model. A complete chart audit and patient interview will be repeated on one day in June 2007 in order to assess nursing assessment and documentation. We hypothesize that there will be a 50% improvement in the post-test results and that there will also be a 50% improvement in assessment and documentation skills.