How incremental video training did not guarantee implementation due to fluctuating population prevalence

Abstract

Patients with stroke admitted at the neurology/neurosurgery ward of the Academic Medical Centre in Amsterdam, The Netherlands, may experience problems in communication, such as aphasia, severe confusion/delirium or severe language barriers. This may prevent self-reported pain assessment; therefore, pain behaviour observation scales are needed. In this project, we therefore aimed to implement the Rotterdam Elderly Pain Observation Scale (REPOS) by video training.We used a stepped-wedge cluster design with clusters of four to five nurses with intervals of 2 weeks, for a total study duration of 34 weeks. Primary endpoint was the proportion of shifts in which nurses used the REPOS when caring for an eligible patient. A questionnaire was send biweekly to assess self-perceived competence and attitude on pain measurement in patients able or unable to self-report pain intensity. No other strategies were used to promote the use of the REPOS.Though the proportion of shifts in which trained nurses cared for eligible patients increased from 0% at baseline to 83% at the end of the study, the proportion of cumulative shifts where the REPOS was used decreased from 14% to 6%, respectively. Process evaluation suggests that this decrease can (in part) be attributed to low and varying prevalence of eligible patients and opportunities for practice. In total, 24 (45.3%) nurses had used the REPOS at least once after 34 weeks, with a median of two times (1–33). Nurses perceived themselves 'competent' to 'very competent' in pain behaviour observation. There was no negative attitude towards pain measurement.This study shows that education alone may not be effective when implementing a pain behaviour observation scale for non-communicative patients with Acquired Brain Injury. Individual motivation of health professionals and individual patient factors may be of influence for the use of the REPOS.

Initiatives Targeting Health Care Professionals

“…Increases in documentation adherence occurred in 3 initiatives. 54,73,76 No differences in documentation practices occurred in 4 studies 51,66,74 .…”

“…These improvements were demonstrated by decreased pain scores (eg, intensity) across studies after participation in KT programs. [49][50][51] Nonsignificant changes in patient pain scores (eg, pain intensity) were reported across studies. [52][53][54][55][56] In 1 study among LTC residents, pain scores did not improve.…”

“…36,60,61 Barriers to change, including high staff turnover, heavy workload, lack of time, scheduling issues, and resource sharing, prevented successful integration of programs into settings after education was delivered. 19,40,51,62,63 Barriers highlighted unmet staff and patient needs after program delivery. Physical therapists delivering updated clinical suggestions to home health care patients noted concerns with limited time per patient and patient adherence to evidencebased strategies.…”

“…In most cases, satisfaction measurements did not include a control group for comparison. 19,35,51,61,62,64 HCPs were often satisfied with the increased attention raised towards older adult pain and reported increased comfort and confidence in delivering evidence-based care. 35,38,62,64 Session delivery and information were often positively received.…”

“…35,38,62,64 Session delivery and information were often positively received. 9,19,51,61 Resident or patient satisfaction in response to staff education was considered in 4 studies. In all cases when patient satisfaction was assessed, patients responded positively to changes in care.…”