Nurse Eases Patients’ Pain While Empowering Hospital Staff

Using change management learned in grad school, ICU nurse shortened time patients spent in intensive care

Published: Thursday, April 28, 2011 - 06:00

Critical care units at St. Joseph’s Hospital Health Center in Syracuse, New York, were faced with a formidable task. They had applied to receive the Beacon Award for Critical Care Excellence, a distinction given only to the top intensive care units in the United States. One of the components on which they would be judged was how they assessed patients’ pain levels in a critical care environment, and that’s where they hit a snag—until a nursing student stepped in.

“The staff and I were measuring pain levels using a tool that was outdated and not suited to ICU work,” says Christopher Kowal, who in addition to being a full-time staff nurse, was pursuing a master’s degree in Science Nursing Education at American Sentinel University.

Using change-management skills he’d gained from his studies, Kowal was able to identify a more appropriate pain-assessment tool and designed a pilot program to study its effectiveness. The results were remarkable. “I was able to better manage patients’ pain and get them out of the intensive care unit (ICU) more quickly,” Kowal says. “And the new tool improved productivity at the same time.”

Navigating the change-management process

In the critical care unit, Kowal and the other nurses routinely had to assess pain levels in patients who weren’t able to talk. They had been using an observational scale known as PAINAD (pain assessment in adults with dementia), a five-item observational tool that looks at a patient’s breathing, negative vocalization, facial expression, body language, and consolability.

Although PAINAD was definitely designed for patients who couldn’t speak for themselves, Chris questioned if it was really appropriate for the critical care population. Most of these were lucid adults who were temporarily rendered nonverbal because they were intubated and on ventilators, rather than those suffering from dementia, the population PAINAD was designed for.

Kowal researched his answer using several medical databases and discovered three or more pain scales that seemed better suited for his post-surgical patients, and the nurses settled on the CPOT (critical-care pain observation tool). CPOT consists of four sections, each with different behavioral categories: facial expression, body movements, muscle tension, and compliance with the ventilator for intubated patients or vocalization for extubated patients.

“But we found it was not an easy fix, although as nurses we assumed it would be,” says Kowal. “We had to go through the hospital’s critical standards committee to get a pilot program approved, even though the tool was already backed by research and statistically valid.”

Fortunately, Kowal was familiar with the change-management process from his coursework at American Sentinel University. Change management is a process for developing and implementing better practice for existing practice (or what some call “unfounded tradition,” “sacred cows,” and “golden geese”). The concept of change also has to do with restratifying how individuals accept change in order to self-enculturate for the sake of doing what is right.

“I definitely had the background, from my education, to do this,” Kowal affirms. The nurses reached out to surgeons and anesthesiologists to get their input and buy-in. “We had never collaborated across disciplines before, and the MDs were impressed that we were so invested in wanting to improve our practice.”

The pilot program lasted six months, and Kowal evaluated the results through a retrospective chart review—comparing patient charts from the pilot period with charts from a prior six-month period.

The findings were significant. Because the nurses could assess pain more accurately using CPOT, they could control pain more effectively. If pain is better controlled, patients are more compliant with the ventilator weaning and less anxious to want to fight it. As a result, patients felt better and were able to come off ventilators sooner.

“If a patient has pain, they are unable to participate in their rehabilitation process to the maximum potential,” explains Kowal. And because patients were spending less time on ventilators, the rates of ventilator-associated pneumonia dropped drastically in the critical care unit.

“Our nursing education programs are all about empowering nurses to use evidence-based research to improve practice at the bedside,” says Dr. Catherine Garner, dean of health sciences and nursing at American Sentinel University. “The bedside nurse is the one who is best positioned to know what is happening within the unit and how care is affecting patient outcomes. With the knowledge of research, change theory, and organizational dynamics, the bedside nurse practices to their full potential as a professional. It is so rewarding to see Chris use his advanced nursing education to make a difference today.”

Thanks in part to Kowal’s help, the ICU unit at St. Joseph’s Hospital Health Center earned the coveted Beacon Award in 2009, awarded by the American Association of Critical Care Nurses. Kowal even wrote an article, published in 2010 in the Journal of the New York State Nurses Association, documenting his success with the program.

“The work I did empowered our nursing staff to identify needs and test new practice methods,” Kowal says. “Now we can have discussions about change in practice. After everyone saw the results of the pain assessment pilot, which took a year to implement, they saw the benefit of the process.

“Now I show nurses how to write proposals and implement changes, and the next person shouldn’t have to be as frustrated as I sometimes was,” adds Kowal. “They should be empowered to move the process for change further.”

About The Author

American Sentinel University

American Sentinel University provides online accredited degree programs in nursing, health informatics, health systems management, health care MBA, and a DNP in nurse executive leadership. Its vision is to provide new levels of access to quality, advanced education for the motivated, nontraditional learner/professional who hasn’t had the opportunity for advanced personal degrees yet seeks to lead in emerging/growing industries. ASU understands and meets the changing needs of its students and communities and strives for innovative use of technology to create new standards in assessment and achievement of academic excellence.