International Journal of Nursing Studies 50 (2013) 552–568

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Do implementation strategies increase adherence to pain assessment

in hospitals? A systematic review
Erwin Ista a,*, Monique van Dijk a, Theo van Achterberg b
a
Intensive Care Unit, Department Paediatric Surgery, Erasmus MC – Sophia Children’s Hospital, Rotterdam, The Netherlands
b
Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: Pain assessment and reassessment is an essential part of the treatment of
Received 30 March 2012 hospitalised patients and must be integrated in pain management protocols. Yet nurses’
Received in revised form 7 November 2012 adherence to pain assessment recommendations is problematic. We sought to review the
Accepted 7 November 2012 comparative evidence for implementation strategies aiming to improve nurses’ adherence
to pain assessment recommendations in hospitalised patients.
Keywords: Design: Systematic review using the narrative method.
Implementation Data sources: PubMed (MEDLINE), CINAHL, Cochrane library and hand searching.
Pain assessment
Review methods: Studies published since 1990, reporting implementation strategies that
Adherence
aimed to improve nurses’ adherence to pain assessment recommendations in hospitalised
Education
Feedback
patients were included. According to the Cochrane Effective Practice and Organization of
Implementation strategies Care group (EPOC) classification system, strategies were categorized as directed at: health
professionals, organizations, financing, or regulations. Given the heterogeneity in
strategies, samples, outcomes and settings, evidence from the studies was synthesized
using a narrative approach.
Results: From 743 initial citations, 23 studies were included. They reported a variety of
implementation strategies, but only directed at health professionals and/or organizations.
In seven studies, a single strategy was applied (e.g. education or feedback). The remaining
16 studies used multifaceted approaches. The effectiveness of the implementation
strategies varied. In all studies but one, adherence rates had improved after
implementation compared to the before measurement, by 9% up to 49%. These effects
were measured at different time points after completion of the implementation, ranging
from 2 weeks to 6 months. Half of the reviewed studies reported an adherence rate of 80%
or higher after implementation activities; other reported rates ranging from 24 to 80%. In
two controlled studies the adherence to pain assessment recommendations increased
significantly when feedback was provided compared to no feedback. Sustained effects
were reported in three studies.
Conclusions: Based on this systematic review we conclude that implementation strategies
to improve nurses’ adherence to pain assessment recommendations vary but generally
address professionals and organizational aspects. Educational and feedback strategies are
often used and seem largely effective.
Due to the heterogeneity of the implementation strategies it is not possible to
recommend one preferred strategy. The level of evidence for strategies to improve pain
assessment recommendations is limited however, as well-conducted studies are lacking.
ß 2012 Elsevier Ltd. All rights reserved.

* Corresponding author at: Intensive Care Unit, Erasmus MC – Sophia Children’s Hospital, Office Sh-4010, P.O. Box 2060, 3000 CB Rotterdam,
The Netherlands. Tel.: +31 10 7037028; fax: +31 10 7036796.
E-mail address: w.ista@erasmusmc.nl (E. Ista).

0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijnurstu.2012.11.003
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568
What is already known about the topic?
 Repeated pain assessment is essential to effective pain
management.
 Adherence to guidelines or protocols for the assessment
of pain in hospitalised patients remains problematic.
What this paper adds
 Most strategies to promote pain assessment are multi-
faceted and target determinants at the levels of
professionals and organizations.
 Strategies can be successful in view of the reported post-
implementation adherence rates of 80% in half of the
studies.
 The level of evidence for strategies directed for improv-
ing pain assessment recommendations is limited how-
ever, due to a lack of well-conducted studies.
1. Introduction
Many hospitalised patients suffer from pain; when left
untreated, pain may delay recovery and prolong hospital
stay (Ferrell et al., 1989; Jakobsson et al., 2007; Kehlet and
Holte, 2001; Morrison et al., 2003; Perkins and Kehlet,
2000). However, patients’ pain is still under treated, not
only due to pain relief policies but also due to inadequate
and infrequent assessment, reassessment and documen-
tation (Dalton et al., 2001; Dihle et al., 2006; Gelinas et al.,
2004; Herr et al., 2004). Better pain detection is a
fundamental first step in improving pain treatment, and
one that has been difficult to achieve (Gordon et al., 2002).
Good pain treatment includes regular assessment and
reassessment, and these elements must be integrated in
pain management protocols or guidelines (Carlson, 2010).
They usually fall to the nursing domain as nurses have
more patient contacts than other health professionals.
Studies on pain assessment in postoperative, cancer,
paediatric and emergency patients identified barriers
related to health care professionals, such as knowledge
deficits, misconceptions about assessment, lack of experi-
ence, resistance to the use of validated tools, limited
competences or assessment skills, inadequate commu-
nication, and not accepting patients’ descriptions of pain
as the gold standard (Berben et al., 2012; Carlson, 2010;
Czarnecki et al., 2011; Horbury et al., 2005; Van Niekerk
and Martin, 2001; Yildirim et al., 2008). Organizational
barriers identified are the lack of assessment protocols
and insufficient feedback on adherence to and quality of
pain assessment (Berben et al., 2012). Finally, patients are
often reluctant to complain about pain. Efforts to improve
pain management have been made through the develop-
ment and dissemination of clinical guidelines. The
updated recommendations of the American Pain Society
focus on pain assessment, patient education, pain treat-
ment, an interdisciplinary approach, effective commu-
nication and coordination of services (Miaskowski et al.,
2005). Another major development is the increased
attention for monitoring quality of care. In the 1990s,
the Joint Commission for the Accreditation of Healthcare
Organizations has mandated routine pain assessment in
553
hospitalised patients in the USA (Joint Commission on
Accreditation of Healthcare Organizations, 2001). As a
result, pain assessment or management quality improve-
ment initiatives and studies have been widely set up. This
resulted in an increased presence of structural elements
(e.g. interdisciplinary work group, standards for assess-
ment and documentation, policies or procedures for
treatment) that are critical to improving pain manage-
ment in practice (e.g. increased use of pain rating scales,
decreased use of intramuscular opioids and increase use of
non-pharmacological strategies) (Dahl et al., 2003;
Gordon et al., 2002).
A variety of implementation strategies are advised to
facilitate the use of pain assessment guidelines (American
Pain Society, 1995; Gordon et al., 2005). Implementing the
recommendations from pain guidelines requires the use of
theoretically underpinned strategies that reduce barriers
and stimulate facilitators (Grol et al., 2007). Continuous
education and training in pain assessment and manage-
ment is widely recommended. However, it is unclear if
training will suffice, and which interventions are most
effective in improving pain assessment adherence rates. A
recent systematic review described the effectiveness of
standardized pain assessment tools on improving patient
(e.g. pain scores) and process outcomes (e.g. adherence) in
paediatrics (Franck and Bruce, 2009). The authors selected
fourteen studies that evaluated the effect of pain assess-
ment on patient outcomes (n = 10) or process outcomes
(n = 12). All studies markedly differed in interventions
applied, pain assessment instruments used, implementa-
tion strategies applied, and reported levels of adherence
with the interventions. The implementation strategy
education was widely used. Nevertheless, the effects on
adherence must be interpreted with extreme caution due
to the preponderance of combined strategies and multiple
major methodological problems (Franck and Bruce, 2009).
Therefore, it was difficult to draw firm conclusions. The
only conclusion made was that pain assessment is not yet
evidence-based.
The overall aim of this study was to systematically
review empirical evidence about the effectiveness of
implementations strategies for the improvement of nurses’
adherence to pain assessment recommendations in
hospitalised patients. We addressed two main questions:
1. What implementation strategies for promoting nurses’
adherence to pain assessment recommendations are
used?
2. What is the effectiveness of these implementation
strategies measured in terms of adherence rates?
2. Methods
2.1. Search strategy
Relevant studies were sought via the databases PubMed
(Medline), Embase, CINAHL and Cochrane library, from
1990 to May 2011 using the following search terms or
equivalent index terms and free-text words for each of the
different databases: nurs* AND (compliance OR adherence
OR nursing evaluation) AND (pain assessment, pain
554 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568
measurement), AND (implementation OR knowledge
transfer OR quality improvement) (see Appendix A for
extended search list). A librarian helped devise the search
strategy. The authors are qualified researchers with
expertise in performing systematic reviews. The search
was not limited by language of publication.
2.2. Criteria for inclusion
We included randomized controlled trials (RCTs);
cluster randomized controlled trials (C-RCTs), non-rando-
mized cluster controlled trials or quasi experimental
studies, controlled before and after studies (CBAs),
interrupted time series (ITS), before–after studies without
a control group and comparative studies with historical
controls.
The following inclusion criteria enabling us to address
the specific research questions were set (see Fig. 1):
1. Descriptions of implementation strategies or interven-
tions to promote adherence to pain assessment
recommendations (e.g. guidelines, protocols or proce-
dures for pain assessment, new or revised assessment
tool).
2. Rates of adherence to (compliance with) pain assess-
ment recommendations (pain assessment or reassess-
ment after interventions) reported before and after
implementation activities and/or for intervention and
control groups.
3. Pain assessment rates for nurses or nurse practitioners
reported.
4. Pain assessment rates in hospitalised patients (children
and adults) or patients admitted to an emergency
department reported.
Studies evaluating non-behavioural outcomes only (e.g.
nurses’ knowledge or attitudes) were excluded. Further-
more, narrative reviews and opinion papers were
excluded.
2.3. Identification of studies
One author (EI) assessed all and each of the other
authors (MvD, TvA) reviewed half of the retrieved titles
and abstracts on relevance for this review. At this stage,
articles were selected if they clearly or possibly met the
inclusion criteria. For these publications, full texts were
Fig. 1. Conceptual model.
obtained. These were then screened by two authors (EI,
TvA) to decide on in- or exclusion. In both rounds, the
reviewer’s selections were compared and discrepancies
were resolved through discussion.
2.4. Data extraction
One member of the review team (EI) independently
extracted data from all included studies; the two other
members (MvD, TvA) extracted data from half of the
studies. Again, results were compared and resolved
through discussion in case of differences. Data on design,
setting, subjects, implementation strategies, implementa-
tion theory or model and outcomes were extracted. The
following outcomes were considered: adherence rates
(percentages) for all types of pain assessment (e.g.
assessment, reassessment after treatment intervention),
and pain intensity or treatment effects before and after
implementation.
To facilitate comparison and discussion, the imple-
mentation strategies were classified using the Cochrane
Effective Practice and Organization of Care group (EPOC)
classification system (EPOC, 2002) as being directed at
Healthcare professionals, Organizations, Financing, or
Regulations. Subcategories within the four main categories
were also considered (Table 2).
2.5. Methodological quality
Methodological quality of the studies was evaluated
with three EPOC tools; the RCT, CBA, and the interrupted
times series (ITS) tools (EPOC, 2002). The RCT tool was
used for (C)RCT and controlled clinical trail designs; it
contains items related to unit of analysis, power, baseline
measure, concealment of allocation, blinded or objective
assessment of outcome(s) protection against contamina-
tion, reliable outcome(s), and completeness of follow-up.
The CBA tool was used for CBA and before–after study
designs without control groups. The ITS tool contains
items related to unit of analysis, power, baseline measure,
comparability of groups, blinded or objective assessment
of outcome(s), protection against contamination, reliable
outcome(s), and completeness of follow-up. Each item
was scored as: done, not done, or: not clear. Two reviewers
assessed each study and discrepancies were resolved
through discussion.
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568 555

2.6. Data analysis
Due to different definitions of adherence rates, pooling
of effects sizes was impossible. Furthermore, the hetero-
geneity of implementation strategies, outcomes and
participants precluded a meta-analysis; a narrative synth-
esis was thought more appropriate.
eligibility. Then, 34 articles were excluded because the
setting was outside the hospital, adherence rates were
not reported before and after implementation activities
and/or for intervention and control groups. Eventually
we included 23 studies meeting all criteria. These are
ranked in Table 1, hierarchically for type of design, and
alphabetically.

3.2. Methodological quality

3. Results

3.1. Search results
The searches resulted in 816 hits and after removing
duplicates 743 abstracts were reviewed. Fig. 2 shows the
search strategy and the results. Based on abstract and
title selection, 57 full-text articles were assessed for
Overall, the quality of the studies was low (Appendix B).
Only two studies were RCTs (Dalton et al., 2001; Johnston
et al., 2007), one study was a controlled clinical trail
(Morrison et al., 2006) and the remaining 19 studies were
before–after studies without control group or time series
comparisons (Narasimhaswamy et al., 2006; Oakes et al.,

Fig. 2. Search strategy.

 556
Table 1
Characteristics of the included studies.

Author (country) Design (data collection) Setting, sample Intervention Implementation Process outcome Model/theory Results – adherence
(focus)a strategiesb (adherence, criteria) driven rates [before (%)
vs. after (%)]

Dalton Cluster-RCT Six community G Educational Perc. of: NRS 0–10; pain ND NRS pain
et al. (2001) hospitals (100–500 programme (3 intensity, quality, duration,
USA beds) (3 Exp; 3 Contr), sessions) behaviour. (pain
PACU and surgical floor. documented yes/no)
Chart audit: Pre (T0); Exp: (n = 368; T1:126; Exp.: 43% (T0) vs. 49%

E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

programme completed T2:131; T3:111) Contr: (T1); 73% (T2)
(T1); 6 mths (T2) n = 418 (T1:134; Contr: 34% (T0) vs. 34%
T2:142: T3:142) (T1); 42% (T2)
(x2 = 12.37, p < 0.001)
Johnston Cluster RCT Multiple (unspecified) PPA One-to-one Perc. of pain PARIHS Exp group: 15 to 58%
et al. (2007) paediatric wards, 6 coaching with A&F documentation model
Canada hospitals (3 children’s (exp) vs. Audit
hospitals) (contr)
Pretest–posttest Hospitals randomized, (x2 = 138.34,
comparison p < 0.0001)
Prospective review of patient chart sampling
patient charts 2 weeks unspecified (n = 464, Cont group: 24% to 9%,
pre and (interval 306 [985 charts] pre, (x2 = 34.86, p < 0.001)
unspecified) post 158 [617 charts] post)
Morrison Controlled clinical trial 1172 beds teaching PPA Ph. 1: Education Perc. pain assessments ND Ph. II: 32% vs. 64%
et al. (2006) hospital, 9 wards (p < 0.001)
USA (surgical, internal)
2 blocks (matched) Ph. 2: 1-item vs. (at least 1 assessment per Ph. III: 64% vs. 85%
enhanced pain shift, for first 5 days) (p < 0.001)
scale (A vs. B)
4 phases: Wards randomized, Ph. 3: both Ph. IV: 79% vs. 64%
I: 0–4 mths; II: 5–11 enhanced scale, (p < 0.001)
mths; III: 12–19 mths; +A&F (block B)
IV: 20–25 mths. 25% of all admissions Ph. 4: enhanced
screened scale, CDSS (A + B);
+A&F (B)
Ang and Pre-post-test (without Tertiary hospital, 24 PPA Education 1. Initial pain assessment GRIP 1. T0: 50% vs. T1: 83%
Chow (2010) control gr) beds oncology ward. programme on admission programme (x2 = 6.207, p = 0.03)
Singapore (workshop)
Prospective (3-weeks) n = 24 A&F 2. Patients reassessed to (barriers 2. T0: 29% vs. T1: 75%
audit: before (T0) determine treatment effect identified) (x2 = 10.492, p = 0.003)
(3-weeks); 3 mths Revised pain
after (T1) management
(flowchart)
Material support
Bach (1995) Retrospective Post operative patients, G, PM Education 1. Perc. standard RU 1. T0: 90%; T1: 73%; T2:
USA Pre-post-test hospital professionals assessment (before: a 4 h; 84%
(without control gr) after: a 2 h)
Chart audit: Pre Patients: n = 30 (T0), Modified guideline 2. Perc. pain intensity 2. T0: 3%; T1: 45%; T2:
(T0); post: 6 mths n = 22 (T1), n = 25 (T2) 84%
(T1), 10 mths (T2) Patient material 3. Perc. of documentation 3. T0: 83%; T1: 91%; T2:
updated after intervention 92%
Material support (no p value reported)
Baumann Pre-post-test Emergency PM Templated chart on Perc. pain assessments at ND Overall: 41% vs. 57%
et al. (2007) Department, urban documentation of triage (physicians/NPs) (p < 0.001) (non
USA tertiary University pain assessment templated vs.
hospital. template)
Prospective chart Patients: n = 768 (T0), Physicians: 39% vs. 59%
review: pre (T0), n = 471 (T1) (p < 0.001)
2 mths post (T1)

E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

NP: 41% vs. 54% (ns)
Bookbinder Pre-post-test Cancer Centre, Tertiary PM Interdisciplinary Perc. twice daily screening QI, framework, T0: 55% vs. T1: 91%
et al. (1996) (without control hospital (12 units, 565- pain team intensity PDSA, barriers
USA group); T0 – beds) identified.
baseline; T1 one Patients: n = 398 (T0), Structure (no p value reported)
year later n = 298 (T1)
Education
Campbell Pre-post-test Emergency department PM Education Perc. of pain assessed ND 1. T0: 25% vs. T1:
et al. (2004) (55 beds), Hospital. (NRS): 43% (a)
USA Chart audit: Pre Patients: n = 100 (T0), New pain protocol 1. Admission ED 2. T0: 63% vs. T1:
(T0); post: n = 30 (T1) 90% (a)
4 mths (T1). Feedback 2. During ED stay 3. T0: 43% vs. T1:
88% (a)
Leadership 3. At discharge (no p value reported)
Dulko Pre-post-test Hospital, nurse G NP weekly 1. Perc. initial pain ND 1. T0: 1% vs. T1: 43%
et al. (2010) practitioners (NP) feedback assessment (overall)
USA (n = 8) thoracic
medicine (4),
neurology (4).
Pre (T0): 3 mths; Patients: n = 96 (T0); Educational session 2. Perc. pain reassessment 1% (1–10) vs. 45% (11–
post (T1): 4 mths. n = 96 (T1) within timeframe 75)
Laminated pocket (p = 0.008) [mean NP
guideline version rate (range)]
2. T0: 5% vs. T1: 87%
[overall]
7% (0–20) vs. 87% (73–
100) (p = 0.008) [mean
NP rate (range)]
Duncan and Quasi-experimental, Orthopaedic unit of a G Individual 1. Perc. of pain assessment ND 1. T0: 72% vs. T1:83%
Pozehl (2001) Pre-post-test mid-size acute care performance every 4 h.
USA hospital (n = 34 nurses) feedback
Retrospective Patients: n = 119 (T0); 2. Perc of reassessment
review of medical n = 122 (T1) after analgesics
patient record, (over 4 days of patient 2. 43% vs. 64%
pre (T0) 15 wks.; admission) (no p value reported)
post 34 wks.
(T1) -17 wks.

557
 558
Table 1 (Continued )

Author (country) Design (data collection) Setting, sample Intervention Implementation Process outcome Model/theory Results – adherence
(focus)a strategiesb (adherence, criteria) driven rates [before (%)
vs. after (%)]

Ellis Pre-post-test 5 paediatric wards, PM Education Perc. of pain scales used Ottawa T0: 5%
et al. (2007) general hospital workshop Model of
Canada Research Use
Clinical audit, Patients (random Champions T1: 43% (T0 vs. T1,
3 times: pre (T0), selected): n = 75 (T0), (leaders) p < 0.001)
6 mths post 1 n = 44 (T1), n = 50 (T2) Feedback T2: 24% (T0 vs. T2,
(T1), post 2 (T2) p = 0.005)
Others (supportive)
Erdek and Pre-post-test 2 surgical ICUs PPA, PM In-service sessions, Perc. of number of VAS PDSA QI, T0: 42%
Pronovost (general/oncologic) importance of scores

E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

(2004) documentation
USA Clinical audit, Patients: random Modified scale Barrier T1: 54%
5 wks: pre wk. sample n = 10–15 per identification
1 (T0), post wk. ICU.
2–5 (T1–T4) Daily discussion T2: 70%
T4: 75%
T5: 71% (no p value
reported)
Gelinas Pre-post-test Intensive Care Unit, PAT Education Perc. of reassessment ND T0: 10%,
et al. (2011) Academic hospital. workshop
Canada (including video)
Pre (T0), post Patients: n = 30 T0, Pocket pain cards T1: 43%,
3 mnts (T1), n = 30 T1, n = 30 T2 Reminders – T2: 59%
12 mnts (T2). posters
Support of (T1–T2: U = 298.00,
clinicians p = 0.97)
Idell Pre-post-test Medical/surgical G, PPA Individual Perc. of reassessment CURN model T0 61% vs. T1 78%
et al. (2007) oncology units, Cancer performance (within 1 h.)
USA hospital. feedback
Chart audit, Patients: unspecified Reminders – (t-test, p = 0.004)
5 charts among posters
patients selected
for each nurse
(n = 42)
Case discussions
Innis Pre-post-test Internal medicine unit PM Pain education Perc. of pain assessment ND T0 52% vs. T1 100%
et al. (2004) (74-beds), teaching (interval unspecified)
Canada Hospital (urban).
Chart audit, Patients: n = 50 (T0), Reminders – poster (x2 = 60.554, p < 0.001)
medical records: n = 50 (T1)
pre (T0), post (T1)
Pocket pain
management cards
Jordan-Marsh Pre-post-test Paediatric ward PM Pain tool 1. Perc. of documentation Social 1. T0: 54% vs. T1: 93%,
et al. (2004) (serial) comparison (number unspecified), pain intensity ecological
USA during and after general hospital. approach
4-phase:
T0: Q1 (pre); T1: Education 2. Perc. evaluation T3 (sustain) 84%
Q2-8; T2: Q 9-13; treatment effect
T3: Q14.
Chart audit: random Leadership
selection of 10% Rounds 2. T0: 80% vs. T1: 97%,
of patients’ charts. T3 89%
Revised pain policy (no p value reported)
Michaels Quasi experimental. 16 units (Medical/ PM, PPA Educational 1. Perc. pain assessment ND 1. No (statistical)
et al. (2007) surgery, adult critical programme (Exp. during 24 h differences were found
USA care, geriatrics, units) between exp. vs. co
paediatrics) of units

E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

Academic medical
centre (841-beds).
Chart audit Exp. n = 8 (units); Contr. 2. Perc. reassessment 2. 43% at baseline
n=8 (within 1 h) versus 52%
Patients: n = 911 (no p value reported)
O’Connor Pre-post-test Surgical, orthopaedic PPA Documentation 1. Perc. of presence pain ND 1. 43% vs. 83%
(2003) inpatients, General tool documentation on
Hospital. admission
Retrospective chart Patients: n = 30 (T0), 2. Perc. of pain assessment 2. 50% vs. 53%
audit: random n = 30 (T1) every 4 h (during first 24
selection pre, (T0) after surgery)
1 month post (T1)
(no p value reported)
Phelan (2010) Pre-post-test + Neuro/neurosurgery PM Multidisciplinary 1. Perc. pain assessment on ND 1. 25% vs. 65%
Australia mixed methods unit (32 beds), Large education admission
tertiary referral programme
hospital.
Chart audit Patients (random): Reminders 2. Perc. pain assessment 2. 5% vs. 35%
(random): pre n = 20 (T0), n = 20 (T1) during admission
(T0), 8 wks Promotional 3. Perc. of reassessment 3. 10% vs. 35%
post (T1) material
(no p value reported)
Treadwell Pre-Post-test Haematology/oncology PPA Education Adherence rate pain QI programme 30% vs. 59%
et al. (2002) (1-year interval) ward (26-beds), large programme assessment (in accordance
USA regional tertiary care with unit protocol)
children’s hospital.
Chart audit: Patients (random Reminders PDSA (no p value reported)
pre (T0), post (T1) sample): n = 36 (T0), (posters)
n = 49 (T1)
Leadership
White (1999) Pre-post-test Neurological hospital, PM Education 1. Perc. of pain assessment ND 1. T0: 40%; T1: 90%, T2
Canada postoperative after programme (first 3 h after surgery) 80% (x2 = 11.31,
spinal surgery. p < 0.01)
Chart audit: pre Patients: n = 15 (T0), 2. Perc. of reassessment 2. T0: 0%, T1: 25%, T2:
(T0), 3 mths n = 20 (T1), n = 15 (T2) 33% (x2 = 5.73, p > 0.05
post (T1), 2 yrs. ns)
post (T2)

559
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Table 1 (Continued )

Author (country) Design (data collection) Setting, sample Intervention Implementation Process outcome Model/theory Results – adherence
(focus)a strategiesb (adherence, criteria) driven rates [before (%)
vs. after (%)]

E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

Narasimhaswamy Time series Suburban teaching PM Education sessions Compliance pain ND Median perc. increased
et al. (2006) (retrospective) hospital (550-beds) assessment during first over time: 77% (January
USA 72 h 2001) to 92% (January
2004) (p < 0.001)
2001–‘02 Patients: unspecified Feedback
(individual nurse)
2003-implementation Clinical case
discussion
2003–‘04 New forms
Oakes Time series Tertiary Children’s PM Continuous QI 1. Perc. of pain assessments ND 1. Overall mean
et al. (2008) cancer hospital (60- every 4 h adherence 87%. Q1: 77%
USA beds). increased to 90% or
higher over time (Q16
and later).
Comparisons over All patient charts for 87 Feedback 2. Perc of reassessment 2. overall 78% (range
6 years (quarterly 24h periods (n = 2478) routine chart (within 1 h) 40–100%)
n = 24 time periods) audit
Reminders

RCT – randomized controlled trial.

a
G – guideline (recommendations); PM – protocol or programme for pain management; PAT – (new) pain assessment tool; PPA – practice or policy of pain assessment.
b
According description of authors, not according to EPOC classification; mths – months; exp. – experimental group; contr. – control group; PACU – post anaesthesia care unit; Ph. – phase; vs. – versus; (a) –
approximately, percentage from figure; ND – not described; A&F – audit & feedback; CDSS – computerized decision support system; PARIHS model – promoting action on research implementation in health
services; GRIP – getting research into practice programme; RU – research utilization; Perc. – percentage; QI – quality improvement; PDSA – plan do study act cycles; ED – emergency department; NRS – numeric
rating scale; ICU – intensive care unit; VAS – visual analogue scale; CURN – conduct and utilization of research in nursing model; Q – quarter.
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568
2008). Most of the studies aimed to evaluate the quality of
pain management following quality improvement pro-
jects. The quality of the studies varied considerably. The
most common problem was the limited detail provided on
the baseline characteristics of the sample. Only, Morrison
et al. (2006) controlled for patient characteristics in
the statistical analysis. Furthermore, sample sizes were
often small, adequate controls were lacking, and statis-
tical analyses were not rigorous enough. Only one study
provided a sample size calculation, relating to establish-
ing significant differences between adherence rates.
The quality of the studies of Morrison et al. (2006)
and Baumann et al. (2007) was considered good.
These provided detailed methodological and statistical
information.
3.3. Implementation strategies
Most of the studies aimed to improve adherence to
pain assessment recommendations combined with pain
treatment. Four studies focused on improving pain
assessment, reassessment or pain documentation only
(Gelinas et al., 2011; Idell et al., 2007; O’Connor, 2003;
Treadwell et al., 2002). The quality of the descriptions of
the implementation strategies varied and the description
was sometimes ambiguous. However, most of the studies
described the strategies in detail, so that they could be
replicated. Table 2 provides the EPOC classification of the
strategies used in the various studies. The studies
reported only strategies related to the domains of health
professionals (e.g. education, feedback and reminders)
and organization (e.g. ‘‘changes in physical structure,
facilities and equipment’’).
Education was the most commonly used strategy, in 17
of 23 studies. However, type and duration of education
largely differed between studies. We identified educa-
tional programmes on the relevance of pain assessment
and barriers in pain assessment (Ang and Chow, 2010;
Bach, 1995; Bookbinder et al., 1996; Dalton et al., 2001;
Michaels et al., 2007; Narasimhaswamy et al., 2006);
educational workshops with discussion on attitudes and
values of assessment (Ellis et al., 2007); and face-to-face
education (Phelan, 2010). Educational sessions lasted from
30 to 60 min (Innis et al., 2004; Phelan, 2010; White, 1999)
to 4 h (Ellis et al., 2007).
In three studies, education was the only intervention
(Dalton et al., 2001; Michaels et al., 2007; White, 1999); in
the remaining 14 studies it was combined with other
implementation strategies, such as feedback, reminders,
outreach visits, or changes in structure (e.g. revised pain
protocol).
Feedback and reminders were used in 11 and 10 of
the studies respectively. We identified feedback on
individual performance (Duncan and Pozehl, 2001; Idell
et al., 2007; Johnston et al., 2007; Narasimhaswamy
et al., 2006) and feedback at unit level (Ang and Chow,
2010; Campbell et al., 2004; Ellis et al., 2007; Morrison
et al., 2006; Oakes et al., 2008). Only Morrison et al.
(2006) and Johnston et al. (2007) used a controlled
design to study the effect of audit and feedback (A&F) on
adherence.
561
Reminders of pain assessment were typically in the
shape of posters, laminated pocket pain tools, manage-
ment cards, or guidelines (including assessment) (Ang and
Chow, 2010; Campbell et al., 2004; Dulko et al., 2010; Ellis
et al., 2007; Erdek and Pronovost, 2004; Innis et al., 2004;
O’Connor, 2003; Phelan, 2010) (Table 2).
Structural interventions in terms of ‘‘changes in
physical structure, facilities or equipment’’ (e.g. modified
pain scales, new or revised pain management protocols,
algorithms or guidelines), belonging to the EPOC category
organizational strategies, were used in 14 studies (see
Table 2).
Finally, in seven studies a single strategy was applied,
either directed at the health professionals (e.g. education
or feedback) (Dalton et al., 2001; Duncan and Pozehl, 2001;
Michaels et al., 2007; White, 1999) or at the organization
(e.g. facilities) (Baumann et al., 2007; Michaels et al., 2007;
O’Connor, 2003) (see Table 2). The remaining studies used
multifaceted intervention programmes.
A rationale for the choice of implementation strategy
was only given in four studies. In three of them, it was
based on an analysis of barriers and facilitators (Ang and
Chow, 2010; Bookbinder et al., 1996; Erdek and
Pronovost, 2004). Only Jordan-Marsh et al. (2004) used
a theoretical underpinning, i.e. the social ecological
model as an ideal approach for overcoming the limita-
tions of interventions that focus simply on changing
individuals’ behaviours at individual, organizational and
societal level (Smedley and Syme, 2000). In eight studies,
the implementation was based on a model (Ang and
Chow, 2010; Bookbinder et al., 1996; Dalton et al., 2001;
Ellis et al., 2007; Erdek and Pronovost, 2004; Idell et al.,
2007; Treadwell et al., 2002). However, these models did
not provide a rationale for the choice of implementation
strategy.
3.4. Effectiveness of type of implementation strategy on
adherence
Overall, the different implementation strategies used
had widely ranging effects on adherence to pain assess-
ment recommendations. In all studies but one, the absolute
adherence rates had improved after implementation
compared to the before measurement, by 9% up to 49%
(see Table 1 and Fig. 3). Fig. 3 shows percentages reported
in the individual studies broken down for EPOC type of
implementation strategy, i.e. health professional strate-
gies, organizational strategies and combinations of both.
After implementation, adherence rates ranged from 24 to
83% and 59 to 100%, for professional strategies and the
combination of professional and organizational strategies
respectively. Furthermore, nearly half of the reviewed
studies reached an 80% or higher pain assessment
adherence rate.
The effect of educational strategies alone varied from 9
to 40% improvement (Dalton et al., 2001; Michaels et al.,
2007; White, 1999). Dalton et al. (2001) found that the
adherence to postoperative pain assessments showed a
significant programme effect from 43 to 73%. Michaels
et al. (2007) found no effect (from 43 to 52%) of education
on adherence to postoperative pain assessments, or
562 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

Table 2
Implementation strategies classified according EPOC taxonomy.

Health professional strategies Health professional and Organizational strategies OS

Narasimhaswamy et al. (2006)

Erdek and Pronovost (2004)
Duncan and Pozehl (2001)

Jordan-Marsh et al. (2004)

Bookbinder et al. (1996)

Treadwell et al. (2002)

Baumann et al. (2007)

Campbell et al. (2004)
Morrison et al. (2006)
Ang and Chow (2010)

Michaels et al. (2007)

Johnston et al. (2007)

Gelinas et al. (2011)

Dalton et al. (2001)

Oakes et al. (2008)

Dulko et al. (2010)

Innis et al. (2004)

Idell et al. (2007)
Ellis et al. (2007)

O’Connor (2003)

Phelan (2010)
White (1999)

Bach (1995)
Health professionals
1 Distribution of X
educational materials
2 Education meetings X X X X X X X X X X X X X X X X
16x
3 Local consensus X X X X
process
4 Outreach visits X X X X
5 Local opinion leaders X X X X
6 Patient-mediated
intervention
7 Audit and feedback X X X X X X X X X X
8 Reminders
a. Computerized X
decision support
b. Concurrent reports
c. Inter-visit reminders
d. Enhanced laboratory
report
e. Administrative X
support
f. Implicit reminders X X X X X X X X X X X
9 Tailored interventions X X X
10 Peer review
11 Combined strategies X
Organizational interventions
12 Structural
interventions
a. Changes in the
settings and/or site of
service delivery
b. Telemedicine
c. Changes in medical X
records systems
d. Changes in
arrangements to
maintain/retrieve
information
e. Changes in physical X X X X X X X X X X X
structure, facilities and
equipment
f. Changes in scope and/
or nature of services
g. Changes in presence X X X X X
and organization of
quality
h. Staff organization
i. Other (rounds) X
13 Staff-oriented
interventions
Revision of professional
roles
Multidisciplinary
teams
Case management
Other integration of
services
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568 563

Table 2 (Continued )

Health professional strategies Health professional and Organizational strategies OS

Narasimhaswamy et al. (2006)

Erdek and Pronovost (2004)
Duncan and Pozehl (2001)

Jordan-Marsh et al. (2004)

Bookbinder et al. (1996)

Treadwell et al. (2002)

Baumann et al. (2007)

Campbell et al. (2004)
Morrison et al. (2006)
Ang and Chow (2010)

Michaels et al. (2007)

Johnston et al. (2007)

Gelinas et al. (2011)

Dalton et al. (2001)

Oakes et al. (2008)

Dulko et al. (2010)

Innis et al. (2004)

Idell et al. (2007)
Ellis et al. (2007)

O’Connor (2003)

Phelan (2010)
White (1999)

Bach (1995)
Skill mix interventions
Interventions to
improve provider
satisfaction with the
conditions of work or
its material and/or
psychological rewards
Other (e.g. case X
discussion)
14 Patient-oriented
interventions
Interventions to X X
facilitate individual
patient participation
Interventions to
facilitate patient group
participation
Other
Regulatory interventions
15 Changes in medical
liability
16 Management of patient
complaints
17 Accreditation
18 Licensure
19 Other
Financial interventions
20 Healthcare-oriented
interventions
21 Patient-oriented
interventions
OS – Organizational strategies.

reassessments within one hour, as compared to the control 3.6. Pain intensity, effects on treatment
wards. In contrast, White (1999) detected an effect of
education on adherence to pain assessment recommenda- Fourteen studies reported effects on pain intensity or
tions (from 40 to 80%). treatment after implementation of pain assessment or pain
Morrison et al. (2006) and Johnston et al. (2007) management programmes (Bach, 1995; Baumann et al.,
reported the effects of audit and feedback on adherence 2007; Dulko et al., 2010; Ellis et al., 2007; Erdek and
rates. Both studies found a significant increase in Pronovost, 2004; Gelinas et al., 2011; Innis et al., 2004;
adherence rates, from 64 to 74% and from 15 to 58% Johnston et al., 2007; Jordan-Marsh et al., 2004; Morrison
respectively, for pain assessment and documentation. et al., 2006; Narasimhaswamy et al., 2006; Oakes et al.,
2008; Treadwell et al., 2002; White, 1999). These effects
3.5. Evaluation interval and effects over time were diverse, however, and are hard to compare because
different outcomes are reported (e.g. median pain score,
The effects of implementation strategies were mea- amount of administered analgesics).
sured at different time points after completion of the Only White (1999), Erdek and Pronovost (2004) and
implementation, ranging from 2 weeks to 6 months. Oakes et al. (2008) reported that patients’ pain scores
Sustained effects, established through repeated measure- decreased after implementation of pain assessment and
ment after implementation, were reported in three studies management. The majority of the studies found no
(Jordan-Marsh et al., 2004; Oakes et al., 2008; White, effects on treatment or pain intensity (Baumann et al.,
1999). These authors found adherence rates of 80% or 2007; Dulko et al., 2010; Ellis et al., 2007; Innis et al.,
higher in the long-term (1–6 years). 2004; Johnston et al., 2007; Morrison et al., 2006;
564 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568
Fig. 3. Adherence rates documented before and after implementation.
Narasimhaswamy et al., 2006; Treadwell et al., 2002).
Treatment effect was also reported in terms of increase
or decrease in analgesics consumption. In the study of
Gelinas et al. (2011) analgesics consumption dropped;
Johnston et al. (2007) reported no change in analgesics
consumption. In contrast, White (1999) reported higher
analgesics consumption, coupled with lower pain scores.
4. Discussion
This systematic review provides an overview of effects
of implementation strategies for improving adherence to
pain assessment recommendations in hospitalised
patients. In summary, the body of properly conducted
studies was too small to allow for a clear conclusion on the
effectiveness of implementation strategies. Most of the
studies were uncontrolled before–after designs with small
sample sizes. However, studies such as performed by
Morrison et al. (2006), Dalton et al. (2001) and Johnston
et al. (2007) had higher quality.
4.1. Implementation strategies
Lack of knowledge (Berben et al., 2012; Czarnecki et al.,
2011); low priority given to pain management; time
constraints; and insufficient physician medication orders
(Czarnecki et al., 2011) may stand in the way of good
adherence to clinical pain assessment or management
guidelines. Education as an implementation strategy
removed the barrier of lack of knowledge in most of the
reviewed studies. Also, getting local opinion leaders or
champions involved could benefit pain management
(Bookbinder et al., 1996; Campbell et al., 2004; Ellis
et al., 2007). Furthermore, selecting implementation
strategies that effectively pull down barriers result in
more successful implementation. The studies in this
review that used this approach showed also an improve-
ment in adherence to pain assessment recommendations
(Ang and Chow, 2010; Bookbinder et al., 1996; Erdek and
Pronovost, 2004). Tailor-made implementation strategies
based on content analysis of barriers and facilitators seem
to be more effective (Baker et al., 2010; Bosch et al., 2007).
Not many of the reviewed studies used tailoring, however,
and further research in this field is recommended. Based on
the adherence rates it seems that multifaceted strategies –
combinations of professional and organizational strategies
– proved more effective than only professional (single)
strategies. This is in line with the literature (Grimshaw
et al., 2004). The latter conclusion is a tentative one,
however, as the studies had methodological limitations.
Theoretical grounding of implementation strategies
brings potential benefit in terms of facilitating and
understanding of implementation (Bhattacharyya et al.,
2006; Davies et al., 2010). Nevertheless, this approach was
little used in these reviewed studies.
Education as implementation strategy was applied in
most of the studies but in different ways. We believe that
education is indeed needed to provide healthcare profes-
sionals with the latest insights on pain management, but
dissemination of written educational materials or didactic
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568
education at large scale seems an insufficient strategy to
improve pain assessment and treatment (Grimshaw et al.,
2004; Grol and Grimshaw, 2003). On the other hand,
interactive educational workshops and are largely effective
(Forsetlund et al., 2009; O’Brien et al., 2007). These findings
could be confirmed partially in this study. Meta-analysis
has revealed that audit and feedback is a more effective
strategy and this could be confirmed in this review
(Jamtvedt et al., 2009).
Finally, several studies had a broader scope, focusing
also on improvement of pain treatment. In these studies it
proved hard to unravel the effects of implementation
strategies directed only at improving adherence to pain
assessment. Also, these studies were performed in many
different settings. Setting and staff attitude may have an
impact: in oncology departments, for example, it will be
easier to motivate nurses to assess pain, whereas in the
emergency setting one tends to move quickly to solve the
problem, with less attention to pain as a result. Further-
more, several studies only briefly described their imple-
mentation strategies, which makes it difficult for others to
replicate these strategies.
4.2. Adherence
All studies but one showed improved adherence to
pain assessment recommendations after implementation
of single or combined strategies. Bach (1995), as the one
exception, found that standard postoperative pain assess-
ment was less adhered to after implementation of a
modified guideline. The modified guideline implied more
frequent pain assessments (every 2 h) than before which
may explain the decreased adherence. In our experience it
is crucial to tailor the frequency of pain assessments in
specific patient groups; not too often which demotivates
nurses and not too infrequent with the risk of missing
pain.
Overall, half of the reviewed studies reported a
clinically relevant adherence rate of 80% or higher after
the implementation activities. However, we should con-
sider that the frequency of prescribed pain assessments
varies considerably among these studies. Although the
American Pain Society designated pain as the ‘‘Fifth Vital
Sign’’, next to heart rate, blood pressure, respiratory rate,
and temperature, based on this review we believe that
adherence to pain assessment is still suboptimal. It has
been suggested that the basic principles and individual
activities related to pain assessment have been inade-
quately incorporated into patterns of daily practice (Dahl
et al., 2003).
The central question is, why do nurses not or poorly
adhere to pain assessment or management protocols, and
is it harmful for patients? Poor adherence may reflect
unspoken resistance to use of methods that are overly
simplistic, burdensome to patients, often inaccurate and
perhaps even disrespectful of clinical expertise and
experience (Franck and Bruce, 2009). On the other hand,
untreated pain may have harmful effects and effective
treatment is therefore crucial (Ferrell et al., 1989;
Jakobsson et al., 2007; Kehlet and Holte, 2001; Morrison
et al., 2003; Perkins and Kehlet, 2000). Finally, quality of
565
care gains transparency with the help of performance
indicators. For Dutch hospitals, pain assessment is a
performance indicator initiated by the Health Care
Inspectorate. However, high adherence rates for pain
assessment is not a guarantee for high quality of care.
Moreover, this performance indicator should be linked to
treatment, so as to improve patient outcomes. This review
showed that this issue was studied insufficiently.
Also, it remains still problematic for physicians,
nurses and other healthcare professionals alike to adhere
to guidelines and protocol in healthcare (Cabana et al.,
1999; Lugtenberg et al., 2011, 2009). It would seem
essential, therefore, to devise implementation strategies
– that are effective to increase adherence to pain
assessment recommendations. First, we must provide
good education on the importance of pain assessment
itself. Second, tailored and barrier-driven implementa-
tion strategies focusing on specific barriers in a certain
setting are needed to improve adherence in practice.
Third, feedback on performance could be useful to
increase the intrinsic motivation of nurses (Johnston
et al., 2007; Morrison et al., 2006). Finally, patient-centric
strategies might be useful, but only if they have an
outcome measure of improving nurses adherence to pain
assessment recommendations (Coulter and Ellins, 2007).
Such strategies were not used in the reviewed studies,
but would be worth exploring in future research. Recent
paediatric and adult studies already found that parent or
patient education about pain management improved
nurses’ pain assessment and documentation (Franck
et al., 2011; Haller et al., 2011).
4.3. Time effects
The improved nurses adherence on pain assessment
recommendations were assessed at different time points,
ranging from 2 weeks to 6 months after implementation,
which may affect validity of the results considerably.
Effects may wane over time or other factors contribute as
well to the results. On the other hand, after a shorter period
the results may be too rosy or implementation has not yet
set in. This underlines the need to assess adherence
repeatedly for a longer period of time. Most of the reported
effects on pain treatment and intensity (scores) were
established in uncontrolled before–after studies. So, the
observed changes may be due to factors other than the
intervention.
Three studies explored the sustainability over time;
however, on methodological grounds (e.g. small sample
size and chart audits) the results and their generalizability
must be interpreted with caution. Furthermore, the
nature of quality improvement is such that it is hard to
separate the outcomes from the effects of environmental
factors. Nevertheless, Oakes et al. (2011) succeeded in
sustained improved pain management over a 10 years
period.
4.4. Limitations of this review
Several methodological limitations of this review need
to be addressed. First, we could not perform a meta-
566 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568

analysis. Second, the EPOC classification is debatable,

follow up
Patient
because the content for e.g. professional and organiza-
tional strategies is incomplete. By example, the profes-

n/a
n/a

n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
sional oriented strategy ‘‘educational meeting’’ is very
general. We would suggest to split this in different types,

follow up
Provider
e.g. large- versus small scale educational meetings and
active versus passive learning. Nevertheless, it is a

UC
UC

UC

UC
UC
UC
UC
UC
UC
UC
UC
UC
currently widely used taxonomy and may be desirable
in order to join this taxonomy in comparing study results
(Grol and Wensing, 2011).

adequate
Statistic
analysis

UC
5. Conclusions

V
V

V
X
V

X
V
V
V
X
Based on this systematic review we conclude that

outcome
measure
Reliable
implementation strategies to improve nurses’ adherence
to pain assessment recommendations vary but generally

UC
V

V
V
V
V
V
V
V
V
V
address professionals and organizational aspects. Educa-
tional and feedback strategies are often used and

contamination
effective in controlled studies. Education is necessary

Protection
to inform nurses and other professionals about the

against
necessity, values, and evidence about pain assessment,

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
however, it is not a guarantee for excellent improve-

V
V

V
ment.
Most of the studies showed an improvement in

assessment
adherence. However, due to the heterogeneity of the

outcome
Blinded
implementation strategies it is not possible to recommend

UC
UC

UC
one preferred strategy. The more so because solid evidence

V
V
V
V
V
V
V
V
V
of effectiveness is lacking due to the general poor quality of
the studies.
Characteristics

For clinical practice we recommend interactive educa-

of control

tion sessions, involving local champions and giving feed-

back on individual or unit level to increase the intrinsic
UV
UC

UC
UC

UC

UC
UC
UC
motivation of professionals. V

V
V

V
Conflict of interest: None declared.
measure
Baseline

Funding: EI was supported by an ‘‘implementation research

UC

UC
UC

UC
V

V
V

V
V
V
V
fellowship’’ grant of The Netherlands Organization for Health
Research and Development (ZonMw), ZonMw grant:
calculation

170996007.
(Controlled) BA methodological quality assessment results and rating
Appendix B Methodological quality if included studies.

Power

Acknowledgement
X
X

X
X
V
X
X
X
V
X
X

The authors thank Ko Hagoort for carefully editing the

RCT methodological quality assessment results and rating

CCT methodological quality assessment results and rating

Provider
Provider

Provider

Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
Provider
analysis
Unit of

manuscript.

Appendix A. Search strategy

allocation

PubMed
Unit of

Ward
Ward

Ward

Ward
Ward
Ward
Ward
Ward
Ward
Ward
Ward
Ward

(nurs*[tw] AND (complian*[tw] OR adheren*[tw] OR

adhaeren*[tw]) OR nursing audit*[tw]) AND (pain mea-
sur*[tw] OR pain assess*[tw] OR pain/diagnosis[mesh])
Erdek and Pronovost (2004)

EMbase
Duncan and Pozehl (2001)
Bookbinder et al. (1996)

((nurs* NEAR/5 (complian* OR adheren* OR adhaeren*)):-

Baumann et al. (2007)

Campbell et al. (2004)

Morrison et al. (2006)

Ang and Chow (2010)

Johnston et al. (2007)

ti,ab,de OR ‘nursing research’/exp OR ‘nurse research’:ti,ab,de

Gelinas et al. (2011)
Dalton et al. (2001)

Dulko et al. (2010)

OR ‘nurse evaluation’:ti,ab,de) AND ((pain NEAR/2 (measur*

Ellis et al. (2007)

OR assess* OR diagnos*)):ti,ab,de)
Bach (1995)
First author
 E. Ista et al. / International Journal of Nursing Studies 50 (2013) 552–568 567

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