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replacement (TJR) surgery. Utilizing the feedback ofpatients and providers, current research, and a PDSA(Plan, Do, Study, Act) methodology, a comprehensive,patient-focused pain assessment and intervention toolwas developed.

Although this paper discusses the development of apatient education tool, it does not focus specifically ondata and outcomes related to pain management.Instead, the goal of this paper is to detail the process bywhich an institution can analyze its existing state, iden-tify needs, and then utilize research and data to developinterventional strategies. Outlining this process pro-vides other organizations with a framework for thedevelopment of specific, needs-driven interventions.

The Impact of PainPain is “a multidimensional experience, consisting of notonly physical stimuli but also psychological interpreta-tions of pain” (Pellino et al., 2005, p. 182). Clinically, painis defined as whatever the experiencing person says it is,existing whenever the experiencing person says it does(McCaffery & Pasero, 1999). Mismanaged pain leads toserious physiological and psychological consequencesfor patients, including delayed healing, altered immunefunction, increased stress and anxiety, and decreasedquality of life. For healthcare organizations, untreatedpain may lead to longer hospital stays, higher readmis-sion rates, increased healthcare costs, and decreasedpatient satisfaction (Gordon, Dahl, & Stevenson, 2000).

Effective pain management poses a significant chal-lenge for healthcare organizations because inadequatepain control is often multifactorial in origin. Providersdo not have the clinical skills necessary to appropri-ately assess and manage pain (Michales, Hubbartt,Carroll, & Hudson-Barr, 2006) and lack the knowledgeneeded for successful pain management (Innis,Bikaunieks, Petryshen, Zellermeyer, & Ciccarelli,

Following the implementation of an innovative analgesicand pain management pathway for patients undergoingtotal joint replacement at Virginia Mason Medical Center, amultidisciplinary team of providers identified additional painmanagement needs related to patient education and com-munication. Utilizing several quality improvement strategies,including a “gemba walk” and a “Plan, Do, Study, Act”methodology, a comprehensive, evidence-based patienteducation tool was developed. The quality improvementprocess detailed in this article focuses on outcomes relatedto enhanced patient and provider communication, en-hanced patient education, and accurate provider pain as-sessment. The framework that is presented can be appliedto many problems that may exist in the acute care setting.

The delivery of effective pain management hasbecome a pressing national issue in healthcare.Pain management is important because itlessens pain experienced by the patient and re-

duces the likelihood of physiological and psychologicalsequelae. In addition, pain management may improvepatient outcomes and increase patient satisfaction. TheJoint Commission (2009) has mandatory organizationalstandards related to pain assessment, management,monitoring, and education. The National GuidelineClearinghouse has published a practice guideline relatedto the assessment and management of acute pain (Carnset al., 2008). Despite regulatory efforts and research-driven innovation in pain assessment and treatment,pain remains undertreated and poorly managed in acutecare settings.

Virginia Mason Medical Center in Seattle, WA, hastaken aggressive action to reverse pain managementtrends and to improve outcomes related to pain manage-ment. This paper details the process used by VirginiaMason to analyze its existing pain management program,identify critical needs, and then utilize research and datato develop interventional strategies. Specifically, a multi-disciplinary needs assessment by the Virginia MasonPain Collaborative identified a need for improved patienteducation related to pain control following total joint

Marisa Gillaspie, MSN, RN, ACNS-BC, St. Francis Hospital, Federal Way,Washington.

The author has disclosed that she has no financial relationships relatedto this article.

Better Pain Management After TotalJoint Replacement SurgeryA Quality Improvement Approach

Marisa Gillaspie

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2004). Although these are major contributing factors,the burden of poor pain management does not liesolely on the shoulders of providers. Literature sup-ports the fact that patients and their families con-tribute to inadequate pain management (Woodward,2004). Patients expect providers to take care of pain,yet to maximize effective treatment, patients have a responsibility to inform care providers about pain andmust be willing to be the experts on their own pain(The Joint Commission, 2009; Zalon, 1997).

Assessing NeedAs a result of pain management standards mandated byThe Joint Commission and a commitment to healthcareoutcomes and quality, Virginia Mason made effectivepain management a high priority. A multidisciplinaryteam, the Pain Collaborative, was formed to emphasizethe voice of the patient in the pain managementprocess, improve the quality of pain-related care, andprovide pain education to all providers. Expert clini-cians participating in the Pain Collaborative identifiedgaps in practice related to pain management. In addi-tion, the Pain Collaborative gathered informationthrough an online, provider pain knowledge and atti-tudes survey (N � 190). On the basis of the results of theneeds assessment, actions related to educational tools,assessment, documentation, and communication wereidentified as top priority issues.

Patients significantly affected by acute pain are thoseundergoing TJR procedures. Despite the recent develop-ment and successful implementation of an innovativeanalgesia pathway and order set for TJR patients,providers and patients reported that pain managementwas unsatisfactory. The needs assessment by the PainCollaborative and suboptimal pain management out-comes for TJR patients demonstrated a specialized needfor this patient population.

Initiating Change: The GembaA component of the Virginia Mason Production System,the gemba, was utilized to gather data and informationfor this project. Gemba is a Japanese term meaning “ac-tual place,” and it refers to a physical location wherevalue is created through work (Gemba Research, 2007).According to Gemba Research LLC, the “gemba is theplace to go for improvement” (2007). For this project,the setting of the gemba was the orthopaedic floor. Byobserving the work of this patient care area, known as“walking the gemba,” it was possible to identify prob-lems related to pain management. For example, bothpatients and providers expressed frustration regardinga perceived inability to communicate well about pain.Observations of workflow coupled with interviews ofpatients, family members, and providers brought clarityto existing issues and helped bring forth potential solu-tions. The gemba walk was critical to this quality im-provement project because data gathered at the sourceof the work (nursing, patient, physical therapy, anesthe-sia, orthopaedic service) exposed gaps in pain knowl-edge that were vastly different from what was initiallyexpected.

The overarching theme of the information gatheringexercise was that education and communication aboutpain needed to be improved for TJR patients. Patientsundergoing total joint replacement had multiple educa-tion opportunities, including preoperative classes, com-prehensive written information, and a one-on-one ses-sion with a provider. Consequently, the education needidentified during the gemba was related to improvedpostoperative education and communication at the bed-side. Feedback from patients and providers indicatedthat both needed a better method to effectively commu-nicate about pain utilizing a standard language. Clearcommunication about pain is critical to pain assess-ment because accurate pain assessment serves as thecornerstone for effective ongoing pain management(Woodward, 2004). Therefore, the goal of this qualityimprovement project became the development of a toolthat would facilitate discussion at the bedside with theaim of improved patient—provider communication andincreased patient satisfaction with pain management.

FORMULATING A PLAN FOR EDUCATION

The existing educational process for TJR patients hadno continuity between preoperative information andpostoperative implementation. In other words, al-though patients received information regarding painmanagement before surgery, there was no process inplace to help patients utilize this knowledge aftersurgery. Research demonstrates that written informa-tion on postoperative pain management distributed be-fore surgery improves the quality of information re-tained and helps facilitate patient and providerdiscussions regarding postoperative pain management(Binhas, Roudot-Thoraval, Thominet, Maison, & Marty,2008). As a result, any pain communication tool utilizedat the bedside after surgery must be included with pre-operative education materials.

Findings gathered during the gemba indicated that abedside tool including nonpharmacological pain man-agement information, a clear pain scale, and “patientencouragement” to speak up about pain would be mosteffective for TJR patients. Suggestions from careproviders, patients, and their families were integratedinto a patient education poster that could be included inpreoperative education packets and utilized at the bed-side after surgery. A literature review focused on patienteducation, pain scale validity, nonpharmacological painrelief strategies, and patient empowerment ensured thatcontent included in the poster was evidence based(Carns et al., 2008; Pellino et al., 2005).

PLAN, DO, STUDY, ACT (PDSA)To test the tool, a PDSA cycle was initiated. The PDSAcycle allows a change to be developed and tested byplanning it, trying it, observing the results, and actingon what is learned (Langley, Nolan, Nolan, Norman, &Provost, 2009). First, nursing staff was introduced tothe patient education and communication tool priorto bedside handoff at the beginning of day shift.Nurses were encouraged to use the tool during patienteducation sessions and communication regardingpain. No formal evaluation metric was used to gather

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data during the PDSA cycle. Over the course of theday, nurses made informal observations regardingtheir perceptions of the tool and put forth suggestionsfor improvement. After gathering feedback from bothnurses and patients about the first “Do” cycle of thePDSA, the tool was modified to capture suggestionsand subsequently maximize usability at the bedside.The patient education tool underwent three PDSA cy-cles to reach its current state (see Figure 1).

Through the PDSA process, a patient-centered, evidence-based tool was developed to help facilitatecommunication regarding pain between patients andproviders following TJR surgery. The next step in theimprovement process will be to fully implement and in-tegrate the tool into the TJR educational process (seeTable 1). After full implementation, the tool will be eval-uated according to outcome metrics.

Evaluation MetricsThe metrics initially proposed to evaluate outcomes re-lated to pain management, patient education, and com-munication also evolved throughout the PDSA cycle.The following outcomes were initially proposed:

1. Patients undergoing total joint replacement willself-initiate postoperative nonpharmacologicalpain control strategies.

2. Patients undergoing total joint replacement willverbalize an understanding of the pain scale.

3. Patients undergoing total joint replacement pa-tients will have satisfactory postoperative paincontrol (numeric pain score less than 3 on thebasis of institutional standards).

Outcomes related to the self-initiation of nonphar-macological interventions are valuable measures be-cause healthcare education helps empower patientswith control, choice, and responsibility for their needsand well-being (Spalding, 2004). Thus, the patient willhave immediate access to pain relief strategies and willnot be reliant upon others for action.

To successfully manage pain, there must be commu-nication between the patient and the provider; how-ever, patients remain reluctant to communicate theirpain (McDonald, McNulty, Erickson, & Weiskopf,2000). Providing a tool to help support patient commu-nication is vital to successful pain management.According to McDonald and Molony (2009, p. 836),when patients are able to communicate their pain tohealthcare providers, they are more likely to receive ef-fective pain management. Providing patients with acomprehensive pain scale and consistent encourage-ment to report pain helps positively reinforce the paincommunication effort.

Achievement of a pain score of less than 3 followingTJR surgery is not a valuable outcome metric. Pain is ahighly subjective and variable experience; therefore, at-tempting to achieve a consistent pain score for this pa-tient population was not realistic. Research suggeststhat patients may be satisfied with the pain manage-ment process even if they suffer from pain; therefore,measuring patient satisfaction would be a more valu-able outcome measure of this quality improvementprocess (Auquier et al., 2005). Rather than evaluatingpain scores, the final outcome metric for this project isto increase patient satisfaction with how well pain ismanaged (Innis et al., 2004). Patient satisfaction withpain management will be evaluated via Press Ganeyhealthcare performance measurements (Press GaneyAssociates, 2009).

TABLE 1. CONTINUITY OF PAIN EDUCATION AND

COMMUNICATION THROUGHOUT TOTAL JOINT REPLACEMENT

Include patient education tool in preoperative TJR information packet.

Preoperative patient education:Teach patients to use pain scale prior to surgery to facilitate

communication about pain after surgery.Teach patients about nonpharmacological pain relief strategies

that can be utilized after surgery.Educate RNs and patient care technicians about how to use

the tool at the bedside to facilitate and improve communi-cation about pain.

Integrate a modified version of patient education tool into postanesthesia care unit/recovery room pain assessment.

Distribute patient education tool to TJR patients following surgery. Ensure that the tool is visible and readily availablefor use at the bedside.

Integrate a modified version of patient education tool into physical therapy/occupation therapy pain assessment.

Note. TJR = total joint replacement.

FIGURE 1. Total joint replacement pain management educa-tion tool.

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Lessons LearnedThe education need that was initially anticipated forthis project was incorrect. As data were gathered re-garding the pain management process for TJR patients,it was expected that patients and their families wouldrequire information about anesthesia options and post-surgical pain relief modalities. It was discovered thatpatients and their families had extensive preoperativeexposure to this content. The gemba yielded a differentand surprising need. According to those surveyed, pa-tients desired ways to reduce pain, wanted a better wayto explain their pain to providers, and required reassur-ance that it was not only appropriate but also necessaryto report pain. Providers wanted a more accurate way toassess pain and desired information at the point-of-careregarding nonpharmacological pain relief strategies.Providers also wanted their patients to speak up aboutpain and to feel comfortable asking for analgesics with-out being prompted.

Information gathered from bedside providers, pa-tients, and their families during the gemba led to the de-velopment of a patient education tool. The tool inte-grated information considered critical by end users intoa practical form. An additional literature review en-sured that all components of the patient education toolwere evidence based. A preliminary literature searchprovided foundational knowledge for the project, but itwas necessary to validate the practical content put forthby staff.

Three PDSA cycles were conducted to determine thepracticality and worth of the tool at the bedside.Feedback from patients and staff led to several roundsof modifications. While each PDSA cycle resulted in for-matting changes to enhance tool usability, each cycleyielded additional valuable findings. In the first cycle,participants identified missing content. During the sec-ond cycle, participants had numerous suggestions re-garding refinement of the content. By the third and finalPDSA cycle, participants were suggesting how the toolcould be extended and adapted for use in different pa-tient care areas. The scope of this project was limited toTJR patients, so additional suggestions for broadeninguse of the tool were not considered for this project.

Throughout the gemba and PDSA cycles, staff partic-ipation and interest demonstrated buy-in for this pro-ject and reflected their strong commitment to patients’comfort and healing. While the content of the patienteducation tool reflects current nursing practice at thebedside, the development of the tool increases the visi-bility of evidence-based practice. The presence of thetool not only helps patients discuss pain with providersbut also serves to remind staff of the importance of ex-cellent pain management.

Quality improvement work often stems from needsidentified at the bedside. The ultimate value of thiswork is not just improved education and communica-tion regarding pain. Gathering feedback and insightfrom the floor resulted in a useful, clinically pertinentsolution. Relying upon assumptions of need and solu-tion would have missed an opportunity for staff and pa-tients to participate in a grassroots effort to improvethe delivery of care.

To effectively assess whether improved educationand communication lessen pain for TJR patients, out-come metrics beyond patient satisfaction will need to beconsidered. Solely measuring patient satisfaction doesnot capture the multidimensional nature of pain man-agement. Patients experiencing high levels of pain mayfeel satisfied with the pain management process.Patients with low pain scores may not have an accept-able level of functional comfort. This demonstrates thelimitations of utilizing patient satisfaction as an out-come measure for pain control.

Ultimately, the purpose of this project was to im-prove communication and education between patientsand providers with a goal of better pain management.Nurses at the bedside must use critical thinking and in-clude patients’ functional comfort, individualized paingoals, and pain scales to maximize pain managementfor every patient. Only after all of these components areevaluated can the goal of improved pain managementfor TJR patients be achieved and sustained.

ConclusionExceptional patient and provider communication, thor-ough patient education, and accurate pain assessmentare critical to effective pain management. At VirginiaMason Medical Center, a comprehensive needs assess-ment followed by the utilization of the gemba and PDSAcycles led to the successful development of a patient-centered, evidence-based pain education and assess-ment tool. The improvement process presented here canbe adapted and implemented by bedside providers toaddress many of the challenges faced in acute care set-tings to improve healthcare quality and outcomes.

ACKNOWLEDGMENTS

The author thanks staff members of Virginia MasonMedical Center for their contributions and input intothis project. The author also thanks Ellen Noel, MN,RN-BC, Clinical Nurse Specialist, for her guidance andinsight throughout this project.

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For more than 22 additional continuing nursing education articles related to the topic of pain management, go to

nursingcenter.com/ce

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