Implementation of national pain guidelines by acute care oncology nurse practitioners using an audit and feedback strategy

Although many institutions in the United States have made efforts to improve pain management quality, the incidence of pain experienced by hospitalized oncology patients has remained constant over the past 10 years. Despite the availability of clinical practice guidelines (CPGs) for cancer pain, consistent integration of these principles into practice has not been achieved. The optimal method for implementing CPGs and the impact of CPGs on healthcare outcomes remain uncertain. This study evaluated the effect of an audit and feedback intervention on nurse practitioner (NP) implementation of cancer pain CPG and on hospitalized patients' self-reports of pain and perception of care.Lewin's change theory guided this intervention study, conducted on two inpatient services within a comprehensive cancer center. Eight NPs and 192 patients provided informed consent and were considered study participants.NP performance and documentation of initial comprehensive pain assessments increased from 1% to 45% (p = 0.008) during audit and feedback. Repeat pain assessment increased from 7% to 87% (p = 0.008). Opioid prescribing according to guidelines increased from 63% to 81% ( p = 0.008) during the intervention.The mean percentage of assessments in which patients reported acceptable pain relief was 70% (95% CI: 63%--77%) prior to audit and feedback and 95.4% (95% CI: 93%--98%) during the intervention (p < 0.0001). While there was no statistically significant change in pain severity during audit and feedback, patients' reported overall interference of pain with function was significantly decreased (p < 0.0001) when compared to patients' reports in the preintervention phase. There was no significant change in patients' perceptions of the quality of NP care with the intervention. Both patient groups rated their perception of NP care highly.Findings of this study support prior research suggesting that audit and feedback may be an effective CPG implementation strategy. The actual effect of guideline adoption on outcomes such as pain requires further study. Patients' improved functional status in the absence of change in pain severity underscores the need to consider symptom clusters when studying pain. Evaluation of patients' perception of healthcare may be subject to the same inherent biases (i.e., ceiling effect) as satisfaction surveys.