21 - Assessment of Students’ Knowledge, Skills and Attitudes after Comprehensive Pain Assessment Training

¹University of Maryland School of Pharmacy, Baltimore, Maryland, USA. ²University of Maryland Capitol Region Health, Baltimore, Maryland, USA. ³Medstar Health, Baltimore, Maryland, USA

Purpose
A comprehensive pain assessment is the first step in safe and effective pain management. Multiple pain assessment tools are used across different health care settings and patient populations. Clinicians must be adequately trained to use various strategies and measures to optimally treat pain and improve patient outcomes. However, there is no gold standard method for the implementation of pain education. Few studies have explored pain assessment education using a variety of strategies and measures in both verbal and nonverbal patients. This can be especially challenging when teaching in an online environment. In this retrospective cohort study, students previously enrolled in University of Maryland Baltimore’s Doctor of Pharmacy (PharmD) program and Master of Science (MS) in Palliative Care program completed an 11-step multidimensional pain assessment training as part of an online pain management course. The program combined multimodal techniques to engage students through sequential worksheets, video lectures and video vignettes of standardized patients. It taught students the PQRSTA mnemonic to assess pain for verbal patients and the Pain Assessment in Advanced Dementia Scale (PAINAD) and Checklist of Nonverbal Pain Indicators (CNPI) tools to assess pain for nonverbal patients. The purpose of this study was to compare and assess the change in knowledge, attitudes and self-perceived skills regarding pain assessment in verbal and nonverbal patients before and after the training.
Methods
Students completed a pre- and post-training survey which measured self-perceived skills and attitudes surrounding pain management. The pre- and post-training survey was divided into 2 parts. Part 1 asked questions related to utilization, components and interpretation of pain measures. Part 2 of the survey asked students to rate their level of agreement on statements related to the relevance and generalizability of pain assessment strategies and measures in routine clinical practice. Additionally, students completed a series of worksheets based on the PQRSTA, PAINAD and CNPI tools to develop their knowledge of pain assessment while progressing through the videos within the training. For the steps involving pain assessment in a verbal patient, worksheets were scored based on the students' ability to correctly identify components of the PQRSTA strategy included in the video vignette. For the steps involving pain assessment in a nonverbal patient, worksheets were scored based on students’ ability to correctly determine the numerical answer as compared to the expert defined score. The number of correct answers for each worksheet and the pain scores on the PAINAD and CNPI were recorded. Data were excluded if the worksheet was incomplete or the student did not follow the directions (e.g., provided text explanations, not scores on the PAINAD and CNPI). Wilcoxon signed-rank test and independent t-test were used to detect differences between worksheets and the pre and post survey. Attitudes and skills of pre- and post-survey were assigned to a Likert scale and analyzed using Fischer’s exact test. For change in knowledge, one-sample Wilcoxon signed-rank test was used to compare students’ answers with the expert defined score for the worksheets.
Results
One-hundred eighty-two students were included in the study. Data were collected from two sections of the Palliative Care Imperative (PharmD) course during Sep 2018- Sep 2019 (a total of 55 PharmD students). Data were also collected from six sections of the Symptom Management in Advanced Illness (MS in Palliative Care) during Jan 2018- Mar 2019 (a total of 127 interdisciplinary students). Disciplines included doctor of pharmacy students (35%), nurses (24%), physicians (11%), pharmacists (8%), social workers (5%), advanced practice nurses (4%), chaplains (3%), and other clinical and non-clinical professions.
Analysis of the survey indicated no change in attitudes in part 1 of the survey, as all components were rated as important both before and after training. For part 2 of the survey, there was a statistically significant increase in favor of using pain assessment strategies and measures for 11/13 (85%) statements indicating an improvement in attitudes.
Results showed a statistically significant improvement in 9/13 (69%) questions related to self-perceived skills in part 1 of the survey. Part 2 of the survey showed a statistically significant improvement in 11/11 (100%) statements related to self-perceived skills.
Regarding change in knowledge, congregate data showed that students could more accurately identify components of PQRSTA strategy included in the video of the verbal patient (p=0.0028) and assess pain during movement in a nonverbal patient using the CNPI (p=0.033) after completion of the training. A subgroup analysis comparing PharmD vs MS students showed that the MS students significantly improved in identifying the components of PQRSTA strategy included in the video of the verbal patient (p=0.0056). PharmD students were able to more accurately assess pain during movement in a nonverbal patient using the CNPI (p=0.026). An additional subgroup analysis removed all PharmD students’ data and divided participants into team body (physicians, pharmacists, advanced practice nurses, nurses) vs team soul (chaplains, social workers, all other disciplines). Team body improved in identifying the components of PQRSTA strategy included in the video of the verbal patient (p=0.012), though the effect was small (Cohen’s d=0.29). Other than these specific findings, data did not support an overall increase in accuracy of scoring or change in knowledge using PQRSTA, PAINAD or CNPI.
Conclusions
This study demonstrates that pain assessment training via video vignettes is an effective way to increase attitudes and self-perceived skills, but not consistently improve knowledge. Future pain assessment programs or research should consider training using only one non-verbal pain measure to minimize confusion. Integrating real-time feedback throughout the training may potentially improve students’ knowledge. An additional learning tactic may include incorporating bedside assessments to gain practical, real-world experience. Lastly, programs may consider adding refresher courses to reinforce concepts after completion of the program.