Managing “total pain” using best practice

A strategically simple new research-based pain assessment tool is making a big difference for home care clients living with pain.

“Pain is pain and those who live with it know that if pain is not effectively managed, it becomes difficult to think or function to do anything else,” says Carol Sloan, a palliative care consultant and nurse for Saint Elizabeth Health Care.

With a commitment to provide quality hospice palliative care services to clients and families in the home setting, Saint Elizabeth Health Care recently embarked on a quest to standardize the organization’s pain assessment and charting procedures and provide its nurses with clinical tools that support best practice.

The outcome is a promising two-pronged approach to pain management: a “Total Pain” Assessment Tool and a companion “Total Pain” Client Care Plan, both developed by an experienced group of hospice palliative care nurses utilizing the current literature as well as the recently published RNAO Best Practice Guideline for Assessment and Management of Pain.

“Total pain” is a holistic conceptual model which acknowledges that pain is subjective and may be experienced as physical, psychological, social or spiritual suffering. Saint Elizabeth Health Care’s pain assessment tool is a quick and easy-to-use questionnaire that covers all aspects of “total pain”, as well as the PQRST factors of pain assessment: (factors that Produce/stop pain; Quality of pain; Region of body affected; Severity of pain; and Timing). The tool also contains other indicators that help the nurse maintain an individualized care plan and provide optimal pain management.

It may be surprising to learn that physical pain is not always the most problematic. “Some clients are overwhelmed with spiritual or emotional pain related to their condition and it is vitally important to tackle those issues as well,” says Carol, who helped develop the tools with her 25+ years of nursing knowledge and experience in the home care and hospital sectors.

In summer 2002, visiting nurses from Saint Elizabeth Health Care participated in a three-month pilot project with palliative care clients of the Community Care Access Centre of Peel to test, evaluate and fine tune the pain management tools, before implementing them across the organization.

The process went smoothly, with both groups responding positively to the tools. The results indicate that the quick and easy assessment process is not too fatiguing for the clients nor too onerous for the nurses. Communication and consistency have improved.

By being asked the same questions on a routine basis, clients have become more conscious of the correlating causes of their pain and changes in its intensity. They were generally more forthcoming about all aspects of their pain and were more easily able to verbalize its non-physical attributes.

Nurses describe the tools as “user-friendly,” and like how easily they can track client responses and receive information in a standardized format “at a glance.”

“The assessment tool provides us with a lot of valuable insight into the client’s experience of pain, including the level and type of pain, as well as any changes since the last visit or assessment,” says Carol. “Furthermore, if we know what’s causing the pain, we can preemptively instruct the client to take a short-acting painkiller prior to performing an activity that incites it. For the client, this may mean the difference between a good day and what would otherwise be a painful one” and that’s something they both can take comfort in.

Built on best practice, the client care plan acknowledges that pain is subjective and provides opportunities to evaluate the effectiveness of pain management strategies. The assessment tool provides succinct information not only to the nurses but also to the attending physician, thereby promoting effective collaboration among members of the multidisciplinary team.

With diverse scope and application, the pain management tools represent one of many initiatives by Saint Elizabeth Health Care to nurture a supportive environment for those living with a progressive life-threatening illness and receiving care at home.

In addition to supporting clients and families by pioneering innovative programs like chemo-in-the-home and promoting culturally-sensitive care through publications such as Caring Across Cultures: Multicultural Considerations in Palliative Care (2002), Saint Elizabeth Health Care is equally committed to supporting its nurses with clinical knowledge, learning and tools.

With a vision to create an “astonishing” professional practice environment, Saint Elizabeth Health Care believes that nurses should have the opportunity to give input into decisions that affect their practice, just as clients should have input into decisions that affect their care.

For Carol, participating in the project was a joy and an honour. “I not only hope but truly believe our efforts will contribute to excellence in care and a very special, therapeutic nurse-client relationship.” And that, in essence, is the spirit behind the “total pain” assessment tool and client care plan.

With nearly a century of experience, Saint Elizabeth Health Care is a Canadian not-for profit charitable organization distinguished by its innovative approaches to palliative care. For more information, please visit