Critical Appraisal of Pain Assessment Tools Essay
Critical Appraisal of Pain Assessment Tools EssayIntroductionPatients presenting with
acute pain in hospital settings need immediate intervention and care to improve health
outcomes (Department of Health Service, 2007). When severe acute pain is not
appropriately managed, this could lead to adverse psychological and physiological effects,
poorer health outcomes and prolonged hospital stay (ANZCA, 2005). In Australia,
approximately a third of patients in hospital settings report experiencing moderate to
severe pain at least once during their hospital stay (DHS, 2007). While this figure may vary
according to the population surveyed in hospital settings, it is observed that inadequate
pain relief is still present in these settings (ANZCA, 2005).Critical Appraisal of Pain
Assessment Tools EssayQuality care for patients presenting with acute pain begins with the
use of an appropriate pain assessment tool. The main aim of this essay is to critically review
current pain assessment tools that are recommended by the Department of Health Services
(DHS, 2007). Published primary studies will be used to support the critical analysis. The
first part of this essay will compare a range of pain assessment tools for patients presenting
with acute pain. The second part critically analyses pain assessment options for patients
who are non-verbal, have significant cognitive impairment or language functions disability.
A conclusion will then summarise the key issues raised in this essay.Critical Analysis of
Current Pain Assessment ToolsPain assessment tools range from the use of subjective to
objective pain-scoring assessment tools. Examples of subjective-pain scoring tools include
the visual analogue scale (VAS), numerical rating scale (NRS) and the faces pain scale (FPS).
Objective measures include the behavioural pain assessment scale,functional activity score
and Abbey Pain Scale. Currently, VAS is one of the recommended tools for assessing acute
pain in different groups of patients (DHS, 2007). Recent studies (Phan et al., 2012;
Angthong, Cherchugit, Suntharapa, & Harnroongroj, 2011; Boonstra, SchiphorstPreuper,
Reneman, Posthumus, & Stewart, 2008) have also shown its validity and reliability for
different health conditions across different groups of patients and in various health care
settings outside Australia. Apart from extensive published data on the reliability and
validity of the VAS, it is also shown to be more sensitive when compared to descriptive pain
scales (Boonstra et al., 2008).Critical Appraisal of Pain Assessment Tools EssayMeanwhile, a
randomised controlled trial (Farrar, Troxel, Stott, Duncombe, & Jensen, 2008) also shows
the validity and reliability of the numeric rating scale not only in assessing acute pain but
also in measuring spasticity of patients suffering from multiple sclerosis. This rating scale
ranks pain from 1 to 10 or 0-11. However, it converts pain sensation to a number (Farrar et

al., 2008). While it is conceptually straightforward, nurses have to explain its use to the
patients. This tool is also language dependent. Hence, it is essential that non-English
speaking patients should be assigned to nurses who speak the same language to reduce the
risk of misunderstanding on the use of NRS.Apart from VAS and NRS, FPS is also commonly
used for pain assessment. One of the advantages of the FPS is its applicability in measuring
pain intensity in paediatric patients. In the study of Tsze, von Baeyer, Bulloch and Dayan
(2013) that recruited 620 patients aged 4 to 17 years old, FPS suggests strong psychometric
properties for this age group. Importantly, this study shows that reliability and validity
were also high between subgroups, sex, ethnicity and age of the children. Tsze et al. (2013)
utilised the prospective, observational study involving Spanish and English-speaking
children. Although this study design might increase the risk of observer bias due to its study
design, a prospective study design is appropriate in validating the FPS (Polit, Beck
&Hungler, 2013). While one of the advantages of FPS is its acceptability in younger and
paediatric patients (Tsze et al., 2013), it could also be used for the elderly.Critical Appraisal
of Pain Assessment Tools EssayIn Kim and Buschmann (2006), 31 older adults were
recruited to determine the validity of the FPS. Findings suggest high construct validity and
test-retest reliability of FPS. However, the small sample size of the study could limit the
applicability of the findings to a larger and more heterogeneous population (Polit et al.,
2013). As a whole, these subjective pain assessment tools have high inter class correlation.
A study conducted amongst Chinese patients during post-operative care (Li, Liu & Herr,
2007) demonstrates high inter class correlation coefficients (ranging from 0.673 to 0.825)
of VAS, FPS and NRS. This suggeststhat healthcare practitioners can use any of these tools
and arrive at a similar pain assessment score.Meanwhile, objective measures for pain such
as the behavioural pain assessment scale and functional activity score are used to assess
pain of patients who are non-verbal or have suffered from cognitive impairment such as
dementia (Husebo et al., 2008). However, this might increase the risk of rater bias (Hek,
Judd & Moule, 2011) since nurses and other healthcare practitioners assess the pain level of
the patient. Hence, it is important that inter-rater reliability and internal consistency of
these tools should be established. A recent study (Voepel-Lewis, Zanotti, Dammeyer &
Merkel, 2010) has shown the use of the Face, Legs, Activity, Cry, Consolability (FLACC)
behavioural scale, which is similar to the behavioural pain assessment scale, as an effective
tool for pain assessment in critically ill adults and children. It has excellent internal
consistency (Cronbach alpha=0.882) and high inter-rater reliability.Critical Appraisal of
Pain Assessment Tools EssayAnother objective pain assessment tool is the Abbey Pain
Scale. This was developed to assess pain in patients with severe cognitive impairment such
as those with severe dementia and non-verbal patients. Recent observational studies
(Lukas, Barber, Johnson & Gibson, 2013; Neville & Ostini, 2013) demonstrated high validity
and reliability of the Abbey Pain scale. In Neville and Ostini (2013), Abbey pain scale was
compared with the Checklist of Nonverbal Pain Indicators Scale and Doloplus-2. Findings
suggest that all scales showed good psychometric qualities. However, the Abbey Pain Scale
is more applicable for nurse raters who demonstrate lower levels of nursing qualification.
Neville and Ostini (2013) suggest that nurses who rarely use pain rating scales could use
the Abbey Pain Scale while still maintaining inter-rater reliability.Lukas et al. (2013)

compared the Abbey Pain Scale with other pain assessment tools such as the Non-
communicative Patient’s Pain Assessment Instrument (NOPPAIN) and the Pain Assessment
in Advanced Dementia Scale (PAINAD). All these tools were validated to improve
recognition of the presence or absence of pain. These tools were also useful in helping
nurses rate the pain severity of older patients with dementia.ORDER A PLAGIARISM- FREE
PAPER NOWWhile pain assessment is a prerequisite for appropriate management of acute
pain, there are some concerns about the use of pain intensity scoring systems. It has been
shown that pain is subjective. This suggests that self-reporting of pain is variable and could
be influenced by a host of factors. Studies (Narayan, 2010; Garcia, Godoy-Izquierdo, Godoy,
Perez & Lopez-Chicheri, 2007) have shown that language, culture and psychological factors
could all influence the perception of pain. Reynolds, Hanson, DeVellis, Henderson and
Steinhauser (2008) explain that self-reporting of pain only provides healthcare
practitioners an insight into how patients perceive their pain levels.Critical Appraisal of
Pain Assessment Tools EssayVariations in reporting of pain present a challenge to
healthcare practitioners since this might lead to over or under-treatment of pain (Wilson,
2007). Other factors such as expectations of the patient in pain, the acceptability of
translated tools and the methodology or terminology used during pain assessment might be
foreign to the patients (Hall-Lord & Larsson, 2006). All these could influence reporting of
pain. There is also the risk that observers might underestimate the pain (Wilson, 2007).
Nurses’ knowledge on pain assessment is crucial since low levels of knowledge on pain
assessment might affect how they assess the patient’s level of pain. Wilson (2007) argues
that poor knowledge could lead to suboptimal care and poor pain management. This could
have important consequences on patients since pain management might not be optimal.
Hall-Lord and Larsson (2006) have stressed that pain assessment could be influenced by
the nurses’ characteristics and knowledge of pain assessment. Lack of knowledge on pain
assessment might lead to inaccurate pain assessment. In turn, this could lead to poor
management and treatment of the underlying cause of pain. This also increases the risk of
patients receiving inappropriate pain therapy (Wilson, 2007).Critical Appraisal of Pain
Assessment Tools EssayConclusionPain assessment is important in managing acute pain in
hospital settings. Various tools have been tested for their reliability and validity. These are
divided into subjective and objective pain assessment tools. The former is generally used for
patients who do not have cognitive impairments while the latter is used for patients with
severe cognitive impairment and non-verbal patients. Studies cited in this essay have
shown the validity and reliability of these tools. Studies that compare the subjective pain
assessments also show high inter-correlation. This suggests that any of the tools could be
used to assess pain. Despite extensive studies establishing the sensitivity, reliability and
validity of the subjective tools, its application could still be limited. Pain is highly subjective
and varies from one person to another. Objective tools might also be influenced by the
nurses’ level of knowledge on pain assessment. Finally, this essay shows the need for nurses
to increase their knowledge on pain assessment to ensure accurate assessment of
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Pain Assessment Tools EssayBoonstra, A., SchiphorstPreuper, H., Reneman, M., Posthumus,
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Assessment Tools Essay