Date of Award

Summer 2021

Document Type

Final DNP Paper

Degree Name

Doctor of Nursing Practice (DNP) in Adult-Gerontology Acute Care Nurse Practitioner



Faculty Chair

Dr. Rachel Wooten


Kelley McPherson


The overarching goal of this project is to ensure patient pain reassessment is completed on all patients in accordance with the facility and The Joint Commission (TJC) standards after the intervention. The last four surveys of the rural critical access hospital yielded subpar results showing noncompliance with pain reassessment. Utilizing quality improvement measures such as staff education and charting reminders, gaps in practice were found and utilized to optimize the care to patients related to pain and reassessment. The study seeks to improve the pain reassessment skills and compliance of nursing staff at a rural critical access hospital. Initial non-compliance was well documented throughout TJC visit in 2018. Initiation of the project began with a baseline evaluation of staff knowledge related to pain, pain reassessment, documentation, and TJC criteria for pain reassessment. Education was developed and given to staff. All information was necessary to have complete and standardized charting regarding pain reassessment. After education, post-assessments were given to staff to evaluate knowledge of keeping pain reassessment a priority. Reminders were also given to staff to keep the idea of charting pain reassessment a priority. Compliance percentages were also examined in the Epic charting system for the unit. Pre-educational assessment scores revealed a score of 74% with 22 participants. The average score of the post- assessment was 87.2% with 15 participants. Results showed an increase in knowledge of the subject of pain reassessment and policy. Every post -assessment survey did agree that the education was sufficient and there was a better understanding of the TJC standards for the unit percentage. Initiation of the project monitoring began in April with a compliance of 94%. May 2021 compliance was higher with 97% pain reassessment documentation being completed within the hour. The percentage increase should be attributed to increased education of staff.

Included in

Nursing Commons



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