Date of Graduation

Fall 12-12-2014

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Mary S. Seed, PhD, RN, CNL


This project took place on a Renal/Endocrine unit of a northern California Hospital. As observed on this unit, pain was not well controlled and this caused the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score for ‘pain well controlled’ to be low. Hence, this project sought to address the underlying reasons why pain was not well controlled and to proffer solutions to raise the HCAHPS score to at least 65% from an average of 55%. In order to find the root causes, the nurses were surveyed, the patients and certified nursing assistants (CNAs) were interviewed, and a 24-hour chart review was conducted on three different days. The results revealed that about 30% of the nurses had little or no knowledge of HCAHPS; 73% of the CNAs did not know when to report patients’ pain score to the nurses and 80% of the patients had to wait until their pain level was severe before asking for pain medication. Following the unit’s policy and procedure for pain management, the goal for effective pain management was to maintain patients’ pain intensity at ≤3 or the patients’ stated goal. To achieve this goal and also address the above issues, it was recommended that the nurses maintain an open communication with the patient, perform an initial assessment, and reassess the patient within one hour of medication administration, offer non-pharmacological therapies such as heat/cold therapy, repositioning, and music therapy.

Keyword: HCAHPS score, pain control, pain management, pain medication