Exploring Internurse Variation in Documentation of the Clinically Aligned Pain Assessment (CAPA) Tool

The Clinically Aligned Pain Assessment (CAPA) tool was developed to facilitate dialogue between clinicians and patients regarding pain, providing more comprehensive information than intensity ratings. However, inconsistency in its administration and documentation may limit its utility. The purpose of this study was to describe variation in nurses' CAPA documentation.

In this descriptive study, electronic health record data documented by 103 registered nurses caring for 1,123 patients hospitalized on an adult medical unit and intermediate care unit were analyzed. Data from a small sample (n = 10) were analyzed initially to refine the research questions. Descriptive and inferential statistics were used to compare documentation patterns between units and individual nurses.

Both low and high documentation frequency were observed: frequency of charting all five CAPA domains ranged from 0%-100% when analyzed by nurse; frequency and timing of each domain's documentation varied widely. Inconsistent use of the tool also included CAPA documentation in sleeping patients and variability in options most frequently selected by individual nurses within each domain.

While significant differences were found between units, comparison of individual nurses within each unit showed similar variability. This suggests that the differences cannot be explained by unit-specific norms, orientation, staffing ratios, or patient characteristics but likely reflects the CAPA tool's inherent ambiguity.

Inconsistencies in individual nurses' use of the CAPA limit the ability to trend pain over time and monitor effectiveness of the treatment plan, compromising the tool's intended benefit of providing a more comprehensive picture of each patient's pain.