Using behavior, not vital signs, to assess pain

Tool focuses on non-communicative patients

How is your pain today? On a scale of 1 to 10, how would you rate your pain? Are you comfortable today? Did the medication lessen your pain? All of these questions are typical methods for physicians and nurses to assess the effectiveness of pain control methods. They work well for most patients, but what do you do when the patient cannot communicate?

"We have a lot of pain assessment tools available for newborn patients but there is no tool that addresses pain in non-communicative adults," says Deborah Bortle, MS, BSN, CHPN, director of quality compliance at Hospice of Lancaster County in Lancaster, PA. Although hospice nurses use observation of various patient responses to assess pain in patients who could not communicate, there has been no standardized method for the process, she says. The need for a proven, standardized tool was the reason her hospice chose to participate in a study of a new tool being developed by researchers at University of Maryland Medical Center.

Initial results for the Multidimensional Objective Pain Assessment Tool (MOPAT) do show that pain control is more effective when assessment of pain and evaluation of pain control methods are standardized,1 says lead researcher Deborah McGuire, PhD, RN, FAAN, professor and director of the Developing Center of Excellence in Palliative Care Research and Oncology Graduate Program at the University of Maryland School of Nursing in Baltimore, MD. The tool is a result of four research projects conducted in several locations over many years, she says. The forms enable nurses and other providers to score behavioral and physiological indicators or signs from the patient, she explains.

Focus groups helped researchers gather information about how nurses assessed pain in non-communicative patients in one of the first projects, explains McGuire. "After the focus groups, we took the Post Anesthesia Care Unit Behavioral Pain Rating Scale (PACU BPRS), a pain tool designed for inpatient post-surgical patients, and modified it to reflect input from hospice nurses," she says. Behaviors such as restlessness, tense muscles, frowning or grimacing, and patient sounds along with physiological signs such as blood pressure, heart rate, respirations, and diaphoresis were evaluated as indicators of pain.

At this time, researchers are waiting on data from their final test of MOPAT in a larger sample of both hospital and hospice inpatient settings before releasing the tool, as some preliminary results may help some people enhance their own pain assessment methods. Although nurses often rely upon physiological symptoms to indicate pain level in non-communicative patients, reliability was more consistent for the behavioral signs, says Karen S. Kaiser, PhD, RN-BC, CHPN, AOCN, clinical practice coordinator at the University of Maryland Medical Center, adjunct associate professor University of Maryland School of Nursing, and co-author of the study. "We were not surprised at this finding," she says. "We know chronic pain in hospice patients does not produce changes in vital signs," she says. The fragile condition of hospice patients and the medications they take reduce the fluctuations in blood pressure, heart rate, and other vital signs, she adds.

"Nurses don't use numbers to evaluate symptoms of pain, they use 'none, mild, moderate, or severe' to rank the intensity of behavioral signs," says Bortle. "The nurses then write a narrative describing the symptoms," she says. The narrative focuses on the behaviors exhibited by the patient, such as restlessness, tensed muscles, or sounds when moved, she adds. The tool is used to assess pain before and after intervention for pain, she says.

When testing the MOPAT for the study, Bortle's nurses only used the tool in the inpatient hospice unit, but nurses who make home visits are now using it, she says. A one-hour CD developed by the hospice teaches nurses how and when to use the tool, she says. "At first, nurses did not want another form to handle, but once they became accustomed to the form they liked how easy it was to use," she says. At this time, use of the tool for home-based patients is voluntary, she adds.

A standardized form enables nurses and other providers to better communicate levels of pain and effectiveness of different interventions, points out Bortle. "When everyone is assessing the same behaviors as signs of pain, we improve our communication with each other and are able to improve patient care," she explains.

Researchers expect the final data and the release of the tool to occur this summer.


  1. McGuire DB, Reifsnyder J, Soeken K, et al. Assessing pain in nonresponsive hospice patients: Development and preliminary testing of the Multidimensional Objective Pain Assessment Tool. J Palliat Med 2011;14:287-292.