Pain Assessment in Patients during Hemodialysis Treatment: Quality Improvement Project

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor

Thank you for the opportunity to review the manuscript entitled “Pain Assessment in Patients during Hemodialysis Treatment: Continuous Quality Improvement Study” submitted for publication in journal Nursing Reports. The purpose of this manuscript is to report on a continuous quality improvement study that (1) describes the characteristics of pain in patients with chronic kidney disease undergoing hemodialysis treatment; (2) reports on the development and implementation of a pain assessment protocol in these patients; and (3) assesses the nurses' level of satisfaction with the protocol and implemented strategies.

The development and application of improvement interventions for the correct assessment and effective management of pain is a particularly important topic given the repercussions for both the patient and society, and may therefore be of interest to Nursing Report readers. However, this manuscript requires major refinement and reorganization to become published.

My suggestions are below, and I hope the authors find them helpful.

 

INTRODUCTION

Pain Context:

- Page 2, lines 57-58. Difficult to understand, it is necessary to clarify this sentence "Pain is defined as an unpleasant sensory and emotional experience associated with, or similar, to tissue or potential injury".

 

- Page 2, lines 69-71. Difficult to understand, it is necessary to clarify this sentence “The process of chronic pain is initiated by the perception of a painful stimulus, followed by cognitive processing and interpretation of the stimulus, which leads the individual to behave and respond in a certain way to the painful stimulus.”

 

Pain Management and Treatment:

- Page 2, lines 99-107. Difficult to understand, this paragraph needs to be simplified and made clearer “The Portuguese Nurses Regulator published an guide manual about Pain - and Good Practice, which sets out some principles of pain assessment and management, namely: everyone has the right to the best pain management; pain is a subjective, multidimensional, unique and dynamic experience; the perception and expression of pain change depending of the person and the experience itself; pain assessment and control requires continuous training; pain control requires a multidisciplinary approach; uncontrolled pain has immediate and long-term consequences, so it should be prevented; nurses should advocate for policy improvement and adequate resources allocation to support effective pain control [21].”

 

MATERIALS AND METHODS

Type of Study

- I suggest moving this section after the study design section. In addition, I suggest changing the title of the section from "Type of Study" to study setting.

 

- Page 4, lines156-161. This phase should be developed (What was included in the protocol? What strategies were implemented?) Also the training should be developed (who performed it? How many nurses participated? Did they participate simultaneously or in small groups? What did training the protocol operationalisation consist of?)

 

Data collection tool

- Data collection instruments should be developed (How many items were there? What were the possible answers). I suggest including the administered questionnaires as supplementary material so that the reader can have a clear view of the questionnaires.

Also, were the questionnaires tested before they were administered? Do we have content and face validity?

 

 

RESULTS

Sociodemographic and Clinical Characterisation of Patients

- Table 1. Correct the minimum and maximum values referred to age. They have been reversed.

 

- Table 2. There is no reference to this table anywhere in the manuscript.

 

Characterisation of Pain in Patients with CKD

- Review this section. Absolute values, already in the text, are also shown in parentheses. I assume the authors wanted to show the percentages.

 

- Page 8, lines 269-270. There is an error. The values mentioned do not coincide with those presented in the relevant table.

 

- Page 8, lines 271-272. This question is not in the relevant table. Where did this data come from?

 

- Table 4. There is no reference to this table anywhere in the manuscript.

 

Assessment of Nurses' Satisfaction with Strategies Implemented

- Table 5. Review the structure of the table. The data do not match with the corresponding columns.

 

- Page 11, lines 318-322. Clarify this paragraph. What do the nurses suggest? Where should the assessment performed be recorded?

 

 

DISCUSSION

- Page 11, lines 324-327. This statement should be made with caution because it is not generalisable. The authors have not calculated whether their sample is statistically representative.

 

- Page 11, lines 327- 330. This sentence needs to be clarified. What does it mean? Older than what?

 

- Page 11, line 334. Not having been measured pre- and post-dialysis, I think it is more appropriate to state that patients report experiencing pain on a daily basis rather than before and after haemodialysis treatment.

 

- Page 13, line 407. “[44,17].” References should be listed in ascending order

 

- Page 13, lines 408-411. Difficult to understand, this paragraph needs to be simplified and made clearer “The WHO recommends a pain management approach based on the assessment of 408 pain intensity, using the analgesic pain ladder. This was initially developed for cancer 409 patients, but it can be adapted for CKD patients, with the necessary prescription adjust-410 ments to avoid adverse effects [45,46].”

 

- Page 13, line 415. Define better and make this sentence clearer “the use of non-pharmacological pain relief measures should be encouraged.”

 

- Page 13, lines 441-444. Difficult to understand, this paragraph needs to be simplified and made clearer. What intervention was requested?

 

 

CONCLUSIONS

I suggest reviewing this section, reporting the conclusions that emerge from the results obtained.

 

- Page 13, lines 485. “throughout the study it was clear that each patient had difficulty characterizing their pain”. This represents a limitation of the study. it is inappropriate to mention it in the conclusions.

 

 

 

U.S. versus U.K. spelling

British and American spelling is used throughout the manuscript in complementary form. For example, “Hemodialysis” versus “Haemodialysis”, “characterisation” versus “characterization”

 

 

Grammar & punctuation

Kindly recheck & perform proofreading.

 

- Page 2, line 59. Missing comma after parenthesis. “(acute or chronic) type of pain ….”

 

Specific Grammar

- Page 3, line 121. “WoL”, I assume the authors meant to write QoL

 

- Page 6, line 228: “vascular acess” add a c (access)

Comments on the Quality of English Language

There are several sentences that are difficult to follow. Grammatical and linguistic revision is required.

Author Response

Dear Reviewers,

We want to thank you for carefully reading our paper and providing useful comments. In this letter, we provide a point-by-point reply to all issues raised. We hope that we have been able to address all issues adequately. The changes in the revised manuscript are highlighted in grey.

 1) 

Pain Context:

Page 2, lines 57-58. Difficult to understand, it is necessary to clarify this sentence "Pain is defined as an unpleasant sensory and emotional experience associated with, or similar, to tissue or potential injury".

Response: Revised as IASP recommended “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (p.1977).

2) - Page 2, lines 69-71. Difficult to understand, it is necessary to clarify this sentence “The process of chronic pain is initiated by the perception of a painful stimulus, followed by cognitive processing and interpretation of the stimulus, which leads the individual to behave and respond in a certain way to the painful stimulus.”

Response: Clarified: “The perception of a painful stimulus, associated with chronic pain, is followed by a cognitive processing and interpretation, that leads to different behaviours and responses by the people who experience it”.

3) - Page 11, lines 318-322. Clarify this paragraph. What do the nurses suggest? Where should the assessment performed be recorded?

Response: Revised the paragraph.

4) DISCUSSION - Page 11, lines 324-327. This statement should be made with caution because it is not generalisable. The authors have not calculated whether their sample is statistically representative.

Response: Revised “continuous quality improvement study carried out showed that the average age of patients studied was…”

5) - Table 4. There is no reference to this table anywhere in the manuscript. 

• Page 8, lines 269-270. There is an error. The values mentioned do not coincide with those presented in the relevant table. Pain Management and Treatment:- Page 2, lines 99-107. Difficult to understand, this paragraph needs to be simplified and made clearer “The Portuguese Nurses Regulator published an guide manual about Pain - and Good Practice, which sets out some principles of pain assessment and management, namely: everyone has the right to the best pain management; pain is a subjective, multidimensional, unique and dynamic experience; the perception and expression of pain change depending of the person and the experience itself; pain assessment and control requires continuous training; pain control requires a multidisciplinary approach; uncontrolled pain has immediate and long-term consequences, so it should be prevented; nurses should advocate for policy improvement and adequate resources allocation to support effective pain control [21].”

Response: Revised. Thanks for your suggestion. 

6) MATERIALS AND METHODS: Type of Study- I suggest moving this section after the study design section. In addition, I suggest changing the title of the section from "Type of Study" to study setting.

Response: It was moved. Thanks for your suggestion.

7) Page 4, lines156-161. This phase should be developed (What was included in the protocol? What strategies were implemented?) Also the training should be developed (who performed it? How many nurses participated? Did they participate simultaneously or in small groups? What did training the protocol operationalisation consist of?) I suggest reviewing this section, reporting the conclusions that emerge from the results obtained.

Response: Thanks for your suggestions. It was improved. 

8) Data collection tool- Data collection instruments should be developed (How many items were there? What were the possible answers). I suggest including the administered questionnaires as supplementary material so that the reader can have a clear view of the questionnaires.

Response: Was added the suggested information. Since the questionnaires and pain protocol are extensive and in Portuguese language it was added the possibility to be requested by email. And was added more descriptive information about it in the paper. Also, was added in Data Availability Statement that information. “The questionnaire and pain protocol designed is also available through requesting.”

9) Also, were the questionnaires tested before they were administered? Do we have content and face validity?

Response: Process was added in the paper.

10) RESULTS: Sociodemographic and Clinical Characterisation of Patients. - Table 1. Correct the minimum and maximum values referred to age. They have been reversed. - Table 2. There is no reference to this table anywhere in the manuscript.

Response: Revised.

11) Characterisation of Pain in Patients with CKD - Review this section. Absolute values, already in the text, are also shown in parentheses. I assume the authors wanted to show the percentages.

Response: We trayed to highlight some percentages in the text.

12) - Page 8, lines 271-272. This question is not in the relevant table. Where did this data come from?Assessment of Nurses' Satisfaction with Strategies Implemented. - Table 5. Review the structure of the table. The data do not match with the corresponding columns. - Page 11, lines 327- 330. This sentence needs to be clarified. What does it mean? Older than what? - Page 11, line 334. Not having been measured pre- and post-dialysis, I think it is more appropriate to state that patients report experiencing pain on a daily basis rather than before and after haemodialysis treatment. - Page 13, line 407. “[44,17].” References should be listed in ascending order. - Page 13, lines 408-411. Difficult to understand, this paragraph needs to be simplified and made clearer “The WHO recommends a pain management approach based on the assessment of 408 pain intensity, using the analgesic pain ladder. This was initially developed for cancer 409 patients, but it can be adapted for CKD patients, with the necessary prescription adjust-410 ments to avoid adverse effects [45,46].” - Page 13, line 415. Define better and make this sentence clearer “the use of non-pharmacological pain relief measures should be encouraged.” - Page 13, lines 441-444. Difficult to understand, this paragraph needs to be simplified and made clearer. What intervention was requested? CONCLUSIONS- Page 13, lines 485. “throughout the study it was clear that each patient had difficulty characterizing their pain”. This represents a limitation of the study. it is inappropriate to mention it in the conclusions. U.S. versus U.K. spelling: British and American spelling is used throughout the manuscript in complementary form. For example, “Hemodialysis” versus “Haemodialysis”, “characterisation” versus “characterization” Grammar & punctuation: Kindly recheck & perform proofreading. - Page 2, line 59. Missing comma after parenthesis. “(acute or chronic) type of pain ….” Specific Grammar: - Page 3, line 121. “WoL”, I assume the authors meant to write QoL - Page 6, line 228: “vascular acess” add a c (access).

Response: Thanks for all suggestions. We revised it. 

We are deeply grateful for the time and effort you have invested in our work, and we certainly remain open to any further suggestions for the continued improve our project. 

Respectfully,

The Authors

 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this descriptive quality improvement study of pain assessment during dialysis for late stage kidney failure. The problem of pain in people with late stage kidney failure is briefly described, along with some background information on both pain as a biopsychosocial phenomenon and pain in people with kidney failure. The study is justified on the basis of high prevalence and impact of pain on quality of life in dialysis recipients.

There are three parts to the project, but only two are reported here.

The first part is a survey of patients having dialysis, conducted by nurses involved in their care. The survey was intended to characterise patient demographics, investigate pain intensity in general and during dialysis, and included questions about impact on daily life activities. There are no details provided regarding the development, testing or content of the patient survey, and no information about the language or form (paper, electronic or verbal) in which it was offered. There is also no information about how participants were recruited to the study, nor how many declined to participate although the paper indicates 19 participants were excluded. This lack of detail makes it difficult to determine how representative the responses are, along with the lack of information about survey items which makes descriptors such as “How would you describe your pain” difficult to interpret. The descriptors for the item “How would you describe your pain” are unusual and suggest participants were given cues or suggestions for their responses. What is “coin-shaped pain”?

Bias is introduced when participants are approached by nurses giving care to them, again making interpretation difficult. There was no information provided about how participants were asked to recall their time in dialysis – and the details of vascular access likely were drawn either from clinical records or by nursing staff, so I’m uncertain why time in dialysis could not be similarly identified from clinical records. Different pain intensity ratings were used, making comparisons within the participant population difficult. The tables lack details (eg “how long have you had pain?” has no indicator eg months/years; “how severe is your pain” has no key for interpretation). I am not sure what ‘osteoarticular’ pain means particularly given that osteoarthritis (if this is what is meant) can occur at many places in the body.

There is no description of the processes used to develop the pain assessment protocol beyond it being based on ‘recent scientific evidence’ and data from the patient survey. Training is very briefly described but content included in the training is scant. The protocol is not provided.

The third part of this study is a survey of nurses who were involved in implementing the protocol. Given there is no information about pre-implementation satisfaction or concerns about pain management, the data drawn from nearly 70% of nursing staff offers limited insight. Similar to the patient survey, no details are given with respect to how the survey was developed, the items included in it, nor how nurses were recruited to the study. While descriptive data characterises the years in practice, gender, specialty, exposure to pain training and beliefs about the importance of pain education, it sheds little light on beliefs and attitudes about pain management in this group, nor knowledge of pain management techniques. I am also curious that nurses were surveyed and not patients when it would be hoped that an intervention to improve pain assessment would result in an improvement in patient’s experiences.

The discussion offers some situating of the results within the current body of literature. I was puzzled by the statement regarding pain descriptors with the authors stating ‘This difference can be explained by the difficult that patients have in characterising their own pain and giving it descriptors’ particularly when no information about how patients were asked this question were offered. While the point that pain is subjective is made several times in this paper, the authors appear not to have taken this point on board themselves when suggesting that their patients were not able to describe their own experience. There is no discussion regarding why the responses from patients in this study differ from other studies apart from the very broad points that there are ‘several factors that interfere with its characterisation’ and the list drawn from two sources. Were there language differences between nurses conducting the survey and patients? Were prompts or a list of descriptors provided? If not, why not and then how were the list of descriptors provided in the table developed? If there were descriptors provided, what were these and where were they developed from?

The limitations provided for this study refer only to ‘difficulty mobilising the entire nursing team to understand the importance of this problem’ rather than any of the above limitations relating to survey development and study design, including bias introduced by having nurses involved in patient care recruit and carry out the patient survey.

The manuscript overall suffers from grammatical errors and numerous typographical errors, making reading difficult at times. I was unable to check references given the majority were not in English nor readily available.

 

Comments on the Quality of English Language

English grammar, typographical errors and coherence require attention.

Author Response

Dear reviewers,

We would like to thank all your for carefully reading our paper and providing your useful comments on it. In this letter, we provide a point-by-point reply to all issues raised.

We hope that we have been able to address all issues in an adequate way.

The changes in the revised manuscript are highlighted in grey.   

1)The first part is a survey of patients having dialysis, conducted by nurses involved in their care. The survey was intended to characterise patient demographics, investigate pain intensity in general and during dialysis, and included questions about impact on daily life activities. There are no details provided regarding the development, testing or content of the patient survey, and no information about the language or form (paper, electronic or verbal) in which it was offered.

Response: It was added.

2) There is also no information about how participants were recruited to the study, nor how many declined to participate although the paper indicates 19 participants were excluded.

Response: In sample description point 2.3 was added that information.

3) This lack of detail makes it difficult to determine how representative the responses are, along with the lack of information about survey items which makes descriptors such as “How would you describe your pain” difficult to interpret. The descriptors for the item “How would you describe your pain” are unusual and suggest participants were given cues or suggestions for their responses. What is “coin-shaped pain”?

Response: Patients had a difficult to describe them pain, so after pre-test with five HD patients it was suggested to insert these possibilities of responses. it was a wrong translation was Crushing.

4) 

Bias is introduced when participants are approached by nurses giving care to them, again making interpretation difficult.

There was no information provided about how participants were asked to recall their time in dialysis – and the details of vascular access likely were drawn either from clinical records or by nursing staff, so I’m uncertain why time in dialysis could not be similarly identified from clinical records.

Different pain intensity ratings were used, making comparisons within the participant population difficult. The tables lack details (eg “how long have you had pain?” has no indicator eg months/years; “how severe is your pain” has no key for interpretation). I am not sure what ‘osteoarticular’ pain means particularly given that osteoarthritis (if this is what is meant) can occur at many places in the body.

Response: The clinical nurses were not part of the research team, but were they who explained the study to patients, when they approached and invited them. Nurses during that invitation ensured that the patient knew that they could decide not to participate, a decision that would not interfere with the care provided. It was revised that information were added to the manuscript. The pain instruments used were the one that patient was capable to use. The indicators were in months.

5) There is no description of the processes used to develop the pain assessment protocol beyond it being based on ‘recent scientific evidence’ and data from the patient survey. Training is very briefly described but content included in the training is scant. The protocol is not provided

Response: Added description.

6)  The third part of this study is a survey of nurses who were involved in implementing the protocol. Given there is no information about pre-implementation satisfaction or concerns about pain management, the data drawn from nearly 70% of nursing staff offers limited insight. Similar to the patient survey, no details are given with respect to how the survey was developed, the items included in it, nor how nurses were recruited to the study. While descriptive data characterises the years in practice, gender, specialty, exposure to pain training and beliefs about the importance of pain education, it sheds little light on beliefs and attitudes about pain management in this group, nor knowledge of pain management techniques. I am also curious that nurses were surveyed and not patients when it would be hoped that an intervention to improve pain assessment would result in an improvement in patient’s experiences.

Response:  The study being a quality improvement project, implies to develop a diagnosis of situation, implement improving strategies and assess that implemented process. So, the patient assessment was planned to make the diagnosis of the situation (stage one of the study). It was decided in third stage of the study to listen nurses’ perspectives. But in this kind of projects this assessment implies a restart of all projects, and the possibility to insert new approaches, new interventions, and new ways to access the outcomes.   In order of that, in discussion that was a point highlighted to future research, mentioned that idea.

7) The manuscript overall suffers from grammatical errors and numerous typographical errors, making reading difficult at times. I was unable to check references given the majority were not in English nor readily available.

Response: A native English speaker was asked to review the article

We hope we were able to answer all your questions.

We are deeply grateful for the time and effort you have invested in our work, and we certainly remain open to any further suggestions for the continued improve our project. 

Respectfully,

The Authors

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript had three aims:

1) to assess the presence of pain in patients with CKD in an HD clinic in central Portugal between November and December 2022; 

2) to implement strategies to improve the pain assessment process in patients with CKD during the HD treatment; 

3) to assess nurses' satisfaction with the strategies implemented. 

 

Although all three aims were corroborated in the discussion section, answers to these aims are missing in the beginning. Usually, here, one or two sentences cover all key study findings. It should be noted that the authors used only descriptive statistics in this manuscript. The authors used a non-validated questionnaire for the nurse satisfaction assessment. Because of that, the importance of these study's findings for clinical practice is below average. Mainly, this is a project report.

However, pain in CKD is a very important topic, especially among nurses. This manuscript, except the aforementioned, highlights one of the possible solutions to improve pain management in patients on hemodialysis and it is well-written. Nevertheless, I suggest that this manuscript could be accepted for publication after all needed changes are made.

The level of English in Tables 4 and 6 is poor. The references should be written according to the journal's guidelines.

 

Comments on the Quality of English Language

Table 3. Authors should check the English grammar and meanings of asked questions. Also, the answers are missing to the questions (I suppose this was the real meaning of these questions) "Where is the place where it radiates?" and "What medication do you usually take?"

Line 281 - This is probably metamizole not "matamizol"

The same problem repeats in Tables 4 and 6. 

The authors should check the complete manuscript for grammar and/or writing errors.

Author Response

Dear reviewers,

We would like to thank all your for carefully reading our paper and providing your useful comments on it. In this letter, we provide a point-by-point reply to all issues raised.

We hope that we have been able to address all issues in an adequate way.

The changes in the revised manuscript are highlighted in grey.   

1) Although all three aims were corroborated in the discussion section, answers to these aims are missing in the beginning.

Response: Present in page 3 before point 2. Materials and Methods.

2) Usually, here, one or two sentences cover all key study findings. It should be noted that the authors used only descriptive statistics in this manuscript

Response: The decision to use only descriptive statistics was based by the type of project developed.

3) The authors used a non-validated questionnaire for the nurse satisfaction assessment.

Response: Once the study is a quality project implementation it was construct an instrument headed to the aims) focus in unit specifications.

4) Because of that, the importance of these study's findings for clinical practice is below average. Mainly, this is a project report.

However, pain in CKD is a very important topic, especially among nurses. This manuscript, except the aforementioned, highlights one of the possible solutions to improve pain management in patients on hemodialysis and it is well-written. Nevertheless, I suggest that this manuscript could be accepted for publication after all needed changes are made.

Response: we revised bibliography and citations. And we are very grateful for all your kind words.

5) The level of English in Tables 4 and 6 is poor. The references should be written according to the journal's guidelines.

Response: Revised.

6) Comments on the Quality of English Language: Table 3. Authors should check the English grammar and meanings of asked questions. Also, the answers are missing to the questions (I suppose this was the real meaning of these questions) "Where is the place where it radiates?" and "What medication do you usually take?"

Response: A native English speaker was asked to review the article.

7) Line 281 - This is probably metamizole not "matamizol".

Response: Thanks for you carefully check. Revised.

8) The same problem repeats in Tables 4 and 6. 

Response: Revised.

9) The authors should check the complete manuscript for grammar and/or writing errors

Response: A native English speaker was asked to review the article.

We are deeply grateful for the time and effort you have invested in our work, and we certainly remain open to any further suggestions for the continued improve our project. 

Respectfully,

The Authors

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

First of all, thank you very much for the opportunity of reviewing again the manuscript titled "Pain Assessment in Patients during Haemodialysis Treatment: Quality improvement project". Secondly I would like to congratulate the authors, they have successfully adjusted and improved their manuscript and my comments were handled satisfactory.

I do not have any further comments to make on this. Take care and kind regards.

Author Response

Dear Reviewer

Thanks for your time and suggestions.

Best regards

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for forwarding this amended manuscript. There remain some grammatical/English translation errors, but most of the other points are now satisfactorily addressed.

Comments on the Quality of English Language

The manuscript should be reviewed by an English speaking editor to ensure all grammatical and typographic errors are corrected.

Author Response

Dear Reviewer

Thanks for your suggestions.

In attachment we send the paper with the English editing  required.

Best regards

Author Response File: Author Response.pdf