Effectiveness of Structured Nursing Interventions in Improving Pain Assessment and Management among hospitalized patients on the surgical ward at Byumba level two teaching hospital

Effectiveness of Structured Nursing Interventions in Improving Pain Assessment and Management among hospitalized patients on the surgical ward at Byumba level two teaching hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Structured Nursing Interventions in Improving Pain Assessment and Management among hospitalized patients on the surgical ward at Byumba level two teaching hospital HAKIZIMANA Leonard, Nanyombi Lubimbi, Helen Ewing This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7159445/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Background Effective pain assessment and management are essential components of postoperative care, significantly influencing recovery, patient satisfaction, and clinical outcomes. An internal audit conducted in January 2025 at Byumba Level Two Teaching Hospital revealed that only 78% of surgical ward patients received adequate pain management. In response, a Quality Improvement (QI) project was launched with the goal of increasing this rate to at least 95% by May 30, 2025. Methods This 4-month QI initiative (February 2025–May 2025) utilized the Plan-Do-Study-Act (PDSA) cycle to implement targeted interventions. Key strategies included structured training for nurses on validated pain scales, standardized assessment tools during admission and ward rounds, and the introduction of a pain management flow sheet. Primary outcomes were the proportion of patients receiving adequate pain control (pain score ≤ 3 within 24 hours) and documented pain assessments. Secondary outcomes included patient satisfaction and staff knowledge, while process measures monitored protocol adherence, reassessment rates, and staff competence via training and pre-/post-tests. Interventions addressed key barriers, including limited leadership support, absence of staff feedback mechanisms, and cultural norms such as silent pain endurance. Results By May 30, 2025, patients receiving adequate pain management increased from 78–95%. Documented pain assessments rose from 62–94%, and those achieving effective pain control improved from 68–96%. Patient satisfaction scores increased from 4.1 to 4.88 (on a 5-point Likert scale). Run chart analysis showed sustained improvement aligned with each intervention phase. Conclusion Structured, evidence-based Quality Improvement interventions can significantly enhance pain management among hospitalized patients, even in rural, resource-limited settings. These results demonstrate that structured, evidence-based interventions can pain management, even in resource-constrained settings. Pain assessment pain management PDSA quality improvement nursing interventions Byumba Level Two Teaching Hospital. Figures Figure 1 Background Pain is one of the most common and distressing symptoms experienced by hospitalized surgical patients. Effective pain management not only alleviates suffering but also contributes to improved recovery, early mobilization, shorter hospital stays, and increased patient satisfaction (Gan et al., 2014 ; Apfelbaum et al., 2003 ). Despite global advances, up to 80% of patients still receive inadequate pain relief, particularly in low-resource settings (Brennan et al., 2007 ). In Rwanda, at Byumba Level Two Teaching Hospital (a district-level hospital providing secondary care services, as described in the methods section), an internal audit conducted in January 2025 revealed that only 78% of surgical ward patients received adequate pain management. This deficiency was associated with delayed recovery and increased patient dissatisfaction, as documented in the internal hospital audit (Byumba L2TH Internal Audit Report, 2025). These findings triggered this quality improvement (QI) project, aimed at addressing systemic and cultural barriers to effective pain management. The surgical ward demonstrated significant gaps in pain management, including irregular assessment practices, inconsistent documentation, and minimal patient involvement (Byumba L2TH Internal Audit Report, 2025). Cultural norms, such as kwihangana—the expectation to endure pain silently—further limited pain reporting (Nsereko et al., 2022 ). Contributing factors also included a lack of standardized protocols, limited staff training, and insufficient tools such as pain scales and flow sheets (Hagenimana et al., 2024 ; Uwimana et al., 2024 ). These gaps posed significant risks to clinical outcomes and patient-centered care. Research consistently links inadequate pain management to adverse outcomes, including delayed wound healing, development of chronic pain, prolonged hospital stays, and decreased patient satisfaction (Medrzycka-Dabrowka, 2017). These consequences underscore the importance of effective pain control as a fundamental component of quality care, particularly in surgical and inpatient settings. In resource-limited settings, these challenges are compounded by limited access to essential analgesics, lack of standardized assessment tools, and insufficient provider training (De Lima et al., 2014; Uwimana et al., 2024 ). Cultural norms promoting stoicism, such as the Rwandan value of kwihangana, discourage patients from reporting pain, complicating assessment and timely interventions. Prior interventions have shown promising results in closing these gaps. Structured pain management protocols, the use of validated tools such as the Numerical Rating Scale (NRS) and Visual Analog Scale (VAS), and staff education have all been associated with improved outcomes (Herr et al., 2011; Al-Quliti & Alamri, 2015 ). Multimodal approaches combining pharmacologic treatments with cognitive-behavioral therapy, physical therapy, and guided imagery have also been effective in enhancing pain relief while minimizing side effects (Chou et al., 2016 ; Gatchel et al., 2014). Quality pain management not only relieves suffering but also builds patient trust and reduces psychological distress (Tawil et al., 2018 ). Despite these advancements, consistent implementation remains challenging in local contexts such as Byumba Level Two Teaching Hospital. Barriers, including limited staffing, poor documentation, lack of institutional guidelines, and myths surrounding opioid use, persist (Hagenimana et al., 2024 ; Tata et al., 2024 ). These underscore the need for targeted, context-specific strategies that strengthen provider competencies and institutionalize pain management practices. To understand the root causes, quality improvement tools were employed. An Ishikawa (Fishbone) diagram (Fig. 1 ) revealed four major categories: People (inadequate training, understaffing), Processes (no standard protocols), Tools (lack of pain scales/flow sheets), and Environment (high patient loads, cultural stoicism). A “5 Whys” analysis identified a lack of reassessment due to tool and training gaps. A process map compared current versus ideal workflows, identifying missed opportunities for early pain control. Guided by the Model for Improvement, the Plan-Do-Study-Act (PDSA) cycles were implemented, focusing on staff training, standardized tools, and routine reassessment. These interventions aimed to improve consistency, documentation, and responsiveness in pain management. The primary aim of this QI project was to increase the proportion of surgical patients receiving adequate pain assessment and management at BLTH from a baseline of 78–95% by May 30, 2025. Secondary aims included increasing the percentage of patients achieving acceptable pain control (pain score ≤ 3) within 24 hours and improving staff adherence to documentation and reassessment protocols. Methods The aim, design, and setting of the study This quality improvement (QI) project was implemented to address deficiencies in pain management practices among patients hospitalized in the surgical ward at Byumba Level Two Teaching Hospital (BLTH), a public healthcare facility located in Gicumbi District, Northern Rwanda. Established in 1947 and designated as a Level Two Teaching Hospital in 2022, BLTH is part of Rwanda’s decentralized health system aimed at integrating clinical training with service delivery. The project aimed to improve the assessment, documentation, and management of pain through a series of structured interventions. The QI initiative used a before-and-after study design and was guided by the Plan-Do-Study-Act (PDSA) cycle methodology to implement and refine changes over time. Baseline data were collected in January 2025, and interventions were rolled out from February to May 2025. The characteristics of participants The QI project involved a multidisciplinary team composed of surgical ward nurses, nurse leaders, physicians, CPD facilitators, and quality assurance officers. All nurses and physicians working in the surgical ward during the implementation period participated in the intervention activities, including training sessions and documentation improvement efforts. Training materials included interactive PowerPoint presentations, role-play scenarios, quizzes, and printed guidelines on the use of validated pain assessment tools such as the Numeric Rating Scale (NRS) and the Wong-Baker FACES scale. Patients in the surgical ward were also engaged through educational materials, including leaflets and bedside visual aids printed in both Kinyarwanda and English. Pain assessment documentation tools, such as revised vital signs charts and dedicated pain flow sheets, were used to record pain scores and prompt reassessments. A clear description of all processes, interventions, and comparisons Following an internal audit in January 2025 that identified gaps in pain assessment and documentation, the hospital formed a QI team to design and implement targeted interventions. These interventions focused on three main areas: staff capacity building, workflow and documentation improvement, and patient engagement. In February and March 2025, two rounds of pain management training were conducted for all ward staff. These sessions emphasized pain physiology, the use of validated tools, and WHO guidelines for pharmacological pain management. Nurses scoring below 70% on post-tests received individualized coaching. Revised documentation tools were introduced in March 2025, including an integrated NRS chart in the routine vital signs sheet and a new pain flow sheet. Visual aids and patient education materials were distributed, and nurses were instructed to use these tools during every patient interaction. Each month-long PDSA cycle allowed for iterative refinement of the interventions. For instance, additional visual cues were introduced in Cycle 2 after observations revealed inconsistent numeric pain scoring. The interventions were evaluated through multiple methods, including repeated reviews of patient charts, structured interviews conducted using a guide developed by the researchers (refer to Supplementary File 1) and informed by relevant literature (Gan et al., 2014 ; Hagenimana et al., 2024 ), and staff knowledge assessments. Monthly review meetings were held to discuss findings and inform ongoing improvement actions. Outcome, process, and balancing measures were analyzed using descriptive statistics and visualized with run charts to monitor trends and changes over time. Results A quality improvement project conducted over three months at Byumba Level Two Teaching Hospital’s surgical ward yielded substantial improvements in pain assessment and management practices. At the project’s outset in February 2025, only 78% of patients received appropriate pain assessment and control within 24 hours of admission. This initial baseline highlighted gaps, including inconsistent pain assessment on admission, low rates of reassessment after analgesia, and inadequate documentation. Following the introduction of interventions, primarily staff training, the implementation of standardized pain assessment tools, such as the Numerical Rating Scale (NRS), and enhanced patient education, marked progress was observed. Pain assessment upon admission improved from 62–94% (Table 1 ), while reassessment within one-hour post-analgesia increased from 62–90% (Table 1 ). Documentation of pain reassessments within 24 hours per patient rose sharply from 45–95% (Table 1 ). Improvements in patient outcomes were also evident. The proportion of patients achieving adequate pain control, defined as an NRS score of 3 or below within 24 hours, increased from 68% at baseline to an impressive 96% by the end of May 2025. Patient satisfaction with pain management, as measured by surveys using a 1 to 5 Likert scale, increased from an average rating of 4.1 to 4.88 (Table 2 ), indicating an enhanced patient experience and engagement. The knowledge and competency of nursing staff improved significantly through targeted educational sessions. Pre- and post-training assessments demonstrated an increase in nurse knowledge scores from 45–88%, underscoring the effectiveness of the training interventions. The project’s run chart demonstrated a steady upward trend in key process and outcome indicators, with several median shifts confirming that these improvements reflected an actual system change rather than random fluctuations. Qualitative feedback through discussions with nurses and medical doctors complemented the quantitative data, with nurses reporting that the visible pain scales at patient bedsides prompted more consistent pain inquiries and reassessments. Patients expressed appreciation for the active involvement in reporting their pain, which contributed to greater satisfaction and a sense of being cared for attentively. Additionally, an unintended positive effect was enhanced communication among healthcare team members regarding pain management decisions. Data completeness was adequate throughout the project, with less than 5% of charts missing key information. Moreover, documentation completeness improved over time, reflecting better adherence to the revised pain management protocols. Table 1 Key Process Indicators – Pre- and Post-Intervention Measures Dates Feb-25 Mar-25 Apr-25 May-25 Pain assessment documented at admission (%) 62% 75% 86% 94% Pain reassessment within 1 hour of analgesia (%) 45% 65% 78% 95% Nurse knowledge (pre-test score) (%) 45% - - - Nurse knowledge (post-training score) (%) - 88% - - Table 2 Outcome Measures of QI Project Implemented Month Pain Control within 24 hrs. (NRS ≤ 3) Patient Satisfaction (Mean Score on 1–5 Scale) Feb-25 68% 4.1 Mar-25 74% 4.5 Apr-25 87% 4.6 May-25 96% 4.88 Discussion This project demonstrated that a targeted Quality Improvement (QI) initiative can significantly enhance pain management practices in the surgical ward of a rural Rwandan Level Two Teaching Hospital. Several factors contributed to the project’s success. Early engagement of ward leadership facilitated access to essential resources, such as printed assessment tools, and fostered a strong sense of staff ownership. Regular monthly feedback meetings helped maintain momentum and motivation among the team. Importantly, cultural barriers, including common beliefs equating pain reporting with weakness, were explicitly addressed during training sessions, a challenge similarly reported by Uwimana et al. ( 2024 ). The deployment of low-cost, high-impact tools, such as printed pain scales and modified flow sheets, proved both practical and sustainable in this setting. The proportion of patients receiving adequate pain management increased from 78–97.6%, surpassing the initial target of 95%. This outcome mirrors the success seen in similar studies such as Hagenimana et al. ( 2024 ), where protocol standardization and staff education were effective. Our approach, combining structured nurse training, patient education, and standardized assessment tools, closely aligns with those findings. Our interventions directly targeted key barriers identified in the literature. Knowledge gaps were addressed through targeted training and evaluation, as highlighted by Al-Mahrezi ( 2017 ) and Al-Quliti ( 2015 ). Additionally, uncertainty in prescribing analgesics was reduced by introducing clear, standardized guidelines, an approach supported by Tawil et al. ( 2018 ), who emphasized that opioid-related fears frequently hinder effective pain control. Patient satisfaction improved notably during the implementation period, coinciding with enhanced pain control and more consistent documentation, outcomes that, while not statistically tested due to the QI project’s observational (Gordon et al., 2005 ; Gordon et al., 2016; Al-Quliti & Alamri, 2015 ; Tawil et al., 2018 ). This demonstrates that patient engagement, including education on pain scoring and timely reporting, along with competent nursing practice, fosters trust, adherence, and psychological well-being. Although 96% of patients had acceptable pain scores within 24 hours (Table 2 ), approximately 10% were still discharged with inadequate pain control. Many of these patients had chronic or complex pain conditions not responsive to standard protocols. This suggests a need for escalation strategies, such as early referrals to anesthetists or palliative care teams. These patients require individualized plans beyond routine ward-based pain control. Continuous monitoring and feedback through Plan-Do-Study-Act (PDSA) cycles facilitated adaptive learning and iterative improvements. For example, after the initial implementation, we observed a tendency among some nurses to document pain narratives rather than numeric scores. In response, Cycle 2 introduced visual reminder labels on patient charts to encourage the use of numeric documentation, reflecting core principles of quality improvement (QI). Limitations and Recommendations While this QI project achieved significant improvements, several limitations should be acknowledged. The project was limited to a single ward in one hospital, which restricts generalizability. Some staff were initially resistant to new documentation protocols, and patient understanding of pain scores was inconsistent despite educational efforts. Data collection relied heavily on chart reviews and verbal surveys, which may have introduced bias. Lastly, due to the QI nature of the study, we did not apply inferential statistical analysis, so causal inferences should be interpreted cautiously. Moving forward, we recommend sustaining the gains by incorporating pain assessment and management into routine audits and expanding promising change ideas to other wards. These steps will help ensure pain management remains a priority, enabling patients to receive timely, compassionate care while improving overall quality and safety throughout the hospital. Conclusion This QI project employed evidence-based strategies to overcome key barriers, namely, irregular pain assessment, limited tools, poor documentation, staff training gaps, and cultural beliefs around stoicism. By addressing these through structured education, protocol development, and patient engagement, we achieved substantial improvements in pain control. Our multi-faceted approach, low-cost, sustainable, and contextually adapted, demonstrates that meaningful change is possible even in under-resourced rural settings. The project serves as a model for similar hospitals aiming to enhance the quality of care through simple, scalable interventions. Sustaining the gains will require ongoing leadership support, continuous training, and institutionalizing pain management as a core quality indicator. Abbreviations Abbreviation Full Term QI Quality Improvement BLTH Byumba Level Two Teaching Hospital PDSA Plan-Do-Study-Act NRS Numeric Rating Scale VAS Visual Analog Scale WHO World Health Organization CPD Continuing Professional Development RN Registered Nurse CGNC Certified Global Nurse Consultant MSN Master of Science in Nursing PhD Doctor of Philosophy MOH Ministry of Health (Rwanda) HMIS Health Management Information System Declarations Ethical Approval and Consent to Participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. This study was approved by the University of Global Health Equity and conducted in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants prior to their inclusion in the study. Consent for Publication All participants provided informed consent for the publication of data and findings derived from this study. Any identifying information has been anonymized to protect participant confidentiality. Consent for Publication Not applicable. This manuscript does not contain any individual person’s data in any form. Availability of Data and Materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' Contributions HL (Hakizimana Leonard) conceptualized the study, led the design and implementation of the quality improvement project, and contributed significantly to manuscript writing. NL (Nanyombi Lubimbi) provided critical mentorship and guidance on quality improvement methodologies and reviewed the manuscript for academic precision. HE (Helen Ewing) contributed to refining the project framework and critically revised the manuscript for clarity, relevance, and completeness. All authors read and approved the final manuscript. Acknowledgements The authors wish to acknowledge the surgical ward team at Byumba Level Two Teaching Hospital for their commitment to implementing improved pain assessment and management practices. Gratitude is also extended to the hospital’s leadership and Quality Assurance Unit for their institutional support. Authors’ Information HL (HAKIZIMNA Leonard), a General Nurse Practitioner and Quality Improvement Officer at Byumba Level Two Teaching Hospital with over 10 years of experience in clinical nursing and quality assurance. He possesses a Master’s in Public Health with a specialization in Global Health. NL (Nanyombi Lubimbi) is a Post-Doctoral Fellow in Nursing Research and Global Health at the University of Washington, Seattle. She is a global health nurse leader with 20 years of clinical and teaching experience in the U.S. and abroad. She holds a certificate in Public Health Management from the University of Illinois, Chicago, and is certified as a Global Nurse Consultant (CGNC) by the International Council of Nursing. HE (Helen Ewing) is a Senior Faculty member in Nursing and Midwifery with a strong background in international nursing education and curriculum development focused on quality and safety in clinical settings. References Al-Mahrezi A. Towards effective pain management: Breaking the barriers. Oman Med J. 2017;32(5):357–8. Al-Quliti KW, Alamri MS. Knowledge, attitudes, and practices of health care providers towards pain management in Eastern Province, Saudi Arabia. Saudi J Anaesth. 2015;9(4):437–45. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534–40. Brennan F, Carr DB, Cousins M. Pain management: A fundamental human right. Anesth Analg. 2007;105(1):205–21. Byumba Level Two Teaching Hospital. Internal Audit Report. 2025. Unpublished internal quality audit report. Chen JS, Kandle PF, Murray IV, et al. Physiology, pain. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–57. Gan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin. 2014;30(1):149–60. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull. 2007;133(4):581–624. Gordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005;165(14):1574–80. Hagenimana JP, Banguti PR, Anderson RLC, Tuyishime JDD, Nyirigira G, Tuyishime E. Improving pain management for trauma patients at two Rwandan emergency departments. Afr J Emerg Med. 2024;14(4):258–62. Medrzycka-Dabrowka W, Dąbrowski S, Gutysz-Wojnicka A, Gawroska-Krzemińska A, Ozga D. Barriers perceived by nurses in the optimal treatment of postoperative pain. Open Med (Wars). 2017;12(1):239–46. Nsereko E, Munyandamutsa N, Umubyeyi A. Cultural attitudes toward mental health and pain reporting in Rwanda: Implications for health service delivery. Rwandan J Health Sci. 2022;11(1):34–42. Republic of Rwanda. Prime Minister’s Instructions 001/03 of 10/08/2022 determining the organizational structure of Ndera Neuropsychiatric Teaching Hospital and Level Two Teaching Hospitals. Off Gaz Rwanda. 2022 Aug 10. Tata TK, Ohene LA, Dzansi GA, et al. Factors influencing nurses’ pain assessment and management of road traffic casualties: A qualitative study at a military hospital in Ghana. BMC Emerg Med. 2024;24:100. Tawil S, Iskandar K, Salameh P. Pain management in hospitals: patients' satisfaction and related barriers. Pharm Pract (Granada). 2018;16(3):1268. Uwimana P, Mukamana D, Babenko-Mould Y, Adejumo O. A framework for capacity enhancement of Rwandan nurse educators and preceptors facilitating nursing students to learn pediatric pain management. BMC Nurs. 2024;23(1):127. Additional Declarations No competing interests reported. Supplementary Files PainAssessmentandManagementImprovementChecklistByumba.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 18 Nov, 2025 Reviews received at journal 16 Nov, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviews received at journal 05 Sep, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 14 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 08 Aug, 2025 Editor invited by journal 06 Aug, 2025 Submission checks completed at journal 05 Aug, 2025 First submitted to journal 05 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7159445","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498300015,"identity":"6b892861-be57-4a06-9162-c1d3e9a379c0","order_by":0,"name":"HAKIZIMANA Leonard","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYBACPiBmZmBIkJNnbwAyDSwIa2GDajE27DkA0iJBvJbEhhsJID4xWtibjz0uqEljbJz5/OqGHwUSDPzt3Qn4tfAcSzeecSyHmV06p+xmD9BhEmfObsCvRSLHTJqHrYKNcXZO2g0eoBYDiVwCWuTfALX8q+BhuHkm7eYforRI8JhJ87blSDDcYD92mzhbeNLSpHn70gwMe3LYbssYSPAQ9As/++Fj0jzfkuvnsx9/dvPNHxs5/vZe/FqQAI8BmCRWOQiwPyBF9SgYBaNgFIwgAADDXD/CHzA0MgAAAABJRU5ErkJggg==","orcid":"","institution":"Byumba Level Two Teaching Hospital Gicumbi","correspondingAuthor":true,"prefix":"","firstName":"HAKIZIMANA","middleName":"","lastName":"Leonard","suffix":""},{"id":498300016,"identity":"f218ea2f-7940-45d2-b942-572bb1c9fd99","order_by":1,"name":"Nanyombi Lubimbi","email":"","orcid":"","institution":"University of Washington Seattle","correspondingAuthor":false,"prefix":"","firstName":"Nanyombi","middleName":"","lastName":"Lubimbi","suffix":""},{"id":498300017,"identity":"b144a689-77b2-41ac-bce0-b5ed0ac639cb","order_by":2,"name":"Helen Ewing","email":"","orcid":"","institution":"University of Global Health Equity","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"","lastName":"Ewing","suffix":""}],"badges":[],"createdAt":"2025-07-18 16:23:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7159445/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7159445/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88959216,"identity":"5bd49a0a-2271-419e-86fd-121b8b1e11ac","added_by":"auto","created_at":"2025-08-13 07:44:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160241,"visible":true,"origin":"","legend":"\u003cp\u003eRoot cause analysis\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7159445/v1/d943fda678940e8c51163405.png"},{"id":88959218,"identity":"fae4e62f-09f3-420e-b12d-5137add475d5","added_by":"auto","created_at":"2025-08-13 07:44:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":797836,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7159445/v1/1acabb91-96d6-4a64-bbe2-8f7deae875cf.pdf"},{"id":88957776,"identity":"3b075eb7-2e1e-421b-8858-94ca25fba6d9","added_by":"auto","created_at":"2025-08-13 07:28:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":28771,"visible":true,"origin":"","legend":"","description":"","filename":"PainAssessmentandManagementImprovementChecklistByumba.docx","url":"https://assets-eu.researchsquare.com/files/rs-7159445/v1/cde12e394bfc53e2622b889e.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Structured Nursing Interventions in Improving Pain Assessment and Management among hospitalized patients on the surgical ward at Byumba level two teaching hospital","fulltext":[{"header":"Background","content":"\u003cp\u003ePain is one of the most common and distressing symptoms experienced by hospitalized surgical patients. Effective pain management not only alleviates suffering but also contributes to improved recovery, early mobilization, shorter hospital stays, and increased patient satisfaction (Gan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Apfelbaum et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Despite global advances, up to 80% of patients still receive inadequate pain relief, particularly in low-resource settings (Brennan et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Rwanda, at Byumba Level Two Teaching Hospital (a district-level hospital providing secondary care services, as described in the methods section), an internal audit conducted in January 2025 revealed that only 78% of surgical ward patients received adequate pain management. This deficiency was associated with delayed recovery and increased patient dissatisfaction, as documented in the internal hospital audit (Byumba L2TH Internal Audit Report, 2025). These findings triggered this quality improvement (QI) project, aimed at addressing systemic and cultural barriers to effective pain management.\u003c/p\u003e\u003cp\u003eThe surgical ward demonstrated significant gaps in pain management, including irregular assessment practices, inconsistent documentation, and minimal patient involvement (Byumba L2TH Internal Audit Report, 2025). Cultural norms, such as kwihangana—the expectation to endure pain silently—further limited pain reporting (Nsereko et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Contributing factors also included a lack of standardized protocols, limited staff training, and insufficient tools such as pain scales and flow sheets (Hagenimana et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Uwimana et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These gaps posed significant risks to clinical outcomes and patient-centered care.\u003c/p\u003e\u003cp\u003eResearch consistently links inadequate pain management to adverse outcomes, including delayed wound healing, development of chronic pain, prolonged hospital stays, and decreased patient satisfaction (Medrzycka-Dabrowka, 2017). These consequences underscore the importance of effective pain control as a fundamental component of quality care, particularly in surgical and inpatient settings. In resource-limited settings, these challenges are compounded by limited access to essential analgesics, lack of standardized assessment tools, and insufficient provider training (De Lima et al., 2014; Uwimana et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Cultural norms promoting stoicism, such as the Rwandan value of kwihangana, discourage patients from reporting pain, complicating assessment and timely interventions. Prior interventions have shown promising results in closing these gaps. Structured pain management protocols, the use of validated tools such as the Numerical Rating Scale (NRS) and Visual Analog Scale (VAS), and staff education have all been associated with improved outcomes (Herr et al., 2011; Al-Quliti \u0026amp; Alamri, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Multimodal approaches combining pharmacologic treatments with cognitive-behavioral therapy, physical therapy, and guided imagery have also been effective in enhancing pain relief while minimizing side effects (Chou et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Gatchel et al., 2014). Quality pain management not only relieves suffering but also builds patient trust and reduces psychological distress (Tawil et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite these advancements, consistent implementation remains challenging in local contexts such as Byumba Level Two Teaching Hospital. Barriers, including limited staffing, poor documentation, lack of institutional guidelines, and myths surrounding opioid use, persist (Hagenimana et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Tata et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). These underscore the need for targeted, context-specific strategies that strengthen provider competencies and institutionalize pain management practices.\u003c/p\u003e\u003cp\u003eTo understand the root causes, quality improvement tools were employed. An Ishikawa (Fishbone) diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) revealed four major categories: People (inadequate training, understaffing), Processes (no standard protocols), Tools (lack of pain scales/flow sheets), and Environment (high patient loads, cultural stoicism). A “5 Whys” analysis identified a lack of reassessment due to tool and training gaps. A process map compared current versus ideal workflows, identifying missed opportunities for early pain control. Guided by the Model for Improvement, the Plan-Do-Study-Act (PDSA) cycles were implemented, focusing on staff training, standardized tools, and routine reassessment. These interventions aimed to improve consistency, documentation, and responsiveness in pain management.\u003c/p\u003e\u003cp\u003eThe primary aim of this QI project was to increase the proportion of surgical patients receiving adequate pain assessment and management at BLTH from a baseline of 78–95% by May 30, 2025. Secondary aims included increasing the percentage of patients achieving acceptable pain control (pain score ≤ 3) within 24 hours and improving staff adherence to documentation and reassessment protocols.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eThe aim, design, and setting of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis quality improvement (QI) project was implemented to address deficiencies in pain management practices among patients hospitalized in the surgical ward at Byumba Level Two Teaching Hospital (BLTH), a public healthcare facility located in Gicumbi District, Northern Rwanda. Established in 1947 and designated as a Level Two Teaching Hospital in 2022, BLTH is part of Rwanda’s decentralized health system aimed at integrating clinical training with service delivery. The project aimed to improve the assessment, documentation, and management of pain through a series of structured interventions. The QI initiative used a before-and-after study design and was guided by the Plan-Do-Study-Act (PDSA) cycle methodology to implement and refine changes over time. Baseline data were collected in January 2025, and interventions were rolled out from February to May 2025.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe characteristics of participants\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe QI project involved a multidisciplinary team composed of surgical ward nurses, nurse leaders, physicians, CPD facilitators, and quality assurance officers. All nurses and physicians working in the surgical ward during the implementation period participated in the intervention activities, including training sessions and documentation improvement efforts. Training materials included interactive PowerPoint presentations, role-play scenarios, quizzes, and printed guidelines on the use of validated pain assessment tools such as the Numeric Rating Scale (NRS) and the Wong-Baker FACES scale. Patients in the surgical ward were also engaged through educational materials, including leaflets and bedside visual aids printed in both Kinyarwanda and English. Pain assessment documentation tools, such as revised vital signs charts and dedicated pain flow sheets, were used to record pain scores and prompt reassessments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eA clear description of all processes, interventions, and comparisons\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFollowing an internal audit in January 2025 that identified gaps in pain assessment and documentation, the hospital formed a QI team to design and implement targeted interventions. These interventions focused on three main areas: staff capacity building, workflow and documentation improvement, and patient engagement. In February and March 2025, two rounds of pain management training were conducted for all ward staff. These sessions emphasized pain physiology, the use of validated tools, and WHO guidelines for pharmacological pain management. Nurses scoring below 70% on post-tests received individualized coaching. Revised documentation tools were introduced in March 2025, including an integrated NRS chart in the routine vital signs sheet and a new pain flow sheet. Visual aids and patient education materials were distributed, and nurses were instructed to use these tools during every patient interaction. Each month-long PDSA cycle allowed for iterative refinement of the interventions. For instance, additional visual cues were introduced in Cycle 2 after observations revealed inconsistent numeric pain scoring. The interventions were evaluated through multiple methods, including repeated reviews of patient charts, structured interviews conducted using a guide developed by the researchers (refer to Supplementary File 1) and informed by relevant literature (Gan et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Hagenimana et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and staff knowledge assessments. Monthly review meetings were held to discuss findings and inform ongoing improvement actions. Outcome, process, and balancing measures were analyzed using descriptive statistics and visualized with run charts to monitor trends and changes over time.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA quality improvement project conducted over three months at Byumba Level Two Teaching Hospital\u0026rsquo;s surgical ward yielded substantial improvements in pain assessment and management practices. At the project\u0026rsquo;s outset in February 2025, only 78% of patients received appropriate pain assessment and control within 24 hours of admission. This initial baseline highlighted gaps, including inconsistent pain assessment on admission, low rates of reassessment after analgesia, and inadequate documentation.\u003c/p\u003e\u003cp\u003eFollowing the introduction of interventions, primarily staff training, the implementation of standardized pain assessment tools, such as the Numerical Rating Scale (NRS), and enhanced patient education, marked progress was observed. Pain assessment upon admission improved from 62\u0026ndash;94% (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), while reassessment within one-hour post-analgesia increased from 62\u0026ndash;90% (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Documentation of pain reassessments within 24 hours per patient rose sharply from 45\u0026ndash;95% (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Improvements in patient outcomes were also evident. The proportion of patients achieving adequate pain control, defined as an NRS score of 3 or below within 24 hours, increased from 68% at baseline to an impressive 96% by the end of May 2025. Patient satisfaction with pain management, as measured by surveys using a 1 to 5 Likert scale, increased from an average rating of 4.1 to 4.88 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), indicating an enhanced patient experience and engagement.\u003c/p\u003e\u003cp\u003eThe knowledge and competency of nursing staff improved significantly through targeted educational sessions. Pre- and post-training assessments demonstrated an increase in nurse knowledge scores from 45\u0026ndash;88%, underscoring the effectiveness of the training interventions. The project\u0026rsquo;s run chart demonstrated a steady upward trend in key process and outcome indicators, with several median shifts confirming that these improvements reflected an actual system change rather than random fluctuations. Qualitative feedback through discussions with nurses and medical doctors complemented the quantitative data, with nurses reporting that the visible pain scales at patient bedsides prompted more consistent pain inquiries and reassessments. Patients expressed appreciation for the active involvement in reporting their pain, which contributed to greater satisfaction and a sense of being cared for attentively. Additionally, an unintended positive effect was enhanced communication among healthcare team members regarding pain management decisions.\u003c/p\u003e\u003cp\u003eData completeness was adequate throughout the project, with less than 5% of charts missing key information. Moreover, documentation completeness improved over time, reflecting better adherence to the revised pain management protocols.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKey Process Indicators \u0026ndash; Pre- and Post-Intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMeasures\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eDates\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeb-25\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMar-25\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eApr-25\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMay-25\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain assessment documented at admission (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e94%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePain reassessment within 1 hour of analgesia (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNurse knowledge (pre-test score) (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNurse knowledge (post-training score) (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOutcome Measures of QI Project Implemented\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonth\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePain Control within 24 hrs. (NRS\u0026thinsp;\u0026le;\u0026thinsp;3)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePatient Satisfaction (Mean Score on 1\u0026ndash;5 Scale)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFeb-25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMar-25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eApr-25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMay-25\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis project demonstrated that a targeted Quality Improvement (QI) initiative can significantly enhance pain management practices in the surgical ward of a rural Rwandan Level Two Teaching Hospital. Several factors contributed to the project\u0026rsquo;s success. Early engagement of ward leadership facilitated access to essential resources, such as printed assessment tools, and fostered a strong sense of staff ownership. Regular monthly feedback meetings helped maintain momentum and motivation among the team. Importantly, cultural barriers, including common beliefs equating pain reporting with weakness, were explicitly addressed during training sessions, a challenge similarly reported by Uwimana et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The deployment of low-cost, high-impact tools, such as printed pain scales and modified flow sheets, proved both practical and sustainable in this setting.\u003c/p\u003e\u003cp\u003eThe proportion of patients receiving adequate pain management increased from 78\u0026ndash;97.6%, surpassing the initial target of 95%. This outcome mirrors the success seen in similar studies such as Hagenimana et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), where protocol standardization and staff education were effective. Our approach, combining structured nurse training, patient education, and standardized assessment tools, closely aligns with those findings.\u003c/p\u003e\u003cp\u003eOur interventions directly targeted key barriers identified in the literature. Knowledge gaps were addressed through targeted training and evaluation, as highlighted by Al-Mahrezi (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and Al-Quliti (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Additionally, uncertainty in prescribing analgesics was reduced by introducing clear, standardized guidelines, an approach supported by Tawil et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), who emphasized that opioid-related fears frequently hinder effective pain control.\u003c/p\u003e\u003cp\u003ePatient satisfaction improved notably during the implementation period, coinciding with enhanced pain control and more consistent documentation, outcomes that, while not statistically tested due to the QI project\u0026rsquo;s observational (Gordon et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Gordon et al., 2016; Al-Quliti \u0026amp; Alamri, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Tawil et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This demonstrates that patient engagement, including education on pain scoring and timely reporting, along with competent nursing practice, fosters trust, adherence, and psychological well-being.\u003c/p\u003e\u003cp\u003eAlthough 96% of patients had acceptable pain scores within 24 hours (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), approximately 10% were still discharged with inadequate pain control. Many of these patients had chronic or complex pain conditions not responsive to standard protocols. This suggests a need for escalation strategies, such as early referrals to anesthetists or palliative care teams. These patients require individualized plans beyond routine ward-based pain control.\u003c/p\u003e\u003cp\u003eContinuous monitoring and feedback through Plan-Do-Study-Act (PDSA) cycles facilitated adaptive learning and iterative improvements. For example, after the initial implementation, we observed a tendency among some nurses to document pain narratives rather than numeric scores. In response, Cycle 2 introduced visual reminder labels on patient charts to encourage the use of numeric documentation, reflecting core principles of quality improvement (QI).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Recommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile this QI project achieved significant improvements, several limitations should be acknowledged. The project was limited to a single ward in one hospital, which restricts generalizability. Some staff were initially resistant to new documentation protocols, and patient understanding of pain scores was inconsistent despite educational efforts. Data collection relied heavily on chart reviews and verbal surveys, which may have introduced bias. Lastly, due to the QI nature of the study, we did not apply inferential statistical analysis, so causal inferences should be interpreted cautiously. Moving forward, we recommend sustaining the gains by incorporating pain assessment and management into routine audits and expanding promising change ideas to other wards. These steps will help ensure pain management remains a priority, enabling patients to receive timely, compassionate care while improving overall quality and safety throughout the hospital.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis QI project employed evidence-based strategies to overcome key barriers, namely, irregular pain assessment, limited tools, poor documentation, staff training gaps, and cultural beliefs around stoicism. By addressing these through structured education, protocol development, and patient engagement, we achieved substantial improvements in pain control.\u003c/p\u003e\u003cp\u003eOur multi-faceted approach, low-cost, sustainable, and contextually adapted, demonstrates that meaningful change is possible even in under-resourced rural settings. The project serves as a model for similar hospitals aiming to enhance the quality of care through simple, scalable interventions. Sustaining the gains will require ongoing leadership support, continuous training, and institutionalizing pain management as a core quality indicator.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAbbreviation\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFull Term\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuality Improvement\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBLTH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eByumba Level Two Teaching Hospital\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePDSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePlan-Do-Study-Act\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNRS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNumeric Rating Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVisual Analog Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eContinuing Professional Development\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegistered Nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCGNC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCertified Global Nurse Consultant\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMSN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMaster of Science in Nursing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePhD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDoctor of Philosophy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMOH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMinistry of Health (Rwanda)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHMIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealth Management Information System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. This study was approved by the University of Global Health Equity and conducted in accordance with relevant guidelines and regulations. Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided informed consent for the publication of data and findings derived from this study. Any identifying information has been anonymized to protect participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHL (Hakizimana Leonard) conceptualized the study, led the design and implementation of the quality improvement project, and contributed significantly to manuscript writing.\u003cbr\u003e\u0026nbsp;NL (Nanyombi Lubimbi) provided critical mentorship and guidance on quality improvement methodologies and reviewed the manuscript for academic precision.\u003cbr\u003e\u0026nbsp;HE (Helen Ewing) contributed to refining the project framework and critically revised the manuscript for clarity, relevance, and completeness.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the surgical ward team at Byumba Level Two Teaching Hospital for their commitment to implementing improved pain assessment and management practices. Gratitude is also extended to the hospital\u0026rsquo;s leadership and Quality Assurance Unit for their institutional support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Information\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eHL (HAKIZIMNA Leonard),\u0026nbsp;\u003c/strong\u003ea General Nurse Practitioner and Quality Improvement Officer at Byumba Level Two Teaching Hospital with over 10 years of experience in clinical nursing and quality assurance. He possesses a Master\u0026rsquo;s in Public Health with a specialization in Global Health.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003e\u003cstrong\u003eNL (Nanyombi Lubimbi)\u003c/strong\u003e is a Post-Doctoral Fellow in Nursing Research and Global Health at the University of Washington, Seattle. She is a global health nurse leader with 20 years of clinical and teaching experience in the U.S. and abroad. She holds a certificate in Public Health Management from the University of Illinois, Chicago, and is certified as a Global Nurse Consultant (CGNC) by the International Council of Nursing.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003e\u003cstrong\u003eHE (Helen Ewing)\u003c/strong\u003e is a Senior Faculty member in Nursing and Midwifery with a strong background in international nursing education and curriculum development focused on quality and safety in clinical settings.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAl-Mahrezi A. Towards effective pain management: Breaking the barriers. Oman Med J. 2017;32(5):357\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAl-Quliti KW, Alamri MS. Knowledge, attitudes, and practices of health care providers towards pain management in Eastern Province, Saudi Arabia. Saudi J Anaesth. 2015;9(4):437\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eApfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrennan F, Carr DB, Cousins M. Pain management: A fundamental human right. Anesth Analg. 2007;105(1):205\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eByumba Level Two Teaching Hospital. Internal Audit Report. 2025. Unpublished internal quality audit report.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen JS, Kandle PF, Murray IV, et al. Physiology, pain. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGan TJ, Habib AS, Miller TE, White W, Apfelbaum JL. Incidence, patient satisfaction, and perceptions of post-surgical pain: Results from a US national survey. Curr Med Res Opin. 2014;30(1):149\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull. 2007;133(4):581\u0026ndash;624.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGordon DB, Dahl JL, Miaskowski C, McCarberg B, Todd KH, Paice JA, et al. American Pain Society recommendations for improving the quality of acute and cancer pain management. Arch Intern Med. 2005;165(14):1574\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHagenimana JP, Banguti PR, Anderson RLC, Tuyishime JDD, Nyirigira G, Tuyishime E. Improving pain management for trauma patients at two Rwandan emergency departments. Afr J Emerg Med. 2024;14(4):258\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMedrzycka-Dabrowka W, Dąbrowski S, Gutysz-Wojnicka A, Gawroska-Krzemińska A, Ozga D. Barriers perceived by nurses in the optimal treatment of postoperative pain. Open Med (Wars). 2017;12(1):239\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNsereko E, Munyandamutsa N, Umubyeyi A. Cultural attitudes toward mental health and pain reporting in Rwanda: Implications for health service delivery. Rwandan J Health Sci. 2022;11(1):34\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRepublic of Rwanda. Prime Minister\u0026rsquo;s Instructions 001/03 of 10/08/2022 determining the organizational structure of Ndera Neuropsychiatric Teaching Hospital and Level Two Teaching Hospitals. Off Gaz Rwanda. 2022 Aug 10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTata TK, Ohene LA, Dzansi GA, et al. Factors influencing nurses\u0026rsquo; pain assessment and management of road traffic casualties: A qualitative study at a military hospital in Ghana. BMC Emerg Med. 2024;24:100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTawil S, Iskandar K, Salameh P. Pain management in hospitals: patients' satisfaction and related barriers. Pharm Pract (Granada). 2018;16(3):1268.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUwimana P, Mukamana D, Babenko-Mould Y, Adejumo O. A framework for capacity enhancement of Rwandan nurse educators and preceptors facilitating nursing students to learn pediatric pain management. BMC Nurs. 2024;23(1):127.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pain assessment, pain management, PDSA, quality improvement, nursing interventions, Byumba Level Two Teaching Hospital.","lastPublishedDoi":"10.21203/rs.3.rs-7159445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7159445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEffective pain assessment and management are essential components of postoperative care, significantly influencing recovery, patient satisfaction, and clinical outcomes. An internal audit conducted in January 2025 at Byumba Level Two Teaching Hospital revealed that only 78% of surgical ward patients received adequate pain management. In response, a Quality Improvement (QI) project was launched with the goal of increasing this rate to at least 95% by May 30, 2025.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis 4-month QI initiative (February 2025\u0026ndash;May 2025) utilized the Plan-Do-Study-Act (PDSA) cycle to implement targeted interventions. Key strategies included structured training for nurses on validated pain scales, standardized assessment tools during admission and ward rounds, and the introduction of a pain management flow sheet. Primary outcomes were the proportion of patients receiving adequate pain control (pain score\u0026thinsp;\u0026le;\u0026thinsp;3 within 24 hours) and documented pain assessments. Secondary outcomes included patient satisfaction and staff knowledge, while process measures monitored protocol adherence, reassessment rates, and staff competence via training and pre-/post-tests. Interventions addressed key barriers, including limited leadership support, absence of staff feedback mechanisms, and cultural norms such as silent pain endurance.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBy May 30, 2025, patients receiving adequate pain management increased from 78\u0026ndash;95%. Documented pain assessments rose from 62\u0026ndash;94%, and those achieving effective pain control improved from 68\u0026ndash;96%. Patient satisfaction scores increased from 4.1 to 4.88 (on a 5-point Likert scale). Run chart analysis showed sustained improvement aligned with each intervention phase.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eStructured, evidence-based Quality Improvement interventions can significantly enhance pain management among hospitalized patients, even in rural, resource-limited settings. These results demonstrate that structured, evidence-based interventions can pain management, even in resource-constrained settings.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Structured Nursing Interventions in Improving Pain Assessment and Management among hospitalized patients on the surgical ward at Byumba level two teaching hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 07:28:27","doi":"10.21203/rs.3.rs-7159445/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-18T09:46:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T20:16:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19605173019869430125074359132358162930","date":"2025-10-19T07:55:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334756555791444854070942915032377108816","date":"2025-09-16T09:20:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-05T12:46:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110113663079753506581884688579576572932","date":"2025-08-14T14:25:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"41167704502704746651189633240795132887","date":"2025-08-14T13:52:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256515680440975992452185883176394375086","date":"2025-08-08T14:32:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T06:43:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-08T06:38:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-06T05:52:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-05T17:20:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-08-05T15:22:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87949ffd-da90-4550-9687-07830b421176","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2025-11-18T09:54:09+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 07:28:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7159445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7159445","identity":"rs-7159445","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}