Assessment of pain in the hospital has often relied on intensity rating alone. To address the gap in meeting patients' pain management expectations, a Midwestern medical center implemented the CAPA (Clinical Aligned Pain Assessment) tool for more comprehensive nursing pain assessments.

This research described nurses' experience using CAPA on an adult general medicine unit and their documentation of the tool in the electronic health record (EHR) more than 5 years after CAPA implementation.

Mixed methods exploratory sequential design.

A convenience sample of nurses (N = 8) participated in 2 focus groups to describe how they used CAPA, how well it assessed pain, how it determined pain interventions, and the challenges and advantages of using CAPA. Patient EHR data (N = 373) for a 6-month period from the same unit were analyzed to evaluate CAPA documentation.

Qualitative themes included: benefits of using CAPA, CAPA leads to a more comprehensive picture, variation in how CAPA is used, and challenges. Quantitative findings demonstrated most frequent documentation in the comfort domain and earlier, though still delayed, reassessment when a higher level of pain was noted. Mixed methods analysis revealed variation in knowledge and practice regarding which domains to document each shift and during reassessment.

As patient advocates, nurses are integral to thorough assessment and treatment of pain. Findings identified the need for methodological research of CAPA. As with any assessment tool, when using CAPA, ongoing monitoring is needed to address how it is administered, coded, and used for decision-making about pain management.