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Non-communicative Patient’s Pain Assessment Instrument (NOPPAIN)
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Practical Information
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Instrument Name:
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Non-communicative Patient’s Pain Assessment Instrument (NOPPAIN)
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Instrument Description:
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NOPPAIN was designed for use by Nursing Assistants (NA) in assessing the pain of nursing home residents with dementia. The presence and intensity of 6 pain behaviors (i.e., pain words, pain faces, pain noises, bracing, rubbing, restlessness) are assessed. The highest intensity of observed pain is recorded along with the presence or absence of pain behaviors during 9 daily care activities (e.g., bathing transfers, dressing). NAs complete the NOPPAIN only after having spent 5 minutes or more with the resident performing care activities. A NOPPAIN score above a cut off score (or the resident’s self-report of pain) prompts referral to a nurse for a comprehensive exam. Simple wording and a generous use of icons minimize the English reading level required of raters. (Ref: 1)
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Price:
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Free; permission required prior to distribution/use. (Personal communication w/A.L. Snow)
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Administration Time:
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30 secs or less. NAs spent ~8 minutes caring for patients before completion. (Ref: 1)
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Publication Year:
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2003
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Item Readability:
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The items are written at a 7th grade level, but the liberal use of icons makes it likely that persons with lower reading levels would be able to comprehend scale items without difficulty.
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Scale Format:
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The NOPPAIN includes dichotomous, 6-point Likert, and pain thermometer scales. (Ref: 1-2)
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Administration Technique:
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Nursing Assistant-administered. The NOPPAIN form is completed after observing patient routine care tasks (i.e. bathing, cleaning and changing a patient) for five minutes. (Ref: 1)
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Scoring and Interpretation:
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Presence or absence of pain behaviors is indicated by scores of “0” or “1” for 9 daily care activities and 6 pain behaviors. Intensity of the 6 pain behaviors is rated on a 6-point Likert response scale from “0-lowest possible intensity” to “5-highest possible intensity.” Highest level of pain intensity during the referent visit is rated via a pain thermometer with scores ranging from “0-no pain” to “10-worst possible pain.” (Ref: 1-2)
Responses to dichotomous, Likert-scale, and pain thermometer items are summed for the total NOPPAIN score. Developers recommend a NOPPAIN score of 3 or more as indicating need for a comprehensive exam by a registered nurse. (Ref: 1-2)
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Forms:
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No information found.
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Research Contacts
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Instrument Developers:
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A. Lynn Snow, Jan B. Weber, Kimberly J. O’Malley, Marisue Cody, Cornelia Beck, Eduardo Bruera, Carol Ashton, Mark E. Kunik
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Instrument Development Location:
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Houston Center for Quality of Care & Utilization Studies, Houston Veterans Affairs Medical Center, Houston, Texas
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Instrument Developer Email:
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asnow@bcm.tmc.edu
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Instrument Developer Website:
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Annotated Bibliography
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1. Snow AL, Weber JB, O’Malley KJ, Cody M, Beck C, Bruera E, Ashton C, Kunik ME. NOPPAIN: a nursing assistant-administered pain assessment instrument for use in dementia. Dement Geriatr Cogn Disord. 2004;17(3):240-6.
[PMID:14745230]
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Purpose:
To validate the Non-communicative Patients Pain Assessment Instrument (NOPPAIN) which is used to assess pain behaviors in nursing home patients with dementia.
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Sample:
Twenty-one nursing assistants (NAs) participated in the study. They were 86% female and had a mean age of 37 years. The ethnic distribution was 5% Caucasian, 76% African-American, 10% Hispanic, and 7% Asian. Fifteen (71%) had a high school diploma or GED. The participants had worked as NAs for an average of 9.8 years. Twenty-nine percent reported working "occasionally" with dementia patients, 19% "often" and 38% "all the time."
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Methods:
Six videotapes were made to portray each of the levels of pain represented in the NOPPAIN measure (no pain, mild pain, moderate pain, quite bad pain, very bad pain, and unbearable pain). The videos included a certified NA and a professional actress. The actress was trained by a geropsychologist and palliative care physician to accurately represent the continuum of pain as it would be expressed by patients with dementia. NA participants completed the NOPPAIN after watching each video. In addition, they compared all possible pairs of videos and indicated which of the two showed the patient in the most pain.
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Implications:
Participants’ ratings were highly concordant with the pain levels portrayed in the video (as assessed by a geropsychologist and palliative care physician). When there was non-concordance, the ratings of the NAs were most often off from the correct rating by only one level on the 6-point Likert scale. The results support the validity of the NOPPAIN as well as the feasibility of its used in nursing homes. Further, the findings indicate that, equipped with the NOPPAIN, NAs can accurately and effectively screen nursing home residents for pain.
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2. Snow AL, Kunik ME, Cody M, Ashton C, O’Malley KJ, Bruera E, El-Issa L, Beck C. NOPPAIN: Reliability and Criterion Validity. In Submission—please contact AL Snow for information. [No PMID]
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Purpose:
To investigate NOPPAIN reliability and criterion validity among nursing home residents with dementia.
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Sample:
There were two samples in this study—a sample of 83 nursing home residents with moderate to severe dementia and 20 Nursing Assistants (NAs). The mean age of the residents was 83.17 years, 70% were female, 68% were Caucasian, 12% African American, 11% Hispanic, and 9% other (mostly Asian). Pain diagnoses were: 41% arthritis, "pain," 28% osteoporosis, and 28% fractures. The NA participants were "fill-ins" from a temporary employment agency and had no prior knowledge of the facility. They were 86% were female, 81% African American, 4% Caucasian, 7% Hispanic, and 7% Asian. Their mean age was 37 years.
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Methods:
The study had 3 phases with 3 unique NA participant groups.
A. In the first phase, 8 NAs were videotaped giving routine care of the nursing home resident participants (lasting 5-15 minutes). After completing care, NAs completed the NOPPAIN. Two physicians reviewed the videotapes and residents’ charts, independently completed the NOPPAIN for each resident, and met and achieved consensus regarding classifications. For a test/retest assessment, 42 of the evaluations of residents were repeated 2 hours later.
B. In the second phase of the study, a random sample of 26 of the videoed pain evaluations was shown to 5 NAs who had not participated in the initial pain evaluations. They completed the NOPPAIN after watching each of the videos (presented in random order).
C. In the third phase of the study, an additional 6 NAs were trained for one hour in the use of the NOPPAIN. These trained raters completed the NOPAIN after viewing each of the random sample of 26 videos (described above).
To evaluate criterion validity, the NOPPAIN scores from the untrained NAs (A, above) were compared to those agreed upon by the physician raters. Inter-rater reliability was assessed for all pairs of ratings from the second phase of the study (B, above). Test/retest reliability was estimated for individual items, for the global pain intensity item. Comparisons were made between the reliability and validity of ratings by trained and by untrained NAs. The sensitivity and specificity of cutpoints were assessed.
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Implications:
Findings support the criterion validity of the NOPPAIN when used with trained or non-trained NAs. Adding an hour of training produced NOPPAIN ratings with substantially higher inter-rater and test-retest reliability.
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Factors and Norms
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Factor Analysis Work:
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No information found.
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Normative Information Availability:
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No information found.
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Reliability Evidence
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Test-retest:
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Test-retest reliability was evaluated 2 hours after initial NOPPAIN assessment. Results follow: (Ref: 2)
| Item
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(Untrained Rater)
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| Pain Behavior Present? (phi)
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0.22 - 0.68
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| Pain Behavior Intensity (Spearman)
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0.25 - 0.68
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| Pain Activity Sub-Total (Spearman)
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0.53
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| Pain Behavior Sub-Total (Spearman)
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0.57
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| Pain Behavior Intensity Sub-Total (Pearson)
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0.60
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| Pain Intensity Scale (Spearman)
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0.65
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| Total NOPPAIN (Pearson)
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0.64
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Inter-rater:
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The inter-rater reliability weighted Kappa was 0.87 (SE: 0.20; 95% CI: 0.82-0.91). (Ref: 1) In another study, NAs watched videos of other NAs performing care tasks of residents with dementia. Inter-rater reliability was assessed for trained and untrained NAs: (Ref: 2)
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Untrained Raters
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Trained Raters
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| Was Activity Done?
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0.79 - 0.94
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0.78 - 0.94
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| Pain During Activity?
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0.66 - 0.87
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0.66 - 0.92
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| Pain Behavior Present?
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0.59 - 0.87
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0.69 - 0.99
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| Pain Behavior Intensity
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0.68 - 0.92
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0.77 - 0.99
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| Pain Activity Sub-total
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0.72
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0.83
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| Pain Behavior Sub-total
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0.58
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0.87
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| Pain Behavior Intensity Sub-total (Intraclass)
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0.64
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0.82
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| Pain Intensity Scale
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0.62
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0.80
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| Total NOPPAIN (Intraclass)
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0.68
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0.85
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Internal Consistency:
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No information found.
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Alternate Forms:
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No information found.
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Validity Evidence
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Construct/ Convergent/ Discriminant:
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The construct validity of the NOPPAIN is supported by the accuracy with which a sample of NAs were able to classify the 6 levels of pain intensity categorized by the NOPPAIN, with the exception of the “mild pain” and “moderate pain distinction.” 65% of raters confused the “mild pain” and “moderate pain” conditions portrayed in the videos. In all other comparisons, they were 82-100% correct. (Ref: 1)
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Criterion-related/ Concurrent/ Predictive:
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The Intraclass correlation between untrained NAs and physician NOPPAIN ratings was 0.70. ROC analysis was used to assess the ability of the NOPPAIN to distinguish between residents with and without pain as classified by physicians. The estimated Area Under the Curve (AUC) was 0.83, p<0.001. Sensitivity and specificity at various cut-scores were as follows: (Ref: 2)
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Sensitivity
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Specificity
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| >1
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0.93
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0.56
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| >2
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0.87
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0.63
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| >3
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0.73
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0.72
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Content:
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The content validity of the NOPPAIN is supported by the method of development. Experts in pain (researchers and non-research clinicians) were consulted during instrument development and evaluation. (Ref: 1)
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Responsiveness Evidence:
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No information found.
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Scale Application in VA Populations:
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No information found.
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Scale Application in non-VA Populations:
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Yes. (Ref: 1)
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Comments
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The NOPPAIN is a brief, observational tool developed for use by Nursing Assistants to rate pain in nursing home residents with dementia.
Overall Usefulness for a Certain Population: The NOPPAIN has been evaluated in its intended population—nursing home residents with moderate to severe dementia. Nursing home resident participants were 70% female and included Caucasians, African Americans, Hispanics, and Asians. Pain diagnoses included arthritis, osteoporosis, fractures, and general “pain.” The NOPPAIN was developed so that it use would be practical in a nursing home environment. The instrument is brief, relies heavily on graphics to communicate item content, and can be effectively administered by NAs with minimal or no training in its use. These characteristics substantially increase the likelihood that the NOPPAIN can and will be used in the nursing home setting.
Advantages: The NOPPAIN is extremely brief, requiring only 5 minutes observation time and less than 30 seconds to score.
Disadvantages: The Activity Chart Checklist score has a potential range of 0 to 9. However, the score can only increase if the particular care behavior (9 total) takes place. The possible score range varies, therefore, depending upon how many care activities the NA engages in during the referent visit. If the resident is not fed during the visit and is too ill or weak to get out of bed, the score for the activity checklist could be no higher than 5. This is problematic, since residents in the most pain could experience fewer of the checklist activities than residents without pain. However, alternative approaches might make scoring the NOPPAIN more complicated and rob it of one its most attractive characteristics—ease of use.
Recommendation: The assessment of pain among nursing home residents with dementia is, arguably, among the most clinically relevant and methodologically challenging endeavors in all of health services research. The developers have vigorously attended to the “real world” requirements of assessing residents in nursing homes. The instrument is relatively new, but early findings indicate the NOPPAIN is psychometrically solid. Future work should compare candidate scoring algorithms, but alternative methods should be considered with respect to how much complexity they add.
Presence (“0”)/absence (“1”) of pain is rated for 9 activities and 6 behaviors. Intensity is rated on a 6-point Likert scale from "0-lowest" to "5-highest." Highest level of intensity is rated via a thermometer with scores from “0-none” to “10-worst.” (Ref: 1-2)
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