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The Pain Assessment Tool (PAT) was developed as a means of objectively assessing pain by focusing exclusively on observable features and physiological signs, rather than relying purely on subjective self-reports. Several other ready-made assessments of pain available on the internet. All reviewed have failed to consider a full range of common signs of pain. The PAT is a ‘wheel’ worth reinventing!

The PAT serves as a structured observational guide for clinicians, facilitating detailed assessments. It is important to understand that this tool is not for diagnosing pain or making definitive statements about an individual’s pain state. While the PAT has not undergone scientific validation, it is specifically developed for its practical observational purpose, where formal validation is not required. See also: Pain in Psychiatric Disorders.

How the PAT facilitates an objective assessment:

1. Focus on observable behaviours: Unlike traditional pain scales that often ask individuals to rate their pain intensity (which is inherently subjective), the PAT shifts the focus to what can be seen, heard, or measured. Each sub-feature, such as “Facial Expression,” “Gait,” “Heart Rate,” or “Vocalised Discomfort,” describes a specific, external manifestation that an observer can identify without needing the individual’s verbal input on their internal experience.
2. Structured sub-features with behavioural anchors: The tool breaks down the complex experience of pain into distinct, manageable sub-features across various domains (Cognitive, Behavioural, Physical Function, Autonomic Signs, Speech & Voice, and Consistency Check). For each sub-feature, an ‘Observation Guide’ (1-5)” is provided. These anchors offer clear, descriptive examples for each point on the 1-5 scale, guiding the observer to score based on specific, predefined criteria. For instance, “Gait” ranges from “Normal gait” (1) to “Visible limp or shuffling” (5), providing concrete observable benchmarks.
3. Minimising subjective interpretation: By providing these anchors, the PAT aims to minimise the observer’s subjective interpretation. The goal is not to guess how much pain someone feels, but to consistently document the degree to which specific pain-related behaviours are present. The “Notes” section further supports objectivity by encouraging factual, descriptive observations rather than interpretive statements e.g. “patient was limping so much that she had to stop walking after 3 to 5 steps.” or “Patient was in so much back pain that she was unable to get out of a chair without assistance.” [The latter sort of statements are quite factual and not dependent on subjective interpretation.]
4. Comprehensive multi-domain assessment: Pain is a multifaceted experience. The PAT’s organisation into distinct domains ensures a holistic, yet objective, assessment. It recognises that pain can manifest not just physically, but also in cognitive function, emotional expression, general behaviour, and even autonomic responses. By observing these various domains, the tool provides a more complete and objective picture of the individual’s pain presentation.
5. Consistency and tracking over time: The standardised nature of the observable sub-features and their scoring allows for greater consistency across different observers and over time. This means the PAT can be used as a reliable instrument to:
   • Track changes in an individual’s pain presentation in response to interventions.
   • Provide a common language for healthcare professionals to discuss and understand a patient’s pain, based on shared objective data.
   • Identify patterns or triggers in pain behaviours.

In essence, the PAT serves as a structured observational aid, transforming the often-elusive concept of pain into a set of quantifiable, observable data points. This objective approach is invaluable for clinical assessment, research, and for monitoring the effectiveness of pain management strategies. The emphasis on objective assessment does NOT mean that subjective experience or assessment is less important or useless.

The PAT cannot prevent observer biases.

The PAT was not designed to be viewed or used on mobile phones.

Pain Assessment Observation Protocol

To ensure the highest level of consistency and reliability when using the Pain Assessment Tool (PAT), please adhere to the following observation protocol:

1. Timing of observation:
   • Whenever possible, observations should be conducted at approximately the same time of day for each assessment. This minimises variability due to circadian rhythms, medication schedules, or typical daily fluctuations in pain levels.
2. Context of activity:
   • Observations should ideally occur when the individual is engaged in the same type of activity or in a consistent context. For instance, if assessing pain during mobility, ensure the individual is performing a similar movement (e.g., walking a set distance, transferring from bed to chair) each time. Avoid comparing observations made during rest with those made during strenuous activity.
3. Duration of observation:
   • Each observation period should last for an agreed minimum number of minutes, ideally no less than 5 minutes. This duration allows for sufficient time to observe a range of behaviours and signs, ensuring a representative snapshot of the individual’s presentation. For more complex or fluctuating presentations, a longer duration may be beneficial.
4. Observer positioning and focus:
   • Position yourself to have a clear, unobstructed view of the individual’s overall presentation.
   • Actively focus on each sub-feature listed in the PAT, consciously looking for the specific behaviours and signs described in the column headed “Observation Guide.” Avoid making assumptions based on prior assessments; observe what is present now.
5. Environmental consistency:
   • Note any significant changes in the immediate environment (e.g., noise levels, temperature, presence of visitors) that might influence the individual’s behaviour. While not always controllable, being aware of these factors can aid interpretation.
6. Pre-Observation check:
   • Before beginning the timed observation, briefly ensure the individual is in a stable state (e.g., not actively engaged in a medical procedure unless that is the specific observation context).
7. Post-Observation scoring and notes:
   • Score each sub-feature immediately after the observation period concludes to ensure accuracy.
   • Utilise the “Notes” section to record specific, factual observations that support your score. Avoid subjective interpretations or diagnostic statements. For example, instead of “Patient seemed agitated,” write “Patient repeatedly shifted in chair, sighed frequently, and clenched fists.”

By consistently following this protocol, clinicians can enhance the objectivity and reliability of their PAT scores, leading to more meaningful data for assessment and intervention planning.

Suggested reliability enhancement

1. Standardised training: Users must read and apply all guidance e.g. Pain Assessment Observation Protocol above.
2. Calibration exercises: Periodically conduct “calibration” sessions where staff observe the same scenarios (e.g., video recordings of patients exhibiting pain behaviours, or mock scenarios) and independently score them. Afterwards, compare scores and discuss any discrepancies to align interpretations.
3. Regular review and discussion: Implement regular, brief meetings where staff can discuss challenging cases, clarify ambiguities in observations, and share insights. This fosters a collective understanding and reinforces consistent application of the tool.
4. Emphasis on the Terminology Glossary: Actively encourage and require staff to refer to the “Pain Assessment Terminology” document. This ensures that everyone is working from the same precise definitions for each sub-feature.
5. Structured observation protocol: Provide a simple checklist or brief protocol for the observation process itself. For example: “Observe the individual for X minutes,” “Note environmental factors,” “Consider baseline behaviours.” This standardises the observation context before scoring.
6. Feedback loops: If feasible, individual feedback to staff members on their scoring patterns can be given by a supervisor. This could involve comparing their scores to an aggregated group average or to a “gold standard” if one is established for training purposes.

These methods, when combined with collaborative scoring, can significantly enhance the consistency and reliability of the PAT’s application across different observers.

Terminology glossary (Click for popup)

No patient identifiable data must be electronically entered on this form.

WARNING: The PAT does not tell an assessor ‘this person is in pain’. Stoicism can confound objective assessment. Assessors will need to demonstrate common sense. If there is stoicism, then it is for an assessor to to document carefully how they arrived at that factor and how it coloured interpretation of the assessment.

Only a printed version can be used to enter staff and patient details

To avoid data entry on this form entirely, copy and paste it into MS Word in Landscape Layout then alter distribution of table columns.

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