The anatomy of safe surgical teams: an interview-based qualitative study among members of surgical teams at tertiary referral hospitals in Norway.

BACKGROUND: In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department. METHODS: This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes. RESULTS: The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning. CONCLUSIONS: This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.

Closed-Loop Communication in Interprofessional Emergency Teams: A Cross-Sectional Observation Study on the Use of Closed-Loop Communication Among Anesthesia Personnel.

OBJECTIVES: Communication failure is one of the most common causes of adverse events in hospitals and poses a direct threat to patient safety. Research recommends the use of closed-loop communication in interprofessional emergency teams to prevent such events. Multiple studies have examined closed-loop communication during simulation training, but few have investigated its use in clinical practice. The aim of the study was to explore the use of closed-loop communication by anesthesia personnel in real-life interprofessional emergency teams. METHODS: This study had a descriptive, cross-sectional design where structured field observations were used to assess anesthesia personnel's use of closed-loop communication in real-life interprofessional emergency teams. A total of 60 interprofessional teams were observed, including 120 anesthesia personnel at a hospital in South-Eastern Norway. Data were analyzed using descriptive statistics. RESULTS: A total of 1626 call outs were registered, in which closed-loop communication was applied in 45%. Closed-loop communication was used more frequently when call outs were directed using eye contact and when the call outs were medication orders. There was no difference in the use of closed-loop communication between nurse anesthetists and anesthesiologists. Closed-loop communication was used more frequently in cardiac arrest teams than in trauma teams. CONCLUSIONS: The findings in this study have contributed knowledge about anesthesia personnel's use of closed-loop communication in real-life interprofessional emergency teams and indicate a potential for improvement. Further research is needed about real-life interprofessional emergency teams' communication patterns and potential barriers from using closed-loop communication, with the aim to improve patient safety.

Anaesthesia personnels' perspectives on digital anaesthesia information management systems - a qualitative study.

BACKGROUND: In Norway, the anaesthesia team normally consists of a nurse anaesthetist and an anaesthetist. Digital anesthesia information management systems (AIMS) that collect patient information directly from the anaesthesia workstation, and transmit the data into documentation systems have recently been implemented in Norway. Earlier studies have indicated that implementation of digital AIMS impacts the clinical workflow patterns and distracts the anaesthesia providers. These studies have mainly had a quantitative design and focused on functionality, installation designs, benefits and challenges associated with implementing and using AIMS. Hence, the aim of this study was to qualitatively explore anaesthesia personnel's perspectives on implementing and using digital AIMS. METHODS: The study had an exploratory and descriptive design. The study was conducted within three non-university hospitals in Southern Norway. Qualitative, individual interviews with nurse anaesthetists (n = 9) and anaesthetists (n = 9) were conducted in the period September to December 2020. Data were analysed using qualitative content analysis according to the recommendations of Graneheim and Lundman. RESULTS: Four categories were identified: 1) Balance between clinical assessment and monitoring, 2) Vigilance in relation to the patient, 3) The nurse-physician collaboration, and 4) Software issues. Participants described that anaesthesia included a continuous balance between clinical assessment and monitoring. They experienced that the digital AIMS had an impact on their vigilance in relation to the patient during anaesthesia. The digital AIMS affected the nurse-physician collaboration. Moreover, participants emphasised a lack of user participation and aspects of user-friendliness regarding the implementation of digital AIMS. CONCLUSION: Digital AIMS impacts vigilance in relation to the patient. Hence, collaboration and acceptance of the mutual responsibility between nurse anaesthetists and anaesthetists for both clinical observation and digital AIMS administration is essential. Anaesthesia personnel should be included in development and implementation processes to facilitate implementation.

Experiences using an instrument for non-technical skills in nurse anaesthesia education: a focus group study.

BACKGROUND: Although there is an increasing amount of research on the use of structured behavioural assessment instruments for non-technical skills in a simulation or clinical setting, there is currently little research into how healthcare professionals experience using these instruments. The structured behavioural assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway, has recently been introduced to nurse anaesthesia education as a means of developing and assessing non-technical skills in clinical practice. The aim of this study was therefore to explore the experiences of Norwegian student nurse anaesthetists, their mentors and clinical supervisors on using the instrument in clinical practice. METHODS: This study has a qualitative descriptive design. Data was collected through semi-structured interviews with four focus groups comprising twelve student nurse anaesthetists and thirteen mentors and clinical supervisors. The interviews were recorded and then transcribed verbatim. Data was analyzed using qualitative content analysis and an inductive approach. RESULTS: Six categories were identified that represented the manifest content. One main theme: Forging a path towards clinical excellence was identified representing the latent content, and three themes that described the participants' experiences with using the instrument: Promotion of excellent non-technical skills: Raising awareness of non-technical skills ensured professional suitability and shaping of a professional identity; internalizing the skills could lead to changes in behaviour. Promotion of cooperative learning: Mentoring was more structured, based on a common language and understanding and clearly defined roles; measurable progress enabled a more reliable and objective evaluation. Promotion of organizational acceptance: A lack of familiarity with the instrument, and challenges with scoring and the terminology impeded acceptance. CONCLUSION: Increased awareness of non-technical skills when using Nurse Anaesthetists' Non-Technical Skills-Norway contributes to a professionalization of the nurse anaesthetist role and mentoring/learning process in nurse anaesthesia education. Using Nurse Anaesthetists' Non-Technical Skills-Norway promotes the ideal of clinical excellence, not only as an assessment instrument but also by guiding the student's learning process. Despite a high level of commitment to using the instrument there is a need to promote further acceptance in the anaesthetic departments.

Moral Courage: Student Registered Nurse Anesthetist Experiences on the Operating Team.

Lack of moral courage may lead to moral stress for healthcare personnel and to unethical behavior or adverse events for patients. Hospital operating room (OR) teams include surgeons, OR nurses, Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, and student registered nurse anesthetists (SRNAs). Due to the multidisciplinary work in a stressful, high-technology and high-risk environment, the OR is the context for most of the unethical behavior reported in hospitals. The purpose of this study was to explore SRNA experiences of moral courage in the OR. We used a critical incident technique, utilizing 40 SRNA narratives of situations including moral courage/lack of moral courage. The narratives were analyzed using thematic analysis. Findings indicate that unethical behavior potentially leading to patient safety or work environment issues could be avoided when OR personnel showed moral courage by speaking up for patients or for colleagues. Lack of moral courage was indicated by tacit acceptance of unethical behavior or lack of collaboration. SRNAs need not only to learn about the CRNAs' professional obligations and tasks but also to develop moral courage to be able to respond to unethical behavior or communication in the OR. Hence, students should be introduced to such issues during their education.

Postdischarge pain, nausea and patient satisfaction after diagnostic and breast-conserving ambulatory surgery for breast cancer: A cross-sectional study.

BACKGROUND: The aims of this study were to assess first day postdischarge pain, nausea and patient satisfaction in ambulatory breast cancer surgical patients, after diagnostic and breast conserving procedures. METHODS: A total of 781 women, aged 18-85 years were included in this prospective, cross-sectional study. All patients received standardized multimodal pain prophylaxis with paracetamol, COX-II inhibitor, dexamethasone and wound infiltration with local anaesthetics. Nausea prophylaxis was provided with ondansetron. Most patients received general anaesthesia with propofol and remifentanil. Data were collected using a validated questionnaire during telephone follow-up on the first postoperative day. RESULTS: The response rate was 94.5%. NRS ≥ 4 was reported by 5.3% at rest, by 17% during activity and by 30.7% as the worst pain score. Young age was strongly associated with more pain both at rest, during activity and regarding worst pain since discharge. Postdischarge nausea was present in 17.8%, and vomiting in 1.2%. High pain score during activity and higher level of worst pain, were associated with nausea. There was no association between nausea and age, type of anaesthesia, surgical procedure or pain at rest. Patient satisfaction was high (97.8%-99.7%) regarding information, time for discharge and overall satisfaction. CONCLUSION: Pain scores and incidence of nausea were generally low on the day after surgery. Young age was a strong predictor for postdischarge pain. A high worst pain score and high pain score during the activity were associated with postdischarge nausea. Patient satisfaction was high.

Anesthesia Personnel's Experiences With Digital Anesthesia Information Management Systems: A Literature Review.

Traditionally, anesthetic records were in paper format. An increasing volume of complex data, legislation, and quality improvement initiatives related to clinical documentation have promoted the transition to digital records. Anesthesia information management systems (AIMS) have been designed to directly extract patient information from the anesthesia workstation and transmit the data into documentation systems and databases. The purpose of this review was to explore existing literature on anesthesia personnel's experiences with digital AIMS. Literature searches were conducted in PubMed, Cumulative Index to Nursing & Allied Health Literature, Embase, and The Cochrane Database of Systematic Reviews. A total of 473 records were identified, of which 40 records were read in full-text. Seven records underwent quality appraisal, representing research from 1991 to 2018, all with a quantitative design. In total, 379 anesthesia personnel were included. Five studies were conducted in the United States; 1, in Korea; and 1, in Germany. Results were collated into the themes user satisfaction, technical aspects, physical placement of the system, paper-based vs electronic data entry, quality of care, and suggestions for improvement. Findings indicate both positive and negative effects of AIMS. Anesthesia personnel's experiences should be included in the planning, development, and implementation of digital data entry systems.

The effects of a psycho-educational intervention to improve pain management after day surgery: A randomised clinical trial.

AIMS AND OBJECTIVES: To evaluate the effectiveness of a psycho-educational intervention for shoulder and breast day surgery patients in decreasing pain intensity and pain interference with function and strengthening adherence with the analgesic regimen; and further to identify factors that influence average pain intensity and pain interference with function. BACKGROUND: Pain is one of the most prevalent symptoms after day surgery. However, pain management is left to the patients and family, and interventions to help patients are needed. DESIGN: Randomised clinical trial with an intervention (n = 101) and a usual care group (n = 119) using multiple measurements during 6 months postoperatively. The CONSORT checklist is used. METHODS: Patients in the intervention group received a booklet about pain and pain management and coaching by research nurses on postoperative days 2, 3 and 7. Differences between groups were identified using the chi-squared analysis and t tests. Changes with time were identified using a linear mixed model with repeated measures. RESULTS: After controlling for covariates, group differences at any time in average pain intensity and pain interference with function were not statistically significant. Changes over time within any one group in average pain intensity and pain interference with function were statistically significant and decreased with time. Higher levels of average pain intensity and pain interference over time were associated with shoulder surgery, female, younger, pain expectation, preoperative pain and poorer adherence. CONCLUSIONS: No group differences related to the intervention were revealed, and preoperative teaching together with a pain management booklet and coaching may help to strengthen the intervention's effects. Further research on interventions directed towards pain management is needed. RELEVANCE TO CLINICAL PRACTICE: Day surgery patients' postoperative pain and pain management is not satisfactorily handled. To encourage and educate patients to use the prescribed analgesics in the immediate postoperative days may be necessary to enhance pain management. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01595035).

Pain in intensive care unit patients-A longitudinal study.

Aim: To assess occurrence of pain during the first 6 days of intensive care unit (ICU) stay and evaluate associations between occurrence of pain and selected patient-related variables. Design: A longitudinal study. Methods: Adult ICU patients from three units were included. Patients' pain was assessed with valid pain assessment tools every 8 hr during their first 6 days in ICU. Possible associations between occurrence of pain and selected patient-related variables were modelled using multiple logistic regression. Results: When pain was assessed regularly with pain assessment tools, 10% of patients were in pain at rest and 27% were in pain during turning. The proportions of patients who were in pain were significantly higher for patients able to self-report pain, compared with patients not able to self-report (p < .001). Several predictors were associated with being in pain. It is important to be aware of these predictors in order to improve pain management.

Psychometric Testing of a Structured Assessment Instrument for Non-technical Skills (NANTS-no) for Use in Clinical Supervision of Student Nurse Anesthetists.

BACKGROUND: This study evaluated psychometric properties of a structured behavioral assessment instrument, Nurse Anaesthetists' Non-Technical Skills-Norway (NANTS-no). It estimated whether reliable assessments of nontechnical skills (NTS) could be made after taking part in a workshop. An additional objective was to evaluate the instrument's acceptability and usability. METHODS: An explorative design was used. Nurse anesthetists (n = 46) involved in clinical supervision attended a 6-hour workshop on NTS, then rated NTS in video-recorded simulated scenarios and completed a questionnaire. RESULTS: High reliability and dependability were estimated in this setting. Participants regarded the instrument as useful for clinical supervision of student nurse anesthetists (SNAs). CONCLUSIONS: Findings suggest that NANTS-no may be reliable for performing clinical assessments of SNAs and encouraging critical reflection. However, further research is needed to explore its use in clinical settings.

Nurse's Evaluation of a Pain Management Algorithm in Intensive Care Units.

BACKGROUND: Many patients have memories of pain during intensive care unit stay. To improve pain management, practice guidelines recommend that pain management should be guided by routine pain assessment and suggest an assessment-driven, protocol-based, stepwise approach. This recommendation prompted the development of a pain-management algorithm. AIM: Evaluate the feasibility and clinical utility of this algorithm. DESIGN: A descriptive survey. SETTINGS: One medical/surgical intensive care unit, one surgical intensive care unit, and one postanesthesia care unit at two hospitals in Norway. PARTICIPANTS/SUBJECTS: Nurses working at the three units. METHODS: A pain-management algorithm, including three pain assessment tools and a guide to pain assessment and pain management, was developed and implemented in three intensive care units. Nurses working at the three units (n = 129) responded to a questionnaire regarding the feasibility and clinical utility of the algorithm used. RESULTS: Our results suggested that nurses considered the new pain-management algorithm to have relatively high feasibility, but somewhat lower clinical utility. Less than half of respondents thought that pain treatment in clinical practice had become more targeted using the tree pain-assessment tools (45%) and the algorithm for pain assessment and pain management (24%). CONCLUSIONS: Pain-management algorithms may be appropriate and useful in clinical practice. However, to increase clinical utility and to achieve more targeted pain treatment, more focus on pain-treatment actions and reassessment of patients' pain is needed. Further focus in clinical practice on how to implement an algorithm and more focus on pain-treatment action and reassessment of patients' pain is needed.

Nurse anaesthetist students' experiences of patient dignity in perioperative practice-a hermeneutic study.

Aim: The aim of the study was to describe how nurse anaesthetist students experienced patient dignity in perioperative practice. Design: A hermeneutical design and the critical incident technique were used to obtain experiences from practice. Method: In the Autumn of 2015, after participating in a mandatory lecture on ethics, 23 nurse anaesthetist students reported their experiences and interpretation concerning violation and preservation of patients' dignity in the operating theatre. The text, which was a compilation of descriptions of 35 incidents, was analysed by using hermeneutical text interpretation. Findings: The text revealed three main themes preserving patients' dignity: allocating time to the patient, inviting the patient to participate and shielding the patient's body. Furthermore, three main themes of dignity violation were identified: alienation, backbiting and violation of intimate sphere. Conclusion: Discussion and reflection based on the personal experience of the students during their practice are ways to strengthen ethical awareness and promote an ethical and dignified caring culture.

Relationship between self-reported pain sensitivity and pain after total knee arthroplasty: a prospective study of 71 patients 8 weeks after a standardized fast-track program.

BACKGROUND AND PURPOSE: This was a prospective cohort study assessing data from 71 adult patients undergoing total knee arthroplasty (TKA) following a standardized fast-track program between January and July 2013. The objective was to examine the relationship between self-rated pain sensitivity, as measured by the Pain Sensitivity Questionnaire (PSQ), and postoperative pain after TKA. METHODS: The baseline questionnaires, PSQ and Brief Pain Inventory, were given to the patients for self-administration at the presurgical evaluation (1-2 weeks prior to surgery). The follow-up questionnaire, Brief Pain Inventory, was administered at the first follow-up, 8 weeks after surgery. RESULTS: A statistically significant association was found between average preoperative pain and average pain 8 weeks after surgery (P=0.001). The PSQ-minor was statistically significantly associated with average pain only for patients younger than 70 years (P=0.03). INTERPRETATION: This is the first study to examine the relationship between pain sensitivity measured by PSQ and postoperative pain in patients after TKA. We found that a lower score on the PSQ-minor was statistically significantly associated with patients' pain 8 weeks after TKA surgery, but only for younger patients. Further research is needed to explore whether the PSQ could be a useful screening tool for patients' pain sensitivity in clinical settings.

Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation.

PURPOSE: This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay. MATERIALS AND METHODS: The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events. RESULTS: Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics. CONCLUSION: Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.

Development of a pain management algorithm for intensive care units.

OBJECTIVES: To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm. BACKGROUND: Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist. METHODS: Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest. RESULTS: An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63). CONCLUSIONS: The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

Implementation of a pain management algorithm in intensive care units and evaluation of nurses' level of adherence with the algorithm.

OBJECTIVES: To implement a pain management algorithm in intensive care units (ICU) and to evaluate nurses' level of adherence with the algorithm. BACKGROUND: Many ICU patients experience pain. Therefore, an evidence-based algorithm for pain management was developed. METHODS: A pain management algorithm was implemented in three units over three weeks. Nurses' level of adherence with the algorithm and associations between level of adherence and patient and unit characteristics over 22 weeks were evaluated using multivariate regression analysis. RESULTS: Nurses' level of adherence was 74.6%. Adherence rates were lower on the evening and night shifts compared to the day shift. Males were assessed significantly less frequently than females. Patients with "injury, poisoning, or certain other consequences of external causes" were assessed significantly less frequently than patients with "diseases of the respiratory system." CONCLUSIONS: ICU nurses can use a pain management algorithm consistently. Findings from this study suggest that a pain management algorithm is a useful tool to increase ICU nurses' adherence with pain assessment.

A randomized clinical trial of the efficacy of a self-care intervention to improve cancer pain management.

BACKGROUND: The undertreatment of cancer pain remains a significant clinical problem. OBJECTIVE: The aim of this randomized controlled trial was to evaluate the efficacy of the PRO-SELF Pain Control Program that was modified for Norwegian cancer patients in decreasing pain and increasing opioid intake compared with control care. INTERVENTIONS/METHODS: Oncology outpatients with pain from bone metastasis were randomized into the PRO-SELF (n = 87) or control (n = 92) groups. A nurse visited patients in the PRO-SELF group in their home at weeks 1, 3, and 6 and conducted telephone interviews at weeks 2, 4, and 5. Patients in both groups completed a daily diary of pain intensity ratings and analgesic intake. RESULTS: For both groups, significant decreases in pain intensity scores and in hours per day in pain (both, P < .001) were found over the 6 weeks of the study. However, no significant group × time interactions were found for any of the pain measures. In both groups, total dose of opioid taken increased over time. However, no significant group × time interactions were found for changes over time in the total dose, around-the-clock dose, or as-needed dose of opioid analgesics taken. CONCLUSIONS: Possible reasons for the lack of efficacy include an inadequate dose of the psychoeducational intervention, inadequate changes in analgesic prescriptions, and/or the impact of attention provided to the control group. IMPLICATIONS FOR PRACTICE: Coaching, nursing support, and the use of a pain diary may be important interventions to reduce pain intensity.

The PRO-SELF pain control program improves family caregivers' knowledge of cancer pain management.

BACKGROUND: The majority of cancer treatment is provided in outpatient settings. Family caregivers' (FCs') knowledge and beliefs about pain and its management are critical components of effective care. OBJECTIVE: This study's aim was to evaluate the efficacy of a psychoeducational intervention, compared with control, to increase FCs' knowledge of cancer pain management. INTERVENTION/METHODS: Family caregivers of oncology outpatients were randomized together with the patients into the PRO-SELF Pain Control Program (n = 58) or a control group (n = 54). Family caregivers completed a demographic questionnaire and the Family Pain Questionnaire (FPQ) at the beginning and end of the study to assess their knowledge about pain and its management. The intervention consisted of nurse coaching, home visits, and phone calls that occurred over 6 weeks. RESULTS: One hundred twelve FCs (60% female) with a mean age of 63 (SD, 10.7) years participated. Compared with FCs in the control group, FCs in the PRO-SELF group had significantly higher knowledge scores on all of the single items on the FPQ, except for the item "cancer pain can be relieved," as well as for the total FPQ score. CONCLUSION: The use of a knowledge and attitude survey like the FPQ, as part of a psychoeducational intervention provides an effective foundation for FC education about cancer pain management. IMPLICATIONS FOR PRACTICE: Oncology nurses can use FCs' responses to the FPQ to individualize teaching and spend more time on identified knowledge deficits. This individualized approach to FC education may save staff time and improve patient outcomes.

Confirmatory factor analysis of the coping strategies questionnaire-revised in samples of oncology outpatients and inpatients with pain.

OBJECTIVES: The aims of this study of oncology outpatients with cancer pain were to perform an exploratory factor analysis (EFA) of the 48-item Coping Strategy Questionnaire (CSQ) and a confirmatory factor analysis of the 6-factor solution of the Coping Strategy Questionnaire-Revised (CSQ-R) suggested by Riley and Robinson in 1997. In addition, differences in latent factor means and in the CSQ-R subscale scores between inpatients and outpatients were evaluated. METHODS: Data from oncology outpatients (n=217) and inpatients (n=225) with pain were used. The Mplus program was used to perform both the EFA and confirmatory factor analysis treating the items as ordinal, and using robust maximum likelihood estimation. Quartimin oblique rotation was used for the EFA. Model fit was evaluated with the chi test, the comparative fit index, the root mean square error of approximation, and the standardized root mean square residual, as well as by substantive evaluation of the solutions. RESULTS: The EFA of the original 48-item CSQ did not reproduce the factor structure defined by Rosentiel and Keefe. The 6-factor structure from the 27-item CSQ-R fit both the inpatient and outpatient data well with strong factorial invariance, as well as the combined data, allowing some correlated errors among items. Differences were found between the 2 samples for the ignoring, catastrophizing, and praying latent factor means, and for the catastrophizing and praying subscale means. DISCUSSION: The 27-item CSQ-R is recommended for use as a clinical instrument. However, further research of the 6-factor structure is recommended to identify reasons for the correlated errors.