Pain Barriers

Lack of leadership, staff turnover correlate with inadequate pain management in LTC, according to researchers

by Gretchen Henkel

PHOENIX--Four years after pain was designated the fifth vital sign in the Joint Commission on Accreditation of Healthcare Organizations standards manuals, pain remains inadequately addressed among long-term care residents, according to two groups of presenters who spoke at a preconference workshop at the AMDA 2004 Annual Symposium.

Researchers from the University of Colorado Health Sciences Center in Denver and from the Royal Oaks Lifecare Community in Sun City, Ariz., reported on their efforts to improve pain practices in the long-term care setting ("Pain Management in Long Term Care").

3-Year Colorado Pain Study

An estimated 45% to 80% of nursing home residents have substantial undertreated pain. In a controlled comparison study, investigators from the University of Colorado Health Sciences Center in Denver and the Yale University School of Nursing recruited 12 Colorado nursing homes (six urban, six rural) to participate in an education-based intervention to improve pain management.

The facilities were deliberately rather than randomly selected because one of the study goals was to develop a culturally appropriate intervention to improve pain management practices in Hispanic as well as English-speaking resident populations.

According to principal investigator Katherine R. Jones, PhD, RN, FAAN, professor at the Yale University School of Nursing in New Haven, Conn., the three-year pain study began in October 2000 and was one of 13 funded under the Agency for Healthcare Research and Quality's Translating Research into Practice (TRIP)-II Initiative.

During a nine-month pre-intervention period, the research team surveyed pain management knowledge and attitudes of staff and residents in the 12 nursing homes. They also simultaneously developed educational materials for use during the subsequent nine-month intervention period.

The survey of 175 staff members, comprising RNs, LPNs, and CNAs, revealed substantial knowledge deficits about:

• Safe and effective analgesia dosing levels and schedules;
• The differences between drug addiction;
• Dependence and tolerance; and
• The potential effectiveness of non-pharmacologic intervention strategies, among other issues.

Following a survey of residents for their knowledge and attitudes about pain relief, Regina Fink, RN, PhD, FAAN, AOCN, a pain specialist and research nurse scientist at the University of Colorado's Professional Resources and Patient Services division, noticed many of the same perceptions that she had found in her 20 years as a cancer pain specialist.

Just like cancer patients, nursing home residents were sometimes reluctant to take medication due to fear of side effects. However, as opposed to cancer patients--who often ask for something to relieve their pain--elderly nursing home residents would not ask because "they didn't want to be a bother to the nurses and physicians."

The surveys also revealed cultural as well as gender biases. Example: True-false questions on staff attitude surveys revealed that some female staff members believed that male residents should be able to bear their pain, considering men unable to tolerate pain to be "babies," said Dr. Fink.

Putting CPGs to Work

Racial, ethnic, and gender biases held by both residents and caregivers comprise only one group of the barriers to the recognition and treatment of pain in long-term care, according to AMDA's clinical practice guideline, Pain Management in the Long-Term Care Setting. Dr. Fink reported that the AMDA CPG "provided a springboard" for the educational materials generated by the Colorado group.

"After examining all the clinical practice guidelines pertaining to pain," said Dr. Jones, "we determined that the AMDA and the [American Geriatrics Society] guidelines were the most relevant and appropriate to our study. There was also a lot of synergy between the two guidelines."

The next step was to make the guidelines more usable. "I think that physicians and nurses sometimes do not have a chance to read those," said Dr. Fink, "We wanted to integrate those [guidelines] into our materials, so we pulled out key pieces of information for staff."

The team chose the fact that nonsteroidal anti-inflammatory drugs can cause serious side effects in older people as the message for one of their "factoid" posters, for instance. Each poster was displayed in the intervention facilities to remind staff of pain management principles on a daily basis. (See "UC's Sample Pain Management Factoids," at right.)

These posters also triggered questions from attending physicians, said Dr. Fink: "When physicians came in and saw, for instance, the Darvocet factoid poster, which cautions against its use in the elderly, they then asked, 'What should I order?' Having the AMDA and AGS guidelines at the nurse's station allowed them to [choose a more appropriate medication]."

Other educational materials included videotaped scenarios depicting three different pain cases: A recently widowed, 67-year-old Hispanic woman who is predominantly Spanish-speaking and experiencing neuropathic pain; an 80-year-old former construction worker with dementia, visceral pain, and a history of substance abuse; and an 83-year-old retired nurse with acute pain following a total hip arthroplasty and chronic pain due to her metastatic breast cancer.

The scenarios demonstrate a staff member interfacing with the resident to elicit pain reports. For each case, the team developed workbook discussion questions specific to each staffing level--physician, nursing, and nursing assistant--and have now made all editions available as part of the "Nursing Home Pain Toolbox," funded by the AHRQ grant.

During the study, these materials existed as draft documents and were not published until after the intervention period. Tools to educate nursing home residents and their families were also developed, in the form of videotapes ("You Don't Have to Live with Pain") and brochures entitled "Pain: Can We Talk?" printed in English and Spanish.

Changing Systems

The Colorado group's intervention strategies were then launched in three urban and three rural facilities. The curriculum consisted of offering four pain practice education sessions for nursing staff (with each session lasting about 30 to 45 minutes), viewing of the training videos, distributing pamphlets to the residents, and providing a 40-minute continuing education session for physicians. The research team made site visits every six weeks and helped establish internal pain teams at the facilities. During these visits, they posted new factoids and provided feedback reports to staff.

Considerable attention was given to correctly assessing residents' pain by furnishing staff members with a checklist of nonverbal pain indicators (for residents unable to report their own pain, mostly due to cognitive impairment), as well as the WILDA Pain Assessment Guide, "Tell Me About Your Pain," devised by Dr. Fink in 1996.

WILDA stands for:

• Words to describe pain, such as aching, stabbing, etc;
• Intensity of the pain, on a 0 to 10 scale;
• Location of the pain;
• Duration of the pain (i.e., is it constant or does it come and go?); and
• Aggravating and Alleviating Factors--what makes it better or worse?

The WILDA assessment guide and the Wong-Baker numeric pain intensity scale (round faces arranged from happy to crying) were applied to opposite sides of a pocket-size handout that was laminated and furnished to front-line caregivers. Also furnished were laminated "Analgesic Reference Guides," which included the World Health Organization's analgesic ladder; commonly used analgesics; equianalgesic conversion tables; and drugs to prevent and/or treat side effects of the major opioids.

What Worked; What Didn't

After the nine-month intervention period, the Colorado group spent a third nine-month period measuring the sustainability of the intervention. Knowledge scores improved in intervention homes, and attitudes toward pain assessment improved significantly in rural intervention homes.

Although they observed a significant decrease in the treatment of nursing home residents reporting constant pain, there was no reduction in residents reporting moderate/severe pain. There was significant improvement in non-MDS pain assessments and reassessments in both the treatment and control (no intervention) facilities.

Challenges that the group faced in implementing the pain management interventions included attendance problems at the training sessions, content overload, and leadership turnover--one facility had four different directors of nursing in one year, they reported. Approximately 8% to 10% of residents refused pain assessments during the implementation period, either because they didn't want to talk to strangers or because they didn't want to sign any consent forms. Nearly half of those who reported pain didn't want to request medication due to stoicism, dislike of the medications, or staff dynamics issues.

The group also encountered multiple barriers in their interactions with physicians. Interestingly, said Evelyn Hutt, MD, an assistant professor in the Division of Health Care Policy and Research who specializes in multicultural geriatrics and a co-investigator on the study, physicians in the rural facilities were more open to the team's pain management messages than were the urban facility physicians.

"It was a challenge to get primary care physicians engaged and to achieve changes in prescribing practices," agreed Dr. Jones. "Academic detailing--also called educational outreach--has been shown to be effective in other settings in altering physician prescribing practices. Our hypothesis is that one-on-one interactions with a geropharmacist in the physician's office might be a more successful change strategy. The meetings would be short [15 minutes] and focused."

The group is still analyzing data from the study, and three manuscripts on various aspects of the study have already been accepted for publication. Time devoted to in-services was a major concern at all levels of the study, a reflection of staffing shortages throughout the industry.

The nursing homes most successful in changing pain practices shared:

• A facility leadership team that was involved with the project at every stage and that relieved staff to attend training sessions;
• A facility physician who also attended the CME sessions offered;
• Posting of signs and reminders; and
• Inclusion of non-nursing staff (housekeeping, dietary) in the pain management program.

The Arizona Experience

The presenters from Arizona had not heard the Colorado group's presentation prior to the preconference workshop, said Jane Winston, MD, FAAFP, medical director of Royal Oaks, Inc., a nonprofit, faith-based continuing care retirement community in Sun City, Ariz. That is why she and her colleague Dina Capek, MS, RN, director of Health Services at Royal Oaks, were "thrilled that they started with the same idea: that it is fundamental to involve the direct caregiver" in a pain management initiative.

Dr. Winston and Capek also used a strong educational component to improve pain assessment and focused their work on cognitively impaired nursing home residents at Royal Oak's 34-bed dementia unit. The study was conducted under the aegis of the Advanced Dementia Care Task Force and the Arizona Cancer Pain Initiative, which included 10 other Arizona nursing homes.

Following development of a pain assessment tool by the pain team, seven in-services were conducted from February to August 2002. The Royal Oaks team used training videotapes developed at the University of Wisconsin. During the workshop presentation, Capek showed a videotape of herself mentoring a CNA who was filling out the Cognitively Impaired Pain Assessment form used in the pain management intervention.

As also noted with the Colorado study, successfully changing pain practices required leadership commitment from the facility's medical director and administrative staff, which set the tone of support for front-line caregiving staff. This is especially key when assessing pain in cognitively impaired residents, said Capek.

"A nurse might do a pain assessment of a resident that takes 10 minutes out of her day," she said, "and she might not see any of the behavioral pain indicators [such as grimacing, guarding of body parts, crying, or verbal aggression]. But when you let CNAs know that the assessment is being done during an eight-hour period and to let you know if they see any of these behaviors, we can better identify and treat residents' pain."

As part of the facility's pain initiative, letters were sent to 30 attending physicians apprising them of the intervention, and the Assessment of Discomfort in Dementia (ADD) protocol was revised for CNA education levels.

The ADD protocol calls for assessing the history of the resident and looking for physical causes of their discomfort. Non-pharmacologic nursing interventions (e.g., offering liquids, giving back rubs) are given first to attempt to relieve discomfort, followed by non-narcotic and then psychotropic medications.

"Sometimes, in a truly advanced cognitively impaired person, you may not know what is causing the discomfort," said Capek. "But by identifying these behavior indicators and giving even routine Tylenol, we have seen those behavior indicators go away. Even though we may not be able to find the true origin of the pain, you can still treat it."

Both groups agreed that facilities must formulate and implement comprehensive pain management programs by having an internal pain team, and consistently addressing barriers to recognition and treatment of residents' pain. With staffing shortages an ongoing problem, education about effective pain management must itself be delivered in the most time-efficient manner.

"What our team found--and what almost all the research teams doing translation studies across multiple settings have discovered--is that the key elements of a CPG must be identified and transmitted to the target audience," noted Dr. Jones. "The key elements are those recommendations most likely to make a difference in clinical practice."

The message about pain management, said Dr. Fink, "must be short and sweet."

Freelance writer Gretchen Henkel is based in California.

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