Abstract and Introduction
Abstract
Acute and chronic pain management for persons residing in long-term care settings is a serious problem. In an effort to change practice in pain management and improve resident outcomes, the Campaign Against Pain education program was instituted at Beatitudes Health Care Center in Phoenix, Arizona. In this pilot study, professional and certified nursing assistant (CNA) staff were surveyed before and after the training program to ascertain change in knowledge, attitudes, and barriers about pain. After the intensive training program and onsite consultation with the concomitant changes in policies, procedures, and documentation, professional and CNA staff knowledge improved after 6 months (F = 6.273; p = .02), attitudes changed (F = 12.26; p = .002), and barriers were mitigated. With a comprehensive quality improvement pain plan in place, the findings suggest that education in pain management in long-term care and program changes that adopt best practices in pain can make a difference.
Introduction
Pain is often underassessed and underaddressed for older adults in long-term care settings. Past research indicates that 40%-45% of persons or more in nursing homes experience persistent pain, most of which is not recognized or treated (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002, American Geriatrics Society Panel on the Pharmacological Management of Pain in Older Persons, 2009, Ferrell, 1995, Teno et al., 2001). Individuals residing in nursing homes with persistent pain may not receive prescribed scheduled pain medications (Hutt, Pepper, Vojir, Fink, & Jones, 2001). Those who are cognitively impaired are at risk for undertreatment of pain when behavioral cues that suggest pain are often missed and are attributed to the progression of dementia (Cipher et al., 2001, Fries et al., 2001, Herr and Decker, 2004, Kovach et al., 2010).
In the United States, various government-led and voluntary initiatives, such as the Nursing Home Quality Initiative and Advancing Excellence in America's Nursing Home Campaign, have promoted quality improvement for the care of residents through a variety of quality measures over the past decade (Advancing Excellence in America's Nursing Homes Campaign, n.d.; Nursing Home Quality Campaign, 2007, Nursing Home Quality Initiative, 2005). Today, long-term care organizations are developing more aggressive strategies to improve care for the residents they serve. One of these measures includes decreasing the percentage of residents with moderate to severe acute or chronic pain (Advancing Excellence in America's Nursing Homes Campaign, n.d.). In addition, federal regulations and F-tag F309 stipulates that facility staff assess and address pain by developing interventions to relieve pain for residents in long-term care. It also specifies that the pain management plan needs to be continually evaluated and modified dependent on the resident's response to the interventions (DHHS CMS, 2009). Therefore, direct care staff, and professional nurses in particular, need to be cognizant of evidence-based pain assessment practices and pharmacologic and nonpharmacologic interventions.
There are numerous reasons why pain can be a problem in long-term care. One reason may be related to barriers, myths, and gaps in information (American Medical Directors Association, 2009, Fink and Gates, 2010). Effective pain management is often linked to licensed nursing and certified nursing assistant (CNA) staff knowledge, biases, beliefs, and attitudes that can influence the overall success in addressing the assessment and management of pain for older adults in these settings (Jones, Fink, Pepper, Hutt, Vojir, Scott, Clark, & Mellis, 2004). Some barriers may be related to licensed nursing staff, such as the need for updated and extensive education on pain assessment and management (Keene & Thompson, 2008). Current information on various pharmacologic and nonpharmacologic approaches to pain management is necessary. Various directives and evidence-based guidelines have defined general and specific pain assessment and management guidelines for older adults who have acute and chronic persistent pain (American Geriatrics Society, 2002; American Geriatrics Society, 2009; American Medical Directors Association, 2009, American Pain Society, 2008, Herr et al., 2006). In addition, information is available to long-term care organizations to assist in managing pain effectively and safely in nursing homes (Advancing Excellence in America's Nursing Homes Campaign, 2008, Advancing Excellence in America's Nursing Homes Campaign, 2010).
Additional barriers may be attributed to the health care system, licensed nursing and CNA staff, and to older adults themselves (Hutt et al., 2007, Jones, 2006, Jones et al., 2004). Lack of knowledge and various biases, beliefs, and attitudes may adversely affect the recognition and treatment of pain. The health care system has typically given low priority to pain and adequate remuneration has been challenging. Documentation may not readily support best practices in pain management in long-term care settings, such as the implementation of pain rating scales and other pain evaluation measures (Cadogan et al., 2005, Leone et al., 2009). Health care quality improvement systems are necessary to assure that barriers are mitigated and the needs of older adults in pain are identified and rectified. Licensed nursing staff may be concerned about the adverse effects of medications, the use of opioids in older adults, and resident addiction. They may have knowledge deficits related to pain assessment and management, and there may be a gap between actual practice and current best practice (Jablonski and Ersek, 2009, Zwakhalen et al., 2007). CNAs may have similar biases, beliefs and attitudes that are misguided. Evidence suggests that attention to the knowledge deficits of professional nursing staff related to pain management, resolving attitudinal concerns, and removing barriers can improve pain in older adults (Baier et al., 2004, Ersek et al., 2006, Herr et al., 2006, Leone et al., 2009). Finally, older adults may also have preconceived notions about pain management practice. They may be fearful of taking medications, concerned about medication side effects, and reluctant to report pain. These, and other reasons, create roadblocks in achieving comfort.
Beatitudes Campus Health Care Center had a keen interest in improving pain for the older adults in their care. The research question for this project was: "Does staff education and training in pain management improve the knowledge, attitudes, and barriers related to pain management in providing care for older adults residing in long-term care?" Through a grant from the Arizona Department of Health Services, Beatitudes Campus embarked on a training program for facility personnel and a total overhaul of the policies, procedures, and documentation for pain assessment and management. Thus, the purpose of this article is to present the approaches and findings of the Campaign Against Pain related to the improvement of staff knowledge and changes in corresponding attitudes and barriers in pain management. The pilot project was successful in achieving target levels of pain management for older adults overall. Using the Minimum Data Set 2.0 over five quarters, two nursing units met the goal of 0.0% incidence of moderate to severe pain for persons with a history of chronic pain and 8.3% for those persons with moderate to severe acute pain and who were not permanent residents in the facility. This study was conducted at the same time as the research presented in the present paper. Additional information on the resident outcomes is reported elsewhere (Long, Morgan, Alonzo, Mitchell, Bonnell & Beardsley., 2010).