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Correspondence: Address correspondence to Katherine Jones, RN, PhD, FAAN, School of Nursing, Yale University, 100 Church St. S., Box 9740, New Haven, CT 06536-0740. E-mail: katherine.jones{at}yale.edu
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Key Words: Pain • Nursing homes • Staff knowledge • Attitudes
Lack of knowledge about pain and its treatment remains an important barrier to effective pain management. Clinicians are unsure about the characteristics of chronic pain and the appropriate use of pain medications in the older adult population (Brockopp, Brockopp, Warden, Wilson, Carpenter, & Vandeveer, 1998; McCaffery & Ferrell, 1997). Pain may be expected to increase with aging, fostering a belief that one should learn to "live with it" (Brown & Williams, 1995; Ferrell, 1996). These beliefs inhibit older adults from reporting pain and decrease clinician readiness to treat pain (Davis, Hiemenz, & White, 2002).
Staff Knowledge and Attitudes About Pain
Staff knowledge deficits result from limited or absent curriculum time devoted to pain management (Weissman, 1988) and inadequate information about pain treatment in textbooks (Ferrell, McCaffery, & Rhiner, 1992). Coyne and colleagues (1999) tested levels of knowledge about pain in hospital nurses and concluded that significant knowledge gaps exist. Mobily and Herr (1996) noted deficiencies in pain management knowledge among both nurses and physicians in the nursing home setting. Beliefs and attitudes are also important in shaping how people respond to pain (Parmelee, 1997; Strong, Ashton, & Chant, 1992). Nurses tend to undervalue residents' reports of pain and employ the most conservative approaches to pain management. Nurses' choice of analgesia may not correspond with the level of pain intensity reported by the patient (Coyne, Smith, Stein, Hieser, & Hoover, 1998). Nurses have a high degree of concern about addiction (Lander, 1990) and also worry about sedation, depression, and constipation, increasing their reluctance to medicate older adults with opioids (Herr & Mobily, 1997).
Improving Knowledge and Attitudes
Staff must be knowledgeable about pain and pain medications to dispel the many resident and family myths and misconceptions surrounding this topic (Herr, 2002). However, success with pain education programs has been inconsistent (Allcock, 1996; Bookbinder et al., 1996; Breitbart, Rosenfeld, & Passik, 1998; de Ronde, de Wit, van Dam, van Campen, den Hartog, & Klievink, 2000; Francke, Luiken, de Schepper, Abu-Saad, & Grypdonch, 1997; Titler et al., 1994; Wallace, Graham, Ventura, & Burke, 1997). A pain education program may increase nurses' knowledge of pain management but may be insufficient to change actual pain management behavior (Mobily & Herr, 1996) or pain outcomes (Carr & Thomas, 1997; Lloyd & McLauchlan, 1994). Staff attitudes and beliefs, resident and physician factors, and organizational issues may exert pressures that prevent more effective practices from being implemented or sustained over time.
This article describes the results of a study to improve pain practices in nursing homes. Baseline and postintervention data included staff knowledge and attitudes about pain and its treatment in the nursing home setting, perceived barriers to effective pain practices within the nursing homes, and case studies requiring documentation of pain intensity and selection of a pain management strategy.
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Methods |
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Intervention
The intervention was multifaceted and included educational and behavioral components. The educational aspects of the intervention included a comprehensive pain resource binder (given to all nursing homes in the study), four 30-min staff development sessions, a 23-min staff training video that included three resident vignettes describing three pain types (neuropathic, visceral, and somatic), single pain "factoids" for posting in visible areas of the nursing home, a 7-min resident educational video and pamphlet (both in English and in Spanish), and a continuing education seminar for physicians. Educational material was based on contents of the AGS (1998) and American Medical Directors Association (AMDA, 1999) clinical practice guidelines for pain in the elderly as well as the American Pain Society Principles of Analgesic Use for Acute and Cancer Pain (American Pain Society, 1999). The behavioral aspects of the intervention included designation of a three-member internal pain team (IPT), IPT development of a pain vital sign, and site visits with discussion of feedback reports, pain rounds, and consultations.
The four educational sessions, which focused on pain assessment, pharmacologic management, pain communication, and integrative case analyses, were scheduled once every 5 weeks and delivered multiple times during the day, from early morning to late afternoon. The sessions were presented by members of the grant team (pain clinical nurse specialist, nurse–pharmacologist, and experts in communication and quality improvement). Although these sessions were targeted primarily at nursing staff, other employees were invited to attend. These educational sessions were followed by five site visits and meetings with the IPT, conducted primarily by the team pain specialist who was often accompanied by the principal investigator or geriatrician. The site visits were focused on working with the IPT, consisting of a certified nursing assistant (CNA), licensed practical nurse (LPN), and third member designated by the nursing home, but the IPTs were soon expanded to include the director of nursing (DON) and staff development coordinator. Pain consultations were provided by the team pain specialist and the physician during site visits and also via telephone between visits.
The research team's physician and nurse–pharmacologist designed and conducted the physician seminar, which was scheduled at a time and location selected by the relevant physician groups. They used case vignettes from the facility and from the physicians' and researchers' personal practices to discuss assessing pain in cognitively impaired residents, prescribing an analgesic appropriate to the type and intensity of pain, equi-analgesic opioid dosing, and preventing and managing common analgesic side effects in the elderly. A list of physicians, mid-level providers, and consulting pharmacists who care for residents at each of the intervention facilities was obtained from the DON. The physician member of the research team contacted the facility's medical director at least twice to discuss the purpose of the seminar, seek advice about its scheduling, ask the director to prepare one or two examples of difficult pain management issues in the facility for discussion, and encourage attendance. Written invitations to the mealtime seminar were sent via mail. Food, continuing education credit, and points that could be used to lower malpractice insurance premiums were offered to those who attended. The physician seminars were targeted at the primary care physicians who regularly admitted residents to the relevant treatment nursing homes.
Instruments
The multidisciplinary research team modified and expanded two existing surveys of pain knowledge and attitudes (University of Wisconsin and City of Hope) (City of Hope, 2002) to align them with the geriatric pain management guidelines (AGS, 1998; AMDA, 1999) and the nursing home environment. The resulting survey included 36 knowledge items (true/false), 21 attitude items (5-point Likert scale ranging from strongly agree to strongly disagree), 2 short case studies requiring pain assessment and treatment decisions, and 14 possible barriers to effective pain management (four levels ranging from very important to not important at all). Items on the knowledge questionnaire included pain myths and misconceptions, pain assessment practices, pharmacologic and nonpharmacologic management, and concepts of addiction/tolerance. Pain and geriatrics experts reviewed the items for content validity. A version appropriate for CNAs was developed that used simpler language (eighth grade level) and excluded the medication management items. A Spanish version of the CNA questionnaire was also developed by a certified translator, back-translated by a bilingual team member, and verified by a native Spanish speaker on the research team. Overall internal consistency (KR-20) reliabilities of the knowledge test of licensed/professional and CNA surveys were.61 and.71, respectively, levels that are adequate for newly developed research measures (Nunnally & Bernstein, 1994).
The attitude questions were developed by a subgroup of the investigators, who first identified key themes to be covered. These included religious traditions and beliefs about pain and suffering, beliefs about cultural and gender differences in the expression of pain, attitudes about why residents might complain about pain (e.g., to get attention), and how staff might respond to complaints about pain. The final attitude scales included general pain biases and attitudes; general beliefs about aging; beliefs and attitudes about the role of religion, culture, and gender; pain medication attitudes; and communication issues. Overall internal consistency (Cronbach's 
) reliability for the attitude survey was.70.
The barrier items were grouped into resident and family, physician, staff, and organizational categories. Staff barriers included knowledge deficits and communication issues. Physician barriers included knowledge deficits and reluctance to order opioids. Resident barriers included inability to report pain and reluctance to take pain medication. Organizational barriers included lack of drug availability and concerns about regulatory oversight. Respondents were asked to note how important each barrier was in their specific nursing home. Cronbach's reliabilities for these subscales ranged from a minimum of.71 (organizational barriers) to a maximum of.87 (staff barriers). Reliability for the overall 14-item barrier scale was.93.
Procedures
Working with the DONs and staff development coordinators, the investigators distributed surveys and consent forms to nursing home staff during mandatory staff meetings or special staff development sessions. Baseline surveys were administered in February 2001; postintervention surveys were administered in November/December 2002. The implementation of the intervention began in January/February 2002 and lasted 9 months. Surveys were voluntary and anonymous, although each staff member was asked to create a unique identifier known only to the research participant for the purpose of matching baseline and postintervention surveys. The investigators collected completed surveys and signed consent forms at the end of each meeting. Small gifts (e.g., pens, Post-It Notes) and snacks were offered as incentives to participate in the survey process. Five staff members attending the baseline meeting and 20 attending the postintervention meeting declined to participate or completed only a part of the survey before returning it.
Analysis
Nested factorial analyses of variance (ANOVAs) and generalized linear models (GLMs) with generalized estimating equations (GEEs) were used to test the first aim of the study. This approach acknowledges the fact that respondents are not truly independent of each other. More specifically, staff members are clustered within the individual nursing homes that are either receiving the intervention or serving as controls. Independent variables included group (experimental/control), job title (registered nurse [RN], LPN, CNA), and change across time (baseline [round 1]/post intervention [round 2]). Those participants with repeated data (n = 43) were omitted from reported analyses, as were the other job titles (n = 74). One treatment nursing home (n = 50) was also omitted after failing to complete the intervention owing to major internal upheavals throughout the course of the study. Although, overall, 678 staff members returned surveys (300 at baseline and 378 post intervention), owing to the two reasons just mentioned as well as a variable amount of information missing on the independent variables, the sample size for analysis was 432 surveys: 176 at baseline and 256 post intervention.
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Results |
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Staff across all the nursing homes demonstrated similar knowledge deficits, which were not improved substantially after the intervention. There was underestimation of the potential effectiveness of nonpharmacologic measures such as distraction techniques and the ability of residents to sleep and interact socially while experiencing moderate to severe pain. Many staff members were unaware of safe and effective analgesia dosing levels and schedules for different types of analgesics. They were also uninformed about drug addiction, physical dependence and tolerance, and which types of laxatives are safest for the elderly.
Case Studies
Two case studies were included to assess the application of knowledge in a real-life resident pain scenario (see Appendix). Both cases presented the same demographic and treatment data; they differed only in described behavior of the resident when reporting level of pain to the nurse. Case A included no obvious pain behaviors, whereas Case B had a marked stereotypic response to pain. In Case A at baseline, 61% of the analysis sample recorded the resident's pain level below the resident-reported 7 on a scale of 0–10. In Case B at baseline, 37% of the analysis sample rated the resident's pain level above the resident-reported 7, whereas 18% rated this resident's pain level below 7. Recording a pain level incongruent with resident pain reports appeared to be a problem for all staff, although the CNAs were more likely to record a pain level different from that reported by the resident. In Case A, 76% of the CNAs at baseline said the pain level should be recorded as <7 contrasted with 47% of the professional staff. In Case B, 30% of the CNAs at baseline said the pain level should be recorded as below 7 compared with 5% of the professional staff. These percentages improved trivially post intervention.
We also examined the change in responses for both cases after the intervention was implemented in the treatment homes. For Case A, treatment home RNs showed improvement across rounds, but this did not reach statistical significance as the majority had already rated pain correctly. Treatment home LPNs showed significant improvement (p =.028) across rounds, with the majority rating pain below 7 at baseline and at 7 post intervention. CNAs in treatment homes also showed significant improvement (p =.045) across rounds, as 20% more CNAs rated pain as 7 post intervention than at baseline. The majority still rated the pain level below 7, however. The control group participants' ratings of pain for this case showed mixed results over the study period; CNAs had the most improvement, although the majority underreported the resident's pain. For Case B, treatment home RNs did not change significantly, and 89% overall rated pain correctly. Treatment home LPNs showed significant improvement (p =.013) across the intervention period. Half had overrated pain at baseline; post intervention, 81% rated pain correctly. Although 12% more treatment home CNAs rated pain correctly post intervention, the change was not statistically significant. The majority still rated pain incorrectly. None of the changes for control group participants was significant.
GLM/GEE analytic strategies with pain assessment coded as correct (a response of "7") or incorrect (all other nonmissing responses) in the analysis sample showed significant job title and treatment group differences. For Case A (p =.012), RNs were 2.6 times more likely than LPNs and 8.7 times more likely than CNAs to choose the correct pain level. LPNs were 3.3 times more likely than CNAs to choose the correct pain level. Treatment group staff members generally were 2.5 times more likely to choose the correct pain level than control group staff members (p =.014). For Case B (p =.011), RNs were 2.1 times more likely to choose the correct pain level than LPNs and 8.0 times more likely than CNAs. LPNs were 3.8 times more likely to choose the correct pain level than CNAs. Treatment group staff members generally were 4.0 times more likely to choose the correct pain level than control staff members (p =.002).
Respondents (excluding the CNAs) were also asked to choose a management strategy for the two scenarios. Responses were classified as conservative if the treatment selected was less intensive than the previous dose (ongoing assessment), unchanged if the treatment was similar in intensity to the previous dose (ibuprofen 400 mg now, oxycodone 5 mg now, oxycodone 10 mg in 1 hr), and aggressive if the recommended treatment exceeded the previous dose (oxycodone 10 mg now). At baseline, treatment approaches similar to previous dose were more frequently selected for Case A (with the modal response being to medicate with ibuprofen). At baseline, more than half of the analysis sample (50.6%) chose more aggressive therapy for Case B (with the modal response being to medicate with oxycodone 10 mg now). There were no differences in approach between RNs and LPNs.
Analysis of patterns between treatment and control home nurses for Case A showed that even though more treatment home RNs selected aggressive treatment post intervention, the improvement was not significant. Control home RNs did as well or better. For Case B, although the majority of treatment home RNs changed to an aggressive treatment strategy post intervention, the shift was not statistically significant. RNs in the control homes showed a similar but smaller association between time period and aggressiveness of the therapy. LPNs showed essentially no improvement patterns over time for either case.
Analysis with GLM/GEE of the aggressiveness of the management strategy showed treatment group differences only for Case A (p =.002). Treatment group staff members generally were 2.5 times more likely to have chosen the most aggressive strategy than were control group staff members.
Staff Attitudes
Table 2 presents the results of the staff attitudes and beliefs section of the survey. The items with the most negative responses were as follows:
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Barriers
Staff perceived a high level of barriers to effective pain management within their nursing homes prior to the intervention phase of the study. As shown in Tables 3 and 4, the percentage of staff reporting little or no importance of the barriers increased markedly between the two data collection periods, and the average barrier scale score (higher numbers reflect less perceived importance) improved over the intervention period (p <.001). This finding was true of both treatment and control homes and probably was related to contextual and environmental factors, including the implementation of the Centers for Medicare and Medicaid Services Nursing Home Compare Report Card in Colorado and the presence of study data collectors in all the nursing homes every 3 months.
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To achieve sustainable quality improvements in nursing homes, the retention and leadership problems must be addressed. In addition, intervention strategies that are succinct and increase the ability of the nursing home to deliver its own educational programs periodically as new staff come on board would probably be more successful. Better strategies to encourage physicians to increase their knowledge of pain management in the elderly are also required.
Staff must be knowledgeable about pain and pain medications to dispel the many resident and family myths and misconceptions surrounding this topic (Herr, 2002). Results of the staff knowledge survey reiterated the findings of surveys in other settings: Knowledge deficits regarding pain assessment and management prevail. Lack of adequate knowledge is a critical factor in the suboptimal pain management documented in large proportions of the nursing home population. Effective pain assessment and management strategies must be based on scientific knowledge and research and systematically applied in patient care delivery (Agency for Health Care Policy and Research, 1992). Without such a foundation, pain treatment will be sporadic, ineffective, or both (Coyne et al., 1999). Existing evidence-based clinical practice guidelines for pain management are apparently not being utilized. None of the nursing homes in our study had clinical practice guidelines for pain management on the units. The inclusion of pain as a quality measure for both short-term and long-term residents in the Centers for Medicare and Medicaid Services Nursing Home Report Card is intended to provide an incentive for nursing homes to improve their practices in this area (Department of Health and Human Services, Centers for Medicare and Medicaid Services, n.d.). However, more aggressive assessment and identification of pain lead to higher pain scores on the report card, a possible disincentive to mount serious pain management programs. In addition, receiving a deficiency from the state related to pain may also serve as an incentive to engage more seriously in pain improvement programs.
Our data indicate that two important aspects of pain management require particular educational attention. Pharmacologic pain management is one area where there are significant knowledge deficits. Items related to appropriateness and side effects of medications were most frequently missed. There was also confusion about the concepts (definitions) of addiction, dependence, and tolerance. The case study analyses also revealed a reluctance to use aggressive pain management strategies, even in the face of reported severe pain and observed pain behaviors. The use of nonpharmacologic strategies such as massage, positioning, and distraction also needs increased attention.
The 1998 and 2002 updated AGS pain guidelines consider educational programs about pain management an essential element of training and orientation programs for all employees and affiliated professionals in long-term care facilities. Nursing assistants and other direct-care staff should receive training and mentoring in pain recognition. A special emphasis needs to be placed on programs for the unlicensed staff, as they have lower knowledge levels and more negative attitudes and beliefs than the licensed staff yet spend an average of 2 hr/day, in contrast to the 45 min/day spent by licensed nurses, with each resident (Kramer, Eilertsen, Lin, Martau, & Hutt, 2000). They therefore have a much greater opportunity to observe behavior changes that could be indicative of pain. The study team, however, noted little involvement of CNAs in care planning, rounds, or reports, and their input was infrequently solicited and sometimes ignored. Any educational interventions that are provided need to be designed so they can be offered on an ongoing basis in the nursing home and delivered with interactive, easy-to-understand, and quick-to-use material.
Increased staff knowledge by itself may be insufficient to achieve substantial practice changes as demonstrated in our case studies, which showed significant improvement in pain assessment by the nursing home staff but not in aggressiveness of pain treatment. Shifts in attitudes and beliefs are essential in the following areas:
This will require alterations in commonly held stereotypes about pain and aging. Our research team has developed a 7-min video about pain, in English and Spanish, that can be shown to new residents and to family members on resident council and family education nights. Several of our nursing homes show this video to new staff members during orientation.
Although the tools for effective pain management have long been available, the best method for disseminating this knowledge remains elusive. This study demonstrates that interactive educational programs may improve knowledge regarding pain management in some nursing homes and within some job titles, but they might not be sufficient to change clinical management behaviors. A multifaceted intervention has to overcome multiple barriers in the nursing home setting. In the case of pain, knowledge and attitudes held by staff, residents, and physicians must all be addressed. The research translation literature indicates that strategies such as self-administered audits of key metrics, quality collaboratives, and designation of internal change champions may be more successful in changing clinical practices. However, different dissemination strategies work for different populations and in different settings. Little work has been carried out in the nursing home setting, so the evidence base for effective translation strategies is limited at this point. Rantz and colleagues (2001) have found that performance feedback reports and on-site consultations have been successful for achieving quality improvement in their sample of nursing homes. But organizational readiness, willingness, and capacity to change must also be considered. Constant turnover of administrators and staff makes implementation of quality improvement interventions difficult and sustainability of improvement over time even more challenging.
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Appendix |
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Circle the number that best represents your assessment of Ida's pain to be marked on her medical record. (scale 0–10 provided).
Her current orders for analgesia are oxycodone 5–10 mg PO q 3–4 hours PRN for pain and ibuprofen 400 mg PO TID PRN pain. Of the following, check what is best for the nurse to administer at this time:
Case B. Same case, except with the following substitution: As you enter her room, she lies quietly in bed, grimaces, and guards her hip as she turns in bed.
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Footnotes |
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1 School of Nursing, Yale University, New Haven, CT.
2 University of Colorado Hospital, Denver.
3 School of Nursing, University of Utah, Salt Lake City.
4 School of Medicine, University of Colorado Health Sciences Center, Denver.
5 School of Nursing, University of Colorado Health Sciences Center, Denver.
6 School of Nursing, University of Missouri, Columbia.
Decision Editor: Linda S. Noelker, PhD
Received for publication July 7, 2003. Accepted for publication January 27, 2004.
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