January 11, 2016
System-level interventions that link pain assessments to intervention measures are likely to be powerful tools for addressing pain in nursing home residents, according to a study published online in Pain Management Nursing.
Researchers led by Clint Douglas, RN, PhD, from the Wesley Mission Brisbane Pain Research Interest Group in Queensland, Australia, implemented a pain identification tool along with pain recognition training for nurses and (published site)
nonprofessional staff at 5 eldercare facilities. Outcomes were compared with that of usual training and standardized care at 4 other facilities operated by the same organization.
Results showed that the 3-month intervention was associated with significant improvement in routine pain assessment and use of nonpharmacologic pain interventions.
However, the effect was confounded by unexpected changes in the control group, and attenuated by relatively high baseline knowledge, skills, and confidence for pain assessment in both groups, the authors suggest.
"I was really surprised, and I agree with [the researchers] that probably part of the reason they didn't get the positive outcomes they anticipated is that the facilities have unusually high knowledge and perceived confidence," Keela Herr, RN, PhD, associate dean for faculty in the College of Nursing at the University of Iowa, and specialist in geriatric pain research and education, toldClinical Pain Advisor.
"When you start out with those high levels, it is hard to show significant change, and those scores were much higher than what you typically see in this kind of study and in nursing homes in particular. So obviously this organization is already doing something right in their approach to pain care," Dr Herr pointed out.
"We found the introduction of pain identification resources with implementation strategies to support frontline staff over a 3-month period was partially effective in improving staff and resident outcomes. Nonetheless, our findings confirm the need for change and importance of translational pain research in residential aged care facilities," the authors write.
Evaluating the Intervention
After a baseline assessment of knowledge in both groups, nurses and nonprofessional staff in the intervention facilities were provided with a pain resource packet consisting of the pain identification tool, an education booklet, and lanyard-sized cue cards. Professional staff also received a pocket-sized comprehensive pain assessment guide. The information was reviewed at pain workshops over the 3-month study period, after which staff knowledge was reassessed.
Other pre- and post-intervention measures included an audit of randomly selected resident charts (50%), and a survey of cognitively intact residents to assess their perception of pain management quality.
A total of 434 staff surveys were completed, representing a 39.5% response rate; 216 surveys were completed at baseline, and an additional 218 were returned following the intervention period. A total of 636 resident charts were audited, including 308 at baseline and 328 at follow-up. Also, 168 cognitively intact residents completed surveys, 74 at baseline and then 94 at follow-up.
In the intervention facilities, the proportion of residents with a documented routine pain review increased from less than half (48.4%) at baseline to approximately three-quarters (73.8%) at the 3-month follow-up. In the control facilities, the rate increased from 75.8% to 83.2%.
Although the average number of documented pain assessments increased slightly in the intervention group (7.0 ± 15.1 to 9.7 ± 7.8), larger improvements were observed in the control group (9.1 ± 13.7 to 19.1 ± 20.9).
Use of analgesics did not significantly change, but the intervention and control groups both showed improvement in the use of nondrug pain therapies (77.4% to 82.1% and 90.2% to 94.2%, respectively). The most commonly employed measures included massage, repositioning or limb elevation, heat or cold application, tubular compression bandaging/stockings, and distraction with music or support.
With respect to staff outcomes, researchers found no significant differences in pain knowledge and awareness between the intervention and control groups. There were notable differences in correct responses among the control group when the researchers looked at specific responses, such as understanding that pain is not an acceptable part of aging (65.8% to 74.0%), or that staff and family members caring for residents are not the best judges of the presence and severity of residents' pain (34.2% to 48.1%).
Among the cognitively intact residents who completed the survey, mean pain problem scores decreased over time, indicating an improved perception of pain management quality. However, pain problem scores did not differ significantly between the groups over time.
In an interview with Clinical Pain Advisor, Fiona Hodson, RN, BaHSc, said that another possible study limitation is that it was unclear if there were any specific validated observational and behavioral pain tools for communicating with cognitively impaired residents, such as those recommended in Australian facilities, including the Abbey Pain Scale and the Pain Assessment in Advanced Dementia (PAINAD) score.
"These can be used as an effective communication tool between staff for baseline and progressive reassessment after an intervention," Ms Hodson pointed out.
Ms. Hodson, who was not involved in the study, is president elect of the Australian Pain Society, and a clinical nurse consultant for pain management with Hunter Integrated Pain Service in New Lambton, Australia.
She noted that more than 52% of residents aged 65 years and older in Australian eldercare facilities have some form of dementia, so it is important to ensure that all staff members understand the targeted, validated pain tools and management resources specifically developed for use in this population.
Directions for Future Research
Dr Herr and Ms Hodson concur that the key to successfully implementing change across an organization is by making pain management a priority, and that more intervention research studies such as this one are needed to better translate guidelines into practice.
"I think this is really a nicely done study. It is very challenging to do this kind of intervention in nursing homes," Dr Herr pointed out. "Any time you're doing implementation research, there are so many factors that impact the ability to implement an intervention effectively. Practical clinical trials are needed to actually look at implementations like this in a real world setting, and examine the challenges and barriers along the way," she added.
"We'll see if it helps advance us in doing a better job," Dr Herr concluded.
The study was funded by fellowship from the Queensland Government department of health, and a grant from the Queensland University of Technology School of Nursing.
Reference
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