Improving the Process of Pain Care in Nursing Homes: A Literature Synthesis

Abstract

Regulatory agencies, researchers, and clinicians have identified improving pain assessment and management in nursing homes as a high priority, but there is no consensus regarding the best strategies to change pain management practices in nursing homes. The goal of this article is to present a synthesis of published literature of process-level pain management improvement projects in nursing homes and identify and describe the role and necessary skills of various clinicians and nursing leaders in successful interventions. This literature synthesis is limited to research in nursing homes. Reports of research or reports of evaluation of quality improvement programs and descriptions of process interventions that targeted pain assessment and management were reviewed. Studies that focused primarily on the efficacy of pain treatment (e.g., analgesic trials or nonpharmacological therapies) were excluded. Of the original 472 articles, 53 were kept for a full text review. Of these, 10 were included in the final synthesis. Findings from this synthesis suggest that pain management practices may improve with the adoption of systematic implementation models, clinical decision-making algorithms, an interdisciplinary approach, continuous evaluation of outcomes, and use of on-site resource consultants. Clinician leaders in nursing homes require adept pain assessment and management skills and working knowledge of organizational change practices, including quality improvement processes, team building, collaborative decision-making, and assessing and solving system-level problems.

Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain

“…Many recent efforts have focused on improving NH pain care and have emphasized multimodal approaches incorporating better pain assessment methods, better communication between staff and clinicians, pharmacological and nonpharmacological treatments, and training and education. [40][41][42] For example, one initiative in 49 long-term care facilities increased the proportion of residents in pain receiving analgesics from 83% (similar to the current study prevalence) to 90%. 42 In the current study, many residents received a prescription analgesic in the 30-day window before they experienced persistent pain under the definition (subsequent MDS measurement with moderate or severe daily pain).…”

“…Based on these findings, changes in NH pain practices may be needed. Many recent efforts have focused on improving NH pain care and have emphasized multimodal approaches incorporating better pain assessment methods, better communication between staff and clinicians, pharmacological and nonpharmacological treatments, and training and education . For example, one initiative in 49 long‐term care facilities increased the proportion of residents in pain receiving analgesics from 83% (similar to the current study prevalence) to 90% .…”

Pain management in patients with dementia

“…Recommendations to improve pain assessment and management in nursing homes, including national guidelines, have stressed the importance of a well-trained, knowledgeable pain team 55,56. In addition, implementation of treatment algorithms and consultation, continuous education, and team building within the care team are seen as the cornerstones of better pain management (Table 2).…”

“…In addition, implementation of treatment algorithms and consultation, continuous education, and team building within the care team are seen as the cornerstones of better pain management (Table 2). 56 A Canadian study that consulted frontline staff and administrators in long-term care revealed overall a general attitude that is open to change in which staff acknowledged the need for better implementation of pain management. Stakeholders identified a number of barriers including a lack of resources and lack of support from funding bodies.…”

Jurisdiction Over Nursing Care Systems in Nursing Homes

“…Specialty care programming that targets patients at risk for nurse-sensitive clinical issues is one potential measure of care processes because it suggests that clinical nursing expertise is present to address these care issues. We hypothesize, therefore, that greater RN jurisdiction will relate to a nursing home having specialty care programs across a wide range of clinical issues that require nursing expertise (Hypothesis 2), including hospice and palliative care (Stevenson & Bramson, 2009; Suhrie et al, 2009), pain management (Herman, Johnson, Ritchie, & Parmelee, 2009; Swafford, Miller, Tsai, Herr, & Ersek, 2009), dementia care and behavior problems (Luo, Fang, Liao, Elliott, & Zhang, 2010; Nobili et al, 2008), continence care (Leung & Schnelle, 2008; Palmer, 2008; Schnelle et al, 2010), wound care (Frain, 2008; Lynn et al, 2007; Vu, Harris, Duncan, & Sussman, 2007), and restorative care (Resnick et al, 2009). …”