Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

An Interview with Mary Arata, BSN, RN, OCN

In 1995, Franciscan Woods, a transitional and extended care facility in Brookfield, Wisconsin, took part in the effort led by Weissman et al. (see Featured Innovation: Part I) to improve pain assessment and pain management in long-term care facilities. Recruited through letters to the directors of nursing in Wisconsin long-term care facilities, teams of two to four people from each institution took part in a series of four one-day training modules spread evenly over a one-year period. Trainings were comprised of didactic lectures, small-group discussions, and focused role plays. After the first day of directed training, participants were charged with the task of creating an action plan to improve pain management within their respective institutions, structured around the adoption of fourteen national practice indicators of an institutional commitment to pain management in long-term care facilities. In the following interview with Staff Editor Samantha Libby Sodickson, Mary Arata, BSN, RN, OCN, team leader and oncology nurse at Franciscan Woods, discusses her experience of the year-long educational intervention, her institution's subsequent progress, and the ongoing challenges involved in implementing best practices in pain management in a long-term care facility. [Citation: Arata M. Changing pain management at Franciscan Woods: An interview with Mary Arata, by SL Sodickson, Innovations in End-of-Life Care. 2001:3(1), www.edc.org/lastacts].

Could you describe the facility in which you work? How many people reside there, what is the general staffing structure, and what is your day-to-day role?

Franciscan Woods is a 120-bed facility for transitional and extended care, which is licensed as a skilled nursing facility. We have six nursing units. Three units are for long-term care and three are transitional care nursing units. Two of the skilled units are medical-surgery rehabilitation units, and the third is our oncology unit. I am a team leader on the oncology unit. Each unit has 20 beds, and over the years our unit has cared for as few as 14 to 16 patients, but more typically we have 18 to 20 patients per unit.

The facility opened in December 1993, and the oncology unit opened in March 1994. I began on the oncology unit, four months after it opened, in July 1994. The unit was initially staffed by one nurse. In 1997, as our census grew, the position of case manager was added. The case manager coordinates care with the other disciplines, does the required assessments for state and Medicare reimbursement, coordinates the family conferences and communicates with physicians. The case manager works Monday through Friday. The floor is staffed with a team leader and two Certified Nursing Assistants (CNAs) per unit.

How did you become involved in the Medical College of Wisconsin (MCW) pain management program for long-term care?

I have worked in oncology/hospice units since 1981. One year after I became part of the oncology unit at Franciscan Woods, we were invited to participate in Dr. Weissman and Ms. Griffie's program. I think there were 20 or 30 long-term facilities that were asked to take part. Administrators at our facility were very excited to have us participate. When we got there we were a little overwhelmed by the program because they laid out a full outline of expectations.

Can you tell me what the climate was, in terms of pain management, before you started the program?

Pain was assessed routinely on admission. There were no policies in place for continued assessments or guidelines for the treatment of pain with pharmacological or non-pharmacological interventions. The prn¹ sheet provided space to chart the reason the medicine was given. No guidance was present for consistent assessment or reevaluation of pain. Since we were a new facility, it was a wonderful time to be on the ground floor and develop a structure for pain assessment and management.

Who else from your institution was involved in the training?

Initially, we were all nurses. When appropriate, the social worker or a pharmacist would attend, depending on the topic. We participated for a whole year in the initial cohort program. The next year they trained staff at an additional group of facilities. I think this is the second year that we've been invited back for a follow-up program, which involves attending four presentations a year on different topics in pain management.

What did the initial training sessions include?

In the first all-day session, we were presented with how to do appropriate pain assessment, and all the things it would involve, in detail. Case studies were presented and discussion followed. Another very helpful presentation was on pain assessment of the elderly. Pain is one of the most frequent complaints of the elderly, but it is rarely addressed in medical or nursing literature. Some of the barriers to the assessment of pain in the long-term care setting are: multiple diagnoses, multiple pain sites, multiple medications, atypical presentations, visual and hearing impairments, the myth that pain is a normal part of aging, stoicism, lack of on-site physician assessment and CNAs filling the role as the primary caregiver.

We also had a presentation on the importance of nonpharmacological methods of pain management combined with pharmacological interventions. As a result of this session, we made it an expectation that with each pharmacological intervention, a non-pharmacological intervention also would be undertaken and documented. Some of the nonpharmacological interventions suggested were changes in positioning, reassurance from the staff, education about a condition, listening to music, applying heat or cold, transcutaneous electrical neuromuscular stimulation and distraction. Additionally, we had presentations on the action and side effects of the various classes of pain relievers, as well as the recommended steps for their usage by a pharmacist. Someone from the state regulatory board talked to us about the state regulations and what the state was looking for in terms of documentation and practice. They covered a wide variety of topics in depth.

I understand that you had to come up with an action plan—how did that go?

The steps of the action plan were outlined by the program. Figuring out how to implement the steps was up to us. Our first task was to develop an interdisciplinary work group. We pulled in a pharmacist, a social worker, a physical therapist, a CNA, and our chaplain. We used them as resources on an as-needed basis to assist with the development of policy, procedures, documentation vehicles, and education plans. Two RNs led the group and our medical director was available to us for recommendations and approval.

As all of the steps of the plan were linked with each other, we found ourselves working on several steps at a time. For instance, we needed to develop the uniform measures for pain assessment so we could include them in our policy and procedures. At the same time, we found that we had to develop our pain flow sheet so that we could also address its specific components in the procedures. In this way, one activity fed another.

The Challenges of Implementation: Staff Education

What was the biggest initial challenge when you returned to Franciscan Woods?

Once we had a program ready to present, we faced numerous challenges, the most significant was the need to educate staff about the theory of pain management, assessment, our basic principles of pain management, and pharmacology. The staff also needed to become familiar with our new paperwork and methods of documentation. We had to teach them how to document what they assessed, how they intervened, and what the outcome was. Because the material presented was extensive, many people had to put in extra time by attending the training before or after their shifts, or covering shifts for other staff so that they could attend.

One of the ongoing challenges is to keep re-educating when new staff comes on board and to continue educating beyond the basics. We have developed a section that is presented in orientation of new staff that includes the basics of pain management and our expectations. But there are many more topics to be presented based on the needs we have assessed in the staff. Our goal is to continue to have two in-services a year on pain-related topics, and address areas of need as identified by quality improvement audits.

The training program also focused on the importance of developing a way to inform the residents and resident council of the facility's commitment to pain management. So, we had to develop a plan to teach the residents how to communicate about pain and what the residents should expect, as far as our response to their reports of pain. We also developed quality assurance surveys and audits for ongoing internal assessments of how we were doing. So, it was a long plan, which involved a lot of development and education.

We have also had in-service training sessions on pain for the therapy department. They have responded very well; the occupational and physical therapists are very good at talking with the nurses about pain interfering with therapies. People with uncontrolled post-operative pain can't take part in their rehabilitation programs. If they can't participate, they won't get stronger. Therapists know that patients can't meet their rehabilitation goals unless their pain is controlled.

Did you find that there were misconceptions about pain among the staff before you did the in-service training?

Oh, there were a lot of misconceptions! I think it's an ongoing process to re-educate and to remind people that pain is real. The patient labeled as "difficult" might reinforce misconceptions about pain. We need to believe the patient's report of pain, and to remember that most people don't get addicted to pain medicine. If patients are reporting pain, we need to take care of it; we need to listen, and we need to look at more than just pharmacological interventions for pain relief.

Tell me about the training of your Certified Nursing Assistants (CNAs).

We have two CNAs per unit and we do a CNA in-service, which involves a hands-on training. We talk about the importance of their conveying patients' reports of pain or any non-verbal signs of pain that they observe while providing care. We emphasize that they are our second set of eyes. What was wonderful in this program was that the MCW faculty provided educational models for us to use with CNAs. We then adapted them to our needs.

How did you adapt the models you got from the MCW training?

We basically followed their outline for the general information. Then we developed handouts for our CNAs that included the main points we discussed. For example, one of these handouts showed positioning techniques. We then did a training exercise in which we had a CNA get into a bed and the other CNAs took turns repositioning her. We spelled out the ABCs of pain control for the CNAs, gave them a copy of our pain scale, and taught them how to use it.

How much time, generally, is spent training CNAs on the units?

They're all certified and trained before they come to us. After general facility orientation, they share an assignment for several days with another CNA. Then they are teamed with a CNA who serves as a mentor on their unit as they take on the responsibility of their own assignment. We also have CNA II positions. These are certified nursing assistants who show interest in learning additional skills. We teach them to do finger stick blood glucose monitoring and G-tube flushing.

Routine Pain Assessment in Long-Term Care Facilities

What is your day-to-day pain assessment and management system? How often do you evaluate residents' pain?

Our protocol is to assess people for pain on admission. If they come in with pain medicines already ordered or if they are exhibiting signs of pain, as sometimes happens with non-verbal patients, then they are put on the pain management protocol, and the pain flow sheet is added to the medication book. People are to be assessed at least once per shift for the first three days, and more often if needed. If they're put on a long-acting pain medicine, they are to be evaluated—depending on whether it is an oral or an IV route—within one to two hours of having received the medication to assess its effectiveness. So, our intervention is evaluated on an ongoing basis to see if it is working. Additionally, the CNAs report observations of pain to the nurses.

If the CNAs report an observation of pain to you, what generally happens after that?

The CNAs' observations are very important to me. They do the observing, and they report it, then the nurses do the more detailed assessment. CNAs are expected to report any patient's complaint of pain or any signs of pain that they observe during care. If there is a patient that I know is having trouble with pain, I will ask the CNA for their observations so I can include them with my assessment.

One of the things the staff knows is that the nurses on my unit are always available for consultation because we deal with complex pain issues on a daily basis. We have two nurse managers in the facility, and they know to recommend that the nurses call us if they are having trouble controlling or treating a patient's pain. I think it's important to get nurses to look at the big picture, look at the pain in the landscape of everything that's going on with the patient, and to call us when they have a question. Because we're asked to do so many things, sometimes it's hard to step back and look at the big picture.

Can you speak about the role of regulatory constraints in long-term care, and their effect on pain management?

We try to work within the guidelines, both of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the state. We learned through talks with state regulators that they were looking to see that our patients were functioning at their optimal level. Specifically, they want to know that pain would not be interfering with patients' ability to function at their individual best, which could mean anything from tolerating sitting up in a wheelchair, to being repositioned, to walking.

Much of the pain experienced in the long-term care setting is chronic. One of the issues that came up was the scheduling of prn pain medicine. We held many discussions on that topic with state representatives. As a result of these talks, it became part of our assessment and re-evaluation to understand that a patient did best if he or she had pain medicines on a scheduled basis. A pain medication that is ordered every four hours prn an be administered every four hours at the discretion of the nurse. So, a patient whose pain interferes with his or her ability to do activities of daily living (ADLs), such as eating or dressing, should have a pain pill scheduled an hour before those activities. For example, a patient who has trouble tolerating sitting in a chair for meals should be medicated before meals. We routinely write nursing care orders to schedule medications to prevent pain from interfering with patients' functioning or to prevent pain from diminishing their quality of life. We need to control the pain, not have the pain control the patient.

We have a weekly summary in written form that specifically addresses the particular issues of each individual patient and his or her condition. We added space for an entry that reports on pain management, because we decided we wanted a weekly summary of how the patient's functioning was impacted by pain. By creating a system that routinely documents pain control and delivers prn medications on a scheduled basis, we are better able to reach our goals of pain control.

JCAHO has accredited our facility twice since we opened. We had developed most of the program by the time they surveyed the second time. One regulator complemented our project by saying that it was marketable. I am currently a member of a system-wide pain team. I have found that our pain flow sheets have made it convenient to document most of the indicators we are looking for in our measurement of patient satisfaction with pain control. Being a small facility, we were easily able to develop a new flow sheet to meet our needs.

Are you in the process of making any further changes to comply with the new JCAHO pain standards?

I think we have all the tools in place. What we have to work on is a more consistent use of what we have developed. However, we are currently developing an audit tool within our system to look at assessment, intervention, and patient satisfaction. Analyzing these audits will lead us to further changes.

The Impact of Training on Nurse/Physician Interactions

The MCW faculty describe their training as having a core function of nurse empowerment. What was your experience?

The program really broadened my base of knowledge, from the simple pharmacological intervention to the more complex, and at our facility, we've had very complex cases. It has given us knowledge that has empowered us to be proactive for the patient—to continually seek out whatever it is the patient needs. As you know, doctors don't make visits very often. They come every 30 days, so we do a lot of telephone consultation with them.

As a result of the training, we now have a form that we can use to gather information, so we have a formalized way of presenting what we see to the doctors. It includes the assessment, the response to the current interventions, and a place that we can figure out in our minds what we think would be best for the patient. We've also talked about ways to best present this information to physicians. Now that we use these strategies, we have had wonderful responses from doctors and have found them to be very accepting of our recommendations and requests. Over these few years we have earned the respect of many physicians because of our expertise in pain management.

What kind of family participation do you have in the day-to-day pain assessment and management?

Some families are active participants in setting the goals for their family member. The nurses provide a lot of education to the families. We explain what's involved in pain management, and discuss what the family's goals are. Is it comfort? Is it alertness? And we talk about what getting the patient to a level of comfort might mean as far as side effects. For example, say we can get their loved one comfortable, but then the patient is going to be sleepy. We ask, "Do you want our loved one awake? Do you want his or her pain controlled?" So, we actively involve the family on an ongoing basis, as the patient's needs change.

How have you educated your patients about assessing their own pain?

We have developed a card that has three different pain scales on it. It has word descriptors, it has numbers, and it has faces. On all three scales, the numbers coincide—the low numbers coincide with the mild, and the middle numbers coincide with the moderate, and so forth. We have those cards posted in each bedroom, and in the initial assessment on admission, we ask patients what their pain level is. Most hospitals in the area use the zero to ten scale. If the person comes to us using the zero to five scale, we stay with that scale. We find that by putting the card in front of patients, the graphic image of the face makes the pain scale more understandable to them. For some patients, it's easier to use the mild, moderate, severe, (the word descriptors scale) at other times and for other patients, the numbers are more meaningful. Whatever scale the patient picks at that time, we put that scale on their pain flow sheets, as well as what that patient's acceptable level of pain is. We keep the card in each patient's room so we can use it, repeatedly.

How do you handle pain assessment in cognitively impaired patients?

That's an ongoing challenge. The key is educating the nurses and the CNAs to behavioral changes. The simplest changes in behavior can be signs of pain. We have a section on our pain flow sheets that specifically addresses all the different behaviors that we might observe that would be indicators of pain, such as increase in body movement, changes in daily activity pattern or aggressive behavior. The ideal is to have staff that's familiar with the patient, to note the changes in patients' behavior, and then it's a trial to see if the behavior changes with a change in medication. This involves knowing your patients, performing repeated assessments, and then trying other pharmacological and nonpharmacological approaches to see what works.

What kind of role does hospice play in your facility?

We usually have several hospice patients on our unit. The number has fluctuated from one to seven. We have two hospice organizations that admit our eligible patients to their programs. What hospice brings to our patients is terminal care expertise, extra staff, extra psychosocial support for the patient and the family. It brings another nurse into the picture for care planning. The extra time the hospice nurse, social worker and chaplain can spend with the patient and family is a real benefit. However, we do provide terminal comfort-oriented care to those who are not eligible for, or do not elect the hospice benefit.

Adopting National Practice Indicators

One of the goals of the educational program was the adoption of fourteen national practice indicators for an institutional commitment to pain management. For example, having a standard assessment tool for cognitively intact residents, or an interdisciplinary pain management team like you have developed. What do you think is the relationship between having these target indicators in place and actual patient outcomes?

I think having the target indicators in place is very important. They provide the road map; they are the guideposts for us for the development of the policies and procedures. The pain flow sheets, the assessment tools, all these things make it easier for us to follow a plan.

You need to have a plan to take all the steps to improving pain management. Once you set things in place, you need to reassess how you're doing—you don't know how you're doing unless you're auditing. With our reassessment, in the three or four years that we have been working through this process, we have already revised our initial tools. Our initial audit was primarily of our documentation. Our next step will include looking at patient satisfaction.

In closing, is there some nugget of advice you could give others in your situation, that you feel would make a significant difference in the day-to-day lives of patients in long-term care?

Work together as a team. Bring all the people who interact with the patients together to work on pain management. Pain leaders need to educate the CNAs, the therapists, the nursing staff, the chaplains and the social worker. Pain management is many faceted. Educating all the members of the care team increases the chances of recognizing and treating pain most effectively, and in that way improves the day-to-day lives of patients.

Endnotes:

1. Pro Re Nata, or 'as needed'[Return to Featured Innovation]

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