Innovations in End-of-Life Care
an international journal of leaders in end-of-life care
Featured Innovation: Part II
Changing Pain Management Practice at Franciscan Woods:
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
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.
The First Day: Principles of Pain Assessment and 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 planhow 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
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
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 evaluateddepending on whether it is an oral
or an IV routewithin 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
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.
Regulations and Standards
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
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 patientto
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
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.
Family and Patient Education
What kind of family participation do you have in the day-to-day pain assessment
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 coincidethe 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,
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 doingyou 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
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.
1. Pro Re Nata, or 'as needed'[Return to Featured Innovation]
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