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

The Palliative Care Program of the Medical College of Wisconsin,
Milwaukee, Wisconsin.

Improving pain management in long-term care facilities has several unique barriers in comparison to the acute hospital setting. To address these barriers the Medical College of Wisconsin Palliative Care Program began a project in 1996, initially working with 87 long-term care facilities, to improve pain management practices through a series of educational and quality improvement steps. This article will review the overall structure, results, strengths and weaknesses of this approach to improving pain management in this important site of clinical care. [Citation: Weissman DE, Griffie, J, Muchka S, Matson S. Improving pain management in long-term care facilities. Innovations in End-of-Life Care. 2001:3(1), www.edc.org/lastacts].

We have been working to improve community pain management practices in Wisconsin since the late 1980's in partnership with the Wisconsin Cancer Pain Initiative. In 1990 and again in 1992, we held our first Cancer Pain Role Model programs, an educational effort designed to break down the common barriers to cancer pain management.^1,2 The educational plan for the Role Model Program focused on bringing together teams of clinicians, nurses and their physician clinical partners at a one-day conference, train them in the principles of cancer pain management and give them suggestions for how to make changes in basic care practices in their clinical practice settings. These early programs were partially successful at helping individuals make change, but we quickly came to recognize that additional work was needed to help individual clinicians fully change the practice of pain management in their practice settings.

Institutions as the locus of change

To this end, in 1994 we began a new project focusing on health care institutions, rather than individual clinicians, as the locus of change. This change represented a fundamental shift by our project team in thinking about how to improve pain management practices. Health care institutions, whether they be hospitals, long-term care facilities (LTCFs), home health agencies or hospice agencies, each have their own distinct culture, which can either support or hinder effective pain management. The elements of institutional culture that impact on pain management include the knowledge, skills, and attitudes toward pain of the professional staff; the presence or absence of standards, policies, or clinical guidelines; and quality monitoring programs regarding pain management. Perhaps most important is the overall institutional commitment to providing excellent pain management services. Although it is true that through their daily practice, physicians and nurses largely control the assessment and treatment of pain, it is also true that institutional aspects of care, e.g., the presence of a standardized facility-wide pain assessment tool, or facility analgesic standards, can help guide clinicians to do the right thing.^3,4,5,6,7

To accommodate this new institutional focus, we expanded the educational content of the original Role Model Program to all pain management practices, not just cancer pain, and increased the educational contact time from one conference to two, including new topics of institutional change theory, hospital standards, and quality improvement. The decision to expand to all pain, rather than just cancer pain, came after the realization that cancer pain typically impacts a minority of the pain problems within a given health care institution, and that just focusing on cancer pain, when similar institutional barriers exist for all aspects of pain management practice, would waste an opportunity for greater institutional impact. Furthermore, the attitudes, knowledge, and skills needed to improve acute, traumatic, post-operative, and much of chronic pain, are nearly identical to those for managing cancer pain.

Special Barriers in Long-Term Care Settings Need to be Addressed

Participants from LTCFs enrolled in an earlier role model project specifically told us their issues for institutional change were different from acute care. These participants were unable to use the information and asked the project team to design a new intervention project, specific to the needs of long-term care.⁸ It is important to understand some of the unique barriers to good pain management practice in the LTCF.^{9,10,11,12,13} First, as a heavily regulated industry, especially concerning the use of psychoactive medication, LTCF nurses and physicians are hesitant to use scheduled analgesics for chronic pain out of fear of regulatory scrutiny by state or federal surveyors. Second, most pain experienced by LTCF residents is non-malignant and to date there has been little acceptance by physicians of routinely scheduled opioid therapy for chronic non-malignant pain, although increasing evidence points to the relative safety and efficacy of opioids for this indication.¹⁴ Third, physician involvement in the day-to-day care of LTCF residents is far less than for hospitalized patients. Contact typically occurs only once every 30 days. Fourth, the bulk of actual patient contact in the LTCF is via certified nursing assistants, who have little to no training in pain assessment. Thus, in the typical LTCF there are physician, nursing, institutional and regulatory barriers that impede pain management above and beyond the already familiar barriers to pain management in hospitalized patients.

New Program Designed Specifically for Long-Term Care Settings

To address the special needs of pain in LTCFs we designed a new educational intervention, building from our prior experiences with hospitals, in collaboration with the Wisconsin Bureau of Quality Compliance and the Wisconsin Division of Health, the regulatory agencies that monitor long-term care in Wisconsin.¹⁵ Recruitment to the project was on a first-come, first-serve basis, with a target goal of 90 facilities. Letters of invitation were mailed to the director of nursing and facility administrator of all long-term care facilities in eastern Wisconsin. In all, 87 facilities enrolled, divided into three training cohorts. To ensure top-level buy-in, each facility's administrator and director of nursing were required to sign a letter of commitment. Facilities were not required to pay any fee for participation; funding for the project came from local private foundations.

The educational plan included the following features:

• A site visit to the facility by a project team member, during which time a facility needs assessment was completed (Figure 1).

• A series of four educational workshops, evenly spaced over one year, attended by a team of two to four facility staff, including middle and senior management in a position to make changes. Topics included pain assessment, treatment, standards development, quality improvement, staff education and staff competencies. Teaching methods included lectures, small group workshops, role play exercises and case studies.

• Completion by participants of a facility-specific Action Plan, a detailed blueprint for proposed changes.

• Chart reviews of pain assessment documentation performed by each facility team.

To help facility staff keep the goals in mind, a list of 14 target indicators of good pain management were developed from existing national standards. Indicators included elements of pain assessment, pain treatment, quality improvement, staff education and facility commitment. The facility needs assessment catalogued the presence or absence of these indicators at the start of the project, and again one year later, at the project's conclusion.

Figure 2.

At the project's inception, only 12 facilities (14 percent) had more than half of the 14 indicators in place, compared to 64 facilities (74 percent) post-project. On average each facility had only 3.4 of the 14 indicators in place at project inception, compared to 8.8 at project completion.¹⁷ The most common indicators established during the year-long project included pain assessment tools for cognitively intact and cognitively impaired residents, development of a standardized facility pain scale, specific pain management policies and protocols, and training in pain management for new nursing staff. Pain documentation significantly improved over the course of the year, as evidenced by the chart review project. Overall, we were pleased with these results, feeling that this project had provided an excellent foundation for facilities hoping to improve their pain management practice.

Empowering Nurses

From the perspective of project design, there were several factors that led to an overall positive impact. First, although not designed as such, this project to improve pain management was just as much a nurse empowerment project. Nurses, by far the largest group of participants at the teaching conferences, came away from each conference with new knowledge about and confidence in their own practices. When these teams first came together, there was a very strong feeling of anger and frustration—frustration because they knew they were not doing a good job, frustration because they did not understand how to do it better, and anger, focused on physicians, about basic conflicts in nurse-physician communication that impede good pain management.¹⁸

What we heard over and over again from participants is that we had empowered them to go home and do things differently; we gave them, in a sense, the building blocks to initiate change. We gave them the knowledge, skills, and a kind of esprit de corps to say, "This is the way it ought to be done." Essentially, this happened because the new information was congruent with what they thought ought to be done; we did not have to spend a lot of time convincing them that what we were telling them was the right thing.

Assessing Pain and Designing a Treatment Plan

Foremost among the new information acquired by nurses was the ability to perform an accurate assessment, design a treatment plan, and then contact the physician for new orders. To effect this empowerment we used case studies and role playing exercises (Figure 3 ).^19,20 In particular, participants all had the opportunity to role play a pain assessment with a simulated patient and develop an analgesic plan. Participants frequently commented about how powerless they felt prior to this instruction, and how they were often frustrated by physicians' seeming indifference to their requests for new analgesic orders. Following the instruction, nurses reported greater self-confidence and outright success at achieving the desired interaction with physicians. Ultimately, nurses bought into the idea that they could perform a credible pain assessment and that the time they spent on pain assessment and treatment planning would pay off. They could save time by being proactive and thus avoid dealing with inevitable consequences of unrelieved pain.

Winning administrative commitment

Another element of our success was that we stressed strong facility buy-in to the project from the outset. We were emphatic about the need for commitment from the top, not just on the part of the director of nursing, but also from the facility administrator. We encouraged the facility teams to meet on a regular basis with their director of nursing and administrator so they could convey the information about project status and work collaboratively to overcome the inevitable barriers to change. We asked the administrators to assist teams by finding a regular monthly meeting time that teams could work on their project.

Generating Facility Staff and Resident Support

We worked to have the facility teams obtain buy-in from other facility staff and from facility residents. In this way, we encouraged teams to transfer the locus of control of the project from the project faculty back onto the end-users—the facility staff and residents. We asked them to take the issues that they were dealing with to the Residents' Council, a forum for residents to speak out on issues of concern, which is required for all LTCFs in Wisconsin.

We emphasized local creativity to solve local problems. For example, we did not mandate use of one specific pain assessment tool; we provided teams with several examples and asked them to try different and creative approaches with their residents. One team developed a pain assessment stick, a two-foot length of wood, with tactile markers for different pain levels for use with visually impaired residents.

Listening to the Needs of Participants

We tried hard to be flexible in response toto the needs of the facility teams. Two key domains of care that were not included in the original project design were added mid-course at the request of participants. The first was education about pain assessment in the cognitively impaired resident. For this topic we enlisted the support of Christine Kovach, RN, PhD, a nurse researcher with expertise in dementia care. Dr. Kovach met with the project teams, presented didactic information, and introduced participants to a novel treatment algorithm for pain in the cognitively impaired resident.^21,22 The second domain was education for nursing assistants. Many project teams requested specific educational material and strategies to use with these important staff members. This led to development of teaching modules for nursing assistants, and separate modules for all staff and licensed nursing staff which were disseminated to all teams.²³

Timing of Workshops and Mentoring Change

We designed the spacing of the educational workshops to occur every three months so as to allow project teams sufficient time between workshops to digest new information and then to work together towards change. At the conclusion of each workshop, the project teams were given time to map out an implementation strategy.

The project faculty's role was one of coaching—we would walk around the room during each education workshop, meet with each project team, discuss their tentative plans, help challenge them to go a bit further in the planning than they thought possible and helped strategize how to overcome barriers. Between workshops, project faculty periodically contacted teams to assess the need for assistance and to give encouragement. We feel the relationship between the faculty and the project teams we established, that of coaches and mentors rather than lecturers and experts, was crucial to success as it helped build the strong sense of trust needed to keep the teams moving forward.

Inviting Regulators as Partners in Change

From the inception of the project, we brought our state long-term care regulators into the project design. We invited a regulatory representative to speak to the project teams on three key issues of concern to facility staff:

How the state regulators would evaluate:

1. the adequacy of pain assessment documentation,
2. use of chronic opioids for non-malignant pain, and
3. the manner of different prescription orders, for example, prn versus scheduled pain medication for a chronic painful condition.

Of note, since this project began, a number of LTCFs in Wisconsin have been cited by state regulators for failure to adequately assess and treat pain. Thus, we feel there was bi-directional learning in this project. Not only did the project teams learn how surveyors would conduct their business, but the surveyors learned key facts about pain assessment and treatment that could be used to raise the general level of pain management via the surveying process.

Barriers to Progress: Turnover, Lack of "Champion," Time

Although this project helped many facilities move forward, some facilities clearly had a hard time getting started and made little progress. The most important factor in project success was a stable facility staff; nothing dampened project momentum faster for a given facility than the turnover of the director of nursing, facility administrator or project team members who attended early workshops. Even though new facility team members would attend subsequent workshops, it was virtually impossible for them to get up to speed. Conversely, when we look at those facilities that were able to make substantial and sustainable progress, we can always identify a core group of senior and middle management staff with a long tenure at that facility.

A second factor that impeded facility progress was the absence of a champion, an individual who recognized the problem of poor pain management and made a very personal commitment to seek change through cheerleading and advocacy. Mentoring champions is not difficult once they are identified, and this project clearly had many. However, if no champion from a particular facility emerged, it was not possible for the project faculty to manufacture one, as champions must have a combination of strong internal motivation, personal energy, and excellent "people skills."

The third impediment to project success was time. LTCFs are typically stretched very thin just to provide routine care; the addition of a new project, requiring considerable staff time for implementation, was clearly a burden for many facilities. Those facilities that needed to devote time to other new projects that came forward during the project year, typically a state regulatory survey, were doubly pressured for time, leading some to scale back or completely abandon their project goals.

These three issues—staff turnover, lack of a champion and time—all relate to one core element needed for successful change: facility buy-in, the fundamental commitment to improvement. In one sense, if the commitment is strong enough from senior leadership, then any or all of the three identified problems are potentially surmountable. Without strong commitment, the presence of any one of these three problems is enough to scuttle significant progress.

Follow-Up

Since completing the one-year project with the initial 87 facilities, we have continued this work, revising project elements and developing new educational tools. A measure of the strong bond between the participating facilities and project faculty occurred at the final conference. In an open forum discussion with participants, project faculty asked, "How can the faculty continue to support you? What do you need?" The response was emphatically, "We want to keep working with you on this project, our work is not done!" The project faculty made a commitment to continue the project. We now hold quarterly meetings with the same facility teams, discussing topics of interest and developing new resources through workgroups comprised of project faculty and team members. Projects have included development of pain algorithms for all facilities and a workbook of educational resources, Pain 101, for facility staff.²⁴ The most recent request by teams has been to expand the pain project to include other aspects of end-of-life care, advance care planning, communication skills, and non-pain symptom control. Plans are now being formulated and funding sought for a LTCF end-of-life project, similar in concept to the pain project.

Subsequent to working with the 87 facilities described above, we have worked with other LTCFs—individual facilities, a group of nine facilities that come together for educational and staff development programs, and one large national LTC organization with more than 200 facilities. Most recently, we participated in a project, using the same design principles, for a consortium of different health care facilities (hospitals, hospices, LTCFs) working together within one community, Missoula, Montana. The project organizers in Missoula were interested in improving both inter-facility and intra-facility communication and coordination of pain care. This project has proven quite successful at breaking down some of the interagency barriers to pain management. As a consequence of this work, one Missoula hospital was cited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for their exemplary pain management work.

We have added two new elements to the original project. First, following the pain assessment role play and development of an analgesic plan, nurses role play contacting the physician for new orders, based on the analgesic plan they develop. This exercise provides nurses with an explicit opportunity to practice and receive feedback on the skill of communicating a pain assessment and treatment plan to a physician. A second element we have added is the use of a project storyboard. We ask each participating facility to design a poster, which graphically displays their work towards improving pain management, new assessment tools, analgesic guidelines, non-pharmacological treatment approaches, et cetera. Participants from each facility bring their storyboard to the final project workshop to share with other participants; they are then encouraged to display the storyboard prominently in their facility for all staff, residents and patients to see. This new feature has been very popular with project participants; they feel a tremendous sense of accomplishment after their year of hard work and want to share their success with others.

Improving pain management practice in long-term care facilities is hard work; it takes an amazing amount of time, resources and commitment to effect positive change. However, once the process is started, once small tasks have been successfully completed, the next task does not seem quite so insurmountable. We always encourage teams to start with the easy tasks first, the "low-hanging fruit," then build from success. The challenge is to take that first step.

Acknowledgement

The project was funded by grants from the Faye McBeath Foundation and the Eastern Wisconsin Area Health Education Center, Inc, under agreement No. STC-M 5U76 PE00234-04, with the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services. Additional funding was provided by Ortho-McNeil Pharmaceutical, Purdue Frederick Co., and Roxane Laboratories, Inc.

References:

1. Weissman DE, Dahl JL, Beasly J. Cancer Pain Role Model Program of the Wisconsin Cancer Pain Initiative. Journal of Pain and Symptom Management. 1993; 8:29-35.[Return to Featured Innovation]

2. Weissman DE, Dahl, JL. Update on the Cancer Pain Role Model Education Program. Journal of Pain and Symptom Management. 1995;10:292-297.[Return to Featured Innovation]

3. Gordon DB, Dahl JL, Stevenson KK. (eds.). Building an Institutional Commitment to Pain Management. Wisconsin Cancer Pain Initiative, Madison Wisconsin, 1996. [Return to Featured Innovation]

4. Gordon DB. Critical Pathways: A road to institutionalizing pain management. Journal of Pain and Symptom Management. 1996;11:252-259. [Return to Featured Innovation]

5. Gordon DB, Stewart JA, Dahl JL, Ward S, Pellino T, Backonja M, Broad JE. Institutionalizing pain management. Journal of Pharmaceutical Care in Pain & Symptom Control. 1999;7:3-16. [Return to Featured Innovation]

6. Ferrell BR, Dean GE, Grant M, Coluzzi P. An institutional commitment to pain management. Journal of Clinical Oncology. 1995;13:2158-2165. [Return to Featured Innovation]

7. Bookbinder M, Coyle N, Kiss M, Goldstein ML, Holritz K, Thaler H, Gianella A, Derby S, Brown M, Racolin A, Ho MN, Portenoy RK. Implementing national standards for cancer pain management: Program model and evaluation. Journal of Pain & Symptom Management. 1996;12:334-347. [Return to Featured Innovation]

8. Weissman DE, Griffie J, Gordon DB, Dahl JL. A role model program to promote institutional changes for management of acute and cancer pain. Journal of Pain & Symptom Management. 1997;14:274-279. [Return to Featured Innovation]

9. Ferrell BA. Pain evaluation and management in the nursing home. Annals of Internal Medicine. 1995;123:681-687. [Return to Featured Innovation]

10. Ferrell BA, Ferrell BR, Osterwald D. Pain in the nursing home. Journal of the American Geriatric Society. 1990;38:409-414. [Return to Featured Innovation]

11. Roy R, Michael T. A survey of chronic pain in an elderly population. Canadian Family Physician Med Fam Can. 1986;32:513-516. [Return to Featured Innovation]

12. Mobily PR, Herr KA, Clark MK, Wallace RB. An epidemiologic analysis of pain in the elderly: The Iowa 65+ Rural Health Study. Journal of Aging Health. 1994;6:139-145. [Return to Featured Innovation]

13. Matson S. Improving pain management in long-term care. Masters Thesis, Medical College of Wisconsin, 1996. [Return to Featured Innovation]

14. Portenoy RK. Chronic opioid therapy in nonmalignant pain. Journal of Pain and Symptom Management. 1990;5:S46-S62.[Return to Featured Innovation]

15. Weissman DE, Griffie, J, Muchka S, Matson S. Building an institutional commitment to pain management in long-term care facilities. Journal of Pain and Symptom Management. 2000;20:35-43. [Return to Featured Innovation]

16. Weissman DE, Griffie, J, Muchka S, Matson S. 2000. [Return to Featured Innovation]

17. Weissman DE, Griffie, J, Muchka S, Matson S. 2000. [Return to Featured Innovation]

18. Weissman, DE. Doctors, nurses and storytelling. Journal of Palliative Medicine. 2000;3:251-252. [Return to Featured Innovation]

19. Griffie J, Matson, S, Muchka S, Weissman DE. Improving Pain Management in Long-Term Care Settings: A resource guide for institutional change. Medical College of Wisconsin, Milwaukee, 1998.[Return to Featured Innovation]

20. Griffie J, Weissman DE. Nursing staff education resource manual: A six session inservice education program in pain management for long-term care facilities. Medical College of Wisconsin, 2000. [Return to Featured Innovation]

21. Kovach CR, Weissman DE, Griffie J, Matson S, Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. Journal of Pain & Symptom Management. 1999;18:412-419.[Return to Featured Innovation]

22. Kovach CR, Griffie J, Muchka S, Noonan PE, Weissman, DE. Nurses perception of pain assessment and treatment in the cognitively impaired elderly. Clinical Nurse Specialist. 2000;14:215-220.[Return to Featured Innovation]

23. Weissman, DE. 2000. [Return to Featured Innovation]

24. Griffie J, Matson, S, Muchka S, Weissman DE. 1998.[Return to Featured Innovation]

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