Geriatric pain competencies and knowledge assessment for nurses in long term care settings.

Pain in older adults is a prevalent problem that affects quality of life and challenges nurses, particularly those caring for older adults living in long term care settings. Despite the national priority of pain management, insufficient knowledge of nurses about geriatric pain is a documented barrier to effective geriatric pain management in all long term care settings. To address this knowledge gap, a website (GeriatricPain.org) was developed by the National Geriatric Pain Collaborative with a grant from the MayDay Fund to provide a single site for evidenced-based, easy-to-use, downloadable resources on pain management. This paper describes the development of the most recent addition to the website, a set of evidence-based core geriatric pain management competencies and a geriatric pain knowledge assessment, and discusses their potential uses in improving pain care for older adults.

Challenges in making a business case for effective pain management in nursing homes.

The lack of a systematic and comprehensive pain management program is a common quality problem in nursing homes. The purpose of this article is to address the business case for effective pain management in this setting, including the conceptual domains and processes that should be considered in improving quality and reducing costs. Unfortunately, the literature contains very little to inform those working to implement effective and efficient pain management programs in nursing homes. This article suggests several strategies for establishing an internal business case to support the implementation of a comprehensive pain management program in a nursing home setting.

Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice.

Many tools are available for the assessment of pain in nonverbal older adults; however, guidelines are needed to help clinicians select the proper instrument for use in the nursing home setting. This article describes a project to identify clinically useful pain-behavioral assessment tools that have undergone sufficient psychometric testing. Phase 1 of the project included a comprehensive review and critique of currently available tools. In Phase 2 the National Nursing Home Pain Collaborative developed criteria to evaluate an updated list of tools and then rated 14 tools using these criteria. As a result, two tools were recommended as most representative of current state of the science, most clinically relevant, and practically applicable to integrate into everyday practice and support adherence to regulatory guidelines. Such recommendations for selection of best-available pain assessment tools are a cornerstone for clinicians in regard to managing pain of nursing home residents who, due to dementia, are unable to self-report pain.

Provision of morning care to nursing home residents with dementia: opportunity for improvement?

Significant contact between nursing staff and nursing home residents with dementia occurs during assistance with activities of daily living during morning care; however, the content and process of morning care have received little attention in the scientific literature. To better understand the morning care process and its role in generation of pain symptoms, 51 videotaped episodes of morning care involving 17 nursing home residents from 3 long-term care facilities were coded and analyzed; each resident had a diagnosis of dementia and concern about possible pain during assistance with activities of daily living. The typical morning care episode involved performance of multiple activities of daily living during a short period of time, during which pain stimulation and expression occurred frequently. Much could be done to make morning care more an activity to be enjoyed rather than a task to be completed.

Observation of Pain in Dementia.

Recognition of pain in older persons with dementia is a considerable challenge to quality pain care for this vulnerable population. Without recognition, pain cannot be thoroughly evaluated and effectively treated. Observing for pain-related behaviors is the most researched means of identifying the presence or likelihood of pain in persons with moderate to severe dementia, or those who are unable to self-report their pain. The purpose of this paper is to discuss the state of observation of pain, primarily focusing on pain behavior tool development, providing an overview of current pain tools and discussing the challenges at this stage of the science, including the issue of assessing pain intensity. We also recommend a number of areas to prioritize future research with the goal to advance effective pain assessment in older persons with dementia. Central to these recommendations is the refinement of existing tools to incorporate those behaviors most predictive of pain in persons with dementia as the science progresses in this area. The future of pain observation in dementia is poised for considerable advancement through these refinements of tools and techniques. Improving our ability to detect and evaluate pain in the vulnerable population unable to self-report their pain, through the results of these suggested research priorities, will likely assist in addressing the related suffering that results from unrecognized and untreated pain.

Improving the process of pain care in nursing homes: a literature synthesis.

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.

Enhancing nursing leadership in long-term care. A review of the literature.

The quality of care provided to nursing home residents has been the subject of broad criticism for years. Mounting evidence suggests that the quality of nursing home care can be improved by strengthening the roles of nurses in these facilities. This article reviews the literature on programs designed to enhance nursing leadership in long-term care, examines outcomes associated with leadership in long-term care, and outlines recommendations for programs to enhance nursing leadership in nursing home settings. The findings suggest that nursing leadership training programs for nurses working in nursing homes are urgently needed to improve quality in the nation's nursing homes and stabilize the workforce. To maximize their effectiveness, these leadership training programs should be part of a continuum of leadership development that begins in nursing education programs and persists throughout a nurse's career trajectory.