Advancing Excellence in Pain Assessment (Part 1)

Every resident has the right to be pain free and this can only be accomplished through an effective pain management program. Every long-term care facility should develop policies and protocols related to pain management and ensure implementation. Standards of practice should be based on accepted evidence-based clinical guidelines.

Success begins with establishing accountability for pain management through designating staff to participate in an interdisciplinary pain management workgroup. The organization must be committed to these policies and procedures.

The CMS proposed regulation provides an outline for best practices related to pain management in long-term care facilities. While the intent to embed this within F309, as opposed to a separate pain management tag, has led to discussion from stakeholders, the content is sound and helps the facility to assist each resident with pain to maintain or achieve the highest practicable level of well-being and functioning. The proposed regs do this by:

• screening
• assessing
• anticipating
• developing and implementing
• monitoring and evaluating

The pain problem

Pain is an all too common experience in the long-term care environment. Although both chronic and acute pain exist, chronic pain is more often unrecognized and not treated. CMS reports that 45 to 80% of nursing home residents have substantial pain that is under-treated and that 41% of nursing home residents are in persistent severe pain.

PointRight Inc. has discovered that predicting a resident’s pain level is done through reviewing the resident’s previous MDS assessment—meaning either the pain items were carried forward without reassessment or pain wasn’t being treated or accurately captured on the MDS. Inadequate treatment of pain can adversely affect residents’ physical functioning, clinical status and emotional well-being and place the family at odds with facility staff.

Pain is not a direct consequence of aging. This major misconception is believed by residents and caregivers alike. There are, however, common conditions seen in nursing home residents that place them at high risk for pain. Assuming pain to be “normal” is false and leads to inadequate treatment. Some believe that dementia is a “buffer” for pain and that confused elders don’t feel pain the same as their non-confused peers. That also is wrong, and doesn’t appropriately link agitation, withdrawal or even the reduction of behaviors to pain.

Finally, there are some who believe that elders shouldn’t be treated with some classes of pain medication due to the possibility of addiction or fear of suppressing respirations, the latter being a finding that has never been convincingly substantiated.

When assessing for pain, it’s important to consider the culture of both the resident and the caregiver. The entire pain experience, including the way pain is expressed (or not expressed) and responded to, is greatly influenced by one’s culture. To speak in very broad terms, some cultures don’t express pain, believing it to be a weakness or a burden that must be dealt with privately. Still other cultures are very articulate about their pain experiences. Knowing the resident’s individual value system as it relates to comfort and pain is the key. Family members are often a good source of this information if residents are unable to provide it themselves.

It’s not just the resident. Staffs have their own prejudices about pain that impact assessment and treatment. Dedicated staff education that is interactive in nature is an effective way to bring these feelings forward and ultimately set them aside.

Language is another challenge when assessing residents’ pain. Residents and caregivers commonly do not share the same primary language. Add to that the fact that pain is described in many different ways, including with euphemisms such as “my burden” and “my old friend.”

Appropriate response

Strategies to help overcome these barriers include:

• Creating an expectation for residents to be pain-free. Any clinician who states that a resident is “pain-free” should be asked to prove it. Document the assessment of pain, and how the assessment authentically evaluates pain in the presence of co-morbidities, like dementia.
• Conducting staff training using specific residents as case studies and using competency-based assessments to document staff ability to assess pain
• Empowering all staff members (clinical and non-clinical) to identify residents in pain. Encourage family participation in the assessment and evaluation process.
• Including the assessment and documentation of pain in the medication administration policy and procedure, and indicating pain level and pain scale used for the resident on the medication administration record.

Systems to manage pain include:

• Pain Screening – Staff need to determine whether or not the resident is experiencing any pain
• Pain Assessment – A comprehensive pain assessment that identifies underlying causes and circumstances for each resident having pain
• Plan of Care – Individualized approaches to manage the resident’s pain based on clinical rationale, consideration of both pharmacologic and non-pharmacologic interventions, and including specific resident goals
• Plan Implementation and Monitoring – Implementing the plan and monitoring the resident to determine the response to the interventions including effectiveness and emergence of adverse consequences