Lois L. Miller

Measuring Pain as the 5th Vital Sign Does Not Improve Quality of Pain Management

AbstractBACKGROUND: To improve pain management, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative in 1999, requiring a pain intensity rating (0 to 10) at all clinical encounters. OBJECTIVE: To measure the initiative’s impact on the quality of pain management. DESIGN: We retrospectively reviewed medical records at a single medical center to compare providers’ pain management before and after implementing the initiative and performed a subgroup analysis of patients reporting substantial pain (≥4) during a postimplementation visit. PARTICIPANTS: Unique patient visits selected from all 15 primary care providers of a general medicine outpatient clinic. MEASUREMENTS: We used 7 process indicators of quality pain management, based on appropriately evaluating and treating pain, to assess 300 randomly selected visits before and 300 visits after implementing the pain initiative. RESULTS: The quality of pain care was unchanged between visits before and after the pain initiative (P>.05 for all comparisons): subjective provider assessment (49.3% before, 48.7% after), pain exam (26.3%, 26.0%), orders to assess pain (11.7%, 8.3%), new analgesic (8.7%, 11.0%), change in existing analgesics (6.7%, 4.3%), other pain treatment (11.7%, 13.7%), or follow-up plans (10.0%, 8.7%). Patients (n=79) who reported substantial pain often did not receive recommended care: 22% had no attention to pain documented in the medical record, 27% had no further assessment documented, and 52% received no new therapy for pain at that visit. CONCLUSIONS: Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.

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.

Establishing partnerships with family caregivers. Local and cosmopolitan knowledge.

Families now provide most of the care received by older people in the United States. Proposed changes in the health care system will mean that families must take an even greater role in delivering health care. It is crucial that nurses practicing in a variety of settings be prepared to establish partnerships with family caregivers in order to attend to the long-term care needs of older people.

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 nations 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 nurses career trajectory.

Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide

Background: When the Oregon Death with Dignity Act (ODDA) legalizing physician assisted suicide was enacted into law in 1997, Oregon hospice clinicians were uncertain how involved they would be with patients who wanted this option. However, 86% of the 171 persons in Oregon who have died by lethal prescription were enrolled in hospice programmes. Method: A mailed questionnaire was sent to all hospice nurses and social workers in Oregon in 2001 (n = 573) to assess their attitudes about legalized assisted suicide and interactions with patients concerning this issue. Responses from 306 nurses and 85 social workers are included in this report. Findings: Almost two-thirds of respondents reported that at least one patient had discussed assisted suicide as a potential option in the past year. Social workers were generally more supportive of both the ODDA and of patients choosing assisted suicide compared to nurses. Twenty-two per cent of all respondents were not comfortable discussing assisted suicide with patients. Ninety-five per cent of both groups, however, favoured hospice policies that would allow a patient to choose assisted suicide while enrolled in hospice and allow hospice clinicians to continue to provide care. Interpretations: Nurses and social workers in hospices and other settings can expect to encounter patient questions about physician-assisted suicide, whether legalized or not, and must be prepared to have these discussions. Most hospice professionals in Oregon do not believe that assisted suicide and hospice enrolment are mutually exclusive alternatives.

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.

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.

Pain in older adults.

This chapter reviews 80 published research reports of pain and pain problems in older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the search terms pain, older adult, aged and pain, and dementia. Reports were included if published between 1985 to 2001, if conducted on samples age 60 or older, if conducted by nurses or relevant to nursing research, and if published in English. Descriptive, qualitative, correlational, longitudinal, and intervention studies were included. Key findings include the following: pain is widely prevalent in older adult populations; few studies have included minority groups; underidentification and undertreatment of pain in older adults is a consistent interpretation of research findings; pain intensity rating scales are as valid and reliable in older populations as in younger populations; current observational methods of assessing pain in cognitively impaired older adults must be used with caution; nursing intervention studies demonstrate the beneficial effects of education and interventions aimed at improved pain assessment. The main recommendations are: careful attention should be given to the conceptualization and definition of pain; examination of pain should include physiological, motivational, cognitive, and affective factors; studies evaluating undertreatment of pain should include measures of pain selfreport; standardized pain measures should be used; studies of persons over the age of 85 and studies of ethnic minorities are needed; more attention should be given to nursing intervention studies and should include both pharmacological and nonpharmacological, psychosocial interventions.

Development of use and cost measures in a nursing intervention for family caregivers and frail elderly patients

The purpose of this pilot study was to refine and evaluate methods of measuring costs of an innovative home-health nursing intervention designed to support frail, older persons and their family caregivers. We evaluated a multifaceted strategy to collect a detailed utilization profile from 22 caregiver/care receiver dyads for hospital, ambulatory, home health, nursing home, and community services. The strategy was feasible for most participants, maximized accuracy of cost data, and minimized research burden on study participants. Lower overall costs were found in the intervention group, but the difference was not significant. Approaches to the measurement of costs in this study can serve as models for evaluating other innovations in nursing, home care, and long-term care.

Dilemmas encountered by hospice workers when patients wish to hasten death

In 1997, Oregon enacted the Oregon Death With Dignity Act, which legalized physician-assisted suicide. This article reports on a qualitative study of the ethical and clinical dilemmas experienced by hospice nurses and social workers when they encounter patients who wish to hasten death through physician-assisted suicide. The biggest dilemma arises from the conflict between two important hospice values: honoring patient autonomy versus promoting a death experience in which personal and spiritual transformation are possible. Hospice professionals report conflict between their advocacy for patients and for the family members who sometimes oppose physician-assisted suicide. Conversely, when patients choose to hasten death by voluntarily refusing all food and fluids, many of these dilemmas dissipate. As more patients request control of the circumstances of their deaths, a better understanding of the complex issues regarding hastening death is needed for patients, families, and the health professionals who provide care during this difficult transition.