Step 1
Step 1: Understand the Problem, the Solution
In most nursing homes today, pain among residents is under-detected and under-treated. The good news is that we have the tools and knowledge to effectively manage most pain.
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"There Is Much Pain That Is Quite Noiseless"
This observation by British novelist George Eliot seems especially true in nursing homes, particularly among long-stay residents, whose pain tends to be chronic, low-grade, and silent. “Few people with chronic pain still cry out or moan or have sweating or a rapid heartbeat,” writes physician Joanne Lynn, a specialist in palliative care (1). “Most just reduce activity and withdraw from interaction. It takes having an attentive and enduring caregiver to notice…”
By most accounts, nursing home providers are not noticing. Findings from recent studies reveal the following:
Pain Management: Just Do It
The literature on pain management lists a litany of reasons why pain goes under-detected and under-treated in nursing homes—lack of staff time, lack of staff knowledge, communication barriers, cultural barriers, social barriers—the list goes on.
In fact, says Dr. Michael Gloth, associate professor of medicine at Johns Hopkins University in Baltimore, Maryland, “There is no reason for folks to be suffering with pain on a daily basis. We have the tools to take care of it, the knowledge to take care it, we just need to do it (7).”
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It Starts With Screening
So where do you start? With an initial pain screening, followed by a comprehensive assessment and appropriate treatment, and then regular reassessments and ongoing monitoring of all residents to detect any changes in status. In the next section, we present instructions and tools for accomplishing the first step: screening for the presence of chronic pain among nursing home residents.
Before you read on, however, consider these program prerequisites.
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Your Assignment
Review the medical charts for a random sample of 10-15 residents. Look for documentation of pain assessments by both licensed nurses and physicians.
What do you find? Are assessments documented for all residents? How are assessments conducted? How many residents have pain documented? Is there documentation of physician follow-up for these residents?
Share your findings with us; please contact us. We hope to post your feedback on future updates to this site.
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Click on one of the following topics to skip to that section:
- There Is Much Pain That Is Quite Noiseless
- Pain Management: Just Do It
- It Starts With Screening
- Your Assignment
"There Is Much Pain That Is Quite Noiseless"
This observation by British novelist George Eliot seems especially true in nursing homes, particularly among long-stay residents, whose pain tends to be chronic, low-grade, and silent. “Few people with chronic pain still cry out or moan or have sweating or a rapid heartbeat,” writes physician Joanne Lynn, a specialist in palliative care (1). “Most just reduce activity and withdraw from interaction. It takes having an attentive and enduring caregiver to notice…”
By most accounts, nursing home providers are not noticing. Findings from recent studies reveal the following:
- An estimated 45% to 83% of nursing home residents are reported to be in pain, most suffering symptoms of osteoarthritis and related musculoskeletal problems (2, 3).
- Despite this high prevalence, pain in nursing homes is under-detected and therefore under-treated. In two studies, physicians had not documented pain in 30%-40% of nursing home residents who reported pain symptoms when independently assessed by research staff (4, 5).
- In one of our recent studies, among the residents reporting pain, only 42% were receiving pain medication, though 80% said they would like to (5).
- This study also found that licensed nurse assessments of pain were documented weekly; however, more than 50% of the residents who reported pain symptoms to us had nurse pain scores of zero during the past four consecutive weeks (5).
- In another study, we found that of the 309 residents who reported chronic pain in interviews with research staff, only 115, or 37.2%, had documentation of pain on their most recent Minimum Data Set (MDS) assessment (6).
- Moreover, this study showed that as a resident’s cognitive impairment increased, nursing home staff were increasingly less likely to document pain presence on the MDS, a finding that suggests that the staff were using subjective criteria to evaluate pain among residents (6).
Pain Management: Just Do It
The literature on pain management lists a litany of reasons why pain goes under-detected and under-treated in nursing homes—lack of staff time, lack of staff knowledge, communication barriers, cultural barriers, social barriers—the list goes on.
In fact, says Dr. Michael Gloth, associate professor of medicine at Johns Hopkins University in Baltimore, Maryland, “There is no reason for folks to be suffering with pain on a daily basis. We have the tools to take care of it, the knowledge to take care it, we just need to do it (7).”
Back to Top
It Starts With Screening
So where do you start? With an initial pain screening, followed by a comprehensive assessment and appropriate treatment, and then regular reassessments and ongoing monitoring of all residents to detect any changes in status. In the next section, we present instructions and tools for accomplishing the first step: screening for the presence of chronic pain among nursing home residents.
Before you read on, however, consider these program prerequisites.
- First, enlist top-level support from a managerial “champion” to facilitate adoption of this new screening procedure by licensed nurses and direct care staff. One way to recruit help: Hand the likely champion a copy of this module and ask if you two can discuss it after s/he has read it. Have you considered that you yourself might be the champion?
- Second, read through the module so that, from beginning to end, you know what’s needed to improve pain management.
- Finally, allow extra time at the beginning to climb the learning curve; staff may need extra reinforcement at the start to establish a new pain screening routine.
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Your Assignment
Review the medical charts for a random sample of 10-15 residents. Look for documentation of pain assessments by both licensed nurses and physicians.
What do you find? Are assessments documented for all residents? How are assessments conducted? How many residents have pain documented? Is there documentation of physician follow-up for these residents?
Share your findings with us; please contact us. We hope to post your feedback on future updates to this site.
Back to Top or proceed to Step 2
