Ideally, pain management should be most effectively managed for residents residing in long-term care (LTC) settings (U.S. Department of Health and Human Services, Agency for Healthcare and Research Quality, 2011). Despite the vast availability of pharmacological and nonpharmacological modalities, patients are still at a disadvantage when it comes to pain relief. Patients in LTC facilities are at an advantage for having optimal pain control because they have around-the-clock health care and access to immediate pain control measures (American Medical Directors Association, 2012). Nevertheless, the literature indicates that pain is common among LTC patients and is often undertreated (Hollenack, Cranmer, Zarowitz, & O’Shea, 2007).
According to the American Geriatrics Society Panel on Persistent Pain in Older Persons (2002), approximately 45% to 80% of LTC residents have substantial pain, and 25% of those with daily pain were not administered any medication or intervention for pain relief. The Centers for Medicare & Medicaid Services has reported that as many as 83% of residents in LTC facilities may experience pain on a regular basis (Baier et al., 2004). The outcomes of poor pain management in older adults are significant and can lead to a diminished ability to perform activities of daily living (ADLs), depression, feelings of isolation, mobility impairment, sleep disruption, anxiety, decreased social involvement, diminished independence, and decreased quality of life (Evans & Crane, 2013; Kaasalainen et al., 2010; Takai, Yamamato-Mitani, Okamoto, Koyama, & Honda, 2010; Wells, Pasero, & McCaffery, 2008). Hix (2007) discussed the challenge of managing pain in older adults and its debilitating effects. Age-related changes in the perception of pain, cognition, medication effects, and interactions are all attributed to this challenge for providers.
Nurse practitioners (NPs) have been found to enhance the overall quality of care and improve health care outcomes in LTC settings (Brooten, Youngblut, Kutcher, & Bobo, 2004; Levy et al., 2005; Stolee, Hillier, Esbaugh, Griffiths, & Borrie, 2006); however, the current limitations of their pain management treatment options have resulted in inadequate pain management in LTC (Kaasalainen, DiCenso, Donald, & Staples, 2007). Despite the many options for analgesic medications on the market, a struggle exists: long delays occur between the time of pain assessment and the improvement of symptoms. Evidence-based factors that may be barriers limiting the role of NPs in pain management include (a) NP prescriptive restrictions of schedule II analgesic medications; (b) time constraints; (c) lack of knowledge; (d) difficulty with assessing pain; (e) physician, staff, patient, and/or family reservations about the use of narcotics; (f) poor collaboration with physicians (Kaasalainen et al., 2010; Kaasalainen, DiCenso et al., 2007); and (g) a lack of access to stock medication (Human Rights Watch, 2009). Schedule II analgesic medications are described as drugs or substances that have (a) a high potential for abuse, (b) been accepted for medical use with severe restriction in treating patients in the United States, or (c) the abuse potential to lead to severe psychological or physical dependence (United States Controlled Substances Act, 2012). The current study focused on the use of schedule II analgesic medications, including morphine, oxycodone, hydrocodone, fentanyl patch, and methadone.
Lazarus and Downing (2003) identified the top five barriers to effective pain management, as perceived by NPs. The identified barriers in order of frequency reported included (a) educational deficits, (b) restrictions by regulating agencies, (c) limitations on scope of practice, (d) physician resistance to prescriptive authority, and (e) the denial of third-party payment. They concluded that multiple studies have shown the effectiveness of NPs in terms of clinical outcomes and patient satisfaction and that granting additional prescriptive authority may increase the effectiveness of NPs’ role in providing adequate pain control in LTC. Furthermore, NPs could develop and facilitate nursing education to LTC nursing staff that focuses on pain assessment and early detection, as well as the safe administration of pharmacological and nonpharmacological interventions for optimal pain control (Kaasalainen, DiCenso et al., 2007).
LTC facilities in the United States stipulate that pharmaceutical services be responsive to patient needs (The Lewin Group, 2004). Timely delivery of drugs is crucial so that patients’ prescribed treatment plans are not delayed. The U.S. Drug Enforcement Agency (DEA) has enforced rules and regulations that can significantly delay or deny patients needed treatment, leaving sick and dying patients without pain relief. Reports indicate that patients have been left suffering for hours up to days, as providers and caregivers strive to comply with DEA requirements (The Quality Care Coalition for Patients in Pain, 2010). The majority of LTC facilities do not have schedule II analgesic medications or a supply of narcotic analgesic medications in their locked back-up supply. They typically contract with an outside pharmacy that specializes in servicing LTC populations. The Quality Care Coalition for Patients in Pain (2010) found that of approximately 900 providers, 65.4% of respondents experienced delays in getting controlled medications to their patients. In addition, 8% reported delays of up to 1 hour, 40% reported delays of up to 2 days, and 12% reported delays of 2 or more days. Finally, providers also reported:
- using less effective, non-narcotic medications that are often insufficient to control pain in older patients;
- delays in treatment caused by DEA rules, thus leading to hospital readmission, increased costs, and the production of unnecessary stress among LTC patients; and
- delays in patient recovery from post-surgical rehabilitation measures and extended need for skilled care.
Many respondents experienced increased stress and tension because of their inability to administer adequate pain medications to their patients in a timely manner. Many also reported that they could not comply with DEA rules as well as meet their professional obligations to patients or practice the established treatment guidelines.
One respondent explained that when a patient is admitted to LTC and is experiencing pain, by the time the physician is called and the medication is delivered from the pharmacy (which can be up to 4 hours at this particular facility), the patient can be in pain for more than 7 hours. Another respondent reported that the paperwork involved in obtaining medication for a patient who was newly admitted post-surgery for a hip repair took approximately 2 hours. Patients in pain look to nurses for pain relief. Cancer, bone, and post-surgical pain require stronger analgesic medications than over-the-counter medications (The Quality Care Coalition for Patients in Pain, 2010).
A review of the recent literature found a limited quantity of research studies regarding pain and its management in LTC. In addition, although literature exists outlining the need for better pain management among the older adult population, outcomes of unmanaged pain among LTC residents is lacking. The purpose of the current study was to describe the pain management processes used by nurses in LTC facilities and identify factors that may be impacting nursing’s role in providing adequate pain control in LTC facilities. Patient medical records were reviewed to determine the typical processes used by nurses to obtain adequate pain control medication within LTC facilities, as well as the documented patient outcomes that come from these processes. Medical records were also examined to determine the time that lapsed between the initial assessment and the time patient symptom improvement had occurred. The results of the current study are intended to provide data for enhancing the role of the NP in pain management, developing a process that will lead to improvement in adequate pain management within LTC facilities, and improving patient outcomes.
The current pilot study used a retrospective design to (a) describe the pain management processes used by nurses in LTC facilities and (b) identify factors that may be affecting nursing’s role in providing adequate pain control in LTC facilities.
Sample and Setting
After gaining institutional review board approval, 150 medical records dated from March 1, 2012 to March 1, 2013, were randomly selected for review from two suburban LTC facilities in the United States. A convenience sample of 80 patient medical records, which met the inclusion criteria, were used for the current study. Both facilities used both electronic and paper charting, as the electronic health record was not at full functioning capacity at the time of data collection. All patients were receiving skilled nursing care.
Facility A is a 90-bed, privately owned, non-profit facility licensed by the state of Michigan and reimbursed/certified by the federal government and individual patients’ health care plans. The facility includes a skilled nursing unit, an enhanced memory services unit, and an assisted living unit. This facility is managed by an executive director who is hired by the board of directors; a director of nursing supervises the nursing staff. The nursing staff consisted of 90% RNs and 10% licensed practical nurses (LPNs). The staffing ratio of nurse to patient is 2 to 15, respectively.
Facility B is a 230-bed, for-profit, corporately managed facility. This facility is also licensed by the state of Michigan and is reimbursed by federal government funding, private insurance, and private pay by individual patients. This facility also employs an executive director and has a director of nursing who manages the medical facet of the organization. Nursing turnover is more common in this facility, with the majority of employed nurses being LPNs.
Participants were male and female LTC residents ages 65 to 96. Patient records indicative of a schedule II analgesic prescription and a pain scale rating of 6 or greater on McCaffrey’s pain scale were included in the study. This pain scale records patient responses to pain as follows: 0 (no pain), 1 to 3 (mild pain), 4 to 6 (moderate pain), 7 to 9 (severe pain), and 10 (the worst pain imaginable) (McCaffrey & Pasero, 1999). Both facilities used the pain scale rating; however, consistent pain assessment protocols and documentation varied by facility.
Two data collection tools were developed to record patient information obtained from the medical records. The first tool recorded demographic data, including patients’ sex, age, race, ethnicity, level of education, and marital status. It also included the time patients were initially assessed for pain; the time the physician was contacted by the nurse or NP; what type of pain medication was ordered and administered; the time the patient received the pain medication; and the time pain relief was obtained. The second tool was titled “Outcomes Checklist” and included reviewing nursing notes for indications of diminished sleep, appetite, performance of ADLs, refusal of rehabilitation exercises, and increased agitation or diminished psychological well-being. In addition, the checklist included any non-narcotic analgesic agents and nonpharmacological pain management given to relieve patient pain. Patients’ pain scales before and after schedule II analgesic medication administration were also recorded on this checklist.
Descriptive statistics, including frequencies, means, and bivariate correlations, were computed using the computer software program SPSS version 20. Level of significance was set at p = 0.05.
Eighty medical records were reviewed for the current study; however, after data cleaning, only 55 cases were used in the final analysis; 60% (n = 33) of medical records reviewed came from facility A, and 40% (n = 22) of charts came from facility B. Table 1 describes demographics of the study participants. The study included approximately the same percentage of men (50.9%) and women (49.1%). The majority of participants were widowed (58.2%), had a high school education (27.3%), and were Caucasian (89.1%). Table 2 shows the time intervals for pain assessment, administration of schedule II analgesic medication, and relief of pain.
Patient Demographic Data (N = 55)
Time Intervals from Pain Assessment to Pain Relief (N = 55)
Table 3 presents bivariate analyses that were calculated to determine the relationships between multiple variables related to lapse of time involving pain assessment to pain relief and six outcomes relating to effects of pain management.
Bivariate Pearson’s Correlations Among Variables (N = 55)
Findings indicated that older adult men had greater pain indicators than female residents (r = −0.27, p = 0.04). Documentation from charts and statistical findings show that a greater time in hours from pain assessment to pain relief among men occurred (r = 0.27, p = 0.05). Women obtained relief from their pain sooner than men. A significant, positive correlation was found between the time in hours from pain assessment to medication administration and time in hours from pain assessment to pain relief (r = 0.52, p < 0.01). Men presented with higher pain scores prior to their scheduled II analgesic medication (r = −0.34, p = 0.05), whereas pain scores following medication administration were not found to be significant (r = −0.25, p = 0.07).
Significant relationships were also found with higher pain intensities. Residents with higher pain scores prior to the schedule II analgesic medication had higher pain scores after the medication was given (r = 0.48, p < 0.01). Residents with higher pain scores prior to the administration of the medication had more sleep disturbances (r = 0.34, p = 0.05); resisted movement with care (r = 0.45, p < 0.01); lacked participation in skilled therapy (r = 0.28, p = 0.04); and showed decreased psychological well-being (r = 0.33, p = 0.05) due to pain. The greater time in minutes from pain assessment to physician contact had a negative effect on appetite and weight (r = 0.37, p = 0.01). Men had a higher indicator of diminished participation in skilled therapy due to pain (r = −0.38, p < 0.05). When nonpharmacological methods were used alone for pain relief, an increase in diminished psychological well-being occurred versus when a scheduled II analgesic medication or other pharmacological pain medication was used (r = 0.30, p = 0.03).
Factors Impacting Nursing’s Role in Pain Management
A review of nurses’ process notes revealed factors that facilitated or constrained nursing’s ability to provide patients with adequate pain management. The following concerns were exposed:
- Nurses received verbal or written orders for schedule II analgesic medication from NPs, physician assistants (PAs), or physicians but did not have a hard copy of the prescription required by the pharmacy to administer or obtain the medication.
- Medications were not being given by nursing when received from the pharmacy. Instead, medications were sometimes given the following day when the times were pre-scheduled on the medication administration record.
- Back-up medications did not include schedule II pain medications. Often, patients were admitted past the pharmacy cut off time, which required nurses to obtain an order for a less effective medication until the stronger and more effective medication was received.
The results of the current study indicate that pain management remains a major problem in LTC. Although no significance or correlation was established between assessment time and pain relief, some significant findings exist, demonstrating a positive correlation on outcomes of well-being and health. In the current study, older male patients were found to have greater pain scores and greater time to pain relief than female patients. This finding is contrary to what has been found in previous research studies. Although little is written comparing gender differences in pain perceptions and management of pain experiences within residents of LTC facilities, Racine et al. (2012) found no significant gender differences in overall pain scores.
In the current study, patients with higher pain scores prior to the administration of a schedule II analgesic medication were found to have higher pain scores post medication administration. Previous research has shown that when pain is not controlled in a timely fashion, it is sometimes more difficult to “catch up” on achieving pain relief (Hollenack et al., 2007). Patients are often advised by medical personnel to take medications early to avoid the pain from progressing to a more severe experience. Severe pain can often lead to an increased use of pain medication, with increased dosages required and an extended relief time, which, in turn, has an effect on outcomes of health and wellness (Institute of Medicine, 2011; International Association for the Study of Pain, 2011).
Another significant finding of the current study was that residents with inadequate pain relief were found to have multiple negative outcomes. Residents experiencing higher pain scores prior to receiving their schedule II analgesic medications experienced sleep disturbances; were less cooperative with repositioning and direct care; exhibited greater signs of depression, anxiety, agitation, and behavioral changes; and were less likely to participate in therapy or experienced shortened therapy services. These findings are similar to those of previous studies (Russell, Madsen, Flesner, & Rantz, 2010; Takai et al., 2010; Tosato et al., 2012). However, residents with negative outcomes, are less likely to be discharged from LTC facilities because of poor therapy results, and they often experience a general decline in well-being. Furthermore, unrelieved acute pain can lead to long-standing chronic pain (Wells et al., 2008).
Finally, the current study found that when nonpharmacological treatments were used independently for pain control, they were not as effective as pharmacological treatments in reducing moderate to severe pain, leading to diminished psychological well-being in some residents. These findings indicate that although non-pharmacological modalities are useful with pain management, some patients require stronger analgesic or narcotic analgesic medications to control their pain. This finding further supports the importance of providing continuing education for nurses in the assessment of pain, the use of pain medication, and the adjunct role of nonpharmacological modalities in pain management.
Findings from this study suggest that current practices and policies in pain management within the LTC facilities examined were limited and insufficient in providing quality patient care and pain relief. Anecdotal evidence and documentation found in nurses’ notes suggested that this limitation may be due to the fact that schedule II analgesic medications were not typically stocked and readily available in these LTC facilities. The usual procedure was to have schedule II prescriptions ordered by a physician or NP, then filled at an outside pharmacy to be delivered to the LTC facility.
Evidence from this medical record review also indicated that the lack of knowledge about adequate pain control and inadequate pain management practices were additional factors causing inappropriate time intervals from pain assessment to medication administration. Nurses were not aware that the schedule II analgesic medication should be immediately administered to the patient for pain relief. Often, nurses waited until the next scheduled medication time to administer the medication to the patient. Other deficiencies found in LTC nursing practices were the lack of follow up of pain medication effectiveness and evaluation on how the pain was affecting patients’ well-being.
Educating nursing staff on effective pain control and pain management practices would help improve patient outcomes and quality of care for LTC residents; it would also empower nurses in their roles. Previous studies have recommended focusing nursing education on pain assessment, medication titration, and the administration of pharmacological and nonpharmacological pain control (Long, 2013; Voshall, Dunn, & Shelestak, 2013). Using LTC NPs’ expanded knowledge of nonpharmacological and pharmacological modalities related to pain management and their role in LTC, nursing staff are more likely to provide improved pain management practices to their residents. The NP role can be one of liaison from the nurse to the LTC resident, as they all work to obtain optimal pain management. This process requires educating not only the nursing staff, but also the residents. The NP remains fundamental to the process of pain assessment, follow up, and management.
The small sample and retrospective descriptive research design limit the current study’s generalizability. Originally, the study had included 80 medical records for review. Because of the elimination of cases with missing data and outliers, the study only included 55 records. In addition, although the study reviewed approximately the same number of male and female residents, caution is warranted when interpreting the findings related to gender differences because of the small sample.
Implications for Nursing Practice
With approximately 2 million Americans currently residing in LTC facilities (and the expectation that this figure will increase to approximately 5 million by 2030), understanding the role of the provider (Levy et al., 2005), or more specifically the NP, in managing pain in LTC residents is of critical importance. The findings from the current study provide greater insight into the need for expanding the role of the NP within LTC facilities to include providing (a) interventions to improve policies and procedures for optimal pain control, (b) staff education on pain awareness, and (c) optimal pain management practices. Future research should include further evaluation on pain assessment protocols in LTC, use of nonpharmacological pain relief measures, pain assessment, and relief among those with cognitive impairment. Specifically, considerations may include (a) how cognitive impairments impact pain relief intervals (i.e., assessment to physician contact, assessment to medication administration, and assessment to pain relief) and (b) further analyses of whether patients with cognitive impairment exhibit a greater amount of negative outcomes than those who are not cognitively impaired. Such considerations would be beneficial in educating and empowering nurses to optimize pain relief in both of these patient populations.
Pain management is not optimal among post-surgery LTC residents or LTC residents at end-of-life or with acute or chronic conditions. By expanding the NP role in LTC, including the expansion of prescribing rights, these residents may experience improved pain management that leads to diminished negative outcomes and an increase in their quality of life.
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Patient Demographic Data (N = 55)
|Age (range, mean [SD])
||65 to 96, 81.51 (9.40)
| Grade school
| High school/GED
| 2-year/technical college graduate
| 4-year college graduate
| Master’s degree or higher
| African American
Time Intervals from Pain Assessment to Pain Relief (N = 55)
|Time from assessment to physician contact (minutes)
|Time from assessment to medication administration (hours)
|Time from assessment to pain relief (hours)
Bivariate Pearson’s Correlations Among Variables (N = 55)
||Assessment to Physician Contact Time
||Assessment to Medication Administration
||Pain Score Prior to Schedule II
||Diminished Ability With ADLs
||Nonpharmacological Modalities Useda
||Lack of Participation in Therapy
|Assessment to pain relief time
|Pain score prior to schedule II
|Pain score after schedule II
|Lack of therapy participation
|Diminished appetite/weight loss
|Resisting movement with care
|Diminished psychological well-being