Advanced Clinical Practice Fellowships

Managing pain as a first line of defense in individuals with cognitive impairment and responsive behaviours


The John Noble Home (JNH) is a Class "A" 156-bed long-term care facility owned and operated by the City of Brantford and the County of Brant. We have six units with no secured unit for residents with responsive behaviours. The John Noble Home (JNH) has recently been approved for an additional 20 long-term care beds. We have submitted an application to the Ministry and waiting an approval for designation of these beds as a dedicated behavioural unit. We realized during our risk management meetings that when our cognitively impaired residents are exhibiting responsive behaviours, the registered staff are using PRN “behavioural” medications instead of ruling out pain and managing pain as a root cause of responsive behaviours. We needed to change the practice and the culture and encourage staff to routinely screen for pain and manage pain before utilizing "behavioral" medications. One of the John Noble Home’s 2020-2025 strategic plan goals is to provide excellence in care by training and engaging staff and creating an inclusive, safe environment for all. The learnings and culture change from this fellowship would positively impact this goal and it will also support the organization’s strategic priorities of providing resident centered care, reducing responsive behaviours, integrating quality improvement and providing higher quality care for residents.

Overall learning goals

The overall learning goals of the fellowship were to enhance my evidence-based knowledge and to understand the link between unmanaged and unidentified pain and responsive behaviours in cognitively impaired residents. I also wanted to learn about the effects of pain on individuals with cognitive impairment. After implementing the new pain screener and pain assessment, I wanted to determine if the pain is screened and managed in cognitively impaired residents, will the pain assessments scores and the ABS (Aggressive Behaviour Scale) scores improve. If the pain assessment and ABS scores improves that means the cognitively impaired residents will be comfortable and they will exhibit less or no behaviours. I wanted to ensure that the learned knowledge and positive outcomes are shared and celebrated with the staff. I wanted to plant a seed of culture change at the JNH, where staff will screen and manage pain as the first line of defence in cognitively impaired residents with responsive behaviours.  


Skills, knowledge and expertise gained

I learned that untreated or undertreated pain can cause depression, decreased socialization, sleep disturbance, impaired ambulation and behavioral problems. The cognitively impaired residents cannot verbalize pain but, they may exhibit pain behaviours. When cognitively impaired residents are exhibiting responsive behaviours, staff should screen for pain and complete a pain assessment and then manage the pain as needed. The most important learning was, by treating pain as the first line of defence we can improve the quality of residents’ lives and decrease the responsive behaviours in cognitively impaired residents.

 I was able to gain the skills of adult teaching by educating the staff about the importance of managing pain in cognitively impaired residents. I implemented a new pain screener, new pain assessment, started a wave of culture change, involved residents and family members, audited and evaluated the pain management process.  I also learned the importance of following up with staff and celebrating the successes.

We created a responsive behaviour Point of Care (POC) electronic health record task, updated the PointClickCare (PCC) electronic health record documentation behavioural note and risk management note to make the culture change process effective. At the end of the fellowship, I gained expertise in pain screening, pain assessment and pain management of residents with cognitive impairment who exhibit responsive behaviours.


I studied 12 residents with an ABS (Aggressive Behaviour Scale) score equal to or greater than 3 with cognitive impairment that cannot express pain verbally. The initial pain screeners and pain assessments were completed on all twelve residents. The Medical Director Dr. Legere and Nurse Practitioner Anna Gora were notified about the pain assessments scores. The HNHB Behavioural Supports Ontario (HNHB BSO) was also involved to assist me in ensuring that appropriate non-pharmacological interventions for pain management were in place for the residents in the study.

After the first four weeks of implementing the new pain screener and new pain assessment, I compared four residents’ initial pain assessments scores and post medication adjustment pain assessment scores. The pain assessment scores for all four residents improved once the pain medications were adjusted. Unfortunately, two residents passed away during the initial time period in the study. One resident’s results were not valid due to staffing challenges during the pandemic and errors during the initial and follow-up pain assessments. Therefore, at six weeks I compared nine residents’ pain assessments scores. A significant improvement was noted in the pain assessments scores of all nine residents. Finally at ten weeks, the new MDS assessments were completed and at seventeen weeks pain assessments were completed. The ABS scores improved for all nine residents and their pain assessments scores also continued to improve. At the end of my study, 100% of the participating residents were assessed as having mild or no pain.

When I started my fellowship, three out of nine residents were on risk management due to high-risk behaviours. At the end of my fellowship none of these residents were on risk management as their behaviours did not pose a risk to themselves and others.  Overall, our staff also verbalized that now the study residents exhibit less responsive behaviours, are more comfortable and show minimal or no signs of pain.

Initially, my colleagues were very excited to start the culture change as most of them agreed that when residents are experiencing responsive behaviours, the staff usually ask for PRN behavioural medication and did not screen for painThe staff was very happy and proud of their efforts to learn and to change their practice when they saw a significant improvement in the six weeks pain reassessment scores of the study residents. The culture change was evident as the pain assessments scores improved not only for the residents with pain medication adjustments but also improved for the residents with no pain medication adjustments because of staff’s ability to screen and recognize pain and use PRN pain medications in place. The pain screener was very well accepted by the PSWs as now they feel that they have a voice and their skills, education and experience are recognized. The PSWs felt empowered and started utilizing the pain screener not just for the residents with responsive behaviours but also for the deteriorating resident, non verbal residents and palliative residents. The staff members were very engaged in culture change activities. They had a lot of fun participating in interactive posters on the home areas. They were laughing and relating their personal experiences about how they react to pain and what helps when they are in pain.  The staff took great pride in sharing their success stories with each other about how effective pain management has impacted the resident’s quality of life and decreased their responsive behaviours.  The Administrator, Director of care, senior management team and staff from all departments were amazed and impressed with the results from the fellowship.

The families of the study residents and family council were very interested in the study and they were thrilled with the fellowship results.  The Psychogeriatric Resource Consultants (PRC) and BSO were very supportive during the learning process.  BSO was very pleased that we implemented their pain screener and that it was a great success. Our BPSO coach was also very pleased with our work and remained very supportive throughout our journey. She shared our results with her BPSO team and other long term care homes. These long-term homes now want to implement our successful strategies in their organizations.

Overall experience

My overall fellowship experience was extremely valuable and rewarding. The knowledge and the experience gained throughout this fellowship have started the wave of a culture change that was required to ensure the successful development and management of our new behavioural unit. One of my favorite moments from my fellowship was being able to see the engagement and willingness of the multidisciplinary team to change the culture. Some other favorite moments were empowering the PSWs with new pain screener and listening to the resident’s emotional pain management success stories from staff.

I would like to acknowledge my appreciation to the RNAO for providing me with this exciting opportunity. I would like to thank my mentor NP Anna Gora, MD Dr Legere, JNH leadership team and staff for their help and engagement in fellowship activities. A special thank you to my Director of Care Mary Cox and BPSO coach Deidre Boyle for being the biggest supports and guidance throughout this fellowship.