The Assessment and Management of Non-Cancer Fellowship Title: Pain in Older Adults
Summary
This fellowship focused on the assessment and management of non-cancer pain in older adults living in a long-term care setting at Meadow Park (Chatham). As a Best Practice Spotlight Organization (BPSO) pre-designate in Cohort E (2018-2021), Meadow Park began implementing the Assessment and Management of Pain (third edition) Best Practice Guideline (BPG) in 2018. The Advanced Clinical Practice Fellowship (ACPF) created an opportunity for the fellow, who is also the Pain Management lead at Meadow Park, to obtain and build upon foundational knowledge related to the physiology of pain and the principles of effective pain management. A secondary focus of this fellowship was on knowledge transfer. The fellow used the evidence-based research to create a comprehensive educational program to disseminate information related to pain management to new nurses, existing staff, and through annual refreshers. Meadow Park is one of 14 long-term care homes in Ontario own by Jarlette Health Services (JHS). The knowledge transfer goal of this fellowship was to create education that follows the corporate policies, adheres to Ministry of Health and Long-Term Care (MOHLTC) standards, and can be shared throughout all JHS long-term care homes.
There were four primary learning goals identified through this ACPF.
1. To identify and describe the two main types of pain (neuropathic and nociceptive) including
the complete physiology behind each.
2. To develop proficient knowledge related to pharmacological interventions including knowledge of mechanism of action and appropriate use for non-opioid analgesics, NSAIDS, antidepressants, anticonvulsants, muscle relaxants, and opioids.
3. To develop knowledge on the safe and effective use of opioids, including dependence, tolerance, adverse side effects, opioid toxicity, and opioid use disorder (including physiological knowledge and appropriate treatments.)
4. To demonstrate competency in developing educational plans for new staff (classroom orientation), existing staff, and annual refresher sessions.
The fellow began by searching for evidence-based research in various databases including CINAHL, PubMed, the Cochrane Library and others, as well as reviewing grey literature from various sources. Throughout the ACPF the fellow was able to develop skills in critiquing research and compiling resources to support the learning goals. The information was used to build the fellow’s knowledge and capacity from a foundational level of what pain is and why/how it occurs, as well as effective measures to manage various pain types.
Throughout the fellowship, the fellow also created a comprehensive educational program to disseminate learned information to a back up resource person, as well as for new and existing staff. Educational materials included a PowerPoint which was recorded (as opposed to live education, due to COVID-19 restrictions) and available to all nursing staff. A toolkit was created to accompany the PowerPoint, as well as resources such as fact sheets and reference cards.
The fellow has gained proficient knowledge related to pain and pain management, which has translated well into her practice as the Pain Management lead at Meadow Park. The corporate pain policy has been revised, allowing the fellow to ensure the policy and procedures are evidence-based and provide residents with the best possible pain management experiences in a manner that is safe and effective.
Outcomes
The residents of Meadow Park have benefited from the ACPF in terms of pain management. According to RAI-MDS data, comparing the indicators “Residents with Pain” and “Residents with Worsened Pain” has indicated significant improvement. The indicator “Residents with Pain” exhibited a decrease of 1.4% from the beginning to end of the fellowship (Q3 to Q4), or a total decrease of 3.33% from Q1 to Q4 of 2020. The indicator “Residents with Worsened Pain” saw a decrease of 1.6% from the beginning to end of the fellowship (Q3 to Q4), or a total decrease of 6.83% from Q1 to Q4 of 2020. Both indicators are now below corporate benchmarks and have been sustained thus far.
Resident’s state they feel staff are more understanding of their pain and attentive to their needs. Resident’s have also stated that they appreciate the efforts of our staff and physician to decrease medications, such as opioids and sedating medications, leading to more wakeful periods and better quality of life. We had anticipated to monitor for changes in social isolation and responsive behaviours, however due to the impact of COVID-19 on these areas, we were unable to accurately retrieve this data.
As an organization, Meadow Park has benefited immensely from the ACPF. This started with the revision of the corporate pain policy, allowing it to better align with MOHLTC standards and to provide support to the entire organization for nurses to provide consistent, evidence-based care. At Meadow Park, the fellow was able to lean some practices, thus saving valuable nursing hours. An example of this is one minor change to the completion of pain assessments, which saved Meadow Park nurses approximately 104 hours per year. Translated into nursing dollars, this was an approximate savings of $4680/year. Since all JHS homes are following the same revised policy, if this savings was duplicated in all JHS homes, this would lead to a potential savings of 1456 nursing hours, or $65,520/year.
Overall experience
The ACPF was an enriching and invaluable experience that I feel privileged to have been selected for. I thoroughly enjoyed the freedom to learn and be creative to meet my learning goals while building capacity within myself as well as teaching others. Although COVID-19 certainly created significant challenges related to how the ACPF unfolded, such as the delivery of the educational components, I learned to be flexible and adapt to these challenges to achieve success.
I have become much more proficient in my knowledge of pain and effective pain management. I have been able to participate in discussions and care conferences with physicians, coworkers and residents with a much deeper level of knowledge and understanding of pain and appropriate treatments. In addition to the comprehensive education created for the nursing team, I have also been able to educate residents on the basic physiology of pain and why some treatments may or may not be effective, providing them with a better understanding of their treatments. One example of how this has benefited myself and others was a particularly challenging situation involving a young, cognitively well resident with several issues contributing to pain, in addition to a life-long history of severe drug abuse and Opioid Use Disorder (OUD). Prior to the ACPF, I had struggled to manage this resident’s situation due to the complex nature. Along with their physician, I have since been able to educate this resident who has stated understanding and agreeance to reducing medications and including non-pharmacological interventions, which had not occurred in the previous years of health teaching and education.
