Implementation of a nursing home quality improvement project to reduce resident pain: a qualitative case study

Healthcare aide-focused interventions to improve pain management in long-term care homes: A systematic review

OBJECTIVES

Pain is common in long-term care residents. We examined the effectiveness of interventions involving healthcare aides that aim to manage pain for these residents.

DESIGN

A systematic review which follows PRISMA reporting guidelines.

SETTING AND PARTICIPANTS

We examined controlled trials and intervention studies that included long-term care residents aged ≥60 years who received interventions to reduce chronic pain. Interventions were either delivered by healthcare aides at the resident level or were directed at healthcare aides to improve their pain management practices for residents.

METHODS

We searched 7 databases to identify relevant studies. After screening 400 articles, we reviewed 131 full-text articles and included them if they reported a pain management intervention and measured pain with a standardized pain scale. Data were synthesized narratively. Risk of bias was assessed using the Mixed Methods Assessment Tool.

RESULTS

In total, 9 studies were examined in the narrative review. Six studies described pain interventions involving education, new pain protocols and/or new assessment tools delivered to healthcare aides. Three studies described pain interventions delivered by healthcare aides to residents, which included a new incontinence care routine, light touch massage, and a bathing intervention.

CONCLUSIONS AND IMPLICATIONS

Interventions involving healthcare aides may be beneficial to pain management for long-term care residents as they have the potential to reduce residents' pain and improve both pain assessment and reporting practices. Further research is warranted on specific elements that contribute to an improvement in residents' pain and to the overall role of healthcare aides care of residents.

SCOPE: safer care for older persons (in residential) environments-a pilot study to enhance care aide-led quality improvement in nursing homes

Background

Nursing home residents require daily support. While care aides provide most of this support they are rarely empowered to lead quality improvement (QI) initiatives. Researchers have shown that care aide-led teams can successfully participate in a QI intervention called Safer Care for Older Persons in Residential Care Environments (SCOPE). In preparation for a large-scale study, we conducted a 1-year pilot to evaluate how well coaching strategies helped teams to enact this intervention. Secondarily, we measured if improvements in team cohesion and communication, and resident quality of care, occurred.

Methods

This study was conducted using a prospective single-arm study design, on 7 nursing homes in Winnipeg Manitoba belonging to the Translating Research in Elder Care research program. One QI team was selected per site, led by care aides who partnered with other front-line staff. Each team received facilitated coaching to enact SCOPE during three learning sessions, and additional support from quality advisors between these sessions. Researchers developed a rubric to evaluate how well teams enacted their interventions (i.e., created actionable aim statements, implemented interventions using plan-do-study-act cycles, and used measurement to guide decision-making). Team cohesion and communication were measured using surveys, and changes in unit-level quality indicators were measured using Resident Assessment Instrument-Minimum Data Set data.

Results

Most teams successfully enacted their interventions. Five of 7 teams created adequate-to-excellent aim statements. While 6 of 7 teams successfully implemented plan-do-study-act cycles, only 2 reported spreading their change ideas to other residents and staff on their unit. Three of 7 teams explicitly stated how measurement was used to guide intervention decisions. Teams scored high in cohesion and communication at baseline, and hence improved minimally. Indicators of resident quality care improved in 4 nursing home units; teams at 3 of these sites were scored as ‘excellent’ in two or more enactment areas, versus 1 of the 3 remaining teams.

Conclusions

Our coaching strategies helped most care aide-led teams to enact SCOPE. Coaching modifications are needed to help teams more effectively use measurement. Refinements to our evaluation rubric are also recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00975-8.

Pain assessment and management in care homes: understanding the context through a scoping review

Background

Internationally, 2–5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management.

Methods

Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective.

Results

Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment – including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes.

Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia.

Conclusions

Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02333-4.

Effect of a QI Intervention on Nursing Assistants' Pain Knowledge and Reporting Behavior

BACKGROUND

Pain among long-term care residents is often underdiagnosed and inadequately treated. We examined the effect of a multimodal intervention on certified nursing assistants' pain recognition knowledge and verbal reporting behavior. Secondarily, we examined pain documentation in a newly established pain log compared with pain verbally reported to nurses and documented in the electronic health record (EHR).

DESIGN

Quality improvement project using a pretest-posttest design.

SETTING

A skilled nursing and rehabilitation facility in Southwestern Pennsylvania including two long-term care units and one transitional rehabilitation unit.

PARTICIPANTS/SUBJECTS

Fifty-six nursing assistants.

METHODS

The intervention was a face-to-face educational session with a training video and introduction of a new pain log used to document residents' pain. Pain knowledge was measured before and after the educational intervention. Multiple measures were used to examine nursing assistants' pain reporting.

RESULTS

Nursing assistants' pain knowledge improved (p < .001). There was no change in verbal pain reporting behaviors. The percent of pain episodes documented in the electronic health record that were reported to nurses varied by unit type (45% on the long-term care units vs. 100% on the rehabilitation unit) but remained unchanged postintervention. Pain logs were used more often on the rehabilitation than the long-term care units; use was low overall. Nursing assistant reports that nurses provided feedback on their reports of resident pain increased from 45% in week 1 to 75% in week 4.

CONCLUSIONS

Although the multimodal intervention improved nursing assistants' pain knowledge and their perceptions of the feedback they received from nurses when they reported pain, it had no effect on certified nursing assistants reporting of pain to nurses (per nurse report).

Effect of an Educational and Organizational Intervention on Pain in Nursing Home Residents: A Nonrandomized Controlled Trial

OBJECTIVES

To determine whether an intervention based on education and professional support to nursing home (NH) staff would decrease the number of residents with a pain complaint, and to determine whether the intervention would improve pain management.

DESIGN

Nonrandomized controlled trial. NHs were nonrandomly allocated either to a strong intervention group consisting in audit, feedback, and collaborative work on quality indicators with a hospital geriatrician, or to a light intervention group (LIG) consisting in audit and feedback only.

SETTING

One hundred fifty-nine NHs located in France.

PARTICIPANTS

A subgroup of 3722 residents.

MEASURES

Information on pain complaint and pain-related covariates at the resident-related and at the NH level were recorded by NH staff at baseline and 18 months later. These covariates were included in a mixed-effects logistic regression on resident's pain complaint. Pain management was compared between intervention groups by chi-square tests.

RESULTS

A greater reduction of residents with a pain complaint after the strong intervention (odds ratio 0.69, 95% confidence interval 0.53, 0.90) and a better pain management (47.6% gold standard, vs 30.6% in the LIG, P < .001) than controls.

CONCLUSION/IMPLICATIONS

Combining educational and organizational measures, evaluating pain as a patient-reported outcome and as a process endpoint, and implementing a broad-spectrum intervention were original approaches to improve quality of care in NHs. Our results support nonspecific, collaborative, educational, and organizational interventions in NHs to decrease residents' pain complaint and improve pain management.

Implementing Frontline Worker-Led Quality Improvement in Nursing Homes: Getting to "How"

BACKGROUND

Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes.

METHODS

Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers.

RESULTS

Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program.

CONCLUSION

Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment

BACKGROUND

Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States.

METHODS

Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach.

RESULTS

Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover.

CONCLUSIONS

Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Influence of leadership on implementing Dementia Care Mapping: A multiple case study

Dementia Care Mapping is an internationally applied method for enhancing person-centred care for people with dementia in nursing homes. Recent studies indicate that leadership is crucial for the successful implementation of Dementia Care Mapping; however, research on this topic is rare. This case study aimed to explore the influence of leadership on Dementia Care Mapping implementation in four nursing homes. Twenty-eight interviews with project coordinators, head nurses and staff nurses were analysed using qualitative content analysis. Nursing homes that failed to implement Dementia Care Mapping were characterised by a lack of leadership. The leaders of successful nursing homes promoted person-centred care and were actively involved in implementation. While overall leadership performance was positive in one of the successful nursing homes, conflicts related to leadership style occurred in the other successful nursing homes. Thus, it is important that leaders promote person-centred care in general and Dementia Care Mapping in particular. Furthermore, different types of leadership can promote successful implementation.

Trial registration of the primary study: Current Controlled Trials ISRCTN43916381.