Original Article

From the *Department of Psychology;†Center on Aging and Health,

University of Regina, Regina, SK;‡School of Nursing, McMaster

University, Hamilton, ON;§Village of Erin Meadows,

Mississauga, ON, Canada.

Address correspondence to Thomas

Hadjistavropoulos, PhD, ABPP,

FCAHS, University of Regina,

Department of Psychology and Center

on Aging and Health, Regina, SK,

Canada, S4S OA2. E-mail: Thomas.

hadjistavropoulos@uregina.ca

Received January 17, 2013;

Revised July 27, 2013;

Accepted July 29, 2013.

1524-9042/$36.00

� 2013 by the American Society for

Pain Management Nursing

http://dx.doi.org/10.1016/

j.pmn.2013.07.009

Improving PainAssessment Practicesand Outcomes inLong-Term CareFacilities: A MixedMethods Investigation--- Thomas Hadjistavropoulos, PhD, ABPP, FCAHS,*,†

Sharon Kaasalainen, PhD,‡ Jaime Williams, PhD,†

and Ramesh Zacharias, MD§

- ABSTRACT:An ongoing concern in long-term care (LTC) is that pain problems are

often not identified correctly. There is also evidence that behavioral

disturbance due to pain is misattributed to psychiatric conditions and

consequently frequently treated with psychotropic rather than anal-

gesic medication. This can result in unnecessary polypharmacy and

ineffective pain management. In a previous study, implementation of

a pain assessment protocol resulted in changes in administration of

pro re nata (PRN) medications and positive outcomes. However, there

were no changes in regularly scheduled medications suggesting that

assessment results were either not communicated to the prescribing

physicians or not taken into account. The goal of this study was to

determine whether a pain assessment protocol, augmented with

communication of the assessment results to the residents’ physicians,

affects prescriptions of analgesic and psychotropic medication. Psy-

chotropic medication reduction would help address the problem of

polypharmacy frequently seen in LTC facilities. PRNmedications were

also examined. This investigation involved a two group design (con-

trol vs. assessment). A mixed methods analysis included both quanti-

tative and qualitative procedures. At the end of the study, residents in

the pain assessment group were administered fewer psychotropic

medications than patients in the control group, helping address the

problem of polypharmacy. Pain levels were comparable between the

groups. Health care staff indicated that the protocol resulted in more

careful evaluation of residents’ pain and greater appropriateness of

prescriptions including reductions in polypharmacy.

� 2013 by the American Society for Pain Management Nursing

Pain Management Nursing, Vol -, No - (--), 2013: pp 1-12

2 Hadjistavropoulos et al.

Pain in long-term care (LTC) residents with dementia is

frequently undertreated (Reynolds, Hanson, DeVellis,

Henderson, & Steinhauser, 2008) largely because of

the difficulties associated with effectively assessing

pain in this population (Hadjistavropoulos, Voyer,

Sharpe, Verreault & Aubin, 2008; Sengstaken & King,

1993). Use of simple self-report procedures to assesspain is appropriate and usually valid among patients

with mild to moderate dementia (Ferrell, Ferrell, &

Rivera, 1995; Scherder & Bouma, 2000; Weiner,

Peterson, Logue & Keefe, 1998). As dementia severity

progresses, however, patients develop severe

limitations in their ability to report pain and nursing

staff frequently fail to identify pain and fluctuations

in the pain experience (McAuliffe, Nay, O’Donnell, &Fetherstonhaugh, 2009).

Pain in patients with dementia can result in behav-

ioral disturbance that may be misattributed to a psychi-

atric problem rather than pain (Cipher, Clifford, &

Roper, 2006). As such, a related concern involves fre-

quent, possibly inappropriate use of neuroleptic and

benzodiazepine medication combined with an under-

utilization of appropriate analgesia (Balfour &O’Rourke, 2003). Balfour and O’Rourke (2003) demon-

strated that less than half of a large sample of patients

withAlzheimer’s disease and comorbid arthritis or rheu-

matismwere treated for pain. These same patients with

undertreated pain were also more likely to have been

prescribed benzodiazepine medication than patients

without dementia. Not only does this cause concern

from the standpoint of painunder-treatment but also be-cause benzodiazepines increase the risk of injurious

falls (and thus future pain) in frail elderly individuals

(Woolcott et al., 2009). Administering psychotropic

medication to treat behavioral manifestations of under-

managed pain may be contributing to unnecessary

polypharmacy. Appropriate pain assessment and com-

munication of assessment results to health care pro-

viders, including prescribing physicians, has thepotential of reducing usage of psychotropic medica-

tions in the treatment of pain-related concerns and pos-

sibly increasing usage of optimal analgesic medication.

Examination of this issue was a key focus of this

investigation.

Nonverbal expressions of pain have been

shown to be useful in the assessment of the variability

in the pain experience (Lints-Martindale, Barber,Hadjistavropoulos & Gibson, 2007). In recent years, ef-

forts have focused on the identification and validation

of effective and clinically useful observational ap-

proaches designed to assess pain in people with de-

mentia (Aubin, Gigu�ere, Hadjistavropoulos, &

Verreault, 2007; Herr et al., 2006; Snow et al., 2004;

Stolee, Hillier, Esbaugh, McKellar, & Gauthier, 2005;

Zwakhalen, Hamers, Abu-Saad, & Berger, 2006a). In

addition, protocols aimed to improve pain

assessment and management practices in LTC have

been developed (Hadjistavropoulos et al., 2009a;

Hadjistavropoulos et al., 2007; Herr, Coyne,

McCaffery, Manworren, & Merkle, 2011; Kaasalainen

et al., 2012).Using the Pain Assessment Checklist for Seniors

with Limited Ability to Communicate (PACSLAC)

(Fuchs-Lacelle & Hadjistavropoulos, 2004), Fuchs-

Lacelle, Hadjistavropoulos and Lix (2008) demon-

strated that regular use of pain assessment with LTC

patients who have severe dementia can affect pro re

nata (PRN; to be taken as needed) pain medication ad-

ministrations by nurses and potentially improve clinicalpractices and pain levels. Although these researchers

concluded that regular pain assessment of dementia pa-

tients had a positive effect when it came to PRNmedica-

tion usage, medications that were prescribed to be

taken on a regular basis were unaffected. This may be

due to various factors (e.g., nursing staff who conduct-

ed the pain assessments may not have consistently in-

formed the physicians of the assessment results; thephysicians may have been informed but might have de-

cided to not take the pain assessment conclusions into

account). In fact, researchhas demonstrated that results

of systematic pain assessments are often not taken into

adequate consideration by prescribing practitioners

(Hadjistavropoulos, MacNab, Lints-Martindale, Martin,

& Hadjistavropoulos, 2009b).

The present investigation was designed to buildon the results of Fuchs-Lacelle et al. (2008) by ensuring

effective communication with prescribing physicians.

For this purpose, pain assessments were conducted

by nursing staff on a regular basis, and a protocol

was developed whereby pain assessment results would

be communicated to the prescribing physician in writ-

ing and by a pain champion physician who was directly

involved in this study. (See Fig. 1 for a protocol over-view.) It was expected that the direct communication

of regular pain assessment results would affect pre-

scribing practices and would result in changes in pre-

scribed medications It was also anticipated that,

consistent with Fuchs-Lacelle et al. (2008), administra-

tions of PRNmedications would also be affected as a re-

sult of systematic pain assessment.

METHODS

Using a mixed-methods research design informed by

a pragmatist philosophical stance (Greene, 2008;

Johnson & Onwuegbuzie, 2004), this study comprises

a quantitative, controlled comparison evaluation of

patient outcomes as well as a qualitative evaluation of

FIGURE 1. - Flow of study research design and methodology.

3Improving Pain in Long-term Care Facilities

staff experiences implementing the assessment

protocol. Concerning the latter, a descriptive

qualitative design and thematic analysis were utilized

(Patton, 2002, p. 55-96, 481-536; Sandelowski, 2000),

including data from both focus group and individual

interviews.

ParticipantsLong Term Care Residents. Resident participants

for this study were recruited from two comparable

LTC facilities in an urban Canadian center, one com-

prising the assessment protocol facility and the other

comprising the control facility. Both the assessment

and control facilities are located in the same geo-

graphic area, are operated by the same organization,

and meet the needs of a variety of residents includingthose diagnosed with advanced dementia and ad-

vanced medical difficulties. Prior to commencement

of the research, all appropriate institutional research

ethics approvals were obtained. Nursing staff initially

4 Hadjistavropoulos et al.

developed a list of all potential participants from

among the residents and their proxies and subse-

quently contacted these proxies via mail in order to ex-

plain the purpose of the research. Approximately two

weeks following this initial contact, study personnel

telephoned proxies to determine interest, answer

questions, and obtain consent for their relative’s datato be included in the research. Assent from residents

was sought and obtained from those who were capable

of providing it.

Consent was obtained for 36 residents residing in

the assessment facility and 29 residing in the control fa-

cility. Over the course of the study, seven participants

in the assessment facility died, and 10 participants in

the control facility passed away, leaving final samplesof 29 and 19 respectively. Demographic information

for the 64 participants enrolled in the research at base-

line is presented in Table 1. At the time of baseline, the

assessment group comprised 27 women and 9 men

(mean age ¼ 86.13, SD ¼ 9.63), and the control group

comprised 16 women and 12 men (mean age ¼ 83.33,

SD ¼ 11.43). Participants in the assessment group did

not differ from those in the control group on any of thedemographic variables including sex, age, days since

admission, or Mini-mental Status Examination

(Folstein, Folstein, & McHugh, 1975) scores. These

comparisons were conducted using either indepen-

dent samples t- or chi squared tests as appropriate.

(See Table 1.)

LTC Staff ParticipantsFocus group and interview data were collected from

staff members (employed at the assessment facility)

who were involved with the study and played signifi-

cant roles in the intervention. The sample was com-

prised of 16 women (84%) and 3 men (16%). A

variety of health care providers were interviewed in-cluding: Personal Support Workers (PSWs) (37%), Reg-

istered Practical Nurses (RPNs) (32%), Registered

Nurses (RNs) (11%), a kinesiologist (5%), a manager

(5%), and physicians (11%). The average age of

TABLE 1.

Participant Characteristics and Comparisons Among

Assessment Group

Sex 27 women; 9 men 1Mean Age (SD) 86.14 (9.63)Days Admitted* (SD) 1395.28 (967.48)MMSE Scores 12.10 (11.59)

MMSE ¼ Mini Mental Status Examination.

*Days admitted to the number of days since admission as calculated at baselin

participants was 46.5 (SD 14.6) years. The majority

of participants (63%) reported that they had received

at least some in-house training in pain management.

Although the majority of participants (84%) were

female, among managers, women accounted for 33%

and there was one female physician. The PSWs were

all female. Most PSWs had been working in LTC for 6-10 years and all PSWs had 6-10 years of experience at

their current place of employment. None of the

PSWs had previous pain management training. The

nurses (RNs and RPNs) were all female and all had 2-

5 years of experience in LTC. Most nurses said that

they had received pain management education from

their undergraduate studies. Two of the managers

had 2-5 years of experience in LTC, and one had 11-19 years of experience. Both interviewed physicians

had over 10 years of experience in LTC as well as spe-

cialized training in pain management.

MEASURES

Pain Assessment Checklist for Seniors WithLimited Ability to Communicate (PACSLAC)The PACSLAC (Fuchs-Lacelle & Hadjistavropoulos,

2004) is a 60-item observational checklist developed

to identify pain in persons with communicative

problems due to dementia. The checklist contains de-

scriptions of pain-related behaviors. The higher the

number of behavioral indicators that are present fora patient, the more likely the patient is to be experi-

encing pain. The PACSLAC has been shown to be

a valid and highly reliable tool and to contribute

unique variance over and above other pain assess-

ment measures (for seniors with dementia) in differ-

entiating pain-related from non-pain–related states

(Lints-Martindale, Hadjistavropoulos, Thorpe, & Lix,

2012; Zwakhalen, Hamers, & Berger, 2006b). Froma clinical standpoint, when used consistently by LTC

staff, the PACSLAC has been shown to lead to

improved pain management practices as well as

other positive outcomes such as reduced stress and

Assessment Protocol and Control Conditions

Control Group Comparison Statistic

6 women; 12 men c2(1, N ¼ 64) ¼ 2.28, p > .0583.33 (11.43) t(61) ¼ 1.06, p > .05

958.62 (777.57) t(59.25) ¼ 1.97, p > .057.91 (9.92) t(51) ¼ 1.37, p > .05

e.

5Improving Pain in Long-term Care Facilities

burnout among health care personnel (Fuchs-Lacelle

et al., 2008). Moreover, nurses have found it to be

more clinically useful than other observationalmethods

(Zwakhalen et al., 2006b). In addition to several reviews

of the literature having identified the PACSLAC as

a leading method (Aubin et al., 2007; Zwakhalen

et al., 2006a), a recent comparative psychometricevaluation of the leading pain assessment tools for

LTC demonstrated that the PACSLAC had the better

psychometric properties than other commonly used

tools (Lints-Martindale et al., 2012).

Medication Quantification Scale–Version IIIThe Medication Quantification Scale Version III (MQS

III) (Harden et al., 2005) is an index used to monitor

medication regimens for patients with non-malignantchronic pain. The tool takes into account drug class

(e.g., opioids, muscle relaxants), dosage, and detri-

ment of the medication (risk) whereby each pain med-

ication is given a score obtained by multiplying

a detriment weight (Harden et al., 2005) by a dosage

level (i.e., 1 ¼ subtherapeutic; 2 ¼ lower 50% of ther-

apeutic; 3 ¼ upper 50% of therapeutic; 4 ¼ suprather-

apeutic dose). The detriment weight is related to thedrug’s potential for abuse, addiction, or severity of

side effects (e.g., acetaminophen ¼ 2.2, non-steroidal

anti-inflammatory drugs ¼ 3.4). Because the sample

comprised older adults, dosage levels (e.g., subthera-

peutic, lower 50% of therapeutic) were obtained

through information specific to a geriatric population

(Semla, Beizer, & Higbee, 2011). MQS scores for each

drug a patient is taking are summed to obtain a totalscore for that patient. Separate MQS scores can also

be calculated for specific drug classes (e.g., benzodiaz-

epines). The detriment weights for the MQS were ob-

tained through a large-scale survey of the American

Pain Society membership (Harden et al., 2005) and

have been validated against a clinical pain population

(Gallizzi, Gagnon, Harden, Stanos & Khan, 2008). Inter-

rater reliability of the MQS is excellent (MastersSteedman et al., 1992). The MQS has been used with

success in previous work examining pain issues in

LTC populations (e.g., Lints-Martindale et al., 2012;

Fuchs-Lacelle et al., 2008).

Mini-Mental State ExaminationThe Mini-Mental State Examination (MMSE) (Folstein

et al., 1975) is a 30-point measure used to screen per-

sons for cognitive impairment. It comprises 11 itemsdesigned to assess orientation, registration, attention,

calculation, and language. It has been found to have ad-

equate interrater and test-retest reliabilities (usually

well above 0.80) and has been shown repeatedly to

be a valid test when used with seniors including

seniors residing in LTC facilities (Harvan & Cotter,

2006; Mitchell & Malladi, 2010; Singer & Luxenberg,

2003).

Numeric Rating Scale (NRS)A numeric rating scale (Chinball & Tait, 2001; Ferrell

et al., 1995) is a tool aimed to facilitate verbal report

of pain wherein a rating of 0 corresponds to ‘‘nopain’’ (0) and 10 corresponds to ‘‘worst pain

imaginable.’’ Many residents with dementia are able

to provide a valid self report of pain using this tool

(Ferrell et al., 1995). Although not all patients with

moderate to severe dementia are able to provide a valid

self report of their pain, especially when they have an

MMSE score of 13 or lower, recent practice guidelines

for assessing pain in this population indicate that selfreport should be attempted with all patients

(Hadjistavropoulos, Dever Fitzgerald, & Marchildon,

2010; Herr et al., 2011).

PROCEDURE

The flow of the research is presented in Figure 1. As in-

dicated in the Figure, following informed consent pro-

cedures (see above section, Participants), researchassistants first administered the MMSE to the partici-

pants. (See Table 1.) Pain assessments (i.e., using the

PACSLAC and NRS) were conducted for the assessment

and control facilities during a baseline period (three as-

sessments over one week) and during a follow-up pe-

riod (three assessments over one week) occurring

threemonths after the assessment protocol. At baseline

and follow up, residents were assessed for pain as fol-lows: (a) once in the morning since that is when pain

isoftenworse for residents; (b)onceduring apotentially

painful, naturally-occurring event (e.g., transfer from

bed to chair, range of motion exercises); and (c) once

at rest in the afternoon. The length of the observation

periodwas about 15minutes for each resident. In order

to assess residents’ ability to complete the NRS, first the

NRS was explained to them. Prior to asking residents torate their ‘‘current pain’’ at rest or during activity, as per

Scherder and Bouma (2000), each resident’s ability to

comprehend the scale was evaluated via standardized

basic questions (e.g., ‘‘What number would you pick if

your pain was extremely severe’’). The goal was to ap-

proximate equal average time periods for both the as-

sessment and control facilities for the time between

baseline and followup,which resulted in a sevenmonthperiod (7.78months for the assessment facility and 6.47

months for the control facility).

Two chart reviewswere conducted for eachpartic-

ipant in both facilities. These chart reviewswere for the

two months prior to the assessment protocol period

6 Hadjistavropoulos et al.

and for the twomonths following the assessment proto-

col. The purpose of the chart reviews was to gather in-

formation about the patients’ pain-related and other

medications, diagnoses, and demographics including

age, sex, and number of days in LTC.

Assessment FacilityIn addition to the assessment conducted to facilitate

clinical decisions by research personnel, nurses fromthe assessment facility received an introduction to

pain assessment procedures. Included was continuing

education regarding the administration, scoring, and in-

terpretation of pain assessment measures (i.e., the PAC-

SLAC and the NRS) during group lunch and learn

sessions. In total, three of these lunch sessions occurred

in the assessment facility. Subsequently, nurses provid-

ing care to participating patients completed the PAC-SLAC and NRS over a period of approximately 4

months (average length ¼ 4.2 months, SD ¼ 1.67).

Nurses were asked to complete these assessments on

a regular basis, ideally two to three times a week. In ac-

tual practice, the number of assessments administered

for each patient varied (average of 14.09 administra-

tions per patient [SD¼ 7.33]). In addition, research per-

sonnel completed the PACSLAC andNRS for residents inthe assessment facility on a once-weekly basis for the

duration of the assessment protocol. The purpose of

the assessments by research personnel was to facilitate

clinical decision making. (Summaries of all assessment

results were sent to the residents’ physicians.)

At the commencement of the research, physicians

treating the participating patients were sent a letter

outlining the purpose of the study and procedures bythe study physician collaborating on this research. Ad-

ditionally, the physicians were sent weekly pain score

summaries (i.e, including research personnel as well

as nurse assessments) compiled by research personnel

for each of their residents who were participating in

the study. At the same time, physicians were informed

about residents who had sustained elevated pain

scores over the course of one or more weeks duringthe assessment period. The study physician (who has

a special interest in pain management) was positioned

as a mentor and resource to the other physicians and

collaborated with them to help make decisions about

treatment plans with reference to the assessment

scores. These decisions were guided by the American

Medical Directors Association (2004, p. 15-31) clinical

practice guidelines on pain management in LTC. Thestudy physician had periodic contact throughout the

project with the physicians of intervention group par-

ticipants to discuss treatment plans and pain scores.

No contact was made with the physicians of control

group participants. Often these discussions resulted

in more conversations with the nursing staff to gather

more information about the resident, evaluate effec-

tiveness of interventions aimed to reduce sustained el-

evated pain levels and side effects of medications, and

if needed, modify approach to managing pain.

Control FacilityParticipants in the control facility received treatmentas usual during the course of the study.

Focus Groups and InterviewsIn total, three focus groups were held at the assess-

ment site, one with managers (n ¼ 4), one with regis-

tered nursing staff (n ¼ 6), and one with PSWs (n ¼ 7).

In addition, two semi-structured interviews were con-

ducted with facility physicians. Participants wereprompted to give feedback about the intervention

strategy and how it facilitated communication about

resident pain in order to improve pain management

in LTC. (Interview guide is available upon request.) In-

terviews and focus groups were recorded and later

transcribed. Member checking occurred in focus

groups and after interviews (Crabtree & Miller, 1999,

p. 109-124, 308-309). Participants were also providedwith summary notes in order to ensure that the data re-

flected what they intended to say.

RESULTS

Effect on Medication Quantification ScaleThe numbers of prescribed medications across several

categories are presented in Table 2, as are the mean

MQS scores. In order to determine whether the assess-ment protocol affected medication administration and

prescription patterns, two 2 � 2 (pre vs. post protocol

� assessment vs. control group) Analyses of Variance

(ANOVA) were conducted with the dependent vari-

ables comprising separate Total MQS scores for regu-

larly scheduled pain-related medications (as listed in

the MQS-III documents) and PRN pain-related medica-

tions. Means and standard deviations are presented inTable 2. With regards to regularly scheduled medica-

tions, a significant interaction was found (F1, 45 ¼3.92, p ¼ .05) as well as a significant main effect for

condition (F1, 45 ¼ 4.75, p < .05). Follow-up compari-

sons using Tukey’s HSD test indicated that although

control participants had significantly higher Total

MQS scores than assessment participants at baseline

(HSD¼ 2.86; q(.05, 47, 2)¼ 9.71 as well as post interven-tion, HSD ¼ 2.86; q(.05, 47, 2) ¼ 15.42), there was also

a significant increase in MQS scores for the control

(but not for the assessment) facility from pre- to post-

intervention (HSD ¼ 2.86; q(.05, 47, 2) ¼ 5.05). The

MQS score increase over time was not observed for

TABLE2.

NumberofMedicationsPrescribedandMedicationQuantificationScale

(MQS)Scores

NumberofMedicationsPrescribed

MQSScores

AssessmentGroupMean(SD)

ControlGroupMean(SD)

AssessmentGroupMean(SD)

ControlGroupMean(SD)

Pre-

assessment

Post-

assessment

Pre-

assessment

Post-

assessment

Pre-

assessment

Post-

assessment

Pre-

assessment

Post-

assessment

MQS(allpain

medications)Regular

2.32(1.56)

2.23(1.89)

2.75(1.83)

2.95(1.90)

11.96(8.51)

11.52(9.21)

17.56(11.29)20.44(16.09)*

PRN

.48(.77)

.42(.99)

.60(.75)

.55(.69)

4.22(8.64)

2.74(7.24)

3.17(4.83)

2.39(3.31)

Benzo

diaze

pine

Regular

.22(.51)

.15(.46)

.22(.55)

.44(.92)

1.78(4.05)

1.19(3.65)

1.56(3.67)

3.56(7.37)†

Antidepressant

Regular

.50(.68)

.57(.68)

.85(.75)

1.00(.73)

1.86(2.56)

2.07(2.64)

4.10(3.70)

4.06(3.31)‡

Antipsychotic

Regular

.30(.47)

.26(.53)

.39(.50)

.33(.59)

1.93(3.40)

1.63(3.19)

2.67(3.63)

2.44(4.58)

Acetaminophen

Regular

.41(.50)

.41(.50)

.50(.62)

.56(.51)

2.37(2.94)

2.37(2.94)

3.00(3.71)

3.22(3.00)

NSAID

Regular

.33(.48)

.33(.48)

.44(.51)

.44(.51)

2.11(3.09)

2.00(2.88)

2.67(3.07)

2.66(3.07)

Opiate

Regular

.19(.56)

.22(.51)

.17(.38)

.11(.32)

1.37(4.60)

1.56(4.35)

1.00(2.52)

.50(1.54)

MQS¼

MedicationQuantificationScale;NSAID

¼nonsteroidalanti-inflammatory

drug;PRN

¼pro

renata.

*Significantinteractionandsignificantmain

effectforinterventiontype,p¼

.05.

†Significantinteractionp¼

.05.

‡Significantmain

effectofinterventiontype,p<

.05.

7Improving Pain in Long-term Care Facilities

the assessment facility. No significant main effects or

interactions were found for PRN medications. Given

the difference in baseline, a similar analysis involving

difference scores and thus controlling for the baseline

difference was conducted. The main conclusions of

the two analyses were the same. That is, even when

the baseline difference is controlled for, the controlgroup received more regularly scheduled medication

post intervention than the experimental group.

In order to examine which medications were con-

tributing primarily to the significant interaction and

group differences found in the previous analysis regard-

ing regularly scheduled medications, each MQS medica-

tion category was considered separately, Specifically,

a series of 2 � 2 (pre vs. post � assessment vs. control)ANOVAs for each class of medication that had sufficient

data (e.g., some medication classes were administered

very rarely) to run the analysis (i.e., wherein participants

from the assessment and control conditions were pre-

scribed medications before and after the treatment)

was conducted. ANOVAswere run for the following clas-

ses: (1) acetaminophen, (2) antipsychotics, (3) antide-

pressants, (4) benzodiazepines, (5) non-steroidal anti-inflammatory drugs, and (6) opioids. Therewas a signifi-

cant interaction for benzodiazepine medications (F1, 48¼ 4.03, p ¼ .05). Follow-up comparisons using Tukey’s

HSD test indicated a significant increase inMQSbenzodi-

azepine scores for the control facility from pre to post

(HSD ¼ 2.86; q(.05, 50, 2) ¼ 5.15). Also, control partici-

pants had significantly higher benzodiazepine MQS

scores than intervention participants at follow up(HSD ¼ 2.86; q(.05, 50, 2) ¼ 5.65) although the groups

did not differ at baseline. There was also a significant

main effect for antidepressant medication for condition,

F1, 47 ¼ 8.70, p < .05. Follow-up comparisons using Tu-

key’s HSD test indicated that participants from the con-

trol condition had significantly higher scores at

baseline (HSD ¼ 2.86; q(.05, 49, 2) ¼ 9.7) and at follow

up (HSD ¼ 2.86; q(.05, 49, 2) ¼ 11.0). No other resultswere significant. The finding concerning the group dif-

ference in antidepressants (but not benzodiazepines)

at baseline helps explain why the two groups differed

with respect to overall MSQ scores at baseline. The anti-

depressants remained unchanged over the period of the

study whereas the interaction effect involving benzodi-

azepines can be attributed to the assessment protocol

as the two groups did not differ at baseline with respectto benzodiazepines. (See discussion section.)

PACSLAC and NRS RatingsMean scores for the before and after the intervention

for the PACSLAC and NRS are presented in Table 3.

In order to determine whether PACSLAC scores

were affected as a result of the assessment protocol

TABLE 3.

Pain Ratings Before, During, and After Assessment Protocol

Preassessment Protocol Postassessment Protocol

PACSLACIntervention group 4.23 (2.03) 4.35 (3.02)Control group 3.98 (1.28) 3.55 (1.28)

NRSIntervention group 2.94 (2.35) 1.60 (2.00)Control group 2.81 (2.54) 1.58 (2.75)

PACSLAC ¼ Pain Assessment Checklist for Seniors with Limited Ability to Communicate; NRS ¼ Numeric Rating Scale.

8 Hadjistavropoulos et al.

implementation, a 2 (preassessment period, postas-

sessment period) � 2 (assessment vs. control group

mixed) factorial ANOVA, wherein the dependent vari-

able was the PACSLAC average scores, was conducted.Results of the ANOVA indicated no significant main ef-

fects or interactions.

Concerning the NRS, it is important to note that

although self report of pain levels was attempted

with each participant throughout the research, given

the average MMSE scores at baseline, the validity of

their ratings is questionable. Moreover, because most

participants were unable to provide a self-report rat-ing, these results are further confounded by lack of

power. A 2 (preassessment period and postassessment

period) � 2 (assessment vs. control group) mixed fac-

torial ANOVA, wherein the dependent variable was the

NRS average scores, was conducted. Results of the AN-

OVA indicated a main effect of time (F1, 21 ¼ 5.78, p ¼.026) with scores decreasing over time for both facili-

ties. No other effects were significant.

QUALITATIVE FINDINGS

OverviewGenerally, nursing staff were positive about the pain as-

sessment program, believing it to be of benefit in im-

proving quality of care. The assessment protocol

facilitated more awareness of resident pain and im-

proved communication within the health care team, in-

cluding with physicians, which seemed to have

resulted in changes in prescribing practices. However,

a number of implementation barriers existed for the as-sessment protocol, primarily related to lack of time and

staff available to complete the PACSLAC. Still, staff and

managers drew on facilitators to help improve the im-

plementation process.

Benefits of Participating in Pain AssessmentInterventionParticipants stated that the pain assessment protocol

allowed for improved ability to assess resident pain.

Specifically, the protocol encouraged staff, including

physicians, to be more deliberate about assessing

pain. A licensed nurse stated, ‘‘Doctors would come

and ask, ‘How is so and so doing?’.they would followup. And because of the study we had to be more alert,

more aware of their [residents’] pain.’’

Moreover, the PACSLAC helped implement regular

monitoring of pain, which, in turn, led to more aware-

ness about pain within the healthcare team. In some

cases, the PACSLAC helped staff discriminate the pres-

ence of pain from other conditions, such as delirium or

dementia, as one PSW elaborated: ‘‘It [PACSLAC] wasa very good tool because there are times when we

might think that a resident has a behavioral problem

when that person is really in pain. So after doing those

checks and it’s assessed, you realize that it’s really not

a responsive behavior—it’s pain.’’

PSWs spoke favorably about their role in assessing

pain using the PACSLAC, noting that involvement in

pain assessment led to more awareness about the resi-dents’ care, more engagement in pain management,

and a greater sense of empowerment. Licensed nurses

also appreciated the PSW role in completing the PAC-

SLAC and reporting pain scores since they did not

always have time to do so. A PSW stated, ‘‘It [PACSLAC]

can give you specific things to chart about, specific

indicators of pain so when you’re communicating to

the registered staff you can report specific indicators.’’One of the main benefits that participants de-

scribed was improved communication among team

members regarding pain management. They stated

that using the PACSLAC provided a clear and objective

means of communication among staff between PSWs

and licensed nurses and also with physicians, resulting

in improved problem solving for challenging pain situ-

ations, as a registered nurse described: ‘‘When we didnot have that tool, basically wewere just writing things

for the doctor. When we started using the pain tool,

the doctor became more aware, not just about giving

medication but becoming more open in discussion be-

cause the major concern is the patient’s overall health.

9Improving Pain in Long-term Care Facilities

Right? And then when we started looking, what could

be the cause of the pain or what could be behind this.’’

Physicians appreciated being informed from both

study personnel and LTC nurses about residents who

had sustained elevated pain scores. As one physician

stated, ‘‘I have to rely on people telling me that resi-

dents are having pain since I see them for maybe 5or 10 minutes at the most, and I can’t see them every

day; I try to see them twice a month.’’ Often, when phy-

sicians were informed about a resident’s sustained ele-

vated pain level, they would reassess current

interventions being implemented for pain relief and/

or order pain medication. Moreover, staff noted that

since the onset of the study, they engaged in more crit-

ical thinking about the medications residents were pre-scribed and utilized a holistic approach to assessment,

often re-evaluating current treatments. For instance,

a licensed nurse stated, ‘‘Before we would just give

medication, and didn’t know what kind of medication

we were giving them; the pills were just pills.’’ Another

nurse stated that, ‘‘Since using the tool [PACSLAC] I

started thinking the medication they [residents] are

on is making them sleepy.before it’s just assumedthey were getting medication that’s good for them

and don’t realize before it might be too much for

them.then we do a chart check.[and we realized]

if they are still complaining of pain they are not being

given the proper medication.’’

Nurses noted that during the study they noticed

the physicians becoming more aware about resident

pain and ‘‘cutting down on some of the medications.’’Prior to the study, residents would ‘‘stay on that medi-

cation forever and become dependent on it,’’ but after

the study was initiated, physicians would ‘‘put a time

limit on medications’’ and then reassess effectiveness.

As noted by one nurse, physician interactions were

‘‘not just about giving medication.they started look-

ing at what could be the cause of the pain or depres-

sion.not just pain, maybe there’s something elsebehind this [behavior].’’ Participants noted positive

changes in residents after the pain assessment protocol

was initiated, which motivated staff to continue with

it. For example, one PSW stated: ‘‘In my case, there

was this particular resident who was quite agitated

and really behaving and you’d think that’s a behavior,

but then when we used the pain tool, she was really

in pain, and then she was tested and had a urinary tractinfection..that was a very good tool [PACSLAC], very

helpful.’’ Other staff noted more generalized improve-

ments in residents’ behaviors, stating, ‘‘some of the res-

idents who were aggressive before kind of calmed

down; they’re not as aggressive as they were, so I’ve

noticed that a lot.’’

Challenges, Facilitators, and Strategies toImprove the Implementation of the PainAssessment InterventionParticipants identified a number of challenges imple-menting the pain assessment protocol primarily re-

lated to time constraints and a lack of staff available

to complete the pain assessments. A manager high-

lighted: ‘‘They have to fill out 6 binders at the end of

their shift, with flow sheets, resident documentation,

communication, and everything else. So, imagine you

coming in with another piece of paper all of sudden

to say we want to do that. So, incorporating some ofthe portions in some of the work they already do

would be very beneficial.’’

Initially, PSWs were slow to complete the pain as-

sessments and organize their time to accommodate

this extra task. A manager described: ‘‘Because it’s

not required, like it’s not part of their job routine, so

it was very difficult to convince those people that

were just like, ‘This is extra work.’ Unless I was thereat the end of the shift to follow up, it was not going

to happen.’’

However, once more coaching was provided by

research staff and managers, most of the PSWs adopted

using the PACSLAC into their routine practice. A man-

ager described her strategy: ‘‘We needed to figure out

a way to roll it out with the staff that would make it do-

able, and then from there, I was an encourager to makesure it was getting done and always dialogue with the

staff to find out why they can’t get it done and try to

figure out different ways with the rest of the manage-

ment team as to how to get it done and keep them

engaged and doing it. And we found just being on

them- that was the best way to get it done.’’

Despite these challenges to implementation,

a number of facilitators were also identified. A numberof staff stated that the in-service training at the begin-

ning of the intervention period was very helpful,

although additional training throughout the implemen-

tation period was needed, especially for the PSWs. A

PSW suggested, ‘‘Maybe having a case study where

you show a picture or video of a resident in pain and

then use the checklist and say, ‘What are you observ-

ing,’ just to show how to use the tool.’’The support of administration in implementing

the pain assessment protocol was a key facilitator

through, for example, including PACSLAC completion

in staff incentive programs an administrator stated: ‘‘I

think our incentive program is quite unique that we re-

ward staff that we call, ‘Passport to Success’. You in-

centivize people who are going above and beyond

their day-to-day work doing various tasks. Whetherthey are volunteering after a shift and get 10 points,

10 Hadjistavropoulos et al.

or we have meetings that they attend which we call

weekly home attending meetings, so we require a little

bit more of them compared to the normal day where

we incentivize. So, even this pain study, because I

felt it was important and was something we were do-

ing to benefit the residents overall, but at the same

time it requires a little extra time; we all know that.’’

DISCUSSION

Perhaps the most significant finding in this investiga-

tion was that, at the end of the study, patients in the as-

sessment condition were receiving considerably lower

amounts of regularly scheduled benzodiazepine medi-

cation as compared to patients in the control condition

although the pain levels were comparable in the two

groups. In other words, it appears that regular pain as-sessment and communication with physicians in this

study helped reduce polypharmacy and particularly

the use of benzodiazepine medications which can

have serious side effects for older adults who reside

in LTC. The results of the qualitative analysis facilitate

interpretation of this finding. Specifically, staff re-

ported that, prior to the assessment protocol imple-

mentation, patients may have been overmedicatedand that repeatedly low scores on the PACSLAC might

have prompted physicians to re-evaluate patients’ med-

ication schedules, which could partially account for

the group differences in medications. Further, partici-

pants reported that when pain was identified, the

care team sought to find underlying causes, such as in-

fection, and provided appropriate treatment to resolve

the issue. This may have also contributed to avoidanceof unnecessary medication over the course of the

study. Resolution of medical issues and pain may

have further resulted in amelioration of behavioral dis-

turbance, potentially accounting for the group differ-

ence in benzodiazepines specifically.

Results of the qualitative component of this re-

search were consistent with the idea that administra-

tion of an observational pain assessment toolfacilitated not only better recognition of pain but also

communication with the physicians which would ex-

plain the differences in the pattern of prescribed med-

ications between the two groups. Given the

complexities involved in pain-management decision

making in LTC (Kaasalainen et al., 2007), the results

demonstrate that the implementation of a protocol

for systematically communicating assessment resultsto physicians of LTC patients is essential for improving

pain management practices. The approach, used in

this investigation, also involved interaction of the pa-

tients’ physicians with a study physician because previ-

ous research has shown that merely communicating

pain assessment results in writing was ineffective in af-

fecting prescribing practices (Hadjistavropoulos et al.,

2009b).

A previous related investigation (Fuchs-Lacelle

et al., 2008) did not involve a specific protocol for

communicating assessment results to physicians, and

consequently, no effect on regularly scheduled medica-tions was found (although there was an impact on ad-

ministration of PRN medications). In the present study,

regular administration of the PACSLAC was not found

to have an effect on PRN medication administration

probably because the nursing staff, due to this study’s

communication protocol, relied more on the physi-

cians for changes in medications. Future research

could focus more on the development of assessmentprotocols designed to improve PRN and regularly-

scheduled medication administrations simultaneously.

LimitationsThe findings are based on a relatively small sample size.

While the effect of benzodiazepine medications was

large enough to be identifiable with this sample size,

it is possible that a larger group might have yielded ad-

ditional differences in clinical practices. Additional re-

search in this area should be encouraged in order toaddress this possibility.

It is also noted that the initial list of all potentially

eligible participants was prepared by nursing staff. Al-

though the nurses were asked to list all eligible partic-

ipants, the possibility of some sampling bias cannot be

completely ruled out. As such, it would be important

for future research to examine the generalizability of

the results reported herein.The study results support the idea that the com-

munication with the prescribing physicians led to a re-

duction in the use of benzodiazepines. The assessment

results (e.g., based on the PACSLAC) were part of this

communication. This design does not allow for defini-

tive determination as to whether the specific assess-

ment tools made a unique contribution to this

communication. Nonetheless, it is expected that thefindings are not specific to the PACSLAC and that sim-

ilar results would be obtained with other well-validated

pain assessment tools. This expectation, however, is

awaiting confirmation from future research.

It is also noted that the PACSLAC is a checklist that

includes 60 items. Although inprevious research, nurses

found the PACSLAC to be more clinically useful than

briefer scales (Zwakhalen et al.,2006b), the scale’slengthmay be perceived as an obstacle in some settings.

As such, a revised version of the PACSLAC, the PACSLAC-

II, was developed and validated recently (Chan &

Hadjistavropoulos, 2013; Chan, Hadjistavropoulos,

Williams, & Lints-Martindale, 2013). The PACSLAC-II

11Improving Pain in Long-term Care Facilities

has excellent psychometric properties and contains ap-

proximately half as many items as the original PACSLAC.

ConclusionsThe study reported herein adds to a corpus of work

(Fuchs-Lacelle et al., 2008) that illustrates the clinical

utility of regular pain assessment in LTC settings. Givensuch positive findings, it is imperative that professional

staff be educated (Ghandehari et al., 2013; Gagnon,

Hadjistavropoulos, & Williams, in press) in pain

assessment procedures for persons with dementia in

order to help address complex clinical challenges

relating to pain in this population (Hadjistavropoulos,

Hunter, & Dever Fitzgerald, 2009c) . While implemen-

tation of large assessment programs can be resource

intensive, at least one pain assessment and manage-

ment program has been proposed that takes limitations

of resource realities into account (Hadjistavropoulos

et al., 2009a) and seems to have support of both front

line and management staff (Hadjistavropoulos et al.,2011).

Acknowledgments

This study was supported, in part, through funding from the

Saskatchewan Health Research Foundation.

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