Quantitative data
Sample size of care workers differed between the three waves of data collection due to care worker turnover and partial decline of response rates, resulting in 136 respondents at baseline (average response rate: 84%), 99 respondents at T1 (69 %) and 83 respondents at T2 (59 %). A sub-sample of 41 care workers participated at each time point. An overview of the baseline’s sample characteristics is displayed in Table 2. The characteristics of respondents did not differ significantly between the time points.
Changes of self- efficacy in pain management
In LPNs and RNs the mean score of self-efficacy increased from 69.6 (SD 14.6) at baseline to 74.2 (SD 15.2) at T1 and 76.8 (SD 14.7) at T2. In nursing assistants, the mean score changed from 64.3 (SD 15.1) at baseline to 72.4 (SD 12.1) and 69.2 (SD 12.4) at T2. Mixed models overall confirmed a significant increase (p< .01) of self- efficacy between baseline and T1/T2 for all educational levels (Table 3).
Associations with self-reported pain management behavior
Self- reported adherence to guideline components ranged between 44% and 73% depending on the component, detailed results were reported in an earlier paper (XXXblinded for review). We found significant associations between care workers’ adherence to core component I (conducting a comprehensive assessment) and II (using PAINAD scale) and corresponding self- efficacy items. However, we did not find significant associations between the other two core components and corresponding self-efficacy items. An overview of the associations is displayed in Table 4.
Qualitative data
In total, we conducted eight focus groups in the four participating NHs, including 30 care workers (15 RNs/LPNs and 15 NAs). Overall, participants were mainly female (80%) and the average age was 36.6 years (SD = 8.6). The majority of care workers had participated in both parts of the workshop, few participated only in the first part due to logistical reasons within their NHs. Overall, care workers’ perception of the project three months after the start were positive. The participants appreciated the project’s focus on pain management, a topic which was recognized to be of high importance for residents’ quality of life.
General experience with workshops
In general, NAs were more satisfied with the workshops than RNs and LPNs, several NAs highlighted that they have never received a training specifically targeted at them before. RNs and LPNs on the other hand, partly perceived the workshops’ content to be redundant to what they already knew before (e.g. with regard to pain assessment instruments). Some RNs remarked that they would have preferred a focus on pharmacological treatment options and less on general principles of pain management. Despite some reservation towards the content, the participants agreed that the workshops were overall helpful to raise the care team`s awareness for residents’ pain situations. One aspect that was highlighted particularly by the NAs was the recognition that pain almost always goes beyond its physical component and can be related to psychosocial or spiritual factors. Though this was not new knowledge for most participants- reflecting this aspect in depth during the workshop was perceived as a major learning moment. Participants of all job levels reported to be more sensitized to pain when talking to residents or observing their behavior than before.
“Because we could delve into the topic of pain, so that we became more aware of what pain really means in that sense. That is a matter of opinion for everybody and that we react more conscious when people complain about pain” (RN).
In particular the perception of residents with cognitive impairment or other conditions limiting communicative abilities has changed. Participants acknowledged that they sometimes forgot that these residents might also perceive pain from time to time though they do not actively express it.
“Well, I was really shocked about the residents with dementia, I just realized: Hey, you have to keep an eye on them, they are not only having dementia and have no other issues” (LPN)
Perception of the pain champions
In general, the idea of having a pain champion on the ward was perceived as a gain by most participants. Similar to the workshops, NA expressed more positive reactions to the introduction of this new role as compared to RNs and LPNs. During the focus group discussions, most NAs agreed that they could easily approach the new pain champion in case of any questions related to resident`s pain. They appreciated to have a designated go- to person on the ward who explains complex matters, e.g. pain assessment instruments, using simple language. Furthermore, NAs repeatedly noted that the pain champion takes their observations and concerns with regard to residents` pain seriously.
“Yes, you just know… simply to whom you can go. And then you don’t have to [think] who should I.. And they are also more attentive, I think, and trained, you know?” (NA)
Discussions with RNs and LPNs on the other hand, showed some variation between different NHs. RNs in one NH questioned the added value of having a nurse pain champion because ultimately the physician would decide about a resident`s medication.
“I think, for me the physician is always the pain expert, in the end, he is telling us when we don’t know what to do with the medication and whatever, in the end the physician is telling us what to do” (RN)
In contrast, RNs and LPNs in another NH reported to see the pain champion as a connector with the responsible physician to advocate residents` needs with regard to appropriate medication.
“The [physician] has a different understanding of applying pain killers, and I think, this is where [the pain champion] can be kind of a connector with the physician” (LPN)
Observing changes in pain management
Overall, there was agreement in most focus groups that during the past three months, changes in the care teams` pain management behavior were noticeable. However, perceptions about the extent of changes differed in parts between professional groups (NAs vs. LPNs/RNs).
One behavior, most participants highlighted to have experienced change is the assessment of residents` pain, in particular with regard to the frequency and the use of more differentiated assessment questions. Several NAs reported that until recently they were not used to have conversations about the residents` pain experience, except when a resident has verbally expressed pain. In contrast, the focus group participants reported that they now ask residents actively about their pain if they see signs of discomfort or if the resident has reported pain before.
“Well, after the course, I .. tried harder to observe the resident and I took more time to look at the mimic and yes, well, I.. I was very glad about the course. And now, I pay more attention, or I ask the resident more “Do you have pain?”, which I’ve done less before.” (NA)
Another aspect that was brought up in this regard, was the newly implemented pain report in the resident documentation. Before, residents` pain was exclusively reported in the overall documentation, focus group participants acknowledged that they used to document only that a resident experiences pain without being specific about the details. However, in the new form there are fields asking for the different qualities of pain e.g., intensity, location, etc. With this new pain report form NAs felt reminded to be more detailed when describing pain situations and also to ask residents more specifically about their experience.
“Or, for example you can’t just write “Mrs. X has pain”. Now you have to describe, where is the pain, what kind of pain, where .. and you have to take this to pieces, in detail.” (NA)
Furthermore, with regard to the use of specific assessment instruments, NA reported to have tried out different self-report scales with residents. Assessing pain in residents with severe cognitive impairment, still was perceived as a challenge by NAs, however, they reported to be more aware of signs of discomfort and changes in the behavior than before. Likewise, LPNs and RNs reported to be challenged by assessing pain in these residents. For most care workers, using the observational pain assessment scale was perceived to facilitate assessment, however, some participants reported challenges applying the scale correctly in the beginning. In addition to changes in assessing pain, participants of all job levels agreed that NAs reports of residents` pain to the charge nurse were more timely. In the mornings, they would inform the responsible nurse as soon as possible instead of waiting till the designated report time in the late morning.
Aside from changes in NAs` behavior, RNs/LPNs reported that the pain champion has motivated them to go through each resident’s medication scheme to critically review if the medication is still appropriate in light of the current pain situation.
“Here, I am working together with the pain champion and we are discussing the residents, what we could do or not. Or if we should reduce something or not.” (RN)
Based on their critical review, they themselves or the pain champion talked with the responsible physicians about their suggestions. Participants reported that based on the reviews they were able to adapt or reduce unnecessary pain medications in several residents.