Generating & Testing Multi-institutional Evidence-Based Standards for Pain Management in Home Care

3. Generating & Testing Multi-institutional Evidence-Based Standards for Pain Management in Home Care Marlene Dufault, PhD, RN Principal Investigator

4. Acknowledgements This project was funded by: • The Eastern Nursing Research Society • The Nursing Foundation of Rhode Island • The Rody Foundation • The URI College of Nursing Weyker Thanatology Endowment

5. Acknowledgements • Jean Schwaeger, MS, RN Project Coordinator, Roger Williams Home Care • Janice Muhlberg, BS, RN Nurse Educator, Roger Williams Home Care • Roger Williams Home Care Staff: Patricia Angulo, RN; Darlene Arthurs, RN; Elaine Diguilio, RN; Karen Mulligan, RN; Lynn Viveiros, RN

6. Acknowledgements • Karen Hockhausen, RN Project Coordinator, VNS Home Health Care • Nursing Staff of VNS Home Health Services: Dayle Reese, RN; Mack McGillvrey, RN; Claudette Martin, RN; Charlene Johnson, RN; Debra Barber, RN; Patricia Viveiros, RN

7. Acknowledgements • Donna MacDonald RN, Project Coordinator, Greater Woonsocket VNS • Robin Devin, Ph.D, Health Reference Librarian, University of Rhode Island • Cynthia Willey-Temke, Ph.D., Statistical Consultant, College of Pharmacy, University of Rhode Island

8. Acknowledgements • Claire Cayer, MS., RNGraduate Research Assistant, College of Nursing, URI • Robin Maroni, RNGraduate Research Assistant , College of Nursing, URI • Members of the Class of Nursing 273Summer II, 1999; Summer II, 2000; Fall, 2000 • Susan Corcoran, RN; Lora Likins, RN; Norma Grills, Rachel CaplanNursing Students, College of Nursing, URI

9. I. Description of the Project

10. Purpose • To create a collaborative partnership between nursing practice and academe that fosters research-based pain management in home care

11. Goal 1. To engage students and clinicians in generating and adopting pain management standards based on AHCPR guidelines and current research

12. Goals 2. To test the effectiveness of these standards on patient & family caregiver outcomes

13. Goals 3. To provide clinicians and students with an experiential learning opportunity to improve their competency in evaluating and using the discoveries of research for solving day-to-day clinical problems

14. Theoretical Framework Roger’s (1983) Adoption of Innovations Theory identified factors that improve research utilization: • Strong body of validated predictable knowledge • Policy-generating organizational structure that promotes innovation and a supportive climate of inquiry • Clinician competency to translate and use research findings

15. COLLABORATIVE RESEARCH UTILIZATION MODEL Change in Scientist Change in Student Change in Clinician Clinician/User System Research Enhancement System Change in Practice Knowledge-Generating System Change in Patient Outcomes

16. Previous Research • Dufault, M., Bielecki, C., Collins, E., & Willey, C (1995) “Changing nurses pain assessment practice: a collaborative research utilization approach. Journal of Advanced Nursing, 21, 634-645. • Dufault, M., & Sullivan M. (2000). “A collaborative research utilization approach to evaluate the effects of pain management standards on patient outcomes. The Journal of Professional Nursing, 16(4), 240-250. • Dufault, M., & Lessne-Willey, C. (1999. Using a collaborative research utilization model to test the effects of clinical pathways on pain management. Journal of Nursing Care Quality, 13(4), 19-33.

17. Hypotheses • Does involving clinicians and students in the generation and testing of research-based pain management standards improve patient/family outcomes?

18. Outcome variables • Decreased severity of pain • Decreased interference of pain with quality-of-life indicators • Increased satisfaction with interventions & with caregiver responsiveness • Decreased family caregiver burden of pain management

19. Quality of Life Indicators • General activity • Sleep • Concentration ability • Mood • Walking ability • Relationships with others • Enjoyment of life

20. Caregiver Burden of Pain Management • Financial burden • Sleep disturbances • Confines caregiver • Family adjustment • Time demands • Upsetting symptoms • Changes in personal plans • Overwhelming

21. Research Design: Two-Group Pretest-Intervention-Posttest STUDY GROUP (n=75)CONTROL GROUP (n=89) Pretest (visit 1) Pretest (visit 1) V V Intervention No Intervention (Research-Based Standard of Care) V Posttest (visit 3) Posttest (visit 3) V V Posttest (last visit) Posttest (last visit)

22. Subjects & Setting 164 patients and their family caregivers: • Whose pain is more than the ordinary in the month prior to referral • Alert and oriented at admission and discharge • Able to respond to questions

23. Total Sample Mean Age 70.0 Gender M= 69 (34.2%) F=133 (65.8%) Site #1 69.9 M= 53 (34.0%) F=103 (66.0%) Site #2 70.3 M= 16 (34.8%) F=30 (65.2%) Demographics:

24. Instrumentation • Brief Pain Inventory (Daut, R., Cleeland, C., Flanery, R, 1983) • Caregiver Burden of Pain Management Scale (Ferrell, B.,Grant, M., Chan,J, & Ferrell, B 1995)

25. Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research • Lack of patient & family understanding about pain management following hospital discharge • Discrepancies between patients, family caregivers, & health care professionals • Fear of side effects of drug therapy • Under-use of complementary methods of intervention

26. Procedure: Step 1. Identification of clinical problems in pain management & assessment of the research

27. Procedure: Step 2.Evaluation of the research as it relates to the selected problem, agency values, standards, policies, and cost & benefits • In-depth review of 122 studies to determine strength of the evidence by 64 students • 8 research roundtables held in 2 project sites with 37 clinicians and students participating

28. Procedure: Step 3 • Designing a Standard of Care that incorporates the research findings and recommendations generated by staff and students in the roundtables

29. Procedure: Step 3. Designing a Standard of Care that incorporates the research and recommendations generated in the roundtables

30. Procedure: Step 4. Evaluation of the Pain Management Standard of Care • Data collection & testing for applicability, usefulness for practice, and effectiveness in improving outcomes in 75 patients and their family caregivers

31. Procedure: Step 5. Decision to adopt, alter, or reject the new standard of care • Analysis & Presentation of Data

32. Data Analysis PurposeMethod Describe demographic Frequency distr. and outcome variables univariate stats Compare pretest, Independent t-test Categorical, demographic, Chi-square & outcome variables Hypothesis testing ANCOVA

33. Findings of Statistical Significance Patients whose caregiver followed the new standards for pain management experienced significantly: • Less pain at its least (p=.04) • Less pain right now (p=.0001) • Less interference by pain with general activity (p=.03), mood (p=.0001), relationships with others (p=.0001), sleep (p=.03), concentration ability (p=.0001), and enjoyment of life (p=.001)

34. Pain As It Occurs Right NowAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-10 Scale P=0.0001

35. Effect of Pain on QOL Variables:Concentration AbilityAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-10 Scale P=0.0001

36. Findings of Clinical Significance Patients whose caregiver followed the new standards for pain management experienced : • Less interference by pain with walking ability (p=.07) • Greater % satisfaction with nurse caregiver responsiveness to pain (p=.08)

37. % Satisfied with Health Care Provider Responsiveness to Reports on PainAnalysis of covariance on visit 4 pain scale variable adjusting for visit 1 (baseline) differences 0-100% Scale P=0.0806

38. Trends in Data Patients whose caregiver followed the new standards for pain management experienced : • Less pain at its worst and on the average • Greater % relief from interventions

39. Trends in Data (con’t) Family caregivers of patients whose nurse followed the new standards for pain management experienced less: • sleep disturbances from patient’s pain • overwhelming financial strain • family adjustment • upsetting symptoms • changes to personal plans caused by pain • time demands caused by pain • feelings of confinement

40. Conclusions & Recommendations • the effectiveness of the evidence-based standard for pain management • the usefulness of the model to change clinician ‘s day to day practice • The greater satisfaction with relief from interventions may be due to nurses assessing pain at more frequent • Trends in caregiver burden need to be further studied.

41. Procedure: Step 6Dissemination of the New Standard • Publication in Clinical Journals • Publication in Research Journals • External Presentations at Conferences

42. Procedure: Step 6 con’tCelebrate Outcomes • Emphasize contributions of all members during implementation of the project