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An Action-Based Approach to Improving Pain Management in Long-Term Care*

  • Sharon Kaasalainen (a1) (a2), Kevin Brazil (a2) (a3) (a4), Esther Coker (a1) (a5), Jenny Ploeg (a1), Ruth Martin-Misener (a6), Faith Donald (a7), Alba DiCenso (a1) (a3), Thomas Hadjistavropoulos (a8), Lisa Dolovich (a2) (a3) (a9) (a10), Alexandra Papaioannou (a10), Anna Emili (a2) and Tim Burns (a11)...


Purpose: The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC.

Methods: A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management.

Results: The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers.

Conclusions: This model can guide the development of innovative approaches to improving pain management in LTC settings.

Objectif : Les objectifs de cette étude étaient double : (1) d’explorer les obstacles à la gestion de la douleur et ceux associés à la mise en œuvre d’un programme de gestion de la douleur en soins de longue durée (SLD) et (2) de développer une approche interprofessionelle afin d’améliorer la gestion de la douleur en soins de longue durée.

Méthodes : Une étude de cas a inclus tous les deux éléments, quantitatifs et qualitatifs. Nous avons recueilli des données sur deux sites LTC à l’aide de sept groupes de discussion pour les infirmières autorisées, fournisseurs de soins non réglementés, et médecins, et 10 entretiens avec des autres groupes de fournisseurs de soins de santé, l’administration et des résidents. Nous avons examiné les documents et administré un sondage à court aux participants à l’étude pour évaluer les perceptions des obstacles à la gestion de la douleur.

Résultats : Les résultats ont révélé des obstacles à la gestion efficace de la douleur au niveau des soins de longue durée des résidents et des familles, des fournisseurs de soins de santé, et des systèmes de santé. Nous avons ensuite élaboré un modèle à six niveaux, avec les interventions proposées pour surmonter ces obstacles.

Conclusions : Ce modèle peut guider le développement d’approches novatrices pour améliorer la gestion de la douleur dans les établissements de soins de longue durée.


Corresponding author

Correspondence and requests for offprints should be sent to / La correspondance et les demandes de tirés-à-part doivent être adressées à: Sharon Kaasalainen, R.N., Ph.D. Faculty of Health Sciences, 3N25F, McMaster University 1200 Main Street West, Hamilton, ON, L8N 3Z5 (


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This study was supported by a grant from the Canadian Institutes of Health Research and the Ontario Ministry of Health and Long-Term Care. The authors are grateful for the willingness of the study participants to share their time and expertise with us for this study. This project benefited greatly from the commitment and expertise of research assistants Nancy Carter and Kenzie Greenhalgh. The first author (SK) was supported by a Canadian Health Services Research Foundation (CHSRF) Postdoctoral Fellowship and an Ontario Ministry of Health and Long-Term Care Career Scientist award, at separate times, during this study and the writing of this article. Dr. Alba DiCenso holds a Canadian Health Services Research Foundation (CHSRF)/Canadian Institutes for Health Research (CIHR) Chair in Advanced Practice Nursing. Dr. Thomas Hadjistavropoulos’ work is supported, in part, by the RBC Foundation. Dr. Faith Donald was supported by a CHSRF Postdoctoral Fellowship. Dr. Ploeg holds a mid-career award from the Ontario Ministry of Health and Long-Term Care, and Dr. Papaioannou is a CIHR Ely Lilly Chair in Osteopososis and Geriatrics.



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American Geriatrics Society. (1998). The management of chronic pain in older persons: AGS panel on chronic pain in older persons. Journal of the American Geriatric Society, 46, 635651.
American Geriatrics Society. (2009). AGS clinical practice guideline: Pharmacological management of persistent pain in older persons. Retrieved September 13, 2009 from
American Medical Directors Association. (2003). Pain management in the long-term care setting: Clinical practice guideline. American Medical Directors Association.
American Medical Directors Association. (2004). Tool kit for implementation of the clinical practice guideline for pain management.
Arata, M., & Sodickson, S. (2001). Changing pain management practice at Franciscan Woods. Journal of Palliative Medicine, 4, 575580.
Aubin, M., Giguere, A., Hadjistavropoulos, T., & Verreault, R. (2007). The systematic evaluation of instruments designed to assess pain in persons with limited ability to communicate. Pain Research & Management, 12, 195203.
Baier, R., Gifford, D., Patry, F., Banks, S., Rochon, T., DeSilva, D., et al. (2004). Ameliorating pain in nursing homes: A collaborative quality-improvement project. Journal of the American Geriatrics Society, 52, 19881995.
Bakerjian, D. (2008). Care of nursing home residents by advanced practice nurses. Research in Gerontological Nursing, 1(3), 177185.
Blomqvist, K., & Hallberg, I. (2001). Recognizing pain in older adults living in sheltered accommodations: The views of nurses and older adults. International Journal of Nursing Studies, 38, 305318.
Bowers, B.J., Esmond, S., & Jacobson, N. (2003). Turnover reimterpreted: CNAs talk about why they leave. Journal of Gerontological Nursing, 29, 3643.
Bowers, B.J., Lauring, C., & Jacobson, N. (2001). How nurses manage time and work in long term care. Journal of Advanced Nursing, 33(4), 484491.
Brown, J.B. (1999). The use of focus groups in clinical research. In Crabtree, B. & Miller, W. (Eds.), Doing qualitative research (2nd ed.) (pp. 109126). London: Sage Publications.
Clark, L., Fink, R., Pennington, K., & Jones, K. (2006). Nurses’ reflections on pain management in a nursing home setting. Pain Management Nursing, 7(2), 7177.
Crabtree, B., & Miller, W. (1999). Doing qualitative research (2nd ed). London: Sage Publications.
Desbiens, N., Mueller-Rizner, N., Connors, A., Hamel, M., & Wenger, N. (1997). Pain in the oldest-old during hospitalization and up to one year later. Journal of the American Geriatrics Society, 45, 11671172.
Duggleby, W. (2005). What about focus group interaction data? Qualitative Health Research, 15(6), 832840.
Ferrell, B., Ferrell, B., & Osterweil, B. (1990). Pain in the nursing home. Journal of the American Geriatrics Society, 38, 409414.
Fox, P., Raina, P., & Jadad, A. (1999). Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: A systematic review. Canadian Medical Association Journal, 160, 329333.
Fuchs-Lacelle, S., & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5, 3749.
Gilchrist, V., & Williams, R. (1999). Key informant interviews. In Crabtree, B. & Miller, W. (Eds.), Doing qualitative research (2nd ed.). London: Sage Publications.
Hadjistavropoulos, T., LaChapelle, D., MacLeod, F., Snider, B., & Craig, K. (2002). Measuring movement-exacerbated pain in cognitively impaired frail elders. Clinical Journal of Pain, 16, 5463.
Hadjistavropoulos, T., Marchildon, G., Fine, P., Herr, K., Palley, H., Kaasalainen, S., et al. (2009). Transforming long-term care pain management in North America: The policy-clinical interface. Pain Medicine, 10(3), 506520.
Herr, K., Bjoro, K., & Decker, S. (2006). Tools for assessment of pain in nonverbal older adults with dementia: A state-of-the-science review. Journal of Pain and Symptom Management, 31, 170192.
Herr, K., & Mobily, P. (1991). Complexities of pain assessment in the elderly. Journal of Gerontological Nursing, 17(4), 1219.
Horgas, A., & Tsai, P. (1998). Analgesic drug prescription and use in cognitively impaired nursing home residents. Nursing Research, 47(4), 235242.
Hurley, A., Volicer, B., Hanrahan, P., Houde, S., & Volicer, L. (1992). Assessment of discomfort in advanced Alzheimer patients. Research in Nursing and Health, 15, 369377.
Jones, K., Fink, R., Pepper, G., Hutt, E., Vojir, C., Scott, J., et al. (2004). Improving nursing home staff knowledge and attitudes about pain. The Gerontologist, 44(4), 469478.
Kaasalainen, S., Coker, E., Dolovich, L., Papaioannou, A., Hadjistavropoulos, T., Emili, A., et al. (2007). Pain management decision-making among long-term care physicians and nurses. Western Journal of Nursing Research, 29(5), 561580.
Kaasalainen, S., & Crook, J. (2003). A comparison of pain-assessment tools for use with elderly long-term care residents. Canadian Journal of Nursing Research, 35(4), 5871.
Kaasalainen, S., Middleton, J., Knezacek, S., Stewart, N., Hartley, T., Ife, C., et al. (1998). Pain and cognitive status of institutionalized elderly: Perceptions and interventions. Journal of Gerontological Nursing, 24(8), 2431.
Martin, R., Williams, J., Hadjistavropoulos, T., Hadjistavropoulos, H., & MacClean, M. (2005). A qualitative investigation on seniors’ and caregivers’ views on pain assessment and management. Canadian Journal of Nursing Research, 37(2), 142164.
Marzinski, L. (1991). The tragedy of dementia: Clinically assessing pain in the confused, nonverbal elderly. Journal of Gerontological Nursing, 17, 2528.
Medical College of Wisconsin. (2000). Nursing staff education resource manual: Pain management 101 in long-term care facilities. Milwaukee, WI: The Medical College of Wisconsin.
Mentes, J.C., Teer, J., & Cadogan, M. (2004). The pain experience of cognitively impaired nursing home residents: Perceptions of family members and certified nursing assistants. Pain Management Nursing, 5(3), 118125.
Middleton, J., Knezacek, S., Robinson, L., Hartley, T., & Kaasalainen, S. (1997). An exploratory study of pain in the institutionalized elderly. American Journal of Alzheimer’s Disease, 12(4), 159166.
Morgan, D. (1997). Focus groups as qualitative research (2nd ed.). London: Sage Publications.
Moulin, D., Clark, A., Speechley, M., & Morley-Forster, P. (2002). Chronic pain in Canada—Prevalence, treatment, impact and the role of opioid analgesia. Pain Research & Management, 7(4), 179184.
Parke, B. (1992). Pain in the cognitively impaired elderly. Canadian Nurse, 88(7), 1720.
Parmelee, P. (1996). Pain in cognitively impaired older persons. Clinics in Geriatric Medicine, 12(3), 473487.
Patton, M.Q. (2000). Qualitative research and evaluation methods (3rd ed). Thousand Oaks, CA: Sage.
Proctor, W., & Hirdes, J. (2001). Pain and cognitive status among nursing home residents in Canada. Pain Research & Management, 6, 119125.
QSR International Ltd. (2007). N Vivo (Version 7.0). Thousand Oaks, CA: Scolari-Sage Publications Software.
Registered Nurses’ Association of Ontario. (2002a). Nursing best practice guideline: Assessment and management of pain. Registered Nurses Association of Ontario, Toronto, ON. Retrieved April 11, 2009, from
Registered Nurses Association of Ontario. (2002b). Toolkit: Implementation of clinical practice guidelines. Toronto, Ontario, Canada: Author. Retrieved March 2002, from
Resnick, B., Quinn, C., & Baxter, S. (2004). Testing the feasibility of implementation of clinical practice guidelines in LTC facilities. Journal of the American Medical Directors Association, 5(1), 18.
Ross, M., Carswell, A., Hing, M., Hollingworth, G., & Dalziel, W. (2001). Seniors’ decision making about pain management. Journal of Advanced Nursing, 35(5), 442451.
Ross, M., & Crook, J. (1998). Elderly recipients of home nursing services: Pain, disability and functional competence. Journal of Advanced Nursing, 27, 11171126.
Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334340.
Simons, W., & Malabar, R. (1995). Assessing pain in elderly patients who cannot respond verbally. Journal of Advanced Nursing, 22, 663669.
Spross, J. (2001). Harnessing power and passion: Lessons from pain management leaders and literature. Journal of Pain Medicine, 4(4), 557566.
Stevens, P. (1996). Focus groups: Collecting aggregate-level data to understand community health phenomena. Public Health Nursing, 13, 170176.
Stolee, P., Esbaugh, J., Aylward, S., Cathers, T., Harvey, D., Hillier, L., et al. (2005). Factors associated with the effectiveness of continuing education in long-term care. The Gerontologist, 45(3), 399405.
Warden, V., Hurley, A.C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4, 915.
Wary, B., & Doloplus, C. (1999). Doloplus-2: Une échelle pour évaluer la douleur [Doloplus-2: A scale for pain measurement]. SoinsGérontologie, 19(August–October), 2527.
Weissman, D., Griffie, J., Muchka, S., & Matson, S. (2001). Improving pain management in long-term care facilities. Journal of Palliative Medicine, 4(4), 567573.
Yin, R. (1984). Case study research: Design and methods. London: Sage Publications.
Zwakhalen, S., Hamers, J., Abu-Saad, H., & Berger, M. (2006). Pain in elderly people with severe dementia: A systematic review of behavioral pain assessment tools. BMC Geriatrics, 6(3), 115.


An Action-Based Approach to Improving Pain Management in Long-Term Care*

  • Sharon Kaasalainen (a1) (a2), Kevin Brazil (a2) (a3) (a4), Esther Coker (a1) (a5), Jenny Ploeg (a1), Ruth Martin-Misener (a6), Faith Donald (a7), Alba DiCenso (a1) (a3), Thomas Hadjistavropoulos (a8), Lisa Dolovich (a2) (a3) (a9) (a10), Alexandra Papaioannou (a10), Anna Emili (a2) and Tim Burns (a11)...


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