Original Article Certified Nursing Assistants’ Perspectives of Nursing Home Residents’ Pain Experience: Communication Patterns, Cultural Context, and the Role of Empathy Debra Dobbs, PhD, Tamara Baker, PhD, Iraida V. Carrion, PhD, Elizabeth Vongxaiburana, MA, and Kathryn Hyer, PhD ---

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From the School of Aging Studies, College of Behavioral and Community Sciences, University of South Florida, Tampa, Florida. Address correspondence to Debra Dobbs, PhD, School of Aging Studies, College of Behavioral and Community Sciences, University of South Florida, 4202 E. Fowler Ave., MHC 1325, Tampa, FL 33620. E-mail: [email protected] Received February 21, 2012; Revised June 21, 2012; Accepted June 22, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.06.008

ABSTRACT:

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents and certified nursing assistants (CNAs) about pain; 2) how race and ethnicity influence NH residents’ pain experiences; and 3) CNAs’ personal experiences with pain that may affect their empathy toward the resident’s pain experience. The study consisted of a convenience sample of four focus groups (n ¼ 28) from a NH in central Florida. A content analysis approach was used. Data were analyzed with the use of Atlas.ti version 6.2. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. Attitudes among CNAs about resident cognitive status and perceived resident burden need to be recognized as barriers to the detection and reporting of pain by CNAs and should be addressed. In addition, NHs should consider a person-centered approach to pain that is culturally competent given the cultural influences of both residents and staff. Finally, educational programs for CNAs that include empathyinducing scenarios could potentially improve the care provided by CNAs when dealing with residents’ pain. Ó 2014 by the American Society for Pain Management Nursing Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 87-96

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The prevalence of pain among nursing home (NH) residents is well documented (Ferrell, 1995; Gerontological Society of America, 2011; Hutt, Pepper, Vojir, Fink, & Jones, 2006; Institute of Medicine, 2011; Reynolds, Hanson, DeVellis, Henderson, & Steinhauser, 2008; Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010). Current estimates suggest that 33%–83% of NH residents have ongoing pain that may impair mobility and increase dependency in activities of daily living (LaPlane, Quilliam, Chow, & Kim, 2012). There is a particular concern that NH resident pain is often undertreated or undermanaged (Ferrell, 1995; Hadjistavropoulos, Marchildon, Fine, Herr, Palley, Kaasalainen, & Beland, 2009; Institute of Medicine, 2011; Lapane, Quilliam, Chow, & Kim, 2012; Takai et al., 2010). Certified nursing assistants (CNAs) provide most of the direct care and surveillance of residents in the long-term care setting. CNAs provide personal care to frail and disabled residents who are unable to perform the most basic activities, such as dressing or toileting without assistance. This contact with the residents allows CNAs to have direct observation of pain behaviors (Bowers, Fibich, & Jacobson, 2001; Weiner & Rudy, 2002) and subtle changes in behavior that may be indicative of a serious health issue (Piven, Anderson, Col on-Emeric, & Sandelowski, 2008). Fisher, Burgio, Thorn, Allen-Burge, Gerstle, Roth, and Allen (2002) found that CNA proxy pain report and assessment was more strongly associated with care outcomes, such as analgesic medication use, than the Minimum Data Set (MDS) pain items. In their study, CNAs reported the presence of pain (yes/no) and the frequency and intensity of pain (13-point Likert scale) on a proxy pain questionnaire (PPQ). That study compared the PPQ data with the MDS pain items of frequency and intensity, both measured using a 3-point Likert scale (frequency ranging from no pain to pain daily, intensity from mild pain to times when pain is horrible or excruciating). The findings of that study suggested that CNA assessment and report of pain are key components of caring for resident pain (Fisher et al., 2002). Despite this role that CNAs play in resident pain care in NHs, there have been few, if any, studies that have examined resident pain from the perspective of the CNA (Takai et al., 2010). Pain communication patterns between residents and their proxies and professional and paraprofessional staff in NHs are a vital component of the management of pain. Given the amount of direct care that CNAs provide, a CNA is the most likely staff member to communicate with the resident on a daily basis and to develop a trusting and intimate relationship

with the resident. Research has been conducted in the field about communication patterns with professional nursing staff and residents with cognitive impairment in NHs (Kaasalainen, 2007), but there is an absence of research related to NH residents’ communication patterns with CNAs about their pain experiences. Based on the literature, racial and ethnic relations between CNAs and residents affect resident care experiences in NHs. A recent systematic literature review suggests that racial/ethnic disparities in pain management exist due to misperceptions about the presence and/or severity of pain, and to patient attitudes, beliefs, and behaviors that influence the acceptance of appropriate analgesics, provider attitudes, and knowledge and beliefs about patient pain (Shavers, Bakos, & Sheppard, 2011). Other research has had similar results specific to language and cultural barriers (Chiauzzi, Black, Frayjo, Reznikova, Grimes Serrano, Zacharoff, & Wood, 2010). One method reported in the literature to reduce racial disparities in pain treatment has been the engagement of nursing professionals in empathyinducing strategies (Drwecki, Moore, Ward, & Prkachin, 2011; Schell & Kayser-Jones, 2007). Drwecki et al. (2011) described an intervention designed for nurses who were to imagine how a patients’ pain affected his or her life. Results from that study indicated a 55% reduction in pain treatment bias compared with the control group (Drwecki et al., 2011). In research specific to CNAs in NHs, Schell and Kayser-Jones (2007) suggested that a care provider may show greater empathy toward someone for whom he/she is caring if the CNA has had a similar personal experience with pain. Using the cognitive and emotional domains of empathy (Davis, 1994; Hojat, Gonnella, Nasca, Mangione, Vergare, & Magee, 2002) as theoretical constructs, their study showed how CNAs used both forms of empathy to improve care for NH residents who were dying (Schell & KayserJones, 2007). Both the cognitive domain (role-taking ability to see the world from the resident’s perspective) and the emotional domain (use of empathetic skills to identify with the emotional experience of residents) were essential in the quality of care. Based on the above literature review, the present study explored the following issues related to the management of NH resident pain: 1) communication patterns between NH residents and CNAs about pain; 2) how race and ethnicity affect NH resident pain experiences; and 3) how CNAs’ personal experiences with pain may affect their level of empathy toward residents with pain. We explored these topics qualitatively from the perspective of the CNA.

Nursing Assistants’ Perceptions of Pain Care

DESIGN AND METHODS Recruitment and Participants A convenience sample of 28 CNAs were selected from a large (120-bed facility) for-profit national chain NH in central Florida. Four focus groups were conducted to assess the CNAs’ perceptions of pain among NH residents. The focus groups ranged in size from six to eight participants. The range of participants was determined based on recommendations from qualitative experts in the field (Berg, 2007). To be eligible for study participation, the CNA had to be employed at the facility for $3 months, be able to speak and understand English, and provide informed consent. This study was approved (blinded for review) by the University of South Florida’s Institutional Review Board. Permission to advertise (flyers were posted in staff break areas) and conduct the focus groups was obtained from the NH’s administrator. All interested participants informed either the NH administrator or their staff supervisor of their desire to participate in the study. Participants were compensated $20.00 for their time. No interested individuals were refused. Procedure The focus groups were conducted from August to December 2009. Each group session was conducted in a private room and lasted 1.5 hours. Before the start of each session, participants were assured that their responses would be kept confidential. In each focus group, the CNAs were asked a series of open-ended questions related to residents’ report of pain, the cultural identity of residents and staff in relation to the treatment of resident pain, and questions about personal experiences with pain related to the role of empathy in caring for NH residents’ pain. The first question, which consisted of two parts, related to residents’ report of pain: ‘‘Do you feel that the residents accurately report their pain experience? Why or why not?’’ The next two questions asked related to cultural background: 1) ‘‘Does the cultural background of residents influence how you treat their pain?’’ and 2) ‘‘Do you think your cultural background influences how you perceive and/or treat pain among yourself or the residents?’’ The last two questions asked about the CNAs own experiences with pain: 1) ‘‘What do you know about pain or chronic pain?’’ and 2) ‘‘Do you experience chronic pain, and if so, how does that influence how you treat the residents with chronic pain?.’’ In addition to these open-ended questions, an anonymous report of survey data was collected from each focus group participant regarding age, sex, race, marital status, occupational status, length of employment, and educational attainment.

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Two groups were facilitated by a graduate student in aging studies with a graduate background in bioethics; the other two were moderated by a PhD trained in behavioral health and health disparities in pain management. Neither facilitator had a prior relationship with the participants. The focus group facilitator took field notes related to the participants’ responses and shared the notes with the other members of the research team. All sessions were recorded and transcribed verbatim by a third party and checked for accuracy by a member of the research team, who listened to the audiotaped focus group interviews and verified the transcription. Analysis For coding and analysis purposes, the authors entered the transcripts into Atlas.ti version 6.2. To assure rigor in the data analysis, a multidisciplinary research team then coded the transcripts independently. One member of the coding team was the graduate student who was also the focus group moderator. The second coder was a PhD-trained sociologist with expertise in qualitative methods and a background in long-term care research. The third coder was a PhD-trained anthropologist and Spanish-speaking licensed clinical social worker with research expertise in qualitative methods related to racial health disparities. Open coding and axial coding were used (Strauss & Corbin, 1998). The open coding strategy was used for a line-by-line content analysis of the responses to the questions asked in the focus group. After the open coding was completed, axial coding provided a more refined analysis. More detailed codes were inductively derived during team meetings in which the transcripts, coded text, and published literature were discussed in relation to each other. Consensus was reached by the five members of the research team, which was composed of the focus group facilitators, the data coding team, and a PhD trained in public policy with expertise in NH research. After a final review by the team, the identified themes were categorized as: 1) attitudes as barriers to communication patterns about resident pain care; 2) cultural religious and gender influences of resident pain care by CNAs; 3) the role of empathy; and 4) worker strategies to detect pain. Credibility of the data collection and analysis process was enhanced by: 1) careful documentation and organized record keeping so that data were maintained in a retrievable form and easily audited by peers; 2) triangulation of data by using colleagues with expertise in aging and qualitative research to improve the conceptual clarity and completeness of the findings; and 3) a multidisciplinary research team analyzing the

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data independently and reaching consensus with the larger research team of multiple disciplines (Miller & Crabtree, 1999).

RESULTS Sample Characteristics All but one of the participants was female, and the mean age was 38.1 (SD 10.5) years. Three selfidentified as white, 20 as black; 2 as Hispanic/Latino, 2 as Asian, and 1 as Native American. Fewer than one-third of the participants completed high school and another 64% completed some college. The average CNA experience was 12.5 (SD 9.1) years. Other demographic characteristics, by focus group, are presented in Table 1. Theme 1: Attitudes as Barriers to Communication About Resident Pain Care CNAs overwhelmingly responded ‘‘no’’ to the question, ‘‘Do you feel that the residents accurately report their pain experience?’’ When probed further, a number of attitudes were elicited from the CNAs supporting myths about pain management in older adults. These attitudes, in turn, became barriers to the detection and reporting of pain for the CNA. The most common TABLE 1. Participant Profile Characteristics

FG #1 FG #2 FG #3 FG #4 (n ¼ 8) (n ¼ 6) (n ¼ 7) (n ¼ 7)

Age, y (mean) 35 Female (%) 87.5 Education (%) Less than High school 0 High school diploma 25 or GED Vocational/some 75 college Hispanic (%) 0 Race (%) White 0 African-American 100 Asian/Pacific Islander 0 Native American 0 Other 0 Did not respond 0 Marital status (%) Married/cohabitating 12.5 Separated 12.5 Divorced 0 Single/never married 75 Widowed 0 Did not respond 0

40.2 100

42.1 100

37.6 100

16.6 16.6

0 42.9

0 14.3

66.6

57.1

85.7

16.7

14.3

0

33.3 33.3 0 0 0 16.7

14.3 42.9 14.3 14.3 0 0

0 85.7 14.3 0 0 0

33.3 0 16.7 16.7 16.7 16.7

42.9 28.6 0 14.3 14.3 0

42.9 0 28.6 28.6 0 0

resident traits mentioned were attitudes about age and cognitive status. One staff member from focus group #1 spoke about their perceptions of how age and cognitive status preclude clear communication about pain: We get a lot of people who are just here for therapy, they’re not that old. So they can tell you exactly [where their pain is] but when you get the real elderly and some with dementia and stuff like that, they can tell you ‘‘Help me. Help me. Something’s wrong,’’ but they really can not tell you what it is.

Another attitude that supports myths about pain management and is a barrier to communication was the residents’ intolerance of pain, which led to drug reliance or pill-seeking behavior. A number of participants in the focus groups shared this common sentiment: I hate to say this, but I know sometimes a lot of them are pill seekers ... and we can not really know whether they’re really actually in pain or are they just wanting a pill, I see that a lot too. [participant in focus group #3]

When probed whether certain types of residents are pill seekers, CNAs reported that personality influences pill-seeking behavior. As quoted from a CNA from focus group #3: I find that the people who have been passive, more calm in their lives are more patient. And the ones that are aggressive and even the bossy ones, like to control everything, it’s ‘‘Now . give it to me . I ain’t waiting.’’

CNAs also question whether some residents are in pain or if they just have attention-seeking personalities. One CNA from focus group #3 described her perception related to attention seeking by some residents: Everybody feels that their pain is the worst pain they’ve ever had or had experienced right then and there, because we want all the attention for me, me, me, me.

One communication pattern that emerged as a subtheme was the use of nonverbal cues, such as grimacing, not eating, or becoming immobile. A CNA from focus group #2 described the contrast of how residents with dementia react differently to having pain compared with residents who are cognitively intact: You can tell the ones that are alert. They verbalize their pain and just tell you that they’re in pain. But the dementia population is just either, they’re grimacing or don’t want to eat. They want to be left alone.

Another barrier to communication about pain was the perceived burden residents have about their complaints of pain, as described by this CNA: They’ll tell you once but they don’t want to tell you again because they feel like when you walk in their

Nursing Assistants’ Perceptions of Pain Care

room the expression on your face and your body language make them feel like they don’t ... you don’t want to be bothered with them so they kind of not tell you and call their family and talk to them.’’

Residents, who felt as if they are a burden, tended to communicate about their pain and symptoms to their family members instead of staff. Family communication about resident pain with all levels of staff was observed by CNAs, and was typical when family members felt that residents are not getting the treatment they need. A focus group #4 participant discussed this: I think that if the person doesn’t feel like they’re getting through to the doctor or to the nurse that the family can intervene and say I really want them to be comfortable, you know.

The perspective of the family member’s need for communication about the resident’s pain was described in the following scenario by this focus group #2 participant: The family members, they tell us, they need to come and tell us, ‘‘my mother has chronic pain, my mother suffers. I mean I know my mother’s history; my mother is a chronic pain person. So if ever she ends up in a nursing home I know what I want for her, I want comfort for her. This is what I want. This is what I want you to do regardless of what you think or what the doctor thinks, this is what I want.’’

Another consequence for residents who waited to report their pain because they felt they are a burden was that the pain became unbearable. A focus group #3 participant described what happens: They’re chasin’ you down the hallway. ‘‘Did you tell the nurse? And how long is she going to wait? I can not wait much longer, I’m dying.’’

Theme 2: Cultural, Religious, and Gender Influences of Resident Pain Care by CNAs Although their cultural beliefs regarding pain may differ from the residents, the CNAs acknowledged that they consistently reported the residents’ pain to the nurses. The following quote from focus group #2 participant is an exemplar of this theme: I’m a type of person that I don’t like meds, I don’t take them. I mean I have a very high tolerance for pain. But I would never say, ‘‘come on and it’s only a little pain, you can deal with.’’ No. Give them [residents] something. You know it’s like I don’t want anybody else to hurt, but I personally, I don’t take medicine ... very often. If I do I’m probably dying.’’

The CNAs recognized that regardless of cultural background, pain is a universal phenomenon that is individually experienced, and each resident’s pain

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tolerance should be respected, as evidenced from the following statement by a participant from focus group #3: Pain is pain no matter who you are or where you’re from.

There were a number of subthemes related to the question, ‘‘Does the cultural background of the resident influence how you treat their pain?’’ The CNAs reported that female Hispanic and black residents prefer to express and receive treatment for pain from female health providers. One CNA from focus group #4 stated: Well, you have to respect their beliefs and how they are. Hispanic people and a lot of the older black women do not want a man to touch them. I don’t really think the white women care.

The cultural background of the resident also precluded some CNAs from assessing pain. One participant from focus group #1 explained: I have one [culture] is a definite barrier; she’s Chinese. It’s very hard to assess pain with her.

A CNA from focus group #3 described how the cultural background of the resident, which may differ from that of the staff member, matters in pain assessment: I have to look at the culture of the person because I’m Hispanic. So again, it all ... boils down to knowing your individual person ... My mother, for instance, will not let a male nurse deal with her. That’s why when she’s sick, it has to be a female. That’s a culture thing.

A second subtheme that emerged in the content analysis was an observation by CNAs that gender and race of the residents affected their willingness to accept treatment for pain. Residents tended to prefer same-race CNAs to care for them when they were in pain, as displayed in this quote by a CNA from focus group #1: We have some like, if you’re black they don’t want you to be bothering with them. You know. Some don’t want black people to take care of them. Some don’t want white people to take care of them, you know. So it depends, you know. Some of them may be hurting so bad but you go in there [their room] to do something, [they say] ‘‘I don’t want you.’’

Another subtheme related to residents’ preferences for home remedies and their lack of trust in the effectiveness of prescribed medication for pain. In those instances when residents were against the use of prescription medicines, CNAs would provide other remedies to decrease the pain, as indicated by one CNA:

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You try to do other things to like help them, you know, through the pain, like warm wash cloths, whatever ... whatever works, but as long as it’s not against their beliefs.

Finally, CNAs acknowledged that religious beliefs and religion as a healing agent are coping mechanisms for dealing with pain. The following quote from a participant in focus group #4 is an example of this: Culture and religion plays a lot, so some people, based on religion, a resident may not want something. They can tolerate or they can not tolerate the pain. It really depends on the individual person and their religious beliefs.

Theme 3: The Role of Empathy in CNAs’ Care of Residents With Pain Many CNAs had personal experience with chronic pain, which translated into empathy for residents with chronic pain. Understanding that medication should be taken on a regular basis, not just as needed, is based on their own personal experiences with, e.g., chronic back pain, as a CNA from focus group #2 described how her experiences helped her empathize with the residents: And with me, if I wait until I’m hurting so bad, once I take the medication it takes a long time for it to level off. So I think that if somebody has chronic pain they ought to be given their medication on a regular basis so that they don’t get to the ... a point where they’re hurting so bad that they’re sick, that it hurts them ... you know they literally get physically sick from it. I think that they shouldn’t have to ask for it. I think that it should be given to them to keep them comfortable.

A second quote that exemplifies personal experience in relation to empathy was from a focus group #1 participant: See I have been there. I was paralyzed for nine months. So I know what it feels like to want to get up and can not. I know what it feels like to want to turn and can not ... So I treat ’em different because I’ve been there and I know how they feel.

A third example of empathy described by a number of CNAs is realizing that just like them, when they are in a lot of pain, they just want to be left alone. This was expressed by a participant in focus group #3, who states she just wants to be left alone and that, A lot of our [patients] are like that then if you look at ’em, you can tell if they want to be left alone. ... Yeah, the elderly are very sensitive to pain.

Empathy was not limited to personal experience with pain. Some of the experiences included caring for a family member at home, as described by a CNA from focus group #1:

I’ve had some, not in the NH, out of the NH, only because I deal with the chronic people at home. One is waiting for her double transplant ... my Mom, that is ... so I have been there.

Theme 4: Worker Strategies to Detect Pain The CNAs reported many worker strategies for pain detection. The most prominent strategy was ‘‘guessing game,’’ which became an in vivo code to address the scope of the guessing games in which the CNAs engaged to assess pain. An in vivo code is one in which the words used by the respondents are so descriptive that the term itself becomes a code. Staff would say that it was a guessing game to identify where the pain was. A focus group #2 participant explained: Anyhow, some may say ‘‘I hurt here,’’ and the pain is way somewhere over [there]. And now you’re in that guessing game.

This guessing game is often the case for those residents who have dementia. For those residents, staff members use the process of elimination by verbally questioning the resident as to where the pain is. Here is one example of that strategy in action based on accounts from a CNA in focus group #1: Well, I’ve done it here. You know: ‘‘Oh, my legs hurt.’’ And I said well, how high can you lift your leg? And they lift their arm. I said, ‘‘I thought you said it was a leg.’’ [The resident said] ‘‘No, no, no. I mean this one,’’ you know, and then you know that they’re confused.

Other strategies mentioned were the use of touch, knowing the resident, watching for nonverbal cues and facial expressions, and documenting when the resident informs them they are in pain. A common strategy related to touch was offering physical care to residents when they are in pain, as described by a participant in focus group #1: A lot of elderly people, when they’re in pain, if they could see you or they could just hold on to you it gives them more security that everything is going to be alright, you know.

A CNA’s perception of the ongoing relationship and his or her knowledge of the resident was an important part of being able to detect pain. This was shown in this excerpt from a participant in focus group #2: No training, just let me see to assess the resident yourself, I mean, because you’ve worked with them so long you already know them.

A focus group #1 participant described her strategy of watching for nonverbal cues and facial expressions:

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If you look at a person, if they’re really in pain you can tell by their expression on their face, and their complexion also changes with pain. So that’s how I deal with the pain.

DISCUSSION The present study used content analysis to explore issues related to residents’ pain experiences from the perspectives of the CNA. The content analysis identified four main themes: 1) attitudes as barriers to communication about resident pain care; 2) cultural, religious, and gender influences of resident pain care by CNAs; 3) the role of empathy in CNAs care of residents with pain; and 4) worker strategies to detect pain. There are long-standing myths that clinician, system, and patient barriers and communication patterns impede the effective assessment, treatment, and management of pain among older adults in NHs (Herr, 2011). In Relieving Pain in America, the Institute of Medicine (IOM) acknowledges that chronic pain is a disease and not just a symptom of other conditions (Institute of Medicine, 2011). The IOM report further addresses disparities in care for older adults and recognizes that undertreated pain may lead to depression and anxiety, decreased quality of life, and functional impairment (Ferrell, 1995; Hutt et al., 2006; Reynolds et al., 2008). Yet, pain assessment among the elderly population has not come without its challenges. Sensory, emotional, and cognitive impairment, lack of standardized assessment tools, concerns of side effects of medications, and insufficient knowledge about pain and methods to reduce it are only a few indicators that place some NH residents at greater risk of unmanaged pain (Gerontological Society of America [GSA], 2011). Results from our focus groups showed that CNAs have considerable issues regarding some residents’ pain intolerance and overreliance on medication. Our respondents described individuals who were assertive in seeking pain medicine as bossy or as ‘‘pill seekers,’’ whereas calm residents were described as more patient. This persistent behavior demonstrates the role that personality has in mental and physical health outcomes, maintenance, and overall quality of life (Buneviviute, Staniute, & Buneviscius, 2011). Our findings revealed that cultural factors directly affect beliefs regarding treatment for pain among NH residents. The residents’ preference of pain management differed depending upon their religious and spiritual beliefs. Factors relating to residents’ discomfort

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with receiving care from a different gender and race also affected the residents’ ability to openly express pain and seek out treatment. The CNAs valued the residents’ religious and spiritual beliefs regarding alternative treatment for pain and consequently communicated them to the nurses. The CNAs also acknowledged that the residents’ beliefs often differed from theirs, yet they expressed willingness to respect the residents’ beliefs to prevent barriers to pain management. This recognizes the importance of cultural factors regarding language, communication, gender, religion, and spirituality in the day-to-day management of pain of LTC residents. This corroborates with Blomqvist’s (2003) findings that the daily care of elderly residents in long-term care facilities is multitiered and involves cultural factors and social and environmental characteristics. The present study also provided support of the use of empathy in assessing the pain experienced by residents. Focus group participants clearly showed their use of cognitive and emotional empathy in their day-to-day relationships and in helping residents to manage their pain. Personal and familial experiences of pain management provided insight into the level and quality of care that the CNAs tried to provide every day. However, CNAs also were aware of the limitations of their own knowledge base when it came to assessment. Focus group participants described mostly informal methods of recognizing pain in NH residents, with the predominant theme that it was a ‘‘guessing game.’’ Urgent Need for Change in Pain Assessment in Nursing Homes With the recognition of a failure to systematically assess NH residents’ pain, the Center for Medicare and Medicaid Services began to require new pain assessment questions in the Minimum Data Assessment 3.0 system in October 2010. Although the expectation in the NH is for nurses to observe and document nonverbal sounds and behaviors, we suggest that assessment should also include direct care staff interviews to augment their reports of resident pain behaviors. In addition to reinforcing the need for more focused assessment, the present study also indicates that CNAs need effective tools that allow them to report their concerns to nurses, especially concerns for those residents with cognitive impairment. Furthermore, there is a need for increased awareness of resident pain behaviors through education of staff (Gessert, Hyer, Kane, Kane, & Rockwood, 2005; Jones, Fink, Pepper, Hutt, Vojir, Scott, Clark, & Mellis, 2004; Tse, Leung, & Ho, 2012; Weiner & Rudy, 2002). Finally, NHs must establish quality improvement plans that

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monitor residents’ pain levels, perhaps by units within NHs, to help CNAs and nurses to recognize how to improve manage pain. Similarly, there remain erroneous beliefs about older adults’ willingness to ask for pain medication (GSA, 2011). National data show that patients, who experience pain, are often unaware of their treatment options and may have inaccurate information that impedes treatment (GSA, 2011). Although our data support the perceptions by CNAs that residents have an overreliance on medication, we suggest this actually may indicate a lack of knowledge by the CNA of pain medication options and current treatment plans for residents. It is difficult to determine if assertive, aggressive, or persevering behaviors are normal personality manifestations or are consequences of pain. Because the individual is now residing in an NH, the change of residence does not mean that their personality changes significantly. Someone demonstrating these types of behaviors before admission will likely exhibit similar behavior after admission to the NH. The CNA may observe that it takes a certain level of assertiveness to have pain complaints (the resident’s) acknowledged and treated. In this setting, the goal of the resident is to have their pain under control. Therefore, the resident may feel that they have to ‘‘complain’’ or be aggressive in seeking treatment. This inference, of course, warrants further investigation as a clinical and workforce development concern. There is continued discussion about the importance that cultural factors have in the assessment, treatment, and maintenance of health among racially and culturally diverse populations. A person-centered approach that is culturally competent to pain should be considered, given the findings in this study related to cultural influences of both residents and staff. Related to this is work from Coggins (2009), who has examined the importance and various levels of cultural competency among health care organizations and nursing school curriculums. What is recognized is that cultural competency is a continuum of diversity awareness rather than a static variable. What may be necessary, specifically for long-term care facilities servicing the needs of ethically and culturally diverse elderly populations, is: 1) to train the nurses, CNAs, and staff regarding what it means to be culturally competent; and 2) to assess where the particular facility stands in addressing the needs of its diverse residential population. We also found that the CNAs had certain perceptions of how the residents’ pain was assessed and the methods used in its assessment. Respondents indicated that although pain could be recognized through direct observation, the most effective way to recognize the

resident’s pain experience was through a close relationship and daily interactions with the resident. Wright, Varholak, and Costello (2003) suggest that CNAs’ proximity to residents allows for more direct access and observations of the subtle nuances of residents’ pain. Pain symptom specifics can vary between individuals; this ambiguity further delays proper pain detection and treatment (Cristofaro, 2004; Loeb, 2004; Norman, 2000). Furthermore, if the resident is unable to appropriately communicate their pain experiences (owing to cognitive impairment or other conditions), it may be necessary to rely on others (e.g., CNAs, family members) to gain a more accurate assessment. In the present study, family members were a vital component in the recognition of pain among NH residents. The findings in this study regarding worker strategies underscore the urgency to address the educational challenges to pain care. CNAs in this study reported a lack of formal education to assist them in caring for the NH residents in pain. Any educational efforts directed at CNAs should begin to address the cultural attitudes, systemic and organizational barriers, and gaps in policy while providing a platform for effectively relieving pain and suffering among NH residents. In addition, educational programs for CNAs that include empathy-inducing scenarios could potentially improve the care provided by CNAs when dealing with residents’ pain, given the findings that CNAs who had personal experiences with pain (or cared for family with pain) had increased empathy for the residents they care for with pain. This study contributes to the field by highlighting the fact that the CNA is invaluable in the recognition and treatment of NH resident pain. Increased focus on collaborative and multifocal pain assessment is necessary for NH residents in general, and particularly for those who are cognitively impaired (Fisher et al., 2002; Horgas, 2008; Horgas & Dunn, 2001). Our findings add to the ongoing body of literature and invite further inquiry. Although the present findings show the importance of the unique perspectives that CNAs have in the pain experience of elderly NH residents, we acknowledge several study limitations. First, we conducted interviews at one NH in the state of Florida. Therefore, the findings of this study are not generalizable to other NHs. Second, the CNAs were from one facility. Future analyses should recruit more CNAs from multiple facilities to determine if there are different perspectives and attitudes. Finally, we did not examine the residents’ pain (cause, severity), so we were unable to determine if the cause, type (acute or chronic), or location influenced the CNAs’ perceptions and

Nursing Assistants’ Perceptions of Pain Care

attitudes of how pain was assessed, treated, and managed. Further investigations (qualitative and/or quantitative) are necessary to determine whether these findings are generalizable to a broader NH population. Despite these limitations, this study makes several contributions, including the racial diversity of our CNA sample. In conclusion, the results of the present study can guide future research in developing quantitative and mixed methods studies to examine the relationship between the quality of care and key processes of care. These processes of care are: 1) how CNA attitudes contribute to communications with residents about their pain experiences; 2) interactions

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between CNAs and residents of different genders as well as different cultural and religious backgrounds; and 3) the promotion of educational programs on the care of resident pain for paraprofessional staff in NHs. The inclusion of empathy-inducing strategies in any educational programs developed for CNAs in NHs could potentially improve processes of care for resident pain. Acknowledgments The authors thank the Florida Health Care Association and all of the Certified Nursing Assistants and nursing home administrators for their dedication in caring for the needs of their residents.

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Certified nursing assistants' perspectives of nursing home residents' pain experience: communication patterns, cultural context, and the role of empathy.

This study explored the following issues related to pain management among nursing home (NH) residents: 1) communication patterns between NH residents ...
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