Solve the mystery of managing pain with home care: New study shows how

Thorough assessment and complementary medicine improve outcomes

While many home health patients may accept pain as a normal part of their condition or of their age, it doesn’t have to be that way, according to experts interviewed by Hospital Home Health.

In a study conducted by University of Rhode Island in Kingston, along with several Rhode Island home health agencies, home care patients reported a decrease in daily pain levels as a result of pain management standards that included better assessment of pain, management of pain medication side effects, and thorough education.

"The whole project was an outgrowth of three studies in hospitals that developed and tested evidence-based care plans for pain management," says Marlene A. Dufault, PhD, RN, professor of nursing at the University of Rhode Island.

"We found that once patients went home, even when they were being seen by a home care nurse, the pain returned to the same level experienced before care in the hospital," she explains. "We wanted to find a way to provide continuity in pain management after discharge from the hospital to home care."

Working with three home health agencies in Rhode Island, Dufault and her students reviewed literature and identified the studies that were most applicable to the home health setting. "We used these studies to brainstorm with the home health clinicians to develop pain management standards that were practical for implementation in home health." The standards help nurses identify the obstacles to accurately assessing pain and suggest ways to address pain in home health patients, she adds.

There are four major problem areas in home care pain management, Dufault says:

  1. discrepancy between family caregiver reports of pain and patient’s actual description of pain;
  2. lack of understanding by the patient and family about proper medication use and pain management techniques;
  3. fear of side effects such as addiction, nausea, constipation, and inability to concentrate;
  4. underuse of complementary techniques such as massage or music therapy.

One of the first steps taken in the pain management project was education of the clinicians. "Clinicians didn’t understand the discrepancy between a patient’s description of pain and the caregiver’s description," she says.

"Many times, patients will not tell a caregiver the full extent of their pain because they don’t want to be a burden," says Jeanne M. Schwager, RN, BSN, PhD, nursing supervisor at Roger Williams Home Care in Providence, RI.

In a qualitative follow-up study conducted within her agency, Schwager also found that in some instances, caregivers will downplay pain levels because they don’t want to appear to be ineffective in their care of the patient or because they don’t want to accept the fact that their loved one is in pain, she adds.

"In the case of a cancer patient experiencing pain, the caregiver may not want to accept the cancer diagnosis, and so he or she ignores the pain associated with cancer," she explains.

To address this issue, the nurse should ask both the patient and the caregiver questions about pain, says Karen Hockhousen, RN, BSN, director of clinical and patient resources for VNS Home Health Services in Narragansett, RI.

Some new questions also were added to the assessment form during the study to prompt more questions about pain, she says. For example, the form now prompts nurses to ask how breakthrough pain is handled and a combination of a numeric scale with descriptive words and pictures of faces to indicate pain level is used, she says.

Enhancing assessment forms to address pain is critical because not all nurses have the same level of knowledge about pain management, Schwager says. This means that some nurses may recognize symptoms of unmanaged pain while others may not, she adds.

"We changed our nursing tool to include pain assessment questions for each visit, not just at admission." As nurses see patients over time, the tool gives them a good picture of which medications or techniques are effective, she adds.

A good screening tactic is to ask if pain interferes with sleep or the ability to move around, Dufault says. Pain in these areas will affect all activities of daily living, so if the answer is positive, the clinician knows that it is necessary to probe more closely and ask very specific questions about pain and medication use, she adds.

It also is important for the nurse to notice behaviors that indicate pain, Hockhousen adds.

"Grimacing, grunting, sighing, and tensing extremities all are possible signs of pain." If a clinician notices any of these behaviors, more questions are asked to identify the cause and severity of the pain, she explains.

Dispel fears

Patient and caregiver information is needed to overcome some of the misunderstandings that hinder pain management, Schwager points out. "Patients are afraid of the adverse effects or the possibility of addiction to pain medication."

Education must address these fears, or the patient and caregiver won’t follow instructions, she adds.

Make sure patients and caregivers understand that following prescription instructions not only will help them manage pain but also will protect them from addiction problems, Schwager says.

Patients also need to understand that if the prescription instructions say to take the medication every six hours, they cannot stretch it to eight and expect the medication to affect pain in the same way, she says. At this point, the pain level may require additional medication to affect it, she adds.

If side effects are a concern, be sure to tell patients to let you know about them, Dufault says. "There are many medications to control the side effects so that the patient can benefit from the pain medication. Also, let patients know that with some drugs such as morphine, the side effects, such as nausea, will go away in one to two days," she adds.

Be aware, too, that your patients’ reluctance to use medication at the full strength or the correct frequency may be due to financial constraints that make them conserve their medication, Schwager says. In these cases, ask a social worker to help the patient find assistance for prescription medication, she adds.  

Use complementary techniques

"Complementary medicine is most effective for medium-range pain, such as that reported in the 4 to 7 range on a 10-point scale," Dufault says. "Remember that complementary medicine will not replace pain medication entirely but can reduce the amount of medication needed." (For more information about complementary medicine in home health settings, see "Touch, music, and imagery can relieve stress, anxiety, and pain, report says," Hospital Home Health, May 2002, p. 49.)

The complementary techniques can be a simple use of cold and hot packs, Hockhousen says.

"If you choose heat to help manage the pain, I recommend moist hot packs in most cases because they are safer for older patients. If you do recommend that the patient use dry heat such as heating pads, make sure you go over safety precautions with them carefully," she warns.

Other complementary techniques, such as relaxation and distraction-using tools such as music, easily can be taught to nurses without the need for a special therapist, Schwager says.

"Other therapies such as heat massage, ultrasound, or the use of a transcutaneous electrical nerve stimulation unit must be ordered by a physician and administered by a physical therapist," she points out. "We’ve found that physicians are very receptive to our suggestions regarding therapy techniques, especially for patients with chronic pain."

Make sure your nurses have all of the information they need, Schwager suggests. "A drug database for the nurse’s laptop is a great resource," she says.

Because physicians are not always up to date on drug interactions and it may take many telephone calls to connect with the physician, it is helpful if the nurse can look up certain medications and their interactions with the patient’s current medications in order to give the physician a complete picture, she explains.

Taking a team approach

A multidisciplinary team that oversees pain management policies and procedures within the agency and one person who is designated as the in-house pain management consultant are other good resources to put in place, Schwager says.

"The field of pain management is too complex for us to expect all clinicians to stay up to date on their own, but having one person with an interest in the field who is in charge of reviewing and disseminating new information is helpful," she adds.

"The biggest surprise to me as we reviewed our process for managing pain was how many patients tolerate, accept, and even expect pain," Schwager says.

"Through education, thorough and ongoing assessments, and a variety of techniques, we not only can help patients manage pain, but we can improve all aspects of their lives," she adds.

[For more information on pain management in home health, contact:

Marlene A. Dufault, RN, PhD, Professor of Nursing, University of Rhode Island, College of Nursing, White Hall, Heathman Road, Kingston, RI 02881. Telephone: (401) 874-5307. E-mail: marlened@uri.edu.

Jeanne M. Schwager, RN, BSN, PhD, Nursing Supervisor, Roger Williams Home Care, 825 Chalkstone Ave., Providence, RI 02908. Telephone: (401) 456-2273. E-mail: jschwager@cox.net.

Karen Hockhousen, RN, BSN, Director of Clinical and Patient Resources, VNS Home Health Services, 14 Woodruff Ave., Suite 7, Narragansett, RI 02882-3467, Telephone: (401) 782-0500. E-mail: khockhousen@vnshomehealth.org.

For information about prescription drug assistance programs, go to: www.needymeds.com. The web site offers a description of all assistance programs offered by drug manufacturers and other groups. The listings are available by manufacturer and by specific drugs.]