Rosene Dunkle RN, MSN, BC, is an Organization, Development & Training Instructor at the Masonic Villages, in Elizabethtown, Pennsylvania. Ms. Dunkle’s interview focuses on her pioneering work starting a Pain Task Force at Masonic Villages.

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Questions

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Evelyn Corsini, MSW:

Tell us about your professional background, and what led you to start the Pain Task Force.

Rosene Dunkle RN, MSN, BC: After I completed school I worked as a nurse in several acute care hospitals and then in several long-term care facilities. I was always looking for an opportunity to teach, and I found that when I took my job at Masonic Villages, where I was encouraged to continue my education. The initial incentive for us to start the Pain Task Force in 1999 was to help prepare for new JCAHO standards for pain assessment, treatment and documentation. A goal of Masonic Villages has always been to be in the forefront when setting high standards for resident care.

EC: Please describe Masonic Villages.

RD: The Masonic Villages of Pennsylvania was founded more than 130 years ago and it includes residences at six different locations, serving over 2,500 people. It is a not-for-profit continuing care retirement community, children’s home, and community service organization. This year we are celebrating A Century of Service, having admitted our first resident in 1910.

The residence at Elizabethtown is the largest Masonic Village community, with more than 1,700 residents located on the 1,400-acre campus. There we have a full continuum of services including retirement living, personal care, and the Masonic Health Care Center, which provides skilled nursing services. I primarily train the nurses and interdisciplinary staff at the Elizabethtown campus, but also train at the other campuses as needed. Since I am located in Elizabethtown, and it is our largest setting, it is where the Pain Task Force has had its biggest impact.

EC: What is the mission of the Pain Task Force and who are its members?

RD: The Task Force is interdisciplinary and our mission statement is simple: “To promote quality of life through the effective assessment and management of resident’s pain.” Membership includes our Medical Director, a pharmacist, social worker, therapeutic recreation specialist, pastor, nurses, a music therapist, a behavioral health psychologist, and therapists from our rehabilitation department. Initially we met twice a month, but now we meet quarterly to coordinate the development of policies, educational offerings, outcome measurements, and to discuss difficult pain issues brought to us by our Pain Resource Nurses.

EC: It sounds like your Pain Task Force has been very far-reaching; can you summarize some of the accomplishments?

RD: There have been multiple projects over the years, focusing on three goals: 1) education of staff and residents about pain; 2) improvement of the quality of pain management we provide to residents; and 3) development of new policies to help meet our mission.

Education for both residents and staff is a major part of the work of the Task Force. All nursing, therapeutic recreation and social service staff at Masonic Villages at Elizabethtown has received training. We have used a wide variety of formats: grand rounds; live in-services, self-study modules, videos, unit conferences, and a Pain Awareness week held in September (Pain Awareness month).

We are particularly proud of the four different self-study modules we developed, which we call Pain Assessment and Management Advocacy (PAMA), for RNs, LPN, NAs, and ancillary staff. The modules combine articles, video and quizzes in notebooks, each of which is customized to communicate the information on pain appropriate to the different levels of care delivery. Nurse Managers can make the completion of the PAMA self study a part of staff’s performance evaluation.

We have tried to be creative in our approach to staff and resident education. One successful initiative (and a great deal of work!) is Pain is No Joke: A Traveling Show. This is a creative 40-minute, vaudeville-like program with humorous characters. We’ve used this program in multiple Masonic Villages locations, including the Health Care Center, dementia care, assisted living, and adult daily living. We wrote about this initiative in an article¹ where Timothy Nickel, Pastoral Care Thanatologist, described “…our pain management task force grudgingly acknowledged that staff attendance at pain management in-services was not standing room only…When we accepted the difficulty of bringing the students to the educators, we decided to take the educators to the students. In this case, the students were the residents and staff of our 450-bed skilled nursing facility…Our goal was to entertain and educate in one grand, tongue-depressor-in check presentation.”

To further our reach beyond the Pain Task Force, we set up a training program and created a Pain Resource Nurse job description, so that each part of the Health Care Center has an identified nurse who can be called on for help with difficult pain management situations.

Each Health Care Center resident has their pain assessed by an RN at their admission. Their ongoing pain is evaluated, treated, and documented, on the Pain Form that the Task Force put together.

EC: Please describe how your Pain Consultations work.

RD: We did Pain Consultations for several years. I coordinated the Pain Consultations program for residents whose pain was difficult to manage. This program was very helpful both on an individual basis, and by giving us an overall look at how we were managing pain at Masonic Villages.

We created an assessment form for the referring staff member to email to us. An RN from the Pain Task Force saw the resident and wrote up the report. The report then circulated to the other members of the task force. This way, all of the specialists could contribute their thoughts. It might lead to the physician or pharmacist suggesting a medication change, or a therapist suggesting a new intervention. After we compiled our recommendations, we put our consultation into the resident’s chart and communicated our recommendations to the Registered Nurse on that unit.

From our consultations, we have developed a very long list of pain resources for our staff to have, so they know what is available to our residents. To list just a few of them, they include: pet therapy, whirlpools, cognitive behavioral therapy, hospice consultation, supportive volunteer visits, psychiatric evaluation, consultation from a neurosurgeon, and special mattresses and cushions.

Currently, we have changed how we handle difficult pain issues. We use our Pain Resource Nurses to do the pain assessments and only send the Pain Task Force the most difficult cases for their input.

EC: You said that you started a resident Pain Support Group. Will you describe your group?

RD: Helping to facilitate the Pain Support Group is the highlight of my month! The group is a lot of effort as it means constantly sending out reminders and encouraging staff to give us new referrals, but we have been doing it for five years now and feel it is a tremendous success. The only criteria are that the resident needs to have chronic pain and be fairly cognitively intact. Three of us, a Nurse, A Social Worker and a Psychologist, facilitate the meetings, which are held once a month for one hour.

The groups have taken on many different formats: sometimes they are purely educational, with a speaker like a dietician or a nurse practitioner, sometimes it is just open discussion, sometimes the members just want to be distracted and talk about things other than their pain. We’ve had an artist who came and helped the residents “paint their pain”, and a music therapist has given a presentation. We’ve celebrated 100th birthdays, enjoyed Christmas parties, and held memorial services for our departed members. The fact that it has lasted for five years, proves that it has been meeting an important need.

References

1. Nickel TA. Pain is no joke! Best Practices in Aging Services, May/June 2003.