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How Nursing Home Certified Nursing Assistants Understand Residents' Pain


Pain is a significant problem for nursing home residents. Pain assessment is complicated by the high prevalence of cognitive loss in this population. Because licensed nurse (LN) staffing levels are low in nursing homes, the majority of resident care is performed by certified nursing assistants (CNAs) who do not have formal training or skills to assess or manage pain. CNAs' role in the assessment and management of pain in nursing home residents is not well understood, because few studies have explored this issue.

To address this gap in our knowledge, a qualitative study using Grounded Theory Methodology was undertaken. The study was conducted at two skilled nursing facilities: Memory Care Units within a large county run hospital and at a 99 bed for-profit corporate owned facility. Twenty-six individuals were interviewed (16 CNAs and 10 LNs) using semi-structured interview guides. CNAs were asked about their experiences caring for residents in pain. LNs were asked about how they perceived CNAs' role in pain management. Interviews were transcribed verbatim and analyzed using grounded theory constant comparative methods.

Both CNAs' and LNs perceived that CNAs had a role in the pain management of nursing home residents. CNAs' recognized pain by using techniques of asking and listening and by observing behaviors. They distinguished pain that they considered normal (everyday pain) from pain that they reported to LNs. As well as reporting pain, they responded to residents who had pain by performing resident-centered care, giving physical care and providing attention to distract residents from their pain. Their ability to do this work was founded on their understanding of pain as multidimensional and their intimate knowledge of individual residents. They described their knowledge of residents as being informed by two types of knowing: working knowledge and knowing residents as individuals. Contextual factors that both promoted and hindered CNAs having a role in pain management were identified. These factors included CNAs' individual skills and experience, low levels of staffing, and working more than 40 hours a week. From this understanding of CNAs' role in pain management, implications for clinical practice and research are identified.

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