Week 14 Activity

Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-term Care

Sharon Kaasalainen, RN, PhD, Jenny Ploeg, RN, PhD, Faith Donald, RN(EC), PhD, Esther Coker, RN, MScN, MSc, Kevin Brazil, PhD, Ruth Martin-Misener, RN-NP, PhD, Alba Dicenso, RN, PhD, Thomas Hadjistavropoulos, PhD

Disclosures

Nurs. 2015; 16(2):78-88. 

 

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Abstract and Introduction

Abstract

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

Introduction

Inadequate pain management in long-term care (LTC) has been identified as a problem worldwide with rates of resident pain ranging from 30% to 83% (Moulin et al., 2002, Proctor and Hirdes, 2001, Zwakhalen et al., 2009). Despite these high rates, pain is consistently underassessed and undertreated, particularly in LTC facilities (Won et al., 2004). Innovative strategies, such as an interdisciplinary pain protocol, are needed to improve pain treatments and reduce pain in residents living in LTC settings.

Kaasalainen et al. (2012)) found that implementing a pain protocol significantly improved resident pain in an intervention group compared with a control group over a 1-year intervention period. In this project, a clinical nurse specialist (CNS) and a nurse practitioner (NP) were identified as key facilitators to the successful implementation of the pain protocol. In Canada, NPs and CNSs are advanced practice nurses (APNs) with "graduate education who work collaboratively in interdisciplinary teams to meet the health needs of individuals, families, groups, communities, and populations" (Canadian Nurses Association, 2008). APNs have been defined internationally as registered nurses who have "acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice" (International Council of Nurses, 2013). NPs also can diagnose, order, and interpret diagnostic tests, prescribe medications, and perform some procedures traditionally associated with physicians (Canadian Nurses Association, 2011). CNSs have expertise in a clinical specialty defined by a specific population, setting, disease, type of care, or type of problem. There is overlap between NP and CNS role responsibilities for clinical practice, education, research, consultation, and leadership (DiCenso et al., 2010). This article reports on a substudy of the pain protocol project that focused on how a CNS and an NP facilitated the implementation of the pain protocol to produce changes in clinical practice. These findings also may shed some light about successful strategies that can be used to implement other types of practice changes in LTC, to ultimately improve the quality of life for residents.

Literature Review

Clinician beliefs and attitudes about pain may influence their decision making regarding pain management and treatment options within LTC settings (Kaasalainen et al., 2007). For example, research has indicated that health care providers underutilize opioid medications in older people, particularly those with cognitive impairment (Kaasalainen et al., 1998, Mezinskis et al., 2004, Won et al., 2004). Both nurses and physicians are reluctant to use opioids in LTC residents, especially for those with cognitive impairment who are deemed nonpalliative (Kaasalainen et al., 2007). Weissman and Matson (1999)) found a widespread fear of treating pain without understanding its exact cause, along with concern about overmedication and drug toxicity, especially for those older people with cognitive impairment. Unfortunately, the amount of physician contact in LTC facilities is limited due to lack of onsite physician coverage, which creates a challenge for careful monitoring and effective individualizing of pain treatments. A way to overcome this challenge may be to use other health care team members more effectively (e.g., NPs, CNSs, pharmacists) to assess and manage residents' pain. The development and evaluation of innovative strategies, such as an interdisciplinary pain protocol, using models of collaborative care, may lead to more effective pain management while ensuring careful monitoring of drug toxicity.

The implementation of innovative interventions is challenging and research clearly shows that instead of passive dissemination, a multifaceted implementation approach is needed that includes audit and feedback, education outreach, and a local opinion leader to address multiple barriers (Grimshaw et al., 2005, Thompson et al., 2006). Baier et al. (2004)) found that a multifaceted collaborative intervention that used audit and feedback, education, training, coaching using rapid-cycle quality improvement techniques, and inter-nursing home collaboration, improved pain management process and outcome measures in 21 LTC facilities in Rhode Island. Using a quasi-experimental, pretest\posttest design, Baier et al. found use of appropriate pain assessments and nonpharmacologic treatments increased significantly (p < .001), but use of pain medications for residents with moderate to severe pain, prescriptions, and change in pain medications did not. Baier et al. suggested that lack of communication between nurses and physicians may have contributed to these poor findings around pain medication use.

Bakerjian (2008)) suggests that CNSs and NPs can play a pivotal role in promoting effective communication between physicians and nurses in LTC, as well as acting as "change coordinators" or "change champions." Change champions have been defined as "individuals who dedicate themselves to supporting, marketing, and 'driving through' an innovation" (Greenhalgh, Robert, Bate, MacFarlane, & Kyriakidou, 2005). Given their advanced education and clinical skills, NPs and CNSs are well positioned to facilitate a practice change, such as implementing a pain protocol.

In this study, the implementation of the pain protocol was guided by the Ottawa Model of Research Use (Graham & Logan, 2004)—a planned model of change. The preimplementation stage of this model includes an assessment of barriers, which once identified, need to be addressed in order to increase the likelihood of successful implementation of the innovation. To assess barriers, we completed an environmental scan before implementing the pain protocol at the two participating LTC facilities (Kaasalainen et al., 2010). In this scan, LTC staff identified a number of barriers to pain management, including lack of knowledge, lack of interdisciplinary collaboration, poor nurse-physician communication, and poor knowledge transfer with staff in LTC.

Based on these scan findings, we designed a multifaceted approach to implement the pain protocol intervention, which was shown to be effective in reducing resident pain in the intervention group (F = 6.35; p = .01; Kaasalainen et al., 2010). One of the key strategies that we used was to position APNs (CNS, NP) as change champions to facilitate the pain protocol intervention. Hence, the purpose of this study is to report on the role of a CNS and an NP as change champions during the pain protocol implementation process. Specifically we addressed the following questions:

1. How do NPs and CNSs facilitate effective change in practice related to the implementation of a pain protocol in LTC?

2. What barriers and facilitators are encountered by the CNSs and NPs in changing team practice related to implementing a pain protocol in LTC?

Methods

This case study sought to explain how advanced practice nurses—who were positioned as change champions—implemented the pain protocol intervention successfully. We used an exploratory, multiple-case study design to address the "how" of an intervention (Yin, 2009).

Setting and Sample

Data were collected from October 2008 to September 2009 at two LTC facilities in southern Ontario, Canada that were involved in the implementation of a pain protocol. They were chosen in part because they employed an NP or CNS. The CNS and NP were designated by their respective LTC home management staff to be the change champion to implement the pain protocol.

Site 1 employed an NP who had a master's degree and more than 10 years of experience working as an NP, 5 of which were spent at this LTC facility. Site 1 was a for-profit LTC facility and had 130 beds. It employed 62 personal support workers (PSWs), 19 registered practical nurses (RPNs), 13 registered nurses (RNs), 1 nurse educator, 1 director of care, 1 medical director, 1 administrator, 12 offsite physicians who were independently employed, and a number of other health care providers, including a consulting pharmacist.

Site 2 employed a CNS who had completed a master's degree and had been practicing in LTC for more than 10 years. Site 2 was a not-for-profit LTC facility and had 110 beds. It employed 45 PSWs, 1 RPN, 27 RNs, a second CNS, 1 medical director, 1 administrator, 5 offsite physicians who were independently employed, as well as a number of other health care providers, including a consulting pharmacist.

Data Collection

Three methods were used to collect data: 1) diaries in which the CNS and NP recorded activities and processes they engaged in related to implementing the pain protocol; 2) participant observation fieldnotes of NP and CNS activities related to the pain protocol intervention; and 3) interviews and focus groups with various interdisciplinary team members who were responsible for implementing the pain protocol. These data collection methods are described here.

APN Diaries. The CNS and NP each completed a diary (after having received instructions how to do so) for the duration of the implementation phase of the pain protocol, recording their activities and processes related to implementation of the pain protocol. Activities were summarized on a weekly basis over the first 3 months as that early phase was expected to be the most intense. After that, they completed diary notes as they felt necessary. At the end of the implementation phase, the NP and CNS were asked to write a two-page reflection on their involvement in implementing the pain protocol, summarizing key strategies used, challenges and facilitators encountered, and an overall sense of their role in the process.

Participant Observation. We used moderate participant observation (research assistant was present and identifiable in the study setting and was involved in structured observation, occasionally interacting with participants) with peripheral membership (research assistant interacted frequently and intensely in the study setting to acquire firsthand information and insight) (Dewalt, 2002). Specifically, a research assistant shadowed each CNS and NP for 3 hours, twice a week for 3 weeks. Hence, 36 hours of participant observation was completed, 18 hours per NP and CNS. Fieldnotes were taken using a standardized template in 15-minute segments over each 3-hour period to capture the CNS or NP involvement in activities related to the pain protocol intervention, such as meetings; interactions with residents, family, and staff; mentoring; and other interdisciplinary communications that may have been missed in the diary entries. To facilitate observer consistency, the CNS and NP were initially observed concurrently by both research assistants using the template. After these sessions, we held debriefing sessions with the research assistants to discuss inconsistencies and to reach consensus. After two of these debriefing sessions, no further inconsistencies were noted; the research assistants then completed the remaining observations individually.

One of the weekly observation sessions was scheduled in the morning and the other in the afternoon of different days of the week. A short debriefing session was scheduled at the end of each week to provide a summary of observations and a time for reflection on early analysis, methods undertaken to collect data, ethical dilemmas, and observers' thoughts and feelings (Bogdewic, 1999).

Interviews and Focus Groups. At the end of the 1-year implementation phase, we conducted interviews with various members of the interdisciplinary teams responsible for implementing the pain protocol. In total, we conducted four focus groups: two with PSWs (unregulated care providers, n = 17), and two with RPNs and RNs (n = 11). Individual interviews were conducted with five members of administration (two administrators and three directors of care), four interdisciplinary team members (pharmacist, physiotherapist, physiotherapy assistant, and restorative care assistant), and the NP and CNS. Each participant was interviewed once, either in a focus group or an individual interview. Focus groups lasted approximately 90 minutes, whereas individual interviews were between 30 and 60 minutes in duration. Unfortunately, all requests to interview a facility physician were denied.

The majority of participants (82%) were women with the lowest percentages of women in the pharmacist group (0%). The nursing groups were comprised of mostly women (91%). Participants, on average, had been working in their current position for 8 years (SD = 6.9) and in LTC for 11 years (SD = 10.1). Administrators had been working in LTC for a longer period of time (mean = 17 years; SD = 14.9) than the health care team members (mean = 9 years, SD = 8.2).

Data Analysis

Within the larger case-study approach, we analyzed the data using thematic analysis (Patton, 2002). Diary records, participant observation fieldnotes, and transcribed interview data were inputted into the qualitative software program, NVivo 8.0, to help organize and analyze the data. Two individuals, who were trained in completing thematic analysis, analyzed all data separately beginning with line-by-line coding and later grouped into larger categories. Initial coding of each transcript was done independently by two individuals to foster credibility and dependability. Any discrepancies were reviewed by the two investigators and discussed until consensus was reached. Once all data were coded, the major themes were identified. Data analysis was conducted in an iterative manner until the research team was all in agreement. All participants were given a two-page summary of findings and asked for feedback to assess the truthfulness of the findings and ensure data were interpreted correctly (Crabtree & Miller, 1999).

We used cross-case analysis by first creating a "word table" that displayed the data from the two cases (sites 1 and 2) separately; each data were labelled in terms of its location, timing, and source (Yin, 2009). In this manner, each case was treated as a separate study, with its own developed codes and categories (Yin, 2009). Data from all sources were then integrated and analyzed together to develop the overall themes using thematic analysis that involved the research team.

Ethical Considerations

We obtained approval from a university-affiliated research ethics board as well as ethics boards at the participating LTC homes. Written consent was obtained from each interview or focus group participant before collecting data.

Results

Overall, the CNS and NP used a variety of strategies to help implement the pain protocol in LTC (see Table 1). They were seen as change champions and active in

· educating staff about pain management and pain protocol implementation;

· phasing in use of the pain protocol;

· providing reminders and prompts to nursing staff;

· using audit and feedback

· organizing and facilitating interdisciplinary practice (e.g., pain team meetings) to reinforce the pain protocol and provide "check-ins" with staff to identify barriers to implementation;

· assessing residents using advanced history and physical assessment skills, conducting in-depth pain assessments, and prescribing pain medications as needed; and

· creating a positive relationship with staff to implement practice changes.

Barriers to implementing the pain protocol included lack of follow-through from nurses, competing demands and heavy workload of LTC staff, and staff resistance to change.

Educating Staff About Pain Management and Pain Protocol Implementation

The NP and CNS educated staff about managing pain in older adults in general and the process of implementing the pain protocol. The education was delivered in two different ways: 1) providing one-on-one educational outreach to staff, and 2) organizing and facilitating scheduled educational sessions.

Providing One-on-one Educational Outreach to Staff. The CNS and NP each provided one-on-one outreach to educate staff about completion of the protocol forms (e.g., checklist, protocol steps). The NP and CNS listened to staff and considered their input about ways to reduce workload related to implementing the pain protocol or make it less cumbersome to use (e.g., replacing the current prn medication flow sheet on the medication administration record with the protocol form to eliminate double documentation) and make the implementation process smoother. As well, they provided staff education about residents' diagnoses and associated pain, recognition of typical and atypical pain responses, and use of pain medications:

A staff came to me with questions about a resident behavior and we attempted to determine if it was pain related which ended up involving some education to staff. (NP diary, site 1) [The NP] was like the library, to help us understand the pain protocol a little better, the pain assessment a little bit better. Understanding the resident, with the different diagnoses, the reasons for having different pain…or maybe expressing pain in a different way. (RN/RPN focus group, site 1) One thing about [the NP] is that [the NP] explains things to us … right to the last detail. If you ask [the NP] a question [the NP] will explain it, [the NP] will even bring it up on the computer and show you. (PSW focus group, site 1)

At site 1, the NP consulted with a nurse regarding a resident who was identified as having pain:

· Nurse said she never asked resident to use number scale, rather she assigned a number based on the information the resident provided (e.g., "scored" resident a 4 for moderate pain).

· The NP discussed how scales should be used (must go by what resident says or use different scale if the number scale is not appropriate).

· Nurse completed new initial pain assessment and reviewed findings with the NP. (Participant observation notes, site 1)

In another encounter, the NP worked with a nurse who was struggling with how to use the pain protocol in practice:

· RPN expressed frustration with pain protocol, takes too much time to do assessments, and interferes with medication administration. The NP spoke with RPN re: use of pain protocol and helped explain how to use it by going through it with RPN step by step.

· RN asked questions about the protocol. The NP explained how to use it by using a specific resident example and had the nurse problem solve what to do. (Participant observation notes, site 1)

At site 2, the CNS met with clinical leaders at each clinical area on a daily basis to discuss pain management issues for residents and to answer questions. The following is an example of an encounter:

· CNS met with a clinical leader to discuss pain management of residents on unit.

· Talked to nurses about using a standardized pain assessment tool.

· Distributed the pain protocol resource binders and binders for interdisciplinary staff members; CNS informed the staff in each clinical area of the following related to the protocol: purpose of the study, and contents of the protocol resource binder, including brief summaries of the journal/research articles found in the binder. (Participant observation, site 2)

In subsequent encounters, the CNS captured learning opportunities by asking staff specific questions about residents' pain to promote critical thinking (e.g., Could the resident's behavior be related to pain? Do residents verbalize the effectiveness of the current pain medication? If the resident is nonverbal, how do the nurses know if the pain medication is effectively managing the resident's pain?). This collaborative approach to problem solving is illustrated here:

If the staff came to me questioning a resident's behavior, we would attempt to determine if it was pain-related together. (CNS diary, site 2)

Organizing and Facilitating Scheduled Educational Sessions. In addition to one-on-one educational outreach, the NP and CNS organized and frequently facilitated scheduled education sessions for staff about gaps in knowledge that were discovered when using the pain protocol. These education sessions were organized on an ad hoc basis when the need or request from staff arose. Specifically, staff requested more information about different types of pain that older adults experience (site 1 only) and about using pharmacologic and nonpharmacologic interventions to manage pain (sites 1 and 2). At both sites, the CNS and NP organized a session on pharmacologic management of pain. They recruited the pharmacist who worked at each LTC facility to present information about using different types of pain medications, common side effects in older adults, and adjuvant therapies to offset some of the side effects.

The NP developed and facilitated interactive educational in-service for team (RNs, PSWs, physiotherapist) re: types of pain (participant observation notes, site 1). The CNS facilitated an in-service with the "med nurses" (RPNs) to go over the pain protocol and using pain medications, covering each step and form, used resident examples to explain the protocol pain. (Participant observation notes, site 2)

Phasing in Use of the Pain Protocol

The CNS and NP discussed how it can be overwhelming for staff to implement a new change in practice and the strategy of "starting small and then expanding later" (NP diary, site 1) seemed to help offset some of the negative feelings of staff and allowed time to "work out the kinks" before implementing it facility-wide. Piloting the pain protocol or "phasing it into practice" was a strategy used by both the NP and CNS but more so by the CNS. For instance, at site 2, the CNS started the pain protocol on one unit first and then gradually expanded to other units. The CNS had a particular strategy that seemed to work for that site:

I asked the clinical leaders on each floor to identify one resident who they knew was in uncontrolled pain and we used the pain protocol on that resident to see how it worked and to help them get used to using the protocol. … On their next clinical day, clinical leaders used the protocol on all residents on whom they were doing their quarterly updates and also will use it on all new residents as they move in. (CNS diary)

On another unit:

The CNS met with another RN to discuss plans to roll out pain protocol implementation. They decided to start the pain protocol on two patients first and then start on three more patients at the end of the month. (Participant observation notes, site 2)

Providing Reminders and Prompts to Staff

The NP and CNS were often engaged in reminding or prompting staff to implement the pain protocol; for example, checking in with the nurses during daily rounds and reminding them to think about the pain protocol and about resident pain itself, and posting newsletters with information about pain and about the study to facilitate its use. At site 1, the NP, along with the clinical educator, created an educational poster board that included the study summary, list of pain team members, pain facts, various pain-related resources including a pocket for journal articles, and handouts from previous education sessions. The CNS at site 2 incorporated the pain assessment tool in the electronic charting system to facilitate use:

I think putting those [pain assessment tools] onto a computerized version was just a lot easier for the staff too as a reminder to automatically do that. And it just made them think of it, too. It just made a lot of people more aware of pain and what it looked like. (CNS interview, site 2)

Sometimes the presence of the CNS or NP on the units reminded staff about implementing the pain protocol. Examples of this were reflected at both sites in all three sources of data: diary entries, participant observation notes, and focus group interviews:

I did my usual weekly round on each floor asking them [staff] if anyone is experiencing new or uncontrolled pain. (CNS diary, site 2) CNS walked to each floor and asked nurses how the pain protocol was going and inquiring if they had any concerns or questions. None were reported at this time pain. (Participant observation notes, site 2) [The CNS] would catch somebody with new pain and she would ask us questions like "by the way, is she on the pain protocol yet?" Like remind us that you need do the proper assessment or intervention. [The CNS] put it into focus. (RN/RPN focus group, site 2) The NP talked to charge nurse about starting pain protocol for a resident who had leg pain and told the oncoming nurse about this resident and to reassess more often using pain protocol. Notes left in residents' charts to remind other nurses when pain assessments need to be completed for each resident (e.g., "assess pain re: contractures every day × 3 days"). (Participant observation notes, site 1)

Using Audit and Feedback

The NP and CNS used audit and feedback as a way to prompt staff either to continue what they were doing well and sustain the change or to bring attention to areas that required improvement:

I [NP] reviewed and audited charts to determine if staff were completing the pain protocol appropriately. I [NP] asked staff to add more details or further explain in their charting about resident pain. (NP diary, site 1)

The NP met with the charge nurse and an RPN and reviewed initial pain assessment for a resident to look for learning gaps:

· For location of pain—right side documented, wants more specific description for location

· Need explanation of exacerbating factors (listed decrease in appetite)

· More specific re: bowel habits (listed "poor")

· Reviewed these gaps with charge nurse and RPN. (Participant observation notes, site 1)

The CNS highlighted errors and added notes and new protocol documentation on to charts for nurses. (Participant observation notes, site 2)

Organizing and Facilitating Interdisciplinary Practice

The CNS and NP were responsible for organizing and facilitating monthly interdisciplinary pain team meetings with staff to help implement the pain protocol and problem solve issues together. At the beginning, these sessions were focused on how to implement the pain protocol most effectively but later became more focused on concerns about specific residents who had challenging pain problems. Here is an example of an issue discussed at a pain team meeting at site 1:

· 10 people in attendance + 2 research assistants: social worker, RPNs, NP, nurse educator, nurse manager, physiotherapist, recreational therapist.

· The NP introduced the meeting and went over agenda.

· The NP asked, "Who in the room is involved in the pain protocol?"

· Any suggestions with using the protocol?

· Physiotherapist suggestions: not sure of follow-up and where they are expected to chart. The NP was disappointed about the lack of follow-up regarding a specific patient whose pain was put off by the RPN as "weather related." Resident approached front desk to ask if something was going to be done about her pain and it was dismissed as if she just had memory issues.

· The NP asked, "Why is pain not being followed up?"

· Group responded: need more education and staff. (Participant observation notes, site 1)

At another pain team meeting at site 1:

The NP developed a case study (for discussion at a pain team meeting) to work through pain protocol and enhance application of knowledge and problem-solving ability. The NP went through entire medication list (explaining why patient is on each med, dosage, and possible side effects). Example of pain medications: fentanyl patch 100 mcg (3 patches) Q72h, oxycontin CR 40 mg Q12h, oxycocet 5/325 2 tabs po Q4h prn. (Participant observation notes, site 1)

At site 2, the CNS held pain team meetings with staff using a communication tool called Situation, Background, Assessment, and Recommendation (SBAR) to identify residents who have pain and for whom the pain protocol should be initiated.

CNS set up SBAR meeting on pain, involving PSWs and RNs on unit. CNS engaged group by asking specific questions:

1. Is resident in pain?

2. How would you know resident is in pain?

3. Showing any nonverbal signs?

4. Any resident guarding or grimacing?

5. Can resident tell you where pain is?

6. What do you think pain comes from?

7. Are PRN medications effective at all? (Participant observation notes, site 2)

The SBAR … was a communication tool originally used for physicians so the situation, the background assessment and recommendation. … So who's in pain, what's the background related to pain, what's the assessment, what are our findings, where do we go from there if we thought someone was in pain. So we just took that time, which was about half an hour a month for each unit, or each home area. (CNS interview, site 2)

Assessing and Treating Residents Using Advanced Clinical Skills

The NP at Site 1 was also involved more clinically than the CNS to implement the pain protocol by completing history and physical assessments as well as advanced pain assessments, prescribing analgesics (NP only), ensuring follow-up with treatments, and enhancing communication with the interdisciplinary team. Advanced practice skills in assessing and treating patients were described:

The NP assessed resident with pain related to lung cancer, reviewed resident's medications and chart, completed initial pain assessment. (Participant observation notes, site 1) [The NP] was like a resource to help us with medications because [the NP] could actually order medication. (RN/RPN focus group, site 1)

Creating Positive Relationships with Staff to Implement Practice Changes

Participants spoke about how the type of relationship they had with the NP or CNS facilitated knowledge transfer related to implementing the pain protocol. They said that the CNS and NP were dedicated to the topic and positive about the change, which facilitated buy-in and motivated staff. The NP and CNS were able to gain respect, develop trust, and establish credibility with nursing staff by displaying a higher level of knowledge and understanding. Participants said that the CNS and NP knew the residents well, enhanced communication, and promoted teamwork. The NP and CNS were described as being innovative, curious, creative, willing to try new things, and were accessible and approachable.

I think that [NPs] are able to display a higher level of knowledge and understanding and so they gain the respect of the nurses who see them that way and not necessarily just another pair of hands. So I think because [the registered nursing staff] have road tested and can see the value of what [NPs] have to offer that I think that has probably helped as well. So [the registered nursing staff] will automatically know if something is not really clear to them say well maybe we need to talk to [the NPs], maybe they need to come and see the resident. (Administration interview, site 1) It really is being there, being around, having your ears opened for what is happening as well as responding when people come to you. But it's a constant presence, right, you don't just sort of drop something one day and say oh, here you go. Some people you can, some people just need the information and they are able to sort of run with that. And other folks it's a little more of a struggle, it's a companion you know. In our particular model we have the nurses doing a lot of tasks, your mind isn't free to think beyond the medication cart. So just having that extra mind there to say, "Why don't you try this?" "Have you thought about that?" Or "Can I do this for you?" It can't just be a parachute sort of thing. It's this constant daily walk together, I think, that makes the difference. (Administration interview, site 2)

Barriers and Facilitators for CNSs and NPs as Change Champions

A number of barriers and facilitators for implementing the pain protocol were identified (Table 2). No barriers were identified specific to the CNS's or NP's implementation of the protocol. Barriers specific to the protocol included lack of RN follow through and the belief held by staff that the protocol is too rigid and it "assumes LTC nurses cannot think for themselves" (CNS diary, site 2). At times, the pain protocol was not viewed as a priority by the nursing staff and it was seen as increasing the amount of paperwork they had to do, making their job more complicated. The CNS and NP stated that timing was a challenge due to competing demands of other larger projects that were concurrently being implemented. They also stated that it was difficult getting all staff educated about the pain protocol, particularly the part-time and night staff. Staff resistance to change, staff turnover, and use of external agency staff were other reported barriers. Facilitators to implementing the pain protocol included having a dedicated NP or CNS who was committed to and persevered with implementing the pain protocol, the ability of the NP to order certain pain medications, having support from administration for the project, and having CNS or NP support for educating staff about pain assessment and management and use of the pain protocol.

Discussion

The findings from this exploratory, multiple-case study provide a new understanding about the important role that NPs and CNSs play when implementing practice guidelines, in this case a pain protocol in LTC facilities. We evaluated the truthfulness of our data in a number of ways. Specifically, we aimed to achieve multiple perspectives by including participants from a variety of disciplines. Also, we used journals to examine our own biases and beliefs that we reflected on throughout the analysis. Moreover, we used multiple and independent coders during the analysis and used a number of data collection methods (i.e., interviews, diaries, observation) for data triangulation. These strategies helped promote the overall truthfulness of the study findings.

The study findings highlight that both the NP and CNS worked closely with staff in various activities to facilitate successful implementation that focused on providing education and reminders to staff while maintaining positive working relationships. The CNS and NP played similar roles but the NP was more engaged in providing direct care while implementing the pain protocol. Bakerjian (2008)) found similar results in her review of the literature, in that NPs were more involved in providing primary care to LTC residents, whereas both CNSs and NPs were active in providing consultation, education, case coordination, and change coordination.

The CNS and NP roles as change champions were clearly supported by this study. These study findings add to the growing body of literature about the nature of these roles in changing practice (Greenhalgh et al., 2005, Ploeg et al., 2010). Ploeg et al. found similar results in their study, which examined how nursing best practice champions influence the diffusion of guideline recommendations in a variety of settings. Specifically, they found that champions influence the use of guidelines most readily by 1) disseminating information through education and mentoring, 2) being persuasive at interdisciplinary meetings, and 3) tailoring the implementation to the organizational context.

According to Graham and Logan (2004)), change is more quickly adopted when it is compatible with current practice and values. An understanding of organizational routines is important when implementing evidence-based innovations in practice (Cranley, Birdsell, Norton, Morgan, & Estabrooks, 2012). The CNS built on this understanding by integrating the pain protocol into an already established practice at the LTC facility—the SBAR sessions. This was a change enabler as staff was already familiar with the SBAR process, and needed to only slightly adapt current practice to include the new pain protocol. Through interactive educational discussions, like the SBAR session, practice change is more likely to occur as opposed to passive dissemination approaches (Thompson et al., 2006). Additionally, if the intervention is implemented within a multifaceted approach using educational outreach visits, reminders, audit and feedback, change champions, local consensus processes, and social marketing, the likelihood of a successful intervention is greater (Grimshaw et al., 2005), which was the case with this pain protocol intervention.

The two most frequently reoccurring themes—the NP and CNS organizing interactive educational meetings and engaging interdisciplinary members in discussions regarding the pain protocol—highlight important strategies for changing practice. In this study, the CNS and NP involved LTC team members in training and activities, building a sense of shared values and community engagement related to the pain protocol. When viewed as partners in the change process, individuals are more engaged and empowered, contributing to a sustained practice change (Scalzi, Evans, Barstow, & Hostvedt, 2006).

Through organizing interactive educational interventions and outreach visits, the NP and CNS were able to address the potential barriers to change, including lack of knowledge or skill and negative attitudes (Graham & Logan, 2004). For instance, through engaging the interdisciplinary members in discussions about the pain protocol and pain management, the CNS used transformative knowledge translation strategies (McWilliam, 2007). The CNS began each SBAR session with probing questions to challenge the group to reflect on current practice. Questions such as "is the resident in pain?" and "how would you know the patient is in pain?" encourage group members to reflect on their current practices, and consider how the care they provide may be changed. Questions related to identifying pain and nonverbal behaviors trigger group members to be more conscious about addressing pain in everyday practice. These clinical triggers encourage practitioners to question their practice and rationale, thus stimulating change (DeBourgh, 2001).

The CNS and NP acted as the interface between the research team and frontline staff to implement the pain protocol intervention, which was facilitated by the positive relationships they developed with staff. For practice change to be successful, the change champion must be well connected to the staff, respected and trusted in their "expert" role (Thompson et al., 2006). It was evident that both the CNS and NP had strong communication and interpersonal skills, were highly respected within their respective organizations. and were viewed as clinical opinion leaders by staff, thereby contributing to their influential role as change champions (Borbas, Morris, McLaughlin, Asinger, & Gobel, 2000).

Limitations

There are some limitations to this study. First, we sampled only two LTC facilities in southern Ontario. Second, only one CNS and one NP led the implementation of the pain protocol in their respective LTC facilities. Hence, the study findings cannot be applied to other LTC facilities where the number and type of staff or role of the NP or CNS may vary. Also, it is possible that more constructive feedback about the CNS or NP roles was not shared during the focus groups and interviews due to the complex relationships among staff. It also should be noted that our results might be skewed because most participants interviewed in this study were women. Further work is needed to examine the implementation of a pain protocol in larger and smaller LTC facilities that use a variety of care models and staff mixes and the types of changes that would benefit the most from the use of NPs and CNSs as change champions.

Conclusion

Clearly, resident pain is an ongoing challenge for LTC staff to manage effectively. However, instituting changes in practice to improve pain management are difficult to initiate and sustain over time due to competing demands for staff. NPs and CNSs may possess different skill sets that help them advocate for change in innovative ways using a multifaceted and interdisciplinary approach, which is needed to foster a comprehensive change. Acting as the interface between the researchers and frontline staff, the NP and CNS encouraged practitioners to question current practice and embrace evidence-based innovations. The knowledge gained from this study will enhance nursing practice regarding the implementation of practice changes through knowledge transfer and exchange in the LTC setting, illuminating the influential roles of the CNS and NP as change champions.