Accuracy and Bias of Licensed Practical Nurse and Nursing Assistant Ratings of Nursing Home Residents Pain

Transcription

1 Jounal of Geontology: MEDICAL SCIENCES 2001, Vol. 56A, No. 7, M405 M411 Coyight 2001 by The Geontological Society of Ameica Accuacy and Bias of Licensed Pactical Nuse and Nusing Assistant Ratings of Nusing Home Residents Pain Veonica F. Engle, Mashall J. Ganey, and Anna Chan Univesity of Tennessee Health Science Cente, College of Nusing and College of Medicine, Memhis. Backgound. This study evaluated the accuacy of licensed actical nuses (LPN) and nusing assistants (NA) Minimum Data Set (MDS) ain atings of nusing home esidents and evaluated the bias in ain atings associated with esidents ace, gende, mental status, function, deession, o disutive behavio. Methods. Data wee obtained on the same day diectly fom esidents, LPNs, and NAs by tained inteviewes in two safety-net nusing homes. A total of 252 esidents wee included in this study: 79% wee Black, and 60% wee men. MDS items J2a and J2b evaluated ain fequency and ain intensity duing the last 7 days (weekly ain fequency and weekly ain intensity). A aallel question evaluated ain intensity on the day of the inteview (daily ain intensity). MDS data wee obtained fo the MDS Cognition Scale, the MDS Activities of Daily Living-Long Fom Scale, the MDS Deession Rating Scale, and the MDS Disutive Behavio Scale. Results. Kaa coefficients documented fai to good esident LPN (K.70,.56, and.50) and esident NA (K.72,.58, and.60) ageement fo weekly ain fequency, weekly ain intensity, and daily ain intensity atings. LPNs and NAs undeestimated esidents weekly ain fequency (.001 fo LPNs, and.001 fo NAs), weekly ain intensity (.001 fo LPNs, and.001 fo NAs), and daily ain intensity (.001 fo LPNs, and.002 fo NAs). LPNs undeestimated weekly and daily ain intensity moe than NAs did (.016 fo weekly ain intensity, and.035 fo daily ain intensity). LPN and NA ain atings wee not biased by esident ace, gende, mental status, function, deession, o disutive behavio. Conclusions. Results documented that (i) LPNs and NAs undeestimated esidents ain fequency and ain intensity, (ii) NAs wee moe accuate than LPNs fo ain intensity, and (iii) esident chaacteistics did not bias LPN o NA ain atings. A LTHOUGH aoximately 80% of nusing home esidents can ovide meaningful infomation about thei ain (1), ain is fequently undeteated in nusing homes. Undeteatment of nusing home esidents ain has been ecognized as a national oblem (2), affecting the quality of life of 49% to 83% of esidents (3). Inadequate ain teatment is not unique to nusing homes but is evasive in all health cae settings (4), even hosice (5), whee ain management is a high ioity. Two studies of nusing home esidents ain using the Minimum Data Set (MDS) fo ain ating, with data collected by nusing home staff in thei usual manne, identified multivaiate edictos fo the esence of daily ain: female gende, black ace, deession, ooe hysical function, being bedidden, o teminal ognosis (2,6). Pedictos of eceiving no analgesia in site of daily ain wee male gende, black ace, olde age, ooe hysical function, and cognitive imaiment. Studies not using the MDS found that esidents ain was associated with disutive behavios (7,8), but esults wee equivocal egading the effects of ain on the ability to efom activities of daily living (ADLs) (9,10), deession (9,11,12), and cognitive status (9,10). Nusing staff atings of esident ain location did not agee with esidents eots (13), and nuses atings of esidents ain wee not elated to thei administation of ain medication (14). Physicians likewise failed to detect the esence of esidents ain, aticulaly the ain of esidents with neuological disodes (15). Nusing staff and esidents may also discount chonic ain (15). Undeteatment of nusing home esidents ain may be due, in at, to the nusing home system of cae. Most cae is ovided by nusing assistants (NAs) (16) who may have limited ability to assess esidents ain and to communicate thei atings to the licensed actical nuse (LPN) unit chage nuse o to the egisteed nuse (RN) sueviso. NAs ae aely involved in fomal cae lanning and aely have knowledge of ofessional goals fo esident cae (17), yet NAs ae able to accuately assess ADLs (18) and symtoms such as edema and shotness of beath (19). Comaed with NAs, RNs ae moe often involved with administative and documentation activities (17). Results ae equivocal egading bias in nusing home staff ain atings (not using the MDS) comaed with esidents self-eots (10,13,15,20). Little attention has been given to the focal ole of the NA as a key infomant with knowledge and exeience vital to MDS ain ating. Desite diffeences between licensed nusing staff (RN and LPN) and NAs in education and in the amount of diect contact with esidents, many studies do not diffeentiate be- M405

2 M406 ENGLE ET AL. tween tyes of nusing staff when evaluating nusing home cae. RNs, LPNs, and NAs may be studied togethe as nusing staff (13,21) athe than seaately in ecognition of thei diffeences. Futhemoe, eseaches fequently combine ain atings of RNs, LPNs, and NAs unde the ubic of nusing staff, making it imossible to estimate and comae the accuacy of ain atings of nusing staff at any given level. The accuacy of the MDS ain ating ovides a foundation fo standadized cae lanning, quality indicatos, and eimbusement fo the teatment and evaluation of esidents ain (22). Although diections fo using the MDS secifically instuct the RN to ask the esident diectly about ain, the RN is also instucted to ask NAs and theaists if the esident has had comlaints o indicatos of ain. In actice, even if the esident is able to esond vebally, the RN may often ask the LPN about the esident s ain because of the RN s limited contact with the esident. It is not feasible, due to time constaints and the limited numbes of RNs in nusing homes, fo the RN to assess the esident daily fo the 7 days needed to comlete the MDS fo ain fequency duing the last 7 days (MDS item J2a) (22). The ecommended MDS ain-ating ocess is in contast to the gold standad fo ain ating, which is an individual s statement about his o he own ain (23). Thus, the uoses of this study wee to (i) estimate and comae the accuacy of LPNs and NAs esident ain atings using the MDS and (ii) to evaluate the bias effects of esident ace, gende, mental status, function, deession, and disutive behavio on nusing staff ain atings. This study extends evious eseach on the ain of nusing home esidents assessed with the MDS by obtaining concuent MDS ain-ating data fom LPNs, NAs, and esidents, and by using MDS data obtained by tained inteviewes athe than elying solely on MDS chat data. We extend evious eseach on ain atings by evaluating the bias effects of esident chaacteistics on LPN and NA ain atings. METHODS Design As at of a lage study, data wee obtained on the same day diectly fom esidents, LPNs, and NAs by tained inteviewes duing the fist 2 weeks following admission. Settings Paticiants wee ecuited fom two county-financed safety-net nusing homes that ovide indigent cae and histoically admit both black and white esidents in a lage city in the midsouth. The homes ae dually licensed fo intemediate and skilled cae and have 250 and 300 beds. The nusing staff is eesented by collective bagaining and eceives the highest ay in the metoolitan aea, ensuing low staff tunove. The majoity of the LPNs and NAs wee women, aoximately 50% of the LPNs wee black, and all of the NAs wee black. Use of these two sites minimizes otentially confounding effects of goss diffeences in socioeconomic status (24), limited access to nusing homes by black olde adults (25), and egion of the county (26) on estimates of ace effects. Use of these sites also contols fo the effects of staff tunove on esident ating. Paticiants This study was aoved by the Univesity s Institutional Review Boad. Residents (N 380) wee enolled sequentially as admitted to the two nusing homes. They met the citeia of not declining to aticiate in the lage study and emaining in the nusing home fo at least 2 weeks. Of the 380 esidents admitted, 73% (n 277) wee able to ovide ain data vebally o nonvebally. Nusing home staff data wee unavailable fo 15 othewise qualified esidents, so the study samle numbeed 252. Measuements Pain. Resident ain was evaluated using two MDS ain items and one additional ain question. MDS item J2a evaluated ain fequency duing the last 7 days (weekly ain fequency) using a thee-oint scale: 0 (no ain), 1 (ain less than daily), o 2 (daily ain). MDS item J2b evaluated ain intensity duing the last 7 days (weekly ain intensity) using a thee-oint scale: 1 (mild ain), 2 (modeate ain), o 3 (hoible ain). A aallel question evaluated ain intensity on the day of the inteview (daily ain intensity) and was also scoed on a thee-oint scale: 1 (mild ain), 2 (modeate ain), o 3 (hoible ain). Data wee obtained concuently the same day by tained inteviewes of the esident, the LPN chage nuse, and the NA who caed fo the esident. Mental Status. Mental status was evaluated by the MDS Cognition Scale (MDS-COGS) (27). MDS items (MDS B2a, B2b, B3b, B3d, B3e, B4, C4, G1Ag) wee ecoded and summed fo a scoe anging fom 0 to 10 (27). Highe scoes indicate geate cognitive imaiment. The MDS-COGS was develoed on 200 esidents, ace not secified, with sensitivity, secificity, chance-coected ageement (Kaa), and aea unde the eceive oeating chaacteistic cuve all 0.80 accoding to data collected by tained eseach staff (27). When comaing the MDS- COGS with the Cognitive Pefomance Scale (CPS), which is also comosed of MDS items, the MDS-COGS was eoted to be moe stongly coelated with the Global Deteioation Scale (.77) and Mini-Mental State Exam (.75) than the CPS in a samle of 290 esidents, ace not secified (28). Data wee obtained by inteviewing and obseving the esident and by questioning the NA who caed fo the esident. Function. Resident function was evaluated by the MDS ADL-Long Fom Scale (29). MDS items (MDS G1Aa, G1Ab, G1Ae, G1Ag, G1Ah, G1Ai, G1Aj) wee each scoed on a five-oint scale: 0 (indeendent), 1 (suevision), 2 (limited assistance), 3 (extensive assistance), and 4 (total deendence). Items wee summed, with scoes anging fom 0 to 28 (29). Highe scoes indicated geate functional imaiment. The MDS ADL-Long Fom Scale noms wee established using 175,000 MDS atings in a sevenstate aea, with a KR , a flat oveall scale distibu-

3 ACCURACY AND BIAS M407 tion, and an oveall scale mean of (SD 9.25). Tained inteviewes obtained data fom the NA who caed fo the esident to contol fo souce of ADL data (30). NAs ae able to assess accuately esidents ADLs (18), and one obsevation of MDS ADLs duing a 7-day eiod can usually accuately eesent ADLs duing the evious 7 days (31). Deession. Resident deession was evaluated by the MDS Deession Rating Scale (MDS DRS) (32). MDS items (MDS E1a, E1d, E1f, E1h, E1i, E1l, E1m) wee each scoed on a thee-oint scale: 0 (not exhibited in last 30 days), 1 (exhibited u to 5 days a week), 2 (exhibited 6 to 7 days a week). Items wee summed fo a scale scoe anging fom 0 to 14. Highe scoes indicated moe deession. The MDS DRS was develoed fom 16 MDS mood and behavio items, the Hamilton Deession Rating Scale, and the Conell Scale fo Deession in Dementia using a samle of 108 esidents, ace unknown. Thee wee five MDS factos: distubed mood, anxiety, fea, loss of meaning, and affect. The MDS DRS was moe sensitive and moe secific than the Geiatic Deession Scale (29). The inteviewe obtained the data by obseving the esident and questioning the NA who caed fo the esident. Disutive Behavio. Resident disutive behavio was evaluated by summing selected MDS items fom section E, Mood and Behavio Pattens (MDS E4Ab, E4Ac, E4Ad, E4Ae). Each item was scoed on a fou-oint scale: 0 (not exhibited in the last 7 days), 1 (occued 1 to 3 days in the last 7 days), 2 (occued 4 to 6 days but less than daily), 3 (occued daily). Items wee summed fo MDS Disutive Behavio Scale (MDS DBS) scoes anging fom 0 to 12, with highe scoes indicating moe disutive behavio. These items wee chosen to measue vebally abusive behavio, hysically abusive behavio, socially inaoiate behavio, and esisting cae. Inteviewes obtained the data by obseving the esident and inteviewing the NA who caed fo the esident. Demogahics. Resident demogahic infomation included gende (MDS AA2); ace (MDS AA4); maital status (MDS A5); age in yeas, comuted fom the esident s bithday and date of inteview; and education in yeas. Pocedue Afte consent was obtained, each esident s ain was assessed one time duing the fist 2 weeks afte admission by tained inteviewes who inteviewed the esident diectly. To assess each esident s ain, inteviewes concuently inteviewed the LPN who was the chage nuse on the unit in which the esident esided and the NA who caed fo the esident that day. Mental status, function, deession, disutive behavio, and demogahic data wee obtained by inteviewing and obseving the esident and by questioning the NA who caed fo the esident on the day of the inteview. Residents wee inteviewed imaily duing the second week afte admission to ensue staff familiaity with the esident. Thee tained inteviewes had an inte-ate eliability 0.85 fo this data-collection ocedue. Data Analysis All statistical data analysis ocedues wee accomlished using SPSS (33) deskto comute ogams. Twotailed obability of Tye I eo of.05 o less was the citeion of statistical significance. The Kaa coefficient (K) (34) was used to evaluate the extent to which esident ain atings ageed with LPN o NA ain atings. Qualitative ating of Kaa s used the citeia of Fleiss (34): K.75 excellent,.40 K.75 fai to good, and K.40 oo ageement beyond chance. Paied data t tests wee used to evaluate within-subject diffeences in ates ain atings. Indeendent samles t tests evaluated the ossible bias of nusing staff ain atings associated with esident ace o gende. Coelation coefficients wee used to evaluate ossible associations between mental status, function, deession, o disutive behavio, and LPN o NA undeestimation of esident ain. Vaiable Secification Fo all ain atings, egadless of souce, lage values in aw data eesented moe fequent o moe intense ain, in accodance with the MDS. The esident LPN diffeence data and esident NA diffeence data analyzed wee the individual esident s ain atings minus the coesonding LPN o NA ain ating, as aoiate. These vaiables eesented the amount that the LPN o NA undeestimated esident ain, because ositive values indicated that the esident ated ain wose than the LPN o NA did, zeo indicated no diffeence, and negative values indicated that the LPN o NA ated ain as wose than the esident did. Findings esented in Tables 2, 4, 6, 7, and 8 ae samle aveages of these within-subject esident LPN diffeence data and esident NA diffeence data. Findings esented in Tables 3 and 5 ae the diffeence between esident LPN and esident NA data. RESULTS Samle Of the 252 study esidents, 79% wee Black, and 60% wee men. Thei mean age was 64.3 yeas (SD 18.3). The mean level of education was 9.6 yeas (SD 3.6). Maital status included 30.8% neve maied, 12.3% maied, 32.8% widowed, 8.3% seaated, and 15.8% divoced. The mean MDS-COGS scoe was 3.7 (SD 3.1), the mean MDS ADL- Long Fom Scale scoe was 13.9 (SD 9.0), the mean MDS DRS scoe was 0.9 (SD 1.7), and the mean MDS DBS scoe was 0.6 (SD 1.4). Pain Vaiables Descitive data fo the ain vaiables by assesso (esident, LPN, o NA) ae esented in Table 1. Accuacy of LPN and NA Pain Ratings Kaa coefficients (K) wee calculated to evaluate the ageement between esident and LPN and between esident and NA ain atings fo weekly ain fequency, weekly ain intensity, and daily ain intensity. Table 2 documents K values, thei 95% confidence intevals (CI), and values testing a null hyothesis of K 0 o no within-subject associa-

4 M408 ENGLE ET AL. Table 1. Descition of Pain Vaiables by Assesso Pain Vaiable Resident LPN NA Weekly fequency Weekly intensity Daily intensity Notes: s ae mean SD. LPN licensed actical nuse; NA nusing assistant. Table 2. Ageement of Resident LPN and Resident NA Pain Ratings Resident LPN Ageement Resident NA Ageement Pain Vaiable Kaa* 95% CI Kaa* 95% CI Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant; CI confidence inteval. *Kaa coefficient of ageement; all with fai to good ageement. Table 3. Diffeence in LPN vs NA Ageement With Resident Pain Rating Pain Vaiable Kaa Diffeence* Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant. *Kaa diffeence esident LPN Kaa minus esident NA Kaa. Test fo equal Kaa s fom nonindeendent samles. tion. All K values wee highly significant (.001) in thei diffeences fom the null value of zeo. The K values fo the esident LPN atings anged fom.50 to.70, indicating fai to good ageement accoding to the citeia of Fleiss (34). The K values fo the esident NA atings anged fom.58 to.72, again highly significant (.001) and indicating fai to good ageement accoding to the citeia of Fleiss (34). The K values fo esident LPN and esident NA wee comaed fo diffeence in ageement with esident ain atings. As shown in Table 3, thee wee no statistically significant within-subject diffeences between esident LPN vesus esident NA K values fo weekly ain fequency o weekly ain intensity. Howeve, in comaing thei K values fo daily ain intensity, NA ageement with the esident was significantly bette than LPN ageement with the esident (.004). Paied data t tests wee used to evaluate ossible systematic bias in eithe LPN o NA ain atings. Table 4 documents the aveage within-subject diffeences between esident and LPN and between esident and NA ain atings, thei 95% CI, and the values fo within-subject aied data t tests comaing esident ain atings with LPN and NA ain atings. Thee wee statistically significant diffeences between esident and LPN ain atings and between esident and NA ain atings: all t tests wee significant at the.002 level o beyond. On aveage, both LPN and NA significantly undeestimated esidents weekly ain fequency, weekly ain intensity, and daily ain intensity. Paied data t tests wee also used to test fo within-subject diffeence in the esident LPN diffeence comaed with the esident NA diffeence in ain atings. Table 5 documents the aveage diffeence scoe fo the esident LPN diffeence minus the esident NA diffeence, t test statistics, and values. Significant diffeences between the amount of diffeence comaing the esident LPN atings with the esident NA atings documented that, on aveage, the NA was significantly close to the esident self-assessment of ain intensity than the LPN was. NAs undeestimated esidents weekly ain intensity and daily ain intensity less than LPNs undeestimated these atings. The aveage within-subject diffeence in weekly ain fequency aoached, but did not attain, statistical significance fo the comaison of the esident LPN diffeence with the esident NA diffeence. Thus, thee was no significant diffeence between LPNs and NAs undeestimations of esidents weekly ain fequency. Bias of LPN and NA Pain Ratings by Resident Demogahics Indeendent samles t tests evaluated if LPN o NA atings of esident ain wee affected o biased by esident ace (black o white) o esident gende. The ain data analyzed wee esident LPN diffeence and esident NA diffeence scoes. Thee was no statistically significant finding of esident ace o esident gende bias in LPN and NA weekly ain fequency, weekly ain intensity, o daily ain intensity atings. Table 6 shows a summay of LPN findings, and Table 7 shows a summay of NA findings. Coelation coefficients detemined the bias effects of esident behavioal o sychological chaacteistics on LPN o NA atings of esident ain. Resident mental status, function, deession, and disutive behavio wee the continuous vaiables included in this analysis. Pain data analyzed wee the esident LPN and the esident NA diffeence scoes. Thee wee no statistically significant findings of mental status, function, deession, o disutive behavio bias of LPN and NA atings fo weekly ain intensity, weekly ain fequency, o daily ain intensity. Table 8 shows summaies of the LPN and NA findings. DISCUSSION Residents in ou study met the inclusion citeia of being able to ovide ain data vebally o nonvebally. Ou samle, theefoe, was tyically mildly to modeately cognitively imaied athe than ofoundly cognitively imaied. Study esidents usually equied limited to extensive assistance with ADLs but wee not deessed and exhibited few disutive behavios. On aveage, these esidents eoted mild daily ain and mild weekly ain intensity, with ain occuing less than daily. Nusing home esidents tend to have moe chonic and nocicetive ain fom musculoskeletal disodes and neuoathies (23), with fluctuations of chonic ain (35). Study esults indicated that all esident LPN and esident NA ain atings had fai to good Kaa coefficients of ageement when using MDS ain items. Although both LPNs and NAs significantly undeestimated esidents

5 ACCURACY AND BIAS M409 Table 4. Within-Subject Diffeences Between Resident LPN Diffeence and Resident NA Diffeence Pain Ratings Resident LPN Diffeence* Resident NA Diffeence Pain Vaiable Mean SD 95% CI t Mean SD 95% CI t Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant; CI confidence inteval. *Resident LPN diffeence esident ain scoe minus LPN ain scoe; ositive value indicates that LPN undeestimates esident s ain. Resident NA diffeence esident ain scoe minus NA ain scoe; ositive value indicates that NA undeestimates esident s ain. Paied data t test. Table 5. Within-Subject Diffeences in LPN vs NA Undeestimation of Resident Pain Rating Diffeence* Pain Vaiable Mean SD t Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant. *Diffeence esident LPN diffeence minus esident NA diffeence. Paied data t test. weekly ain fequency, weekly ain intensity, and daily ain intensity, NAs wee moe accuate than LPNs when undeestimating esidents weekly ain intensity and daily ain intensity. LPN and NA ain atings wee not biased by esident ace, gende, mental status, function, deession, o disutive behavio. All Kaa coefficients fo the esident LPN (ange.50.70) and esident NA (ange.58.72) ain ating ageement wee in the fai to good ange, but none attained excellence. Excellent, athe than meely fai to good, Kaa s fo esident LPN and esident NA ageement may be equied fo otimal ain evaluation and teatment. LPNs and NAs undeestimated weekly ain fequency, weekly ain intensity, and daily ain intensity. This bias was in the exected diection because nuses in othe health cae settings also undeestimated ain (36). The nusing home nusing staff wee educated imaily in acute-cae hosital settings and had acute-cae exeience. They evidently caied thei skills and biases in ain ating and teatment fom the hosital into the nusing home. NAs undeestimated both weekly and daily ain intensity less than LPNs did. NAs may be moe accuate in thei ain intensity atings because of thei olonged contact with esidents when oviding daily cae comaed with LPNs. NAs ovide about 60% of esident cae, and LPNs ovide about 20% of esident cae (37). Fo undeestimation of weekly ain fequency the comaison of LPN to NA data aoached, but did not attain, statistical significance. This may be due to samling eo o scale scoing fo ain intensity. Weekly ain fequency was measued using a theeoint scale: 0 (no ain); 1 (ain less than daily); and 2 (daily ain); howeve, weekly and daily ain intensity was scoed using a fou-oint scale: 0 (no ain), 1 (mild ain), 2 (modeate ain), and 3 (hoible ain). The thee-oint scale may have attenuated the study esults. Othe studies suot the findings of undeestimation of esident ain by nusing home staff and geate accuacy of ain atings by eole with geate esident contact. Weine and colleagues (13) found that nusing home nusing staff (RNs, LPNs, and NAs, studied as one gou) wee moe accuate in thei ain atings than family caegives who visited at least twice a month. Physicians also undeestimate esident ain (15), but hysician ain atings wee infeed fom chat eview fo ogess notes indicating ain o ain medication odes. The moe accuate souce of ain fequency data, LPN o NA data, was not established by study data. Also, the elationshi of a seies of seven daily esident s ain intensity atings to esident, LPN, and NA MDS weekly ain fequency and MDS weekly ain intensity atings is not known. Residents may not be able to emembe thei ain intensity and ain fequency duing the evious week, so this is a question fo futue eseach. Due to time constaints, it is not feasible fo RNs in the nusing home to assess esidents ain daily to accuately comlete the MDS. Time constaints may also event the NA fom eoting esident ain to the LPN (8). We ecommend that if the ain intensity data cannot be obtained diectly fom mild o modeately cognitively imaied nusing home esidents by the RN, daily and weekly ain intensity data should be obtained fom the NA and used to comlete the MDS. The RN is esonsible fo ensu- Rating Table 6. Bias of LPN and NA Pain Ratings by Resident Race Black (Mean SD) White (Mean SD) t * Resident LPN Diffeence Weekly fequency Weekly intensity Daily intensity Resident-NA Diffeence Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant. *Indeendent samles t test. Resident LPN diffeence esident ain scoe minus LPN ain scoe; ositive value indicates that LPN undeestimates esident s ain. Resident NA diffeence esident ain scoe minus NA ain scoe; ositive value indicates that NA undeestimates esident s ain.

6 M410 ENGLE ET AL. Table 7. Bias of LPN and NA Pain Ratings by Resident Gende* Rating Male (Mean SD) Female (Mean SD) t Resident LPN Diffeence Weekly fequency Weekly intensity Daily intensity Resident NA Diffeence Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant. *LPN o NA undeestimation of esident ain comaed with esident ain ating. Indeendent samles t test. Resident LPN diffeence esident ain scoe minus LPN ain scoe; ositive value indicates that LPN undeestimates esident s ain. Resident NA diffeence esident ain scoe minus NA ain scoe; ositive value indicates that NA undeestimates esident s ain. ing the comleteness of the multidiscilinay MDS ating that assesses weekly ain fequency and weekly ain intensity and often elies on the LPN fo esident ating data athe than on the NA, whose accuacy may be undeecognized. Fo otimal ain management and teatment, additional data on the quality of ain (e.g., buning o aching), the temoal atten of the ain (e.g., constant o intemittent), and the location of ain (e.g., joint, head, o feet) may be needed by the health cae ovide witing escitions fo analgesic and adjuvant ain medications. Howeve, the MDS does not obtain infomation on the quality o atten of ain; it obtains infomation on the location of ain. Additional eseach is needed to establish the accuacy of LPN and NA atings of ain quality, ain atten, and ain location. We found no liteatue evaluating the effect of esident chaacteistics (mental status, function, deession, and disutive behavio) on the accuacy of nusing home nusing staff ain atings. Studies have identified that esidents who Table 8. Biases of LPN and NA Pain Ratings by Resident Mental Status, Function, Deession, and Disutive Behavio Rating Mental Disutive Status* Function Deession Behavio Resident LPN Weekly fequency Weekly intensity Daily intensity Resident NA Weekly fequency Weekly intensity Daily intensity Note: LPN licensed actical nuse; NA nusing assistant; coelation coefficient. *MDS Cognition Scale. MDS ADL-Long Fom Scale. MDS Deession Rating Scale. MDS Disutive Behavio Scale. wee olde, black, cognitively imaied, moe functionally able, o less deessed wee moe likely to have daily ain (2). Could the ace and gende of the LPN and NA also be a souce of bias in thei atings of esidents with diffeent chaacteistics? All study NAs wee black, aoximately one half of the LPNs wee black, and the majoity of LPNs and NAs wee women. We have neithe ace vaiance fo NAs no accuate ace data fo LPNs and ae unable to answe this question. Howeve, because thee was no esident ace o esident gende bias fo eithe LPN o NA atings, the ace and gende of the assesso does not aea to influence ain atings. Ou esults can be genealized to othe safety-net nusing homes that ovide cae to the undeseved and indigent. Ou samle had moe men (60%) and black (80%) and younge (mean age 64 yeas) esidents than the aveage nusing home. Although the use of safety-net nusing homes allowed us to study ace and gende diffeences, additional studies ae needed to elicate ou esults in othe egions of the county and in diffeent tyes of nusing homes. Summay Ou esults documented that (i) LPNs and NAs undeestimated nusing home esidents weekly ain fequency, weekly ain intensity, and daily ain intensity; (ii) NAs undeestimated weekly and daily ain intensity less than LPNs did; and (iii) LPN and NA ain atings wee not biased by esident ace, gende, mental status, function, deession, o disutive behavio. Thee was fai to good Kaa ageement of LPN and NA ain atings with esident atings, but consistently excellent Kaa coefficients may be equied fo otimal ain ating and management. Acknowledgments This study was funded by the NIH National Institute of Nusing Reseach and was esented at the annual meeting of the Ameican Geiatics Society, We thank the esidents, nusing staff, and administation of Shelby County Health Cae Cente and Oakville Health Cae Cente fo thei aticiation in and suot of the study. Addess coesondence to D. Veonica Engle, 877 Madison Avenue, Room 616, Memhis, TN vengle@utmem.edu Refeences 1. Feell BA, Feell BR, Rivea L. Pain in cognitively imaied nusing home atients. J Pain Symtom Manage. 1995;10: Benabei R, Gambassi G, Laanne K, et al. Management of ain in eldely atients with cance. JAMA. 1998;279: Fox PL, Raina P, Jadad AR. Pevalence and teatment of ain in olde adults in nusing homes and othe long-tem cae institutions: a systematic eview. 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