Should Nurses Blow the Whistle or Just Keep Quiet? Carolyn Buppert, MSN, JD June 24, 2014 Confused? I'm Not Surprised Apparently, a lot goes on in healthcare that makes nurses uncomfortable, because I am asked this question, in some form, frequently. The answer is complicated. People may differ in their opinions of what falls into the realm of incompetent, unethical, or unsafe practice, and the laws of every state are different. And even though I read law every day, I had trouble figuring out what to advise, given the current law governing nurses. No wonder nurses aren't sure what to do. Nurses are told that they have a duty to protect patient safety. They learn this from language such as this, in one state's (Maryland) nursing regulations. Under "Ethical Responsibilities," it says: "A nurse shall...Act to safeguard a client and the public if health care and safety are affected by the incompetent, unethical, or illegal practice of any person."[1] The implication is that when a nurse becomes aware of a patient safety threat, the nurse is supposed to do something. Maryland is not alone in making such pronouncements. Here is language from the Texas Board of Nursing Website: Situations involving potential risk of harm to patients or the public are referred to as "violating the nurse's duty to the patient" because all nurses have a duty under Rule 217.11(1)B to maintain a safe environment for patients/clients and others for whom the nurse is responsible.[2] It makes sense to tell nurses that they are expected to safeguard patient safety. It would be even better if nurses who try to do something were better rewarded for their efforts. However, according to nurses I hear from, when a nurse reports a patient safety problem, the nurse often is surprised to find that he or she is considered the "bad guy." A nurse who raises quality issues that require a change of policy, practice, or staffing can be seen as a disruptor rather than someone who is making constructive criticism. Some nurses who have identified problems have found themselves out of a job. This is bothersome. It's perfectly legal for a hospital to terminate a nurse, for any reason or for no reason. The only job protections are those granted by contract between the nurse and the hospital (whether it is an individual contract or a contract offered through a labor union) and those granted by the US Constitution and civil rights laws. The latter include the right to be free of discrimination on the basis of age, sex, national origin, race, sexual orientation, and religious preference. If the hospital isn't firing the nurse because of age, sex, national origin, race, sexual orientation, or religious preference, in general the firing is legal. A possible exception is a whistleblower law, which may, in some situations, provide protection for nurses who report patient safety problems. We will get to that shortly. Although it is legal to fire a nurse for raising a patient safety issue (with a poss.

1. Should Nurses Blow the Whistle or Just Keep Quiet?
Carolyn Buppert, MSN, JD
June 24, 2014
Confused? I'm Not Surprised
Apparently, a lot goes on in healthcare that makes nurses
uncomfortable, because I am asked this question, in some form,
frequently. The answer is complicated. People may differ in
their opinions of what falls into the realm of incompetent,
unethical, or unsafe practice, and the laws of every state are
different. And even though I read law every day, I had trouble
figuring out what to advise, given the current law governing
nurses. No wonder nurses aren't sure what to do.
Nurses are told that they have a duty to protect patient safety.
They learn this from language such as this, in one state's
(Maryland) nursing regulations. Under "Ethical
Responsibilities," it says: "A nurse shall...Act to safeguard a
client and the public if health care and safety are affected by the
incompetent, unethical, or illegal practice of any person."[1]
The implication is that when a nurse becomes aware of a patient
safety threat, the nurse is supposed to do something.
Maryland is not alone in making such pronouncements. Here is
language from the Texas Board of Nursing Website:
Situations involving potential risk of harm to patients or the
public are referred to as "violating the nurse's duty to the
patient" because all nurses have a duty under Rule 217.11(1)B
to maintain a safe environment for patients/clients and others
for whom the nurse is responsible.[2]
It makes sense to tell nurses that they are expected to safeguard
patient safety. It would be even better if nurses who try to do
something were better rewarded for their efforts. However,
according to nurses I hear from, when a nurse reports a patient
safety problem, the nurse often is surprised to find that he or
she is considered the "bad guy." A nurse who raises quality

2. issues that require a change of policy, practice, or staffing can
be seen as a disruptor rather than someone who is making
constructive criticism. Some nurses who have identified
problems have found themselves out of a job.
This is bothersome. It's perfectly legal for a hospital to
terminate a nurse, for any reason or for no reason. The only job
protections are those granted by contract between the nurse and
the hospital (whether it is an individual contract or a contract
offered through a labor union) and those granted by the US
Constitution and civil rights laws. The latter include the right to
be free of discrimination on the basis of age, sex, national
origin, race, sexual orientation, and religious preference. If the
hospital isn't firing the nurse because of age, sex, national
origin, race, sexual orientation, or religious preference, in
general the firing is legal. A possible exception is a
whistleblower law, which may, in some situations, provide
protection for nurses who report patient safety problems. We
will get to that shortly.
Although it is legal to fire a nurse for raising a patient safety
issue (with a possible exception of whistleblower laws) it is not
a situation one would hope for, from a patient's perspective.
Blowing the Whistle, Fighting the System
The following story is an example of a case in Texas where
nurses were very concerned about the care being provided by a
physician at their hospital, did something about it, and suffered
as a result.
Two nurses, one of whom was the hospital's compliance officer,
reported a hospital physician to the state medical board, citing
patient safety issues. The problems, according to the source
listed below, included the following: (1) The physician was
taking patients with serious diagnoses off their medications and
instead recommending herbal remedies, for which he was the
vendor; (2) the physician was performing surgery, including a
skin graft, in the emergency department, even though he wasn't
a surgeon; and (3) the physician almost never read patient

3. charts nor ordered diagnostic testing, preferring instead to
diagnose on the basis of history alone.
The nurses who reported him essentially were relaying the
observations and complaints of many nurses. The nurses filed an
anonymous report with the medical board. Once the medical
board contacted the physician, the physician enlisted his friend,
the sheriff, to do some digging, and the sheriff found out who
had filed the complaint against the physician. The physician
then filed a complaint, with the sheriff, against the nurses, for
harassment. The sheriff arrested the nurses, and the local
prosecutor charged them with "misuse of official information,"
a felony punishable by 10 years in prison. (They had accessed
patient charts to describe, specifically, the threats to patient
safety.)
The prosecutor had a few conflicts of interest. He was not only
the doctor's personal attorney, but also the personal attorney for
the sheriff and the hospital's counsel. The physician convinced
the hospital to fire the nurses. Eventually the case went to trial
against one of the nurses, and she was found not guilty. Charges
against the other nurse were dropped before her trial, for
reasons unspecified. As of 1 year later, the physician still was
working at the hospital.
Much later, the sheriff, the hospital administrator, and the
prosecutor all were prosecuted for misuse of official
information (the same charge that had been applied to the
nurses), and all were found or pleaded guilty. The nurses sued
the hospital and received a settlement. Eventually, the physician
too was charged with misuse of official information and
retaliation. He pleaded guilty. The full story can be heard on the
radio program Old Boys Network, which originally aired on
June 3, 2011. A transcript is also available.
The nurses in this case were vindicated, but both went through
several years of extreme stress, joblessness, and legal fees.
Reportedly, neither wants to be a nurse any longer.

4. Whistleblower Laws
A nurse who is fired for bringing up a patient safety issue may
think he or she is protected against retaliation under a
"whistleblower law," but in fact, the nurse may not be
protected. Whether such protection exists depends on exactly
what the state's whistleblower law covers; whether the nurse
followed the dictates of the law precisely; and whether there
was any other reason, aside from reporting the patient safety
issue, for which the hospital could reasonably have fired the
nurse. The following case illustrates what can happen when a
nurse tries to rely on a whistleblower law.[3,4]
A hospice nurse reported to her supervisors that starter packs of
controlled drugs were being given to patients without a
physician's order. She was worried because some of the patients
were children and because she feared the drugs would be
misused. Shortly after she complained about this practice, she
was fired. She was denied unemployment compensation because
she had been fired. She protested the denial of unemployment
and filed for wrongful termination, hoping to use the state's
Health Care Worker Whistleblower Protection Act.
The nurse found that the purpose of that law wasn't to protect
nurses, but to protect employers against frivolous whistleblower
actions filed by disgruntled former employees. A judge found
that she hadn't conformed with a provision of the law, so the
law didn't apply. (She hadn't reported the problem to an outside
agency -- only to individuals within the agency.)
The state's highest court reversed the finding of the lower court,
holding that it was enough to have reported the problem
internally, and essentially said she could avail herself of the
whistleblower law. However, when the case was tried, a jury
believed the hospice, her employer, who argued that they
terminated the nurse for a reason other than the complaint about
the starter packs. The jury believed that the nurse was right in
making the complaint, but that didn't help the nurse, ultimately.
The nurse spent $150,000 on her legal efforts.

5. Maryland's Whistleblower Protection Act didn't work for that
nurse, but let's look at another state's whistleblower protection
for nurses. It appears that Texas law has some protections for a
nurse who reports a quality issue [5]:
A nurse may report to the nurse's employer or another entity at
which the nurse is authorized to practice any situation that the
nurse has reasonable cause to believe exposes a patient to
substantial risk of harm as a result of a failure to provide
patient care that conforms to minimum standards of acceptable
and prevailing professional practice or to statutory, regulatory,
or accreditation standards. For purposes of this subsection, an
employer or entity includes an employee or agent of the
employer or entity.
A person may not suspend or terminate the employment of, or
otherwise discipline, discriminate against, or retaliate against, a
person who: (1) reports in good faith under this section; or (2)
advises a nurse of the nurse's right to report under this section.
This law was added in 2011, after the Texas case described
earlier. The key is to research the law of your state, so you
know up front whether you have any protections when
complaining about a patient care issue.
In a recent article[6] a nurse-attorney and a social worker who
have experience with whistleblowers discourage nurses from
whistleblowing, for their own good.
Federal whistleblower protection acts exist, which are meant to
encourage reporting of healthcare fraud, and if the nurse
follows the exact provisions of these laws, the nurse may share
in the government's recovery of money. That is a different
subject, however, and not addressed here.
The Nurse's Duty to Protect Patient Safety
What if a nurse doesn't report a quality of care or patient safety
issue? Is he or she likely to be disciplined?
Let's look at Texas law on reporting. It appears that reporting of
a patient safety issue involving an agency or facility problem is
optional ("may report"), but reporting of another nurse is

6. mandatory ("shall report").
Here is the language that says reporting a facility is optional
[7]:
In a written, signed report to the appropriate licensing board or
accrediting body, a nurse may report a licensed health care
practitioner, agency, or facility that the nurse has reasonable
cause to believe has exposed a patient to substantial risk of
harm as a result of failing to provide patient care that conforms
to:
· (1) minimum standards of acceptable and prevailing
professional practice, for a report made regarding a practitioner;
or
· (2) Statutory, regulatory, or accreditation standards, for a
report made regarding an agency or facility.
Here is the language that says reporting a nurse is mandatory in
Texas:
· (1) "Conduct subject to reporting" means conduct by a nurse
that:
· (A) violates this chapter or a board rule and contributed to the
death or serious injury of a patient;
· (B) causes a person to suspect that the nurse's practice is
impaired by chemical dependency or drug or alcohol abuse;
· (C) constitutes abuse, exploitation, fraud, or a violation of
professional boundaries; or
· (D) indicates that the nurse lacks knowledge, skill, judgment,
or conscientiousness to such an extent that the nurse's continued
practice of nursing could reasonably be expected to pose a risk
of harm to a patient or another person, regardless of whether the
conduct consists of a single incident or a pattern of behavior.[8]
A nurse shall report to the Board in the manner prescribed under
Subsection (d) if the nurse has reasonable cause to suspect that:
· (1) another nurse has engaged in conduct subject to reporting;
or
· (2) The ability of a nursing student to perform the services of
the nursing profession would be, or would reasonably be
expected to be, impaired by chemical dependency.[9]

7. Under Texas law, therefore, the nurse may, but has no
obligation to, report a facility to the appropriate licensing
board, when the nurse has reason to believe that a patient has
been exposed to substantial risk for harm. But a nurse must
report another nurse.
Here is what Texas law says about failure to report: "(a) A
person is not liable in a civil action for failure to file a report
required by this subchapter. (b) The appropriate state licensing
agency may take action against a person regulated by the agency
for a failure to report as required by this subchapter.[10]
In Texas, the Board of Nursing could take action against a nurse
who failed to report, but isn't required to do so.
Let's go back to the state law language cited earlier that implies
that nurses must safeguard patient safety. A search of the
disciplinary actions of the Maryland Board of Nursing indicates
that the language "a nurse shall act to safeguard a client..." is
invoked when it is the nurse who is incompetent or unethical.
The nurse is supposed to report him- or herself, but not
necessarily report someone else, or a facility. I found no cases
where that clause was used to discipline a nurse who discovered
that someone else was incompetent, and failed to report it. I
could find no disciplinary actions reported on the Texas Board
of Nursing Website against nurses who had failed to report a
patient safety issue.
Other states may have different law on this, or no law on this,
but it is becoming clear that a nurse doesn't have to report a
facility and will do better personally if he or she does not.
So, Don't Report?
Am I recommending that nurses adopt the "see nothing, hear
nothing, speak nothing" attitude? No. I am saying that under
current law, it is safer for a nurse not to report than to report.
That surprises me, and it may be right- or wrong-minded, but
it's the way it is.
To argue the hospital or facility's side, a facility can't have
every nurse they fire come back and say he or she was fired

8. because the nurse complained about a patient safety issue.
Hospitals will lobby legislators for laws that protect the
hospital. And a hospital is going to defend itself against
allegations of breach of patient safety, even if that means firing
a nurse and discrediting the nurse. In all fairness, with every
safety issue that a nurse might identify, there usually is an
opposing argument that it isn't a safety issue or is a necessary
risk. And some nurses are vulnerable to being discredited
because they don't have spotless records.
My purpose in this article is to inform nurses of the things they
must do to protect themselves, before complaining, both within
their company and to outside agencies.
First, check your state's Nurse Practice Act for any law on
reporting patient safety issues. Also check the state's Board of
Nursing Website for any direction on this.
Then, look at the whistleblower laws for your state, if there are
any. If you decide to blow the whistle, follow the dictates of the
law, exactly. Gather your evidence. Keep detailed records.
I urge nurses to conduct a safety analysis on themselves before
blowing the whistle on safety problems in the workplace, and
even before complaining. I don't like to see nurses get nowhere
with their patient safety concerns and also suffer personal
setbacks. It is smart to consult an attorney who is experienced
in whistleblower cases before complaining. (I am not an expert
on whistleblower cases.) It may be best to line up your next job
before complaining to higher-ups.
Think before you act. Spend some time thinking about how to
raise the issue, and with whom to raise it. Read some of the
many books about the ins and outs of workplace
communication. Watch and listen, and observe individuals in
your workplace who seem skilled at working with others to
effect change. It may be best to frame complaints as
volunteering to help solve a problem. I don't know of a "charm
school" for nurses, but if there is one, I would enroll and would
encourage others to do so.
Consider your risk. Be sure that your own practice is in order. If

9. you complain about a policy or practice at your facility and
someone wants to get back at you, what would they say? What
are your vulnerabilities?
Assess the gravity of the problem. If the problem you have
identified is putting a patient or employee at imminent and
serious risk, you may need to put all thoughts of yourself aside
and report it. If the risk isn't so serious or isn't so imminent,
then perhaps volunteering to problem-solve is in order.
Assess the administration and your supervisors. Is there
someone you can talk to in confidence whom you trust? Is there
a financial reason why the problem is present? If so, be
prepared for a struggle, unless you can suggest a legal, more
cost-effective alternative.
Taking a big-picture view, I recommend that nurses, throughout
their careers, safeguard their ability to find another job, if they
need to. Cultivate people who will give you positive references
throughout your career, and do the same for them. This means
treating colleagues professionally, not sharing personal dramas
at work, keeping up with the latest developments in the field,
handling disagreements in a way that doesn't leave others
feeling bruised, and going up the chain of command when
necessary. Conduct periodic self-assessments to identify your
own vulnerabilities, and make a plan to minimize them.
The bottom line is: It's always better to prevent problems, in
law as well as healthcare.
Nurses Advocating for Patients
By University Alliance
Nurses play many vital roles in the care of their patients,
including that of advocate – someone who acts or intercedes on
behalf of another. Typically the healthcare professional with the
most interpersonal contact with the patient, themay be in the
best position to act as the liaison between patient and family

10. and other team members and departments. To perform this
function adequately, the nurse must be knowledgeable about and
involved in all aspects of the patient’s care and have a positive
working relationship with other team members.
The American Nurses Association (ANA) defines nursing as
“the protection, promotion, and optimization of health and
abilities, prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment of human
response and advocacy in the care of individuals, families,
communities, and populations.”
The ANA addresses the importance of advocacy in its Code of
Ethics, including Provision 3: “The nurse promotes, advocates
for, and strives to protect the health, safety, and rights of the
patient.”
Three core values help form the basis of nursing advocacy:
preserving human dignity; patient equality; and freedom from
suffering.
· Preserving Human Dignity: Every person has the right to be
treated with honor and respect. Patients and their families are
often confused, anxious and frightened. At such times, they
need an advocate to help navigate the unfamiliar healthcare
system and facilitate communication among caregivers. This
may include interpreting tests, procedures and instructions from
physicians in terms the patient can understand and follow. It
also may be necessary for nurses to educate the patient on the
need for tests and procedures, as well as to provide emotional
and physical support during the process. Nurses are in a
position to integrate all aspects of the patient’s care and ensure
that concerns are addressed, standards of care are met and a
positive outcome for the patient remains the goal of the
healthcare team.
Cultural and ethnic beliefs can be of great importance to
patients and families and must be respected by the nurse.
Although those beliefs may not be understood or appreciated by
the nurse, they must be considered and accepted in all

11. interactions, especially since they may have an impact on the
patient’s physical and emotional well-being and comfort level.
In order to be an effective advocate, the nurse must be
considerate of patient privacy issues and regard patient and
family information as privileged and confidential. Nurses must
adhere to organizational, state and national laws when
discussing or disclosing healthcare or other personal
information.
· Patient Equality: As the healthcare profession evolves in
response to funding changes, technological advances and
governmental regulations, disparities in the provision and
delivery of care may become more defined.
The ANA Code of Ethics directs nurses to practice “with
compassion and respect for the inherent dignity, worth, and
uniqueness of every individual, unrestricted by considerations
of social or economic status, personal attributes, or the nature
of health problems.”
Nurses must provide care for all patients with the same degree
of compassion and professionalism, without allowing personal
biases to influence their practice.
· Freedom from Suffering: Many nurses list a desire to help
others as a major factor in their decision to enter the profession.
Helping to prevent or manage suffering – whether physical,
emotional or psychological – is perhaps the most important
aspect of care from the patient’s perspective.
Nurses may also be called upon to provide emotional support, or
simply offer a friendly ear. That requires a commitment on the
nurse’s part to be available to patients and their families.
The role of advocate can require a nurse to act as a
communicator, liaison, educator, interpreter and caregiver.
Choosing a career in nursing means making the choice to fill
that role while providing optimal care and striving for positive

12. outcomes for all patients.
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

13. 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

14. 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

15. 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, pretestposttest 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.

16. 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

17. 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

18. 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).

19. 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

20. 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.

21. 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,

22. 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

23. 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

24. 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)

25. 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)

26. 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

27. 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,

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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.