Project Week 2

Project Week 2

MSN Capstone Project Proposal Form This is a building assignment that you will be completing over Week 1 through Week 9. This is a stepwise project proposal assignment in which you will complete one (1) section each week for your MSN Capstone Project Proposal. By the end of the Week 9, this form will have been filled in completely and your MSN Capstone Project Proposal will be completed. It is important that you keep up with the Weekly Assigned Section. Each section is graded separately on a weekly basis while the final completed form will be graded with an overall grade. Each week the student will receive feedback from the instructor and the student is expected to incorporate the instructor feedback to edit and improve the weekly sections. The Week 9 final Capstone Project Proposal with be based on students incorporating the instructor’s weekly feedback. How to use this form.

• Must use the same form for all sections. The purpose is to have a completed the entire form by the end of the course.

• Complete the week’s section with the requested information. • There are suggested word counts for each weekly section to provide you with an idea of what is

expected. • You are to write in full sentences, paragraphs, correct grammar, and spelling. • Use APA formatting with citations and references list. • Refer to the MSN Capstone Project Proposal Form Example found in Week 1 and in the Course

Resources tab. • Do not delete or edit the week section instructions. • Do not lock the form because that will stop you from editing and revising within the form. • Leave NO blank sections. All sections are graded separately. • You may work ahead; however, the instructor will only grade the week’s section due for the

assigned week and the form must be submitted each week. • Read the item descriptions carefully. Items request very specific information. Be sure you

understand what is requested. • Use primary sources for any references. Textbooks are not acceptable as references.

Late Assignments: Students will receive a 10-point grade reduction for each day the assignment is submitted past the due date. After three (3) days past the due date, students will receive a zero (0) for that weekly section but must complete for the final Week 9 grading.




MSN Capstone Project Proposal Form

Student Name George Peraza-Smith

MSN Program Adult Gerontology Primary Care Nurse Practitioner

Project Title Nurse Practitioner Adherence to Practice Protocol: Management of Persistent Pain in Older Adults

Week 1 State Your Clinical Question

[100 to 150 words]

• State your clinical question or topic for your capstone project proposal. • What issue is the question/topic addressing? • What are the reasons you selected this question/topic?

Pain in older adults is often unrecognized, underassessed, and undertreated. Providers often

believe incorrectly that older adults don’t feel pain at the same level as younger adults. Older

adults often incorrectly believe that they may become a burden to others if they complaint

about their pain or that on one would believe them anyway. This proposal addresses an

opportunity to improve providers’ skills on effective pain assessment and management in older

adults through the implementation of a best practice protocol based on a national practice

guideline. On my unit in the skilled nursing facility, I have noticed that older adults are often

suffering in pain due to caregivers and older adults own negative agist myths of pain. I choice

this topic because I believe older adults deserve to be heard and provided the same respect in

controlling pain that young populations are provided.

Week 2 Background Information

[200 to 250 words]

Address the following questions/bullets in completing this section: • Start at the starting point – What, Where, When, Why, and How? • What is known about this topic or what is the evidence on this topic (Scoping Search)? • What is the outcome of interest? • What are the gaps in our understanding or knowing related to this topic?




Over the past few decades, pain management has garnished more clinical attention due to the

consideration of pain as the fifth vital sign. However, recently the use of pain as the fifth vital

sign has received negative press as the opioid crisis continues. Today, pain is widely regarded

as equally important to the assessment of body temperature, blood pressure, heart rate and

respiratory rate (Walid, et al., 2018). In the last decade research on effective pain assessment

and management strategies have significantly soared. But this increased focus on pain has not

necessarily improved the management of pain in older adults. With advancing age come

numerous physical illnesses that can lead to significant pain (Malanga & Paster, 2020). In the

literature, the terms “chronic pain” and “persistent pain” are often used interchangeably.

“Persistent pain” has become the preferred term because it is less likely to be associated with

negative stereotypes that providers and older adults often connect with the “chronic pain” label

(AGS, 2021). Persistent pain is a personal emotional and physical experience. The pain is an

unpleasant, subjective, and multifaceted experience that ranges from mild discomfort to agony;

the frequency may be periodic, persistent, or always present. Persistent pain continues beyond

the anticipated healing time of acute pain caused by injury or disease and lasts for at least three

months. Outcomes of interest in this proposal are to improve persistent pain assessment and

management for older adults. A secondary outcome is to ensure that older adults with

persistent pain are treated effectively based on the best evidence. There are significant gaps in

provider understanding of the use of opioids for pharmacological management of moderate to

severe persistent pain in older adults.

Week 3




Literature Search Strategies [150 to 200 words]

Provide details of your exhaustive search process. Be certain to list:

• Databases searched. • All the keywords or search phrases used. • How many articles in total that were found? • List the inclusion/exclusion criteria. • Provide the number of articles that were retained and a description on why those

articles were retained. • Consider using a flowchart to outline the search process.

MEDLINE, and PsycINFO (via Ovid), CINAHL Plus, Cochrane Central Register of

Controlled Trials in the Cochrane Library (via Wiley), ProQuest, and OpenGrey databases

were searched from January 2010 to October 2021. Search terms were identified from existing

reviews. Free-text terms for searching titles, abstracts, and key words were combined with

database-specific MeSH terms that reflect the following aspects: [opioids] AND [pain] AND

[older adult population] AND [chronic pain OR persistent [pain] AND [skilled nursing OR

nursing home OR long-term care]. Full-text electronic limits were applied to database searches.

Inclusion criteria included studies with adults 50 year and older and assessment tools while

exclusion criteria included articles that were non-English, non-full text, primarily focused on

adults 50 years and younger, and acute pain. A total of 541 articles were identified and

included 22 systematic reviews. Total articles after duplications were removed were 128.

Articles meeting the inclusion criteria resulted in 47 for scanning. After scanning and

determining those articles that were not studies or that had weak methodology were removed.

The total number of articles remaining for the literature review was 10 articles. These articles

were used for the review because they all included persistent or chronic pain assessment and

management in older adults in skilled nursing facilities or long-term care.

Week 4




Literature Review [500 to 1000 words]

Conduct a review of the literature. Include at least five (5) research articles and/or evidence- based guidelines. Address the following questions/bullets in completing this section:

• Conduct a review of the literature. • Provide the highlights from the research. • Synthesize the literature on the topic. • Summarize how the project will contribute to knowledge by filling in gaps, validating, or

testing knowledge. • Cite references in this section per APA and list the reference in the References section

at the end of the form. Persistent pain is a personal emotional and physical experience. This pain experience is

an unpleasant, subjective, and multifaceted ranging from mild to severe agony with periodic

episodes to persistent and always present. Fox (2029) describes persistent pain as pain that

continues beyond the anticipated healing time of an acute injury or disease and lasting for three

months or more. Persistent pain is an unpleasant, subjective, personal and multidimensional

experience that is constantly present (Oware-Gyekye, 2019). The American Geriatrics Society

[AGS] (2021) defines persistent pain as ”pain that exists beyond an expected time frame for

healing” that “is understood as persistent pain that is not amenable to routine pain control

methods” (p. 636). The International Association for the Study of Pain defines persistent pain

as “continuous or intermittent pain or discomfort that has persisted for at least three months”

(Elliott, Smith, Penny, Smith, & Chambers, 2, p. 2020). The American Society of

Anesthesiologist Task Force on Chronic Pain Management (2010) stated that the elderly

experience a significant burden of persistent pain with persistent pain being defined as

“persistent or episodic pain of a duration or intensity that adversely affects the function or

well-being of the patient” (p. 812). The common threads to these definitions are that persistent

pain is a personal, multifaceted experience that last beyond an expected time frame, usually




three or more months, and negatively affects the older persons function and diminishes quality

of life.

Untreated Persistent Pain

Persistent pain has been found to be under-recognized and under-treated in older adults

in many settings (AGS, 2021; Collett, et al., 2018). Elderly residing in nursing homes are at an

increased risk for inadequate pain relief due to providers’ under-prescribing practices. Won

and her colleagues (2018) conducted a cross-sectional study of 10,372 nursing home residents

from geographically diverse States who were over the age of 65 years and who experienced

persistent pain. The researchers used the Minimum Data Set (MDS) which includes

assessments of functional status, as well as assessments of pain and analgesic use. The MDS

has been shown to have strong validity and reliability. Findings revealed suboptimal

compliance with current practice guidelines by providers on geriatric prescribing

recommendations. The most common analgesics prescribed were acetaminophen (37.2%),

propoxyphene (18.2%), hydrocodone (6.8%) and tramadol (5.4%) with 25% of participants

receiving no analgesics. Evidence has not demonstrated that propoxyphene is superior to

acetaminophen. Propoxyphene use by older adults has been linked to increased hip fractures in

community elderly (Mort & Schroeder, 2019), as well as increased risk for hospitalization,

emergency visits and death (Kamal-Bahl, Stuart, & Beers, 2021). Geriatric prescribing

practices recommend that propoxyphene should be avoided in older adults (Terrell, Heard, &

Miller, 2018). This strong designed study has implications on the underutilization of

appropriate pain management analgesics for older adults experiencing persistent pain. The

study results provide strong evidence for support toward improving provider prescribing




patterns and the need for further education on appropriate analgesic selection for persistent

pain in older persons.

Community-dwelling older persons with dementia have a greater risk for inappropriate

and inadequate treatment of persistent pain. Shega and colleagues (2016) found that elderly

persons with cognitive impairment and persistent pain were at greatest risk for insufficient

analgesia. A cross-sectional design was used for this study by observing a convenience sample

of 115 dyads of community-dwelling elders and their caregivers. Pain assessment was

determined by both the older adult and their caregiver. Over half of the participants (54%) who

experienced daily pain reported no use of any analgesic. The majority of caregivers who

administered an analgesic used NSAIDs. No participant was prescribed a strong opioid, such

as morphine. Forty-six percent were reported to have had insufficient pain relief. Insufficient

pain relief was 1.07 times as likely for each additional year of age (95% confidence interval

(CI) = 1.01-1.14), 3.0 times as likely with advanced cognitive impairment (95% CI = 1.05-

9.10), and 2.5 times as likely for older adults with impairment in daily functioning (95% CI =

1.01-6.25). Limitations of this study include a sample of convenience and reliance on

caregivers’ report of pain. The study design was unclear on the distinction between provider

prescribing practices and caregiver administration practices. This vagueness in reviewing

provider prescribing patterns of opioids makes interpretation of the data uncertain. The results

suggest that older adults with dementia and persistent pain may not be prescribed or given

adequate analgesic. Further study is required to examine the impact of cognitive impairment

and adequacy of persistent pain management in this population.

Nurse Practitioners’ Persistent Pain Management Practices




There is a dearth of research on practice patterns of nurse practitioners in the

management of persistent pain in the elderly. Kaasalainen, et al., (2017) examined 18 Ontario

nurse practitioners practice patterns and pain management approaches in older adults residing

in LTC. A cross-sectional survey resulted in sixteen (89%) of the NPs indicating 33 activities

related to pain management and identified barriers to the fulfillment of their pain-management

role in LTC. Most of the NPs (81.3%) reported utilizing pain-assessment tools with less than

half reporting the use of pain-management clinical practice guidelines. The barriers to effective

pain management by NPs included time constraints; prescribing restrictions; lack of

knowledge; difficulties with assessing pain; reservations by physicians, staff, residents, and

families toward use of opioids; and poor collaborative relationships with physicians. The

design of this study would have been better suited using a grounded theory approach to

generate a clearer understanding of the practice facilitators and barriers in prescribing opioids

by NP for older adults. These results suggest that NPs may not be utilized to their fullest

potential in managing persistent pain among older LTC residents. In addition, the results

demonstrate that NPs may not be using current pain management guidelines and thereby

inaccurately treating persistent pain in older adults.

In a subsequent study, Kaasalainen et al. (2010) investigated the role of the NP in

managing pain in the LTC environment and explored the barriers and facilitators toward the

optimal use of NPs in managing resident’s pain from the perspective of physicians,

pharmacists, nurse managers, staff and nurse practitioners. The researchers conducted focus

groups and individual interviews. Five pain management activities performed by NPs were

identified, including assessing pain, prescribing pain medication, monitoring pain levels and

side effects of pain medications, consulting and advocating for staff and residents, and leading




and educating staff related to pain management. Of particular interest from this study are the

identified factors which influenced the NP’s role in pain management. Themes that emerged

from the data analysis included the availability of the NP, scope of practice, role clarity,

perceived added value of NP role, terms of employment, and NP-physician relationships. The

data illuminates the pain management role of NPs in LTC and provides a springboard for

further study. Clarifying our understanding of the obstacles NPs encounter gives guidance

toward better assessment and management of persistent pain.

Gaps in the literature

Nurse practitioner programs and certification bodies require the inclusion of advanced

knowledge and training in the prescribing and/or management practices for analgesics and

opioids (Burman et al., 2019). Nurse practitioners who may not have prescribing authority of

opioids should continue to remain knowledgeable and advocate for appropriate opioid use in

the management of pain in older adults. There continues to be a lack of uniformed

requirements and standards on the inclusion of geriatric practices in pain assessment and

management in nursing programs (Brown & McCormack, 2010). Gaps continue to exist in our

understanding of NPs’ pain management competencies with older populations and use of

opioid analgesic in the management of persistent pain in older adults. Although mounting

scientific evidence supports the use of opioid treatment for both continuous nociceptive and

neuropathic persistent pain in older adults, the prescribing of opioid analgesic remains

inconsistent. Few studies exist regarding knowledge and practices of NPs’ related to opioid

usage in managing pain in older adults. This project will fill this gap and validate the use of the

best practice protocol in effectively managing pain in older adults.





Week 5

PICOt Question

State your PICOt question here. Use the elements of the PICOt in separate sections below to describe each component.

• Population – Provide the description of the targeted population. • Intervention – Describe your evidence-based intervention. • Comparison – What is currently happening? • Outcomes – List at least two (2) measurable outcomes. • time – What duration of the study for the project? (e.g., usually 6 months or 3 months)


Population (P): NP providers who make rounds in a 50-bed skilled nursing facility located in

a sub-urban area


Intervention (I): Implementation of an Evidenced-Based Protocol on the Management of

Persistent Pain in Adults 50 years and Older


Comparison (C): There is currently no standard or practice protocal. Providers are currently

practicing using various evidence or guidelines.


Outcomes (O): 20% improvement in self-report pain relief (Iowa Pain Thermometer), 90%

compliance rate of providers with protocol (total number of compliance number / total number

of compliance and non-compliance number), 50% reduction on the use of NSAIDs with adults

50 years and older (total number of NSAIDs prescribed during study / total number of number

of NSAIDs prescribed in previous month)


time (t): 60 days





Week 6 P (Target Population)

[75 to 100 words]

Address the following questions/bullets in completing this section: • Who is your target population? • Describe your population, i.e., age, ethnicity, gender, condition/diagnosis, etc.? • Describe the setting where this project be implemented?

The population for this study is 15 nurse practitioners from various medical offices and with

Optum care who practice at the 50-bed SNF unit. There 12 females and 3 males. Years of

experience range from 2 years to 21 years with the mean being 11 years. The age range is from

26 years to 61 years. Average age is appropriately 44 years. The setting for this project will be

a 50-bed SNF located within a 300-bed nursing home. The nursing home is part of a senior

living community that includes homes, condos, apartments, and assisted living.


[As a student if you do not know these number then estimate or describe in more general terms, e.g., there over 10 NPs with more females than males and most are middled age with over 10 or so years of experience.]

Week 7 I (Intervention)

[100 to 200 words]

Address the following questions/bullets in completing this section: • What are you planning to investigate or implement as a policy/process or program? • What are you doing that is different than what is currently happening? • List 2-3 potential actions that will be applied in this practice change. NOTE: Be very specific in your description.

This project will evaluate the effectiveness of implementing a best practice protocol with nurse

practitioners on a skilled nursing unit. There are currently no standardization or protocol on the

unit for assessing and managing persistent pain in older adults. The intervention for this project

will be the implementation of a best practice protocol using the evidence-based




recommendations from the American Geriatrics Society on the pharmacological management

of persistent pain in older adults. A team of stakeholders and clinicians will meet as a team to

develop the protocol. The protocol will be used as a practice guideline for assessing and

managing moderate to serve persistent pain in older adults 50 years and older. Potential

interventions include:

1. Standardized pain assessment tool

2. Initial treatment – Acetaminophen

3. NSIDs and COX-2 used rarely

4. For pain scores at moderate or greater, opioid therapy is considered.

*For purposes of this Proposal Project Form the assumption will be that the C (Comparison Group) is ‘traditional care or current care’

Week 8

O (Outcomes to be measured) [100 to 150 words]

Every project is required to have an evaluation plan. Address the following questions/bullets in completing this section:

• Which 2-3 outcomes are expected for your project? • What outcomes will be measured?

o How do you plan to do this? o What tool will you be using to measure your outcome(s)? o What data will be used to validate success of the project?

Be sure your outcomes link to the identified problem.

• How will you know if your intervention resulted in change? Outcomes from a quality improvement or evidence-based project are important in providing

data results on the effectiveness of a intervention. The following outcomes for this project will


1. Iowa Pain Thermometer (IPT) self-report on pain intensity related to a thermometer.




The IPT has a Spearman rank coefficient ranged from 0.78 to 0.86 supporting

concurrent validity and test-retest reliability between 0.67 to 0.85.

2. NP compliance rate with implementing protocol. This is a simple formula on

comparing compliance with implementing the best practice protocol.

3. Filled NSAIDs per day compared to prior to implementation of protocol. This is a

simple formula comparing prescriptions one month prior to implementation with those

during the study period.

Week 9 & References 9.1 Conclusion

[200 to 250 words]

• Provide a summary for your MSN Capstone Project. • Select and provide the rationale for three (3) competencies or specialty standards that you would expect

to use in implementing this project [List of your specialty competencies are listed in the Week 9 Reflection Post]

9. 2 References [Minimal of 5 research articles and references are paged on the last page.]

• Add your references in APA formats on the last page.


It is challenging to manage persistent pain in older adults in general and even more so for those

with comorbid conditions and polypharmacy. These challenges should not discourage opioid

use in the management of moderate to severe pain. Current guidelines provide guidance for the

safe and effective use of opioids in this population. A best practice protocol that guides NPs in

the assessment and management of moderate to severe persistent pain in older adults may

demonstrate effective positive outcomes. National Organization for Nurse Practitioner Faculty

(NONPF) competing that will be used with implementing this project include:




§ Competency 3 – Quality Competencies – I will be using the quality competency in the

implementation of a best practice or quality improvement project. This project will use

my leadership skill in the role of change agent.

§ Competency 4 – Practice Inquiry Competencies – I will be using the practice inquiry

competency by asking the clinical question – Will an evidence-based practice protocol

to guide nurse practitioners in the effective assessment and management of old adult

with persistent pain?

§ Competency 8 – Ethics Competencies – I will be integrating the ethical principles of

justice and fairness in clinical decision-making. Older adults who suffer from persistent

pain deserve to be treated with the same respect and practices that younger adults.



References in APA format should begin on the next page.





References [Provide at least 5 References]

American Geriatrics Society Panel on Persistent Pain in Older Adults. (2021). The management

of persistent pain in older persons. Journal of American Geriatric Society, 50(6 Suppl.).

S205-224. Doi: 10.1046/j.1532-5415.50.6s.1.x

Collett, B., O’Mahoney, S., Schofield, P., Closs, S. J., & Potter, J. (2007). The assessment of

pain in older people. Clinical Medicine, 7(5), 496-500.

Brown, D. & McCormack, B. (2019). Determining factors that have an impact upon effective

evidence-based pain management with older people, following colorectal surgery: An

ethnographic study. Journal of Clinical Nursing, 15(10), 1287-1298. doi: 10.1111/j.1365-


Burman, M. E., Hart, A. M., Conley, V., Brown, J., Sherard, P., & Clarke, P. N. (2019).

Reconceptualizing the core of nurse practitioner education and practice. Journal of the

American Academy of Nurse Practitioners, 21(1), 11-17. doi: 10.1111/j.1745-


Fox, F. (2019). Managing pain in osteoarthritis. Primary Health Care, 19(7), 38-45.

Kaasalainen, S., DiCenso, A., Donald, F. C., & Staples, E. (2007). Optimizing the role of the

nurse practitioner to improve pain management in long-term care. Canadian Journal of

Nursing Research, 39(2), 14-31.

Kamal-Bahl, S., Stuart, B. C., & Beers, M. H. (2021). National trends in and predictors of

propoxyphene use in community-dwelling older adults. American Journal of Geriatric

Pharmacotherapy, 3(3), 186-195.

Malanga, G. & Paster, Z. (2020). Update on managing chronic pain in the elderly. The Journal of

Family Practice, 56(12), S11-S16.





Mort, J. & Schroeder, S. (2019). Propoxyphene and pain management in the elderly. South

Dakota Medicine: The Journal of the South Dakota State Medical Association, 62(11),


Oware-Gyekye, F. (2019). Pain management: The role of the nurse. West African Journal of

Nursing, 19(1), 50-54.

Shega, J. W., Hougham, G. W., Stocking, C. B., Cox-Hayley, D., & Sachs, G. A. (2016).

Management of Noncancer pain in community-dwelling persons with dementia. Journal

of American Geriatric Society, 54(12), 1892-1897. doi: 10.1111/j.1532-


Smith, G. B. (2011). Persistent pain in older adults: Don’t be afraid to prescribe opioids. Advance

for NPs PA, 2(9), 23-28.

Terrell, K. M., Heard, K., & Miller, D. K. (2018). Prescribing to older ED patients. The

American Journal of Emergency Medicine, 24, 468-478. doi:10.1016/ j.ajem.2006.01.016

Walid, M. S., Donahue, S. N., Darmoharay, D. M., Hyer, L. A., & Robinson, J. S. (2018). The

fifth vital sign—what does it mean? Pain Practice, 8(6), 417-422. doi: 10.1111/j.1533-


Won, A. B., Lapane, K. L., Vallow, S., Schein, J., Morris, J. N., & Lipsitz, L. A. (2018).

Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home

residents. Journal of American Geriatric Society, 52(6), 867-874. doi: 10.1111/j.1532-



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