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 Helped 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 Assessment 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
include:
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-
2702.2006.01553.x
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-
7599.2008.00365.x
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),
433-5.
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-
5415.2006.00986.x
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-
2500.2008.00222.x
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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