Nurses' perceptions of pain management in older adults.
Pain is a serious issue facing older adults in nursing care facilities today. The lack of pain management can affect older adults' quality of life and general well-being (Centers for Disease Control and Prevention, 2006). Older adults in long-term care (LTC) facilities are faced with issues regarding chronic and acute pain. Brief admission to LTC facilities following surgery such as joint arthroplasty is a common practice, because many older adults need rehabilitation. Changes in admission criteria for inpatient rehabilitation services by the CMS in 2004 (Vincent & Vincent, 2008) meant some patients admitted previously to inpatient rehabilitation units were admitted to LTC following joint arthroplasty. Nurses in LTC facilities now manage acute pain for patients as early as 3 days postoperatively (Feeney, 2008; Lourde, 2011).
In addition, nurses in LTC settings manage pain in some older adults who are unable to verbalize their pain due to dementia. Among individuals age 65 and older in the United States, 5 million experience dementia, which complicates their ability to express pain. The number is projected to rise over the next few decades (Alzheimer's Association, 2012). In long-term care facilities, an estimated 50%-75% of older adults have chronic pain (Planton & Edlund, 2010). Older adults face many chronic health problems that cause pain and contribute to depression, decreased mobility, sleep disturbances, increased health care utilization, and social role dysfunction (Ersek & Polomano, 2011). Even concerning pain management in the hospice setting, researchers found there is an opportunity for improvement in pain management (Oliver et al., 2008).
Attitudes and beliefs by nurses and older adults about pain can hinder effective pain management (Bergman, 2012; Dihle, Bjolseth, & Helseth, 2006). Patients' beliefs and attitudes about pain are viewed primarily as fear-based (Bedard, Purden, Sauve-Larose, Certosini, & Schein, 2006; Duignan & Dunn, 2009).
Identifying nurses' barriers, attitudes, and perceptions of pain management are important to improving pain management. Nurses assess older adults for pain, and offer and administer analgesics as needed. They are key to successful pain management in older adults.
A comprehensive search was conducted using the Cumulative Index to Nursing and Allied Health Literature from 2005 to 2013. Use of search terms such as pain or pain management yielded over 70,000 citations. However, when the search term of older adult or elderly was added to the search, only 137 citations were identified. When the search terms attitudes, perceptions, or barriers were added to the search of pain without inclusion of age, less than 10 citations were noted; with the term older adult, only three citations were identified. The literature is very limited in the area of nurses' perceptions of pain in older adults in long-term care settings.
Pain in older adults should not be viewed as a normal part of aging (Cann, 2008). It is believed pain changes with age and is different from young adults but still occurs (Hallingbye et al., 2011). The older adult faces issues regarding pain management that may vary from the young adult, such as different doses and medications due to decreased renal function and possible issues with assessing pain using a numeric scale. The literature regarding pain management in older adults gives conflicting findings. One study found pain prevalence and intensity increased with age (Cohen, Musgrave, Munsell, Mendoza, & Gips, 2005). In contrast, another study found the pain threshold may be higher in older adults with dementia (Carlino, Benedetti, & Rainero, 2010).
Older adults have multiple health care issues that contribute to acute and chronic pain (Horgas & Yoon, 2008). The literature suggests pain is undertreated and often underestimated in older adults (Denny & Guido, 2012; Zanocchi et al., 2007). The lack of effective pain management has been attributed to many barriers and attitudes (Duignan & Dunn, 2009).
Nurses' beliefs and attitudes may contribute to inadequate pain management in adult postoperative patients. In an observational design study using two surgical units in a metropolitan teaching hospital in Australia, nurses were observed for pain activities for fixed observation times (Manias, Backnall, & Botti, 2005). Researchers found nurses underestimated pain and believed patients should expect pain. The importance of communication to successful pain management also was identified in this study.
Other studies (Rejeh, Admadi, Mohammadi, Kazemnejad, & Anoosheh, 2009; Rejeh & Valsmoradi, 2010) also investigated perception of pain in surgical areas in Iran. One study (Rejeh & Valsmoradi, 2010) examined the pain management experiences of elective surgical patients. The patients' experience reflected three main themes: perceptions of pain management goals, patients' views of nurses' role in pain management, and interaction in pain management. They indicated their pain was managed, but noted the nurses had no time for patients and their concerns were not addressed. In another study (Rejeh et al., 2009) involving nurses' perceptions of pain management, four themes evolved: lack of educational preparation, nurses' limited authority, limited nurse-patient relationship, and disturbances to pain management interventions.
Education of nurses had an impact on appropriate pain management (Khalaileh & Qadire, 2012; Polkki et al., 2010). The expert nurse was more likely to care holistically for the patient and provide more effective pain management (Richards & Hubbert, 2007). Also, Polkki and coauthors (2010) found nurses in the neonatal intensive care unit lacked the needed pain management education to manage pain effectively. Some nurses, for example, did not know premature infants are more sensitive to pain than full-term babies. The educational level and years of experience impacted the attitudes and perceptions of pain. In a third study of Jordanian nurses working with patients with cancer, Khalaileh and Qadire (2012) also found a lack of education caused barriers to successful pain management.
Barriers to pain management were investigated in a descriptive study (Duignan & Dunn, 2009) conducted in an emergency department (ED) in the Republic of Ireland. Questionnaires were returned by 67 ED nurses. Findings were compared to a study conducted with ED nurses 9 years earlier in the United States (Tanabe & Buschmann, 2000). Findings were similar. Identified barriers included organizational barriers (e.g., inability to offer analgesia until a diagnosis is made), lack of time to assess and manage pain, responsibilities to care for other acutely ill patients, and the inability to monitor side effects. The most common patient-related barrier was drug and alcohol abuse. Other barriers included patient reluctance to report pain, inability to determine history, patient reluctance to take opioids, nurses' reluctance to give opioids, and physician reluctance to order analgesics.
Another study (Bergman, 2012) conducted in the United States investigated ED nurses' perceived barriers to managing adult patients' pain. Fifteen nurses were interviewed about their perceived barriers to effective pain management. The themes that emerged included feeling overwhelmed due to lack of control and adequate staffing, perceived noncohesiveness of the health care team, frustration about abuse of the ED, and unrealistic patient expectations of the nurses' role.
Critical care nurses in Canada were studied regarding pain assessment and management practices (Rose et al., 2012). Questionnaires were mailed to nurses throughout the country. Findings showed a substantial proportion of nurses did not use assessment tools for patients unable to communicate about pain, and were unaware of pain management guidelines published by professional organizations.
Nurses working on acute medical units with older patients in Canada were studied to determine the extent to which they adopted pain assessment and pain management guidelines, as well as perceived barriers to optimal pain assessment and management (Coker et al., 2010). A sequential exploratory mixed method design was used. The first phase used a qualitative approach to identify pain management barriers and contribute to the development of a tool. In the second phase, the tool was used in a cross-sectional descriptive study to evaluate barriers to pain management. Of the 115 nurse respondents, most believed the guidelines were being followed, but only 28% (n=31) indicated they implemented the practice guideline for patients with cognitive impairments. The nurses also identified the following barriers to pain management: nurse difficulty in assessing patients with cognitive impairments and language difficulties, patients reporting pain to the doctor but not the nurse, patient willingness to accept pain, and patient reluctance to take medications due to side effects. Organizational barriers included disorganized system of care, unavailable nonpharmacological pain management measures, and inadequate time for patient teaching and implementation of nonpharmacological pain management strategies. Nurses also reported physicians were reluctant to prescribe analgesics because of a fear of overmedicating.
Schofield (2006) studied pain management of older adults in care homes in the United Kingdom. Staff in the care facilities were interviewed to determine their level of pain knowledge and the barriers to effective care management. The staff identified the failure of residents to report pain as a serious barrier. Other issues identified included concerns about staff communication and lack of education.
One study (Kaasalainen et al., 2007) in long-term care focused on physician and nurse attitudes on pain management that affect decisions about prescribing and administering analgesics for older adults. In a grounded theory study, physicians, registered nurses (RNs), and licensed practical nurses (LPNs) in four LTC facilities were interviewed. Major themes that evolved from the data included lack of recognition of pain, uncertainty about the accuracy of the pain assessment, reluctance to use opioids, individualized treatments, and issues related to physician and nurse trust.
Pain management remains a focus by professional organizations, regulatory agencies, and research, with a great deal of empirical research in the literature (Bell & Duffy, 2009). Despite the amount of pain management research, most has focused on hospital settings rather than older adults in LTC. Issues regarding pain management in older adults need to be addressed as their number grows.
Purpose and Research Question
The limited research of nurse perceptions and attitudes about pain management of older adults in LTC facilities and the lack of any research about acute pain management for older adults admitted to nursing homes following surgery indicate a need to focus on nurses' perceptions about chronic and acute pain management in long-term care. The purpose of this study was to determine nurses' perceptions of pain management in older adults in long-term care. The research question for this study was: What are nurses' perceptions of pain management for older adults in long-term care facilities?
A qualitative descriptive design with a content analysis approach was used to investigate the nurses' experiences with pain management in the older adult. The dynamic interaction between older adults and their health care providers are complex. Content analysis is a systemic and objective research method that provides a means of describing phenomena. This method is a logical first step when knowledge of a particular problem is limited and complex, and where phenomena such as perceptions are being investigated (Burns & Grove, 2009; Elo & Kyngas, 2007). The information from the participants is used inductively to develop theory rooted in participants' experiences (Polit & Beck, 2011).
Content analysis served as the method for analysis of the data. Through the use of interviews, this method allowed the researcher to explore the phenomenon of nurses' perception of pain management in older adults. This research method uses a systematic set of procedures to develop an inductively derived theory about phenomena. Data collection and analysis occur in a simultaneous and ongoing fashion. As data are collected and analyzed, findings influence data collection, which then influences ongoing data analysis.
The study of nurses' perceptions is rooted in symbols, experiences, and interactions with the world. Symbolic interaction, the theoretical foundation that formed the basis of this qualitative study, is particularly appropriate because the study sought to uncover processes and perceptions, and elicit meanings of interaction (Blumer, 1969). With content analysis, understanding of phenomena related to experiences of pain management can be gained.
Sample and Setting
The sample consisted of any nurse including RNs and LPNs who work at a LTC facility caring for older adults. The sample size for this study was determined by attaining theoretical saturation according to the qualitative method of a grounded theory approach (Strauss & Corbin, 2008). Theoretical saturation is a process over time in which the researcher makes the case that the concepts are discovered repeatedly in the data, with less and less new information emerging.
Sixteen subjects, 15 females and one male, were interviewed. Participants consisted of nine RNs and seven LPNs. The nurses in this study ranged in age from 29 to 62, with an average age of 41. The sample consisted of nurses who were licensed for an average of 15 years, and the average time employed at the facility was 11 years. The study was conducted at a large skilled nursing facility in the northeastern United States. The facility consisted of nursing units for patients with dementia, patients with traditional skilled needs, and patients in short-term rehabilitation who expected to return home in a few weeks.
Institutional review board approval was obtained and participation was on a voluntary basis. The purpose and procedure of the study were explained to the participants and written informed consent was obtained. A set of questions (see Table 1) guided a focused interview with nurses. The questions explored perceptions by the nurses regarding pain management in the older adult and they were developed based on the review of the literature. Questions were open-ended to encourage expression of thoughts and feelings. With permission of the participants, the interviews were audiotaped and transcribed verbatim for analysis. The interviews were conducted in a private area agreeable to the participant. As data were collected and analyzed, initial analysis led to more focused questions as the study continued. Demographic data also were obtained, to include the participant's age, sex, occupation, department, number of years employed at the facility, and number of years as a nurse.
Audio recordings of the interviews were transcribed. Data were coded during a line-by-line analysis as interviews were read. The process of content analysis included open coding, creating categories, and abstraction. During the first step of data analysis, the data were examined, broken down, conceptualized, and categorized (Elo & Kyngas, 2007). The written transcripts were read through many times, and written headings and concepts were identified. The data then were analyzed using a coding method in which categories were examined according to a coding paradigm, and relationships between categories were identified. Next, core categories or themes were identified from the data. Finally, the categories were evaluated to identify any introductory theory about nurses' perceptions of pain management in the older adult that became evident from the core categories.
The participants in the study consistently described an environment where effective pain management was possible and noted pain management recently had improved greatly at this facility. Most participants believed older adults were satisfied with their level of pain management. However, as the interviews progressed, the participants clearly described perceptions about other nurses and department practices that exposed concerns about pain management in older adults. The negative perceptions about pain management were rarely a reflection of the nurses' own practices, but concerns were reported about other nurses or other departments.
Analysis of the data identified major perceptual categories about pain management in the older adult. These categories emerged consistently among participants and served to organize the data into a conceptual whole. According to the data, the experiences of the nurses were similar. The difference appeared in the intensity of their perceptions, which seemed to be related to the department in which they worked and their past experiences, such as working at other facilities.
The categories that emerged and seemed to impact the nurses' perceptions included perceptions about the older adults and their families, lack of education, inability to recognize an individualized plan of care, and failure to communicate effectively with the entire health care team (see Figure 1). These categories emerged to create a situation where the nurses' own perceptions and possibly the lack of self-reflection caused barriers to effective pain management in older adults. These self-perceptions were not recognized readily, and that failure could be impeding nurses' ability to maximize effective pain management in older adults.
Nurses' Perceptions about Older Adults and Families
Perceptions about older adults and families were a significant concept that arose from the data. During the interviews, it was apparent the nurses chose to work at this facility because they enjoyed working with older adults. Most participants described behaviors of empathy and caring toward older adults. However, some biases were apparent that could affect nurses' care of older adults. All nurses indicated the lack of effective pain management could affect older adults' quality of life. Most nurses were focused on the physical aspect of quality of life, with less interest in other aspects. One nurse stated, "If their pain is not managed, it causes problems with ADLs, and the healing process." Some nurses discussed depression and problems interacting with others as a result of being in pain. Because most of the nurses did not discuss the psychological, social, and spiritual aspects of quality of life, this could impact how nurses view the effectiveness of the pain management program.
Some comments about the older adults and families were negative. One nurse stated, "Some of the residents are more dramatic about pain." Another nurse also said,
I believe in pain management, but I also think as a society we are at a point where we think a pill can cure all. Maybe I am a little from the old school that no pain no gain. You have to have a little pain to know that you are getting better. I have noticed lately that a lot of the patients just want the pain medication. I don't think they understand the ramifications of taking all these pain medications.
A few nurses expressed concerns with the families, which varied from not providing adequate pain management or overmedicating to keep the older adult quiet.
Nurses also expressed concerns that older adults' pain was related to other factors, such as coping and anxiety. One of the participants described her theory about the relationship between anxiety and pain.
She believed anxious older adults have more pain and are less able to deal with the pain. The nurse never suggested pain or the lack of pain management may be causing the anxiety. She believed anxiety was the root of the problem. Some nurses expressed concerns about older adults' ability to cope with pain. One nurse stated, "They have absolutely no skills in coping with pain at all, no matter what you do."
In contrast, some nurses thought some older adults were able to cope with the pain. Some nurses indicated older adults are more likely to wait to ask for analgesia until the pain is unbearable. One nurse described the issue thus: "The biggest barrier we face is the residents' perceptions of their pain and I think that when they say 'I can handle it' that it is not that bad." Nurses had definite beliefs about pain management.
Lack of Education
During the interviews, nurses demonstrated a lack of current education on pain management. Some nurses noted certain educational opportunities were provided by the facility but most did not appear to attend the pain education sessions. The educational programs they described attending were related to a new pain management assessment form and a program by hospice.
Only two nurses described attending a pain management seminar outside the facility, and other nurses described reading journals to keep their knowledge current. Also, a few nurses stated they had not received any education regarding pain management in many years. A few nurses indicated the only education they received was during nursing school, which was many years ago.
Several nurses described the lack of education as a barrier to pain management. During the interviews, nurses seemed knowledgeable about caring for chronic pain, assessment of pain in older adults with dementia, and use of nonpharmacological measures. They described these activities comprehensively as an apparent area of strength within the facility. However, nurses indicated they needed to improve in the assessment of older adults who could not identify their pain verbally.
None of the nurses described a lack of education about acute pain management, yet in the interviews this seemed to be the greatest need. They described problems with pain management in their short-term rehabilitation unit and yet did not express concerns about a lack of knowledge in this area. During the interview, some nurses working in the rehabilitation unit described trying nonpharmacological measures first and giving medications as a delayed second or third step. Also, these nurses admitted residents 3 days after total hip or knee arthroplasty yet expressed concerns about addiction and complications of opioids, such as respiratory depression.
Inability to Recognize an Individualized Plan of Care
A consistent category that emerged from the data was the inability to provide an individualized plan of care. Participants were asked if older adults' pain experiences were individualized. All nurses in the study clearly believed the pain experience was unique to each older adult and the plan of care needed to be individualized. However, despite recognition of the personal pain experience of older adults, most nurses did not describe the plan of care as individualized for each older adult.
Most described having polices and procedures to follow. They also described a protocol they followed and wanted the approach to be the same for all. A few expressed frustration when the plan of care was not effective. Also, nurses described frustration when the pain intensity scale was interpreted differently by older adults at the facility. One nurse described this concern with the lack of an individualized plan of care:
Recently we are on this idea that the patients' rate their pain level too high. We are trying to make everyone more uniform with the levels. I don't know that is good since everyone is different. We need to individualize for the patient.
Failure to Communicate
Failure to communicate effectively with the entire health care team emerged from the interviews. Nurses described written communication to the physician by the use of a pain management tool. All study participants described the tool and how it has enhanced communication. However, interviews indicated timely verbal communication was lacking. Most nurses stated the physician would be contacted only if the pain became severe or unbearable for the older adult. The nurses also noted it could take 1-2 days to make a change in orders. Only a few participants clearly described their immediate changes to the plan of care.
Also, communication within the entire health care team seemed to be lacking. The communication primarily focused on the physician and nurse practitioner, and also among the nurses. Effective communication with other members of the team, such as the older adult, family, nursing assistants, and staff in other departments, seemed limited and even lacking in some situations. Nurses described active involvement with physical therapy staff, yet only one subject described communication about pain with therapy staff. Also, only two nurses expressed the value of the nursing assistant in the pain management program.
While some older adults have dementia and have difficulty participating actively in the pain management program, many older adults receiving analgesics are on the rehabilitation unit for a short stay following total hip or knee arthroplasty. These older adults are cognitively independent and will be discharged to their home in a few weeks. Few nurses saw enhanced communication with these older adults as important to pain management.
This lack of communication with families about pain management can result in misperceptions. One nurse stated, "Families feel that they are not being attended to properly and you see anger and frustration." Another nurse said, "Families are really hard, they think you are addicting their family member or you are just trying to keep their loved one quiet." Concerns about families were expressed in the interviews; however, only one subject described family members as part of the team and used their input.
Nurses' Perceptions and the Possible Lack of Self-Awareness Cause Barriers
In this study, the nurses' perceptions seemed to be a barrier to effective pain management. The nurses consistently focused on the perceptions and actions of other nurses and they did little self-reflection of their practice. The lack of education, individualized plan of care, and communication, as well as negative perceptions to older adults and their families, seemed to emerge in most of the interviews. One nurse stated this concern about the nurses' perception: "I don't think other nurses' perceptions of pain should affect how they manage pain." Another nurse stated, "The barriers to pain management are the nurses' own personal beliefs about pain management."
Nurses described other nurses' perceptions as having an impact on quality pain management of the older adult. A nurse stated, "We have some very close-minded individuals in which they worry about addiction." Another nurse continued by saying, "I feel that there are some nurses that are afraid to overmedicate." These perceptions can affect quality pain management. As one nurse summarized, "I think generally most patients believe their pain is relieved, but we do have ones here that feel that it is not managed well at all."
The purpose of this study was to investigate nurses' perceptions of pain management in the older adult. The nurses indicated effective pain management is possible and occurred most of the time. However, they also described perceptions and beliefs that could bias their ability to manage older adults' pain. Obstacles to effective pain management for older adults seemed to be related to the nurses' perceptions or lack of self-awareness.
Findings in this study have some similarities to past research, but new points also were made. Some subjects suggested older adults were reluctant to report pain and waited until the pain became unbearable. Others indicated older adults readily reported pain and believed patients should expect pain, a finding similar to Manias and colleagues (2005). The results of this study were consistent with past findings that the beliefs of the nurse and older adult can affect pain management (Bedard et al., 2006; Dihle et al., 2006).
However, some findings were different from past studies. Barriers, such as staffing shortages, lack of time, and increased workload that were discussed in other literature (Schafheutle, Cantrill, & Noyce, 2001), were not mentioned by any nurses in this study. The lack of education about pain management and acute pain in rehabilitation patients was a new finding that emerged in this study. This finding was similar to the results of Polkki and coauthors (2010). The lack of and need for continuing education emerged from this study which was different than past qualitative research that focused more on a traditional LTC setting without patients experiencing acute pain (Kaasalainen et al., 2007). Also, the lack of an individualized plan of care was identified in this study and by Kaasalainen and co-authors; however, in this study the nurses focused more on the need to use standardized protocols and in the past study the nurses believed they should be working to individualize the plan of care.
Effective communication among all members of the health care team is important for effective pain management. Determining the older adult's individualized plan of care needs to include the older adult, significant others to the older adult as appropriate, all members of the nursing team (e.g., nursing assistants), staff from other departments involved with care, and the physician. Communication needs to be timely to meet patient needs. Interdisciplinary care teams focusing on pain management are needed in practice to improve pain outcomes.
The strongest implication from this study is the need for education for all members of the team, including older adults and families. Pain management is evolving and continuous education is imperative to effective nurse performance. Teaching methods need to take a variety of approaches, including formal programs, journal club reviews, posters, and bulletin boards about various topics. Topics need to include pain assessment and evaluation, acute and chronic pain management, treatment modalities (pharmacologic and nonpharmacologic), and identification of perception and biases. Education and communication about these issues will assist in improving pain management.
Even though practice standards support the focus on pain in current practice, future research is needed to test preliminary concepts identified in this study. Also, a need exists to study nurses' perceptions of pain management of older adults in other settings (e.g., acute care and the community). As changes are implemented based on research findings, more studies are indicated about older adults' satisfaction with pain management. Future research also could explore personal nursing experiences related to pain and its impact on their practice.
The study was conducted at one long-term care facility. The demographic characteristics of the sample, such as only one male and similar cultural background, limited interpretation of study results. The sample also was limited to persons who were able to participate. Also, by agreeing to participate in the study, subjects may have stronger feelings about pain management than nurses who did not agree to participate. The perceptions of the nurses were within the context of their experiences primarily within the study facility, as many participants had not worked recently at another facility.
Development of successful pain management programs for older adults needs to focus first on nurses' perceptions and biases. Nurses need to understand their perceptions so they can address the effects. Education empowers nurses to make the best decisions about pain. By improving nurses' knowledge base and understanding pain management perceptions, effective health care teams can build and improve quality pain management programs for older adults.
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Theresa Gropelli, PhD, RN, is Associate Professor, Indiana University of Pennsylvania, Indiana, PA.
Janine Sharer, MSN, RN, is Advanced Practice Nurse, University of Pittsburgh Medical Center, St. Margaret Hospital, Pittsburgh PA.
TABLE 1. Guide Questions for the Interview A. Demographic Data 1. Age 2. Sex 3. Occupation 4. Department 5. Years employed at the facility 6. Years licensed as a nurse B. Interview Guide Questions 1. Tell me about your experience with pain management for the older adults at your facility. Probe questions: a. Do you feel pain is managed effectively at your facility? b. Do the experiences vary between residents? 2. Tell me about your feelings about pain management. Probe questions: a. What are your thoughts about pain management? b. What is your personal philosophy about pain management? 3. Do the residents feel their pain is managed effectively? 4. Tell me about what occurs when pain management is not effective for the resident. Probe questions: a. Do you have a different protocol to follow? b. Do you contact the physician? 5. How do you think pain impacts the residents' quality of life? 6. Are there any barriers to effective pain management at your facility? If so, what are the barriers? 7. Do you follow the prescribed pain management orders? 8. Do you feel effective pain management is possible for the residents at your facility? 9. Tell me about nonpharmacological measures that you use to manage pain. Probe questions: a. What interventions do you use? b. What is your feelings about these measures? 10. Tell me about any education that you have received about pain management. 11. Describe to me the communications that you have with the health care team about pain management. 12. Do you have anything that you want to share that could improve pain management for the older adults at the facility?
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|Title Annotation:||Research for Practice|
|Author:||Gropelli, Theresa; Sharer, Janine|
|Date:||Nov 1, 2013|
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