Hospitalized patients’ vs. nurses’ assessments of pain intensity and barriers to pain management

Pain management inequities by demographic and geriatric-related variables in older adult inpatients

BACKGROUND

Pain is ubiquitous, yet understudied. The objective of this study was to analyze inequities in pain assessment and management for hospitalized older adults focusing on demographic and geriatric-related variables.

METHODS

This was a retrospective cohort study from January 2013 through September 2021 of all adults 65 years or older on the general medicine service at UCSF Medical Center. Primary exposures included (1) demographic variables including race/ethnicity and limited English proficiency (LEP) status and (2) geriatric-related variables including age, dementia or mild cognitive impairment diagnosis, hearing or visual impairment, end-of-life care, and geriatrics consult involvement. Primary outcomes included (1) adjusted odds of numeric pain assessment versus other assessments and (2) adjusted opioids administered, measured by morphine milligram equivalents (MME).

RESULTS

A total of 15,809 patients were included across 27,857 hospitalizations with 1,378,215 pain assessments, with a mean age of 77.8 years old. Patients were 47.4% White, 26.3% with LEP, 49.6% male, and 50.4% female. Asian (OR 0.75, 95% CI 0.70-0.80), Latinx (OR 0.90, 95% CI 0.83-0.99), and Native Hawaiian or Pacific Islander (OR 0.77, 95% CI 0.64-0.93) patients had lower odds of a numeric assessment, compared with White patients. Patients with LEP (OR 0.70, 95% CI 0.66-0.74) had lower odds of a numeric assessment, compared with English-speaking patients. Patients with dementia, hearing impairment, patients 75+, and at end-of-life were all less likely to receive a numeric assessment. Compared with White patients (86 MME, 95% CI 77-96), Asian patients (55 MME, 95% CI 46-65) received fewer opioids. Patients with LEP, dementia, hearing impairment and those 75+ years old also received significantly fewer opioids.

CONCLUSION

Older, hospitalized, general medicine patients from minoritized groups and with geriatric-related conditions are uniquely vulnerable to inequitable pain assessment and management. These findings raise concerns for pain underassessment and undertreatment.

Do we really know if they are in pain? A cross-sectional study in hospitalised adult patients in Spain

AIMS

To describe the prevalence and characteristics of pain in adult hospitalised patients, as well as to analyse the concordance between patient-reported and recorded pain and its impact on analgesic management.

DESIGN

A cross sectional study.

METHODS

The study was performed on a sample of 611 patients, from October to December 2017. Data were obtained from patient interviews, review of medical and nursing records and review of electronic prescribing.

RESULTS

The prevalence of pain at the time of the interview was 36.7%. The median VAS score was 4. 90% of the patients had their pain assessed within the last 24 h; however, concordance between patient-reported pain and recorded pain in the nursing record was slight.

CONCLUSION

Pain is still often documented inadequately. Despite the wide use of analgesics, half of the patients with moderate to severe pain do not have adequate pain management. A systematic assessment and recording of pain promotes appropriate analgesic prescription.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The findings of our study provide insight into the main gaps in the correct management of pain in hospitalised patients. A systematic assessment and recording of the pain suffered by the patient facilitates its control and allows a better management of the analgesic prescription by the physician. This information could help hospital managers to develop training programmes on pain assessment and on the importance of doctor-nurse collaboration to improve pain management, increasing the quality of care and reducing hospital costs.

REPORTING METHOD

The study has adhered to the relevant EQUATOR guidelines, according to The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

Nurses' pain management practices for admitted patients at the Comprehensive specialized hospitals and its associated factors, a multi-center study

BACKGROUND

Pain is the most common challenge that most hospitalized patients complain of and is influenced by several patients, nurses, and institutional-related factors. Most studies in Ethiopia on pain were focused on surgical illnesses only.

OBJECTIVE

To assess nurses' pain management practice and associated factors for admitted patients at Comprehensive Specialized Hospitals.

METHODS AND MATERIALS

A multi-center institution-based cross-sectional study was conducted at the five randomly selected Comprehensive Specialized Hospitals of the Amhara region from May 01 to June 01, 2022. A multi-stage sampling method was employed to select a total of 430 nurses and patients for whom the nurses were responsible. Data were collected using standard self-administered, structured, and checklist questionnaires from nurses, patients, and patients' charts respectively. The modified Bloom's criteria categorized the overall practice as good, moderate, and poor. Data were checked, coded, and entered into Epi-Data version 4.6 and exported to SPSS version 25. An ordinal logistic regression model was applied, and variables with a p-value < 0.05 with a 95% CI in the multivariable analysis were considered significant.

RESULTS

The study evaluated the pain management practices of 430 nurses and only a quarter had good pain management practices. Those nurses with first degrees and above education level (AOR = 2.282) and who attended in-service training (AOR = 2.465) were found to have significantly higher pain management practice. Expected though patients with painful procedures (AOR = 5.648) and who had severe pain (AOR = 2.573) were receiving better pain management practices from their nurse care provider. Nurses working in the institutions with a pain-free initiative focal person (AOR = 6.339) had higher pain management practices.

CONCLUSION AND RECOMMENDATION

Overall, the majority of nurses had poor pain management practices. Higher educational levels, in-service training, and assigning a pain-free focal person had an impact on pain management services. Patients with higher pain levels and painful procedures were getting better attention. Hospital administrations need to provide due attention to the pain management of hospitalized patients by providing in-service training and educational opportunities to improve the capacity of nurses. Patients would be benefited considerably if hospitals focus on assigning focal persons for advocating regular pain management for admitted patients regardless of their pain level.

Nurses' assessment and management practices of pain among intensive care patients in King Khalid Hospital, Kharj, Riyadh

Background

Pain is a disagreeable combination of sensory and emotional sensations. Employing behavioral pain assessment tools is strongly associated with improved identification of pain.

Purpose

The main purpose of the study is to investigate Nurses' Assessment and Management Practices of Pain among Intensive Care Patients in King Khalid Hospital, Kharj, Riyadh.

Materials and methods

A self-administered questionnaire was employed in a descriptive cross-sectional study. The study focused on nurses employed in the intensive care unit at King Khalid Hospital in Al-Kharj Province. The researchers utilized convenience sampling to recruit participants. Out of the total 48 nurses approached 45 of them provided responses, leading to a response rate of 94%. The Critically Ill questionnaire was utilized to gather information regarding the treatment and evaluation of pain in patients who were in critical condition. Descriptive statistics and inferential statistics were employed to analyze the collected data.

Principal results

it was found that 88% of them utilized instruments to evaluate pain in patients who could express themselves. Among these instruments, the numeric rating scale was the most commonly employed. Furthermore, 77% of the nurses (35 in total) used a pain assessment tool for patients who were unable to communicate, with the Adult Nonverbal Pain Scale being the most frequently used tool in this case. The nurses' perception of the significance of pain assessment was positively associated with the regular utilization of pain assessment tools. Additionally, the nurses considered the use of pain assessment tools with patients who could communicate as more important compared to using such tools with patients who could not communicate.

Conclusions

Most ICU nurses utilized nurses' pain assessment instruments to assess the discomfort levels of both patients who could communicate and those who couldn't express themselves effectively. By employing such tools, nurses can improve patient outcomes, ensure effective pain management, and demonstrate a high standard of professional care.

Pain Assessment Disparities by Race, Ethnicity, and Language in Adult Hospitalized Patients

AIM

Nurses assess patients' pain using several validated tools. It is not known what disparities exist in pain assessment for medicine inpatients. Our purpose was to measure differences in pain assessment across patient characteristics, including race, ethnicity, and language status.

METHODS

Retrospective cohort study of adult general medicine inpatients from 2013 to 2021. The primary exposures were race/ethnicity and limited English proficiency (LEP) status. The primary outcomes were 1) the type and odds of which pain assessment tool nursing used and 2) the relationship between pain assessments and daily opioid administration.

RESULTS

Of 51,602 patient hospitalizations, 46.1% were white, 17.4% Black, 16.5% Asian, and 13.2% Latino. 13.2% of patients had LEP. The most common pain assessment tool was the Numeric Rating Scale (68.1%), followed by the Verbal Descriptor Scale (23.7%). Asian patients and patients with LEP were less likely to have their pain documented numerically. In multivariable logistic regression, patients with LEP (OR 0.61, 95% CI 0.58-0.65) and Asian patients (OR 0.74, 95% CI 0.70-0.78) had the lowest odds of numeric ratings. Latino, Multi-Racial, and patients classified as Other also had lower odds than white patients of numeric ratings. Asian patients and patients with LEP received the fewest daily opioids across all pain assessment categories.

CONCLUSIONS

Asian patients and patients with LEP were less likely than other patient groups to have a numeric pain assessment and received the fewest opioids. These inequities may serve as the basis for the development of equitable pain assessment protocols.

Critical care nurses' perceived barriers and enablers of pain assessment and management

Aim: To examine critical care nurses' perceived barriers and enablers of pain assessment and management. Materials/methods: This descriptive correlational study recruited a convenience sample of 200 Jordanian nurses. Pain Assessment and Management for the Critically Ill questionnaire was used to measure the study variables. Results: The most common barriers to pain assessment and management were patient inability to communicate (57.5%), patient instability (56.5%), and the lack of protocols/guidelines for pain assessment (55.0%). Whereas the most common enablers for effective pain management practices were the ongoing education on pain for nurses (60.5%) and physicians who prescribe adequate doses of analgesia (60.0%). Conclusion: Addressing nurses' perceived barriers and the enablers of pain assessment and management is crucial for optimal pain practice.

Nurses' Perceived Barriers to and Facilitators of Pain Assessment and Management in Critical Care Patients: A Systematic Review

Aim

This review aims to examine nurses’ perceived barriers to and facilitators of pain assessment and management in adult critical care patients.

Background

Pain is one of the worst memories among critically ill patients. However, pain among those patients is still undertreated due to several barriers that impede effective management. Therefore, addressing the perceived barriers and facilitators to pain assessment management among critical care nurses is crucial.

Methods

A systematic search of pain assessment and management in critical care patient-relevant literature from four databases was done, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

The barriers and facilitators were categorized into four groups: nurse-related, patient-related, physician-related, and system-related. The most frequently reported barriers in this study included nurses’ lack of knowledge regarding the use of pain assessment tools, patients’ inability to communicate, physicians’ prescription of analgesics being independent of pain scores evaluation, and absence of standardized guidelines and protocols for pain evaluation and control. For the facilitators, the most reported ones include ongoing education and professional training related to pain assessment and management, patients’ ability to self-report pain, effective collaboration between physicians and nurses, and productive discussion of patients’ pain scores during nurse-to-nurse handovers.

Conclusion

Various barriers and facilitators to pain assessment and management were identified and examined in this review. However, future research is still needed to further investigate these barriers and facilitators and examine any other potential associated factors among critical care nurses.

Relevance to Clinical Practice

The findings of our study could help hospital managers in developing continuous education and staff development training programs on assessing and managing pain for critical care patients. Also, our findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat pain in critical care patients.

Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight

AIMS

This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented.

DESIGN

Focused ethnography.

METHODS

Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts.

RESULTS

The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person.

CONCLUSION

This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.

Procedural Pain in Hospitalized Children in a Chinese Children's Hospital

BACKGROUND

Pain prevalence in pediatric hospitals has been investigated in many developed countries, but little is known about this topic in China.

AIMS

This study sought to describe the frequency and pain intensity of procedures for medical care in hospitalized children in a Chinese children's hospital.

DESIGN

A cross-sectional study was designed to include interviews with children, their parents and the nurses.

SETTINGS

This survey was administered in a teaching hospital in southeast China.

PARTICIPANTS/SUBJECTS

Infants and children up to 16 years old who were admitted to the study units for more than 6 days were eligible for inclusion.

METHODS

Information regarding patient demographics, painful procedures and pain management strategies was obtained during the day shifts of the children's hospitalization.

RESULTS

A total of 3886 procedures were performed on 342 children during the data collection period. The reuse of intravenous indwelling needles ( n = 577), removal of tape from the skin (n = 420) and venipuncture on the back of the hand ( n = 401) were the most frequently performed procedures on children. A total of 1941 procedures, accounting for 49.9% (1941/3886) of painful procedures caused moderate to severe pain (pain score ≥4.0). However, only 25.3% (984/3886) received a valid pain assessment, and only 14.4% (560/3886) received pain interventions.

CONCLUSIONS

Most children, especially those who are younger (<4 years old), experienced moderate or severe pain during their hospitalization, but did not receive appropriate interventions.

Measuring sleep in the intensive care unit: Electroencephalogram, actigraphy, or questionnaire?

BACKGROUND

Studies consistently report deranged sleep in patients admitted to intensive care unit. Poor sleep has harmful physical and cognitive effects, and an evidence-based intervention to improve sleep is needed. It is, however, difficult to measure sleep in the intensive care unit. 'Gold standard' monitoring (polysomnography) is unsuitable for usual care.

METHODS

We collected concurrent sleep data from electroencephalograph recordings, activity monitoring, and nurse- and patient-completed Richards-Campbell Sleep Questionnaires (RCSQ).

RESULTS

Electroencephalograph data (n = 34) confirm poor sleep. Individual bouts last approximately 1 min and around 2 h of sleep overnight is common. Correlation between electroencephalograph, self-report, nurse-report, actigraphy and overall activity score is low (ρ = 0.123 (n = 24), 0.127 (n = 22), and 0.402 and - 0.201 (n = 13), respectively). Correlation between nurse and patient assessment is limited (ρ = 0.537 (n = 444)).

CONCLUSIONS

No current method of sleep monitoring seems suitable in the intensive care unit. However, to facilitate comparison across studies, the patient-completed RCSQ seems the most meaningful measure.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis

BACKGROUND

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients.

METHODS

Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence.

RESULTS

We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty.

CONCLUSIONS

The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Nurses' Assessment Practices of Pain Among Critically Ill Patients

BACKGROUND

Systematic pain assessment is necessary to ensure effective pain management. Despite the availability of recommendations, guidelines, and valid tools for pain assessment, the actual implementation in clinical practice is inconsistent.

AIMS

The purpose of this study was to investigate intensive care nurses' pain assessment practices among critically ill patients in Jordanian hospitals.

DESIGN

A descriptive cross sectional design was used in this study.

SETTINGS

This study was conducted in 22 intensive care unites located in eight hospitals in Jordan.

PARTICIPANTS/SUBJECTS

Convenience sampling was used to recruit a sample of 300 nurses working in intensive care units.

METHODS

The Pain Assessment and Management for the Critically Ill survey was used to collect data. Descriptive statistics, χ², and correlational analysis were used to analyze data.

RESULTS

A total of 89.7% of nurses (N = 300) used pain assessment tools with patients able to communicate, and the numeric rating scale was the most commonly used tool. A total of 81.7% of the nurses used a pain assessment tool with patients unable to communicate, and the Adult Nonverbal Pain Scale was the most commonly used tool. Nurses' perceived importance of pain assessment was positively associated with frequent use of pain assessment tools. Nurses perceived the use of pain assessment tools for patients able to communicate as being more important than the use of pain assessment tools for patients unable to communicate.

CONCLUSIONS

The majority of intensive care unit nurses used pain assessment tools for patients both able and unable to communicate; however, the most valid and reliable tools were not used often. Nurses were not aware of the pain behaviors most indicative of pain among critically ill patients.

Healthcare professionals' perceptions on the use of opioid analgesics for the treatment of cancer-related pain in Cyprus: A mixed-method study

OBJECTIVES

Pain is considered the most common and debilitating symptom reported by patients affected by cancer, and opioids are at the front line for its effective management. However, the appropriate use of opioids can be limited by healthcare professionals' perceptions on opioids. Therefore, the aim of this study was to explore their perceptions on the use of opioids medication.

METHODS

This was a study of sequential mixed-method design conducted in Cyprus. As part of the quantitative phase of the study, the Barriers to Opioid Analgesic Availability Test questionnaire was completed by 73 physicians randomly selected. In the qualitative phase, 28 healthcare professionals working in primary and secondary healthcare centers participated in two focus groups. They were asked to express their perceptions on the use of opioid analgesics for the treatment of cancer-related pain. Data were analyzed according to Colaizzis' seven-stage phenomenological analysis.

RESULTS

The quantitative analysis showed that 69.85% of physicians acknowledge opiophobia as a main barrier to appropriate pain relief but also explicitly for cancer pain which is not adequately managed (45.19%). In terms of opioids availability, physicians stated that moderate to severe problems in opioids availability were mainly caused by their reluctance to prescribe opioids (49.3%) followed by the laws/regulations in place (41.08%). The qualitative analysis yielded the following six main themes: inadequate training of healthcare professionals in the use of opioid analgesics, inadequate patient/caregivers' awareness of opioid analgesics, opiophobia in healthcare professionals, opiophobia of patients/caregivers, poor management of opioid analgesics by healthcare professionals and patients/caregivers, and ineffective pain relief with opioids.

CONCLUSIONS

The lack of appropriate education is a significant barrier to opioids use in Cyprus. This is compounded by the attitudes and phobias of both healthcare professionals and the general public. In addition, there are barriers to opioid availability and unsatisfactory cancer pain relief.