Educational needs of health care providers working in long-term care facilities with regard to pain management

Pain assessment and management in care homes: understanding the context through a scoping review

Background

Internationally, 2–5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management.

Methods

Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective.

Results

Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment – including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes.

Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia.

Conclusions

Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02333-4.

Effectiveness of Educating Health Care Professionals in Managing Chronic Pain Patients Through a Supervised Student Inter-professional Pain Clinic

OBJECTIVE

To address the need for increased and more effective medical education regarding chronic pain and pain management, an inter-professional (IP) training program in the form of a supervised student IP pain clinic was implemented in 2016. In the current study, we evaluated its feasibility and effectiveness in improving health care professional students' skills in (1) managing chronic pain and (2) working in an IP team.

METHODS

From January 2016 to December 2018, we assembled 12 IP teams that included students from the following six professions at the University of New England: nursing, osteopathic medicine (OM), occupational therapy (OT), pharmacy, physical therapy (PT), and social work (SW). During this 12-week training program, each team conducted the initial evaluation, generated treatment plans, and performed follow-up examinations for its assigned patient under the supervision of a pain specialist at the Mercy Pain Center. Surveys were conducted with all participating students and patients.

RESULTS

Overall, students showed significant improvement in knowledge regarding pain physiology and chronic pain management as well as attitude and perception regarding IP practice and perceived team skills. Specifically, prior to the program, nursing students showed the greatest pain-related knowledge and perceived team skills, while OT students scored the highest in attitude and perception regarding IP practice. Following the program, improvement in various measures was observed in all professions with PT students showing the most significant improvement in all areas. Surveys also indicated patients' satisfaction with their IP pain clinic experience.

CONCLUSIONS

These results demonstrated the feasibility and the effectiveness of this IP training program for all participating professions.

The objectivity and subjectivity of pain practices in older adults with dementia: A critical reflection

Providing nursing care for people with dementia residing in long-term care facilities poses specific challenges regarding pain practices. With underlying communication barriers unique to dementia pathologies, this population is often unable to communicate verbal sentiments and descriptions of pain. In turn, nurses caring for older persons with dementia have difficulty assessing, managing and treating pain. Objectivity is an imperative factor in healthcare pain practices; however, it is difficult to objectively evaluate someone who cannot accurately communicate their experience of pain. Therefore, the authors believe that subjectivity is also an essential part of evaluating the person with dementia's experience of pain. In this critical reflection, the authors explore objectivity and subjectivity in relation to pain practices for dementia in long-term care. A historical summary of pain is provided outlining the evolution of objectivity and subjectivity related to pain practices. The authors discuss the complexities of assessing and managing pain and offer a new perspective about the role of objectivity (and co-existence of subjectivity) for nurses treating pain in the older adults with dementia.

Experiencing improved assessment and control of pain in end-of-life care when using the Abbey Pain Scale systematically

Aim

To describe staff's reflections on aspects influencing pain assessment at end-of-life (EoL) care in nursing homes before and after the implementation of the Abbey Pain Scale (APS).

Background

People with cognitive impairment in the EoL care often suffer from underdiagnosed and undertreated pain due to the lack of knowledge and guidelines for systematic pain assessment.

Methods

Semi-structured focus group interviews were conducted and analysed using qualitative content analysis.

Results

The staff described their experiences before the implementation of APS as striving to achieve control of pain by trusting in themselves and the team, while the experiences after the implementation of APS were described as improving symptom control with remaining weak confidence in the team.

Conclusions

Implementation of APS was experienced as improving systematic pain assessment. Efforts to establish clear routines and improve confidence in the care team would be prioritized to optimize pain assessment and pain relief in EoL care.

Exploring the educational needs of nurses on children's pain management: A descriptive qualitative study

Aim

To explore the educational needs of nurses on children's pain management.

Design

A descriptive qualitative study.

Methods

Individual and group interviews were conducted among 28 nurses and four nurse managers at four hospitals in the Ashanti region of Ghana. The recorded interviews were later transcribed verbatim and thematically analysed based on a conceptual interest in the educational needs on paediatric pain management.

Results

Nurses were acquainted with pain assessment of children who can verbally communicate. They mainly used drugs in treating pain and were familiar with the use of some non-pharmacological interventions. Notwithstanding, they desired to know more about pain assessment for children with non-functional speech. Additionally, they were interested in learning more about both drug and nondrug pain relief methods for children. The sampled nurses and nurse managers indicated diverse preferences on the nature of the paediatric pain educational programme based on their personal choices and working dynamics.

Developing a Training for Certified Nursing Assistants to Recognize, Communicate, and Document Discomfort in Residents With Dementia

Nursing home residents with advanced dementia experience significant symptom burden and may be unable to articulate their needs. Observational tools, such as the Pain Assessment in Advanced Dementia (PAINAD) scale, are available to evaluate changes in behavior that may signify discomfort or pain. Studies proposing a short and effective curriculum, primarily for certified nursing assistants (CNAs) on how to use and incorporate the PAINAD in daily patient care, are scarce. This performance improvement project involves the design and implementation of a training curriculum for CNAs for using the PAINAD and discusses barriers to be considered for further projects. Certified nursing assistant perceptions of their experience with the training and the use of the tool were also assessed with a brief evaluation. Seventy-three initial PAINAD forms were completed along with 52 follow-up PAINAD forms. A paired t test (N = 52) showed a significant decrease in the PAINAD scores from initial (mean, 6.06) to follow-up (mean, 1.85) (P < .001), suggesting a reduction of patient discomfort. The process of collecting and examining these data was meant to reinforce the identification and reduction of behavioral distress through the application of this tool. The training was perceived as effective and the tool as easy to use, indicating it can be incorporated into daily care responsibilities of CNAs.

A meta-ethnography of health-care professionals’ experience of treating adults with chronic non-malignant pain to improve the experience and quality of health care

Background

People with chronic pain do not always feel that they are being listened to or valued by health-care professionals (HCPs). We aimed to understand and improve this experience by finding out what HCPs feel about providing health care to people with chronic non-malignant pain. We did this by bringing together the published qualitative research.

Objectives

(1) To undertake a qualitative evidence synthesis (QES) to increase our understanding of what it is like for HCPs to provide health care to people with chronic non-malignant pain; (2) to make our findings easily available and accessible through a short film; and (3) to contribute to the development of methods for QESs.

Design

We used the methods of meta-ethnography, which involve identifying concepts and progressively abstracting these concepts into a line of argument.

Data sources

We searched five electronic bibliographic databases (MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Allied and Complementary Medicine Database) from inception to November 2016. We included studies that explored HCPs’ experiences of providing health care to people with chronic non-malignant pain. We utilised the Grading of Recommendations Assessment, Development and Evaluation Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) framework to rate our confidence in the findings.

Results

We screened 954 abstracts and 184 full texts and included 77 studies reporting the experiences of > 1551 HCPs. We identified six themes: (1) a sceptical cultural lens and the siren song of diagnosis; (2) navigating juxtaposed models of medicine; (3) navigating the patient–clinician borderland; (4) the challenge of dual advocacy; (5) personal costs; and (6) the craft of pain management. We produced a short film, ‘Struggling to support people to live a valued life with chronic pain’, which presents these themes (seeReport Supplementary Material 1; URL:www.journalslibrary.nihr.ac.uk/programmes/hsdr/1419807/#/documentation; accessed 24 July 2017). We rated our confidence in the review findings using the GRADE-CERQual domains. We developed a conceptual model to explain the complexity of providing health care to people with chronic non-malignant pain. The innovation of this model is to propose a series of tensions that are integral to the experience: a dualistic biomedical model compared with an embodied psychosocial model; professional distance compared with proximity; professional expertise compared with patient empowerment; the need to make concessions to maintain therapeutic relationships compared with the need for evidence-based utility; and patient advocacy compared with health-care system advocacy.

Limitations

There are no agreed methods for determining confidence in QESs.

Conclusions

We highlight areas that help us to understand why the experience of health care can be difficult for patients and HCPs. Importantly, HCPs can find it challenging if they are unable to find a diagnosis and at times this can make them feel sceptical. The findings suggest that HCPs find it difficult to balance their dual role of maintaining a good relationship with the patient and representing the health-care system. The ability to support patients to live a valued life with pain is described as a craft learnt through experience. Finally, like their patients, HCPs can experience a sense of loss because they cannot solve the problem of pain.

Future work

Future work to explore the usefulness of the conceptual model and film in clinical education would add value to this study. There is limited primary research that explores HCPs’ experiences with chronic non-malignant pain in diverse ethnic groups, in gender-specific contexts and in older people living in the community.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Meta-ethnography to understand healthcare professionals' experience of treating adults with chronic non-malignant pain

OBJECTIVES

We aimed to explore healthcare professionals' experience of treating chronic non-malignant pain by conducting a qualitative evidence synthesis. Understanding this experience from the perspective of healthcare professionals will contribute to improvements in the provision of care.

DESIGN

Qualitative evidence synthesis using meta-ethnography. We searched five electronic bibliographic databases from inception to November 2016. We included studies that explore healthcare professionals' experience of treating adults with chronic non-malignant pain. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We screened the 954 abstracts and 184 full texts and included 77 published studies reporting the experiences of over 1551 international healthcare professionals including doctors, nurses and other health professionals. We abstracted six themes: (1) a sceptical cultural lens, (2) navigating juxtaposed models of medicine, (3) navigating the geography between patient and clinician, (4) challenge of dual advocacy, (5) personal costs and (6) the craft of pain management. We rated confidence in review findings as moderate to high.

CONCLUSIONS

This is the first qualitative evidence synthesis of healthcare professionals' experiences of treating people with chronic non-malignant pain. We have presented a model that we developed to help healthcare professionals to understand, think about and modify their experiences of treating patients with chronic pain. Our findings highlight scepticism about chronic pain that might explain why patients feel they are not believed. Findings also indicate a dualism in the biopsychosocial model and the complexity of navigating therapeutic relationships. Our model may be transferable to other patient groups or situations.

Advancing the pain management in older adults agenda forward through the development of key research and education priorities: A Canadian perspective

Background: The undermanagement of pain in older adults has been identified as a problem worldwide. Aims: The purpose of this research is to identify priority areas in education and research for future development with the aim of improving pain management in older persons. In addition, barriers to addressing these priorities are identified. Methods: This mixed methods study, based on a modified Delphi approach, included three distinct components: (1) a qualitative component using focus groups with key informants or experts in the field of pain management in older adults (n = 17), (2) a scoping review of the literature, and (3) a survey of ranked responses completed by the same key informants who attended the focus groups. Thematic analysis was used to identify the initial list of issues and descriptive statistics were used for ranking them. Results: A number of concerns related to both education and research were frequently endorsed by participants. For education, they identified the need for more content in both undergraduate and continuing education programs related to documenting about pain; assessing pain, and learning about the complexities of pain. Research priorities included the need to explore successful practice models; costs of untreated pain; effects of mobility on pain; and patient preferences for pain management. Key barriers to addressing these barriers included lack of staff time and resources and unfamiliarity with pain assessment tools. Conclusion: These findings highlight priority issues related to pain management in older adults from a nationwide perspective.

'There's a Catch-22' - The complexities of pain management for people with advanced dementia nearing the end of life: A qualitative exploration of physicians' perspectives

BACKGROUND

Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown.

AIM

To explore physicians' experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges.

DESIGN

Qualitative, semi-structured interview study exploring barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes.

SETTING/PARTICIPANTS

A total of 23 physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care ( n = 9), psychiatry ( n = 7) and hospice care ( n = 7).

RESULTS

Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialities. Cross-speciality mentoring and the creation of knowledge networks were believed to improve pain management in this patient population.

CONCLUSION

Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients' families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

Assessing the need for arthritis training among paid carers in UK residential care homes: A focus group and interview study

OBJECTIVE

The aim of the study was to perform an educational and training needs assessment for arthritis care in residential homes.

METHODS

Qualitative data were collected from three purposively selected residential homes: one independent, one in a regional chain and one in a national chain. Three researcher-led focus groups were conducted with paid carers (N = 22) using vignette exercises; interviews were undertaken with 12 residents with joint pain (N = 12), five managerial staff and two general practitioners (GPs). Data were compared and analysed thematically around care practices, communication and training.

RESULTS

There is a lack of arthritis awareness among paid carers, although they regularly identify and manage arthritic symptoms. Residents rely on paid carers to recognize when pain and mobility problems are treatable. Senior staff and GPs rely on carers to identify arthritic problems. However, paid carers themselves undervalued the health significance of their activities and lacked the confidence to communicate important information to healthcare professionals. Few of the paid carers had received training in arthritis and many expressed a strong desire to learn about it, to improve their ability to provide better care.

CONCLUSIONS

Education for paid carers regarding arthritis is lacking and lags behind education about conditions such as dementia and diabetes. To meet the expectations of their care roles fully, paid carers require an awareness of what arthritis is and how to recognize symptoms. We suggest that training should be aimed at improving confidence in communicating with colleagues, residents and health professionals, with senior care staff receiving more in-depth training.

Knowledge, Perceptions and Attitudes toward Chronic Pain and Its Management: A Cross-Sectional Survey of Frontline Pharmacists in Ontario, Canada

The treatment of chronic pain consumes a significant share of primary care. Community and family health team pharmacists frequently see patients with chronic pain, thus have the opportunity to improve their care. To assess the knowledge, perceptions, and attitudes of Ontario pharmacists, we invited 5,324 Ontario pharmacists, to participate in an online survey we developed using Qualtrics. The 31-question survey gathered demographic information, assessed pharmacists' knowledge of three chronic pain conditions; chronic lower back pain (CLBP, eight true/false statements); chronic headache disorder (CHD, eight true/false statements) and painful diabetic neuropathy (PDN, seven true/false statements), and their attitudes toward and perceptions of patients with these conditions, and knowledge, attitudes, and perceptions of opioids in pain management. We received 688 responses (12.9%) and 392 pharmacists completed the survey. The mean age of respondents was 48.5 years and 48.5% were male. More than 50% of respondents were in practice for more than 20 years and 58.7% worked 25-40 hours per week. The mean knowledge scores were 4.5/8, 5.5/8, and 5.3/8 for CBLP, CHD, and PDN respectively. While 95% of respondents were aware of the increasing death rates due to opioid use, only half were familiar with the Canadian guideline for safe opioid prescribing for non-cancer use. Responses were compared based on gender, time in practice and location of practice. Pharmacists with more than ten years of experience scored significantly higher than those with less experience. Fewer differences were found in comparisons of gender and location of practice. Safe and effective care of chronic pain patients, particularly with opioids, will require additional pharmacist education.

Comparison of pain neurophysiology knowledge among health sciences students: a cross-sectional study

Background

A key tool for use in approaching chronic pain treatment is educating patients to reconceptualize pain. Thus, health professionals are fundamental to the transmission of pain information to patients. Because their understanding of pain is acquired during the educational process, the aim of this study was to compare the knowledge about pain neurophysiology in first and final-year students from three different health science programs at a single University to determine their gain in knowledge using a well-known questionnaire designed to evaluate the understanding of pain.

Methods

The Neurophysiology of Pain Questionnaire (19 closed-ended questions) was administered to students in their first and final years of study in Medicine, Physiotherapy, or Nutrition. The percentage of correct responses was determined and comparisons of the results were analyzed between the programs as well as between the first and final years of study within each program. For all tests, p-values were two-sided, and results with p-values below 0.05 were considered statistically significant.

Results

The participation rate was greater than 51 % (n = 285). The mean percentage of correct responses, reported as mean (SD), among the first year students was 42.14 (12.23), without significant statistical differences detected between the programs. The mean percentages of correct responses for students in their final year were as follows: Medicine, 54.38 (13.87); Physiotherapy, 68.92 (16.22); Nutrition, 42.34 (10.11). We found statistically significant differences among all three programs and between the first and final years in Medicine and Physiotherapy. A question-by-question analysis showed that the percentage of correct responses for questions related to the biopsychosocial aspects of pain was higher for students in Physiotherapy than those in Medicine.

Conclusions

Students in their final years of Medicine and Physiotherapy programs know more about the neurophysiology of pain than students in their first years of these programs, however there are some questions where first years students have better results. Physiotherapy students have greater knowledge of neurophysiology of pain than Medicine students, especially the biopsychosocial aspects. Even so, their understanding may not be sufficient and does not guarantee an approach to chronic pain that will help patients reconceptualize their pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1585-y) contains supplementary material, which is available to authorized users.

Pain intensity among institutionalized elderly: a comparison between numerical scales and verbal descriptors

AbstractOBJECTIVECorrelating two unidimensional scales for measurement of self-reported pain intensity for elderly and identifying a preference for one of the scales.METHODA study conducted with 101 elderly people living in Nursing Home who reported any pain and reached ( 13 the scores on the Mini-Mental State Examination. A Numeric Rating Scale - (NRS) of 11 points and a Verbal Descriptor Scale (VDS) of five points were compared in three evaluations: overall, at rest and during movement.RESULTSWomen were more representative (61.4%) and the average age was 77.0±9.1 years. NRS was completed by 94.8% of the elderly while VDS by 100%. The association between the mean scores of NRS with the categories of VDS was significant, indicating convergent validity and a similar metric between the scales.CONCLUSIONPain measurements among institutionalized elderly can be made by NRS and VDS; however, the preferred scale for the elderly was the VDS, regardless of gender.

Pain management in patients with dementia

There are an estimated 35 million people with dementia across the world, of whom 50% experience regular pain. Despite this, current assessment and treatment of pain in this patient group are inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioral symptoms, which can lead to inappropriate treatment with antipsychotic medications. Pain also contributes to further complications in treatment and care. This review explores four key perspectives of pain management in dementia and makes recommendations for practice and research. The first perspective discussed is the considerable uncertainty within the literature on the impact of dementia neuropathology on pain perception and processing in Alzheimer's disease and other dementias, where white matter lesions and brain atrophy appear to influence the neurobiology of pain. The second perspective considers the assessment of pain in dementia. This is challenging, particularly because of the limited capacity of self-report by these individuals, which means that assessment relies in large part on observational methods. A number of tools are available but the psychometric quality and clinical utility of these are uncertain. The evidence for efficient treatment (the third perspective) with analgesics is also limited, with few statistically well-powered trials. The most promising evidence supports the use of stepped treatment approaches, and indicates the benefit of pain and behavioral interventions on both these important symptoms. The fourth perspective debates further difficulties in pain management due to the lack of sufficient training and education for health care professionals at all levels, where evidence-based guidance is urgently needed. To address the current inadequate management of pain in dementia, a comprehensive approach is needed. This would include an accurate, validated assessment tool that is sensitive to different types of pain and therapeutic effects, supported by better training and support for care staff across all settings.