Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies

BACKGROUND

We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings.

METHODS

A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom.

RESULTS

Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management.

CONCLUSION

Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain

Background

The alleviation of pain is a key aim of health care yet pain can often remain a puzzle as it is not always explained by a specific pathology. Musculoskeletal (MSK) pain is one of the most predominant kinds of chronic pain and its prevalence is increasing. One of the aims of qualitative research in health care is to understand the experience of illness, and make sense of the complex processes involved. However, the proliferation of qualitative studies can make it difficult to use this knowledge. There has been no attempt to systematically review and integrate the findings of qualitative research in order to increase our understanding of chronic MSK pain. A synthesis of qualitative research would help us to understand what it is like to have chronic MSK pain. Specifically, it would help us understand peoples' experience of health care with the aim of improving it.

Aim

The aim of this study was to increase our understanding of patients’ experience of chronic non-malignant MSK pain; utilise existing research knowledge to improve understanding and, thus, best practice in patient care; and contribute to the development of methods for qualitative research synthesis.

Methods

We used the methods of meta-ethnography, which aim to develop concepts that help us to understand a particular experience, by synthesising research findings. We searched six electronic bibliographic databases (including MEDLINE, EMBASE and PsycINFO) and included studies up until the final search in February 2012. We also hand-searched particular journals known to report qualitative studies and searched reference lists of all relevant qualitative studies for further potential studies. We appraised each study to decide whether or not to include it. The full texts of 321 potentially relevant studies were screened, of which 77 qualitative studies that explored adults’ experience of chronic non-malignant MSK pain were included. Twenty-eight of these studies explored the experience of fibromyalgia.

Results

Our findings revealed the new concept of an adversarial struggle that explains the experience of people with chronic MSK pain. This included the struggle to affirm self and construct self over time; find an explanation for pain; negotiate the health-care system while feeling compelled to stay in it; be valued and believed; and find the right balance between sick/well and hiding/showing pain. In spite of this struggle, our model showed that some people were able to move forward alongside their pain by listening to their body rather than fighting it; letting go of the old self and finding a new self; becoming part of a community and not feeling like the only one; telling others about pain and redefining relationships; realising that pain is here to stay rather than focusing on diagnosis and cure; and becoming the expert and making choices. We offer unique methodological innovations for meta-ethnography, which allowed us to develop a conceptual model that is grounded in 77 original studies. In particular, we describe a collaborative approach to interpreting the primary studies.

Conclusion

Our model helps us to understand the experience of people with chronic MSK pain as a constant adversarial struggle. This may distinguish it from other types of pain. This study opens up possibilities for therapies that aim to help a person to move forward alongside pain. Our findings call on us to challenge some of the cultural notions about illness, in particular the expectation of achieving a diagnosis and cure. Cultural expectations are deep-rooted and can deeply affect the experience of pain. We therefore should incorporate cultural categories into our understanding of pain. Not feeling believed can have an impact on a person’s participation in everyday life. The qualitative studies in this meta-ethnography revealed that people with chronic MSK pain still do not feel believed. This has clear implications for clinical practice. Our model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed by pain. Listening to a person’s narratives can help us to understand the impact of pain. Our model suggests that feeling valued is not simply an adjunct to the therapy, but central to it. Further conceptual syntheses would help us make qualitative research accessible to a wider relevant audience. Further primary qualitative research focusing on reconciling acceptance with moving forward with pain might help us to further understand the experience of pain. Our study highlights the need for research to explore educational strategies aimed at improving patients’ and clinicians’ experience of care.

Funding

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

A comparison of CAL with a conventional method of delivery of cell biology to undergraduate nursing students using an experimental design

This paper describes the development and evaluation of a series of computer assisted learning (CAL) packages on cell biology produced for an undergraduate nursing course. The CAL packages were based on the material originally delivered in Kindermann's slide practical classes. The decision to convert this teaching material into CAL packages was taken for a number of reasons, but mainly in response to student evaluations and lack of equipment and staff resources needed to adequately deliver the sessions. Student feedback showed that CAL was preferred to the slide classes. Two studies were carried out to compare the CAL method of delivery with the conventional method using an experimental design. Students taught using CAL felt more confident that they would be able to use the material they had learnt if required as a basis for future work. The distributions rating 'how necessary was the contribution of a teacher in the session' were skewed towards the 'essential' end of the scale for the slide group but towards the 'unnecessary' end for the CAL group. Learning effectiveness was not compromised by the introduction of CAL, even though this meant that no lecturer was on hand to deal with questions.

Student nurses' experiences of caring for patients in pain

Poor pain assessment contributes to inadequate pain relief. Studies in the United States have shown that while student nurses become more sensitive to psychological distress during training, they become less sensitive to pain. However, a recent study by the authors in the United Kingdom found that while inferences of psychological distress increased there was no change in inferences of pain over the common foundation programme. This study set out to explore their experiences of caring for patients in pain during the first 18 months of their training in order to understand how these experiences might affect their sensitivity to patient's pain. Interviews with 15 students following their common foundation programme showed that they experienced a wide range of strong emotions when caring for patients in pain. Their relatively junior status in the wards seemed to place them in difficult positions and provided them with little support. Theories of desensitisation, cognitive dissonance and acculturation have been proposed to explain decreasing sensitivity to pain. The lack of a significant change in students' inferences of pain and the analysis of their interviews suggest that their experiences are more varied than these theories suggest. The students experiences echo those found in previous studies relating to the socialisation of student nurses and emotional labour (Melia, 1987. Learning and Working. The Occupational Socialization Nurses. Tavistock Publishers, London; Smith, 1992. The Emotional Labour of Nursing. Macmillan, London). These findings have important implications for both nurse education and the mechanisms to support student nurses in clinical practice.

Physiological rationale for early pain management

An understanding of spinal cord functioning will increase awareness of the effect of painful sensations on the workings of the central nervous system. Dorsal horn hypersensitivity can result in central sensitisation. Early and effective pain management is required to avoid the development of both acute and chronic pain.

The effect of student nurses' experiences over the Common Foundation Programme on their inferences of suffering

Poor pain assessment contributes to inadequate postoperative pain relief. Studies in the U.S.A. suggest that nurse education might make students less sensitive to patients' experience of pain. This research examined this process and the factors that influence it in the U.K. Two-hundred and seventeen students completed the Standard Measure of Inferences of Suffering Questionnaire (SMIS) before and after their Common Foundation Programme (CFP). Their inferences of psychological distress increased as studies in the U.S.A. had found but, unlike these studies, no change was found in their inferences of pain. These findings have important implications for both nurse education and the mechanisms to support student nurses in clinical practice.

Factors affecting the assessment of postoperative pain: a literature review

The report of the Royal College of Surgeons and College of Anaesthetists has stimulated much interest in the relief of pain following surgery. Despite the development of new techniques such as patient controlled analgesia, pre-emptive analgesia and complementary techniques that have helped to improve the situation, the role of pain assessment remains central. This literature review discusses the standard of nurses' assessment and looks at the factors suggested to influence nurses' assessment of pain.

The theory/practice "gap': taking issue with the issue

Theory/practice issues have a long-standing history in nurse education, and are a chronic source of controversy to which there is no easy or perfect solution. We have argued that it is the tension between theory and practice and research which can be usefully exploited in teaching and research. Students need to be introduced to the debates surrounding the genesis and generation of nursing knowledge. They need to gain an appreciation of what counts as nursing knowledge at different points in time and the politics which drive the legitimation of nursing theory and practice. Such an approach has much to offer in helping students deal with reality shock and make sense of their experience as they confront the ambiguities, uncertainties and contradictions that characterize the stock-in-trade of professional life.

The use of different research methodologies to evaluate the effectiveness of programmes to improve the care of patients in postoperative pain

Much research has supported the conclusion of the report from The Royal College of Surgeons and College of Anaesthetists (1990), London, England, that the relief of postoperative pain is in many cases unsatisfactory and calls for more research on the effectiveness of educational programmes. A prime aim of nursing research is to influence and to improve practice. In relation to postoperative pain Sofaer's (1985) study was an example of the use of a quasi-experimental approach to improve postoperative pain relief through nurse education. Sofaer suggests that although positive effects were demonstrated they may not have been sustained in the long term. Further, Sofaer suggests that action research may have produced a more sustainable change. This paper critically discusses the use of these two research methods in relation to this problem.

The use of posters in the teaching of biological sciences on an undergraduate nursing course

Posters are commonly used at research conferences for communicating information and in education as an alternative way of teaching and assessing students. We report the use of posters as a means of teaching and assessing part of the biological sciences component of an undergraduate nursing course. Tutors felt it was a valuable exercise enabling students to develop a number of skills, alongside the learning and revision of knowledge, including working as a team, condensing information and word and graphic processing. Students evaluated the exercise as being challenging but rewarding and preferred to be assessed by this method than by oral presentations or examinations. Lecturers and guided study/tutorials were preferred to posters as teaching methods.

A survey of the teaching and learning of biological sciences on undergraduate nursing courses

Curriculum planners developing degree courses in nursing have to decide how much time to allocate to each of the academic disciplines including biological sciences. There is no research-based evidence to suggest what depth and detail of knowledge of biological sciences is required to support nursing practice. There is also some debate about the teaching methods used and who should teach the biological sciences. This paper reports the results of a small survey investigating the teaching of biological sciences on 16 nursing degree courses in the UK. The survey uncovered great variation in the number of hours spent on biological sciences in the different universities and in the science entry requirements of the different universities. Most teachers of biological sciences had a first degree in the subject but few were nurses. The possible implications of these findings are discussed. Problems associated with shared learning and didactic teaching methods are also highlighted. Although the biological sciences input will largely be a matter of institutional preferences, nursing needs to develop a research-based framework to aid curriculum planning.

Interpretation of pressure-sore prevalence

Pressure sores result in patient morbidity and mortality as well as commanding considerable resources within the British National Health Service. To assess the impact of preventive measures, accurate and reliable rates of prevalence and incidence are required. This information is likely to be used as a measure of quality of care as well being included in future purchaser/provider contracting. A number of prevalence studies have been carried out in the United Kingdom using a variety of populations and different methods. The methods employed in these studies need to be considered before any meaningful comparisons can be drawn. In particular, there are variations in the reported rates possibly related to the under-reporting of pressure sore prevalence. This paper describes a recent point prevalence study which suggested that this may be the case. The need for caution when comparing crude rates is highlighted and the importance of standardizing the methods used for determining prevalence rates is discussed.

Bachelor of nursing students' experiences of learning biological sciences alongside medical students

One of the features of the Bachelor of Nursing (BN) course at Nottingham University is that the students study some biological sciences alongside their medical counterparts. Formative evaluation of the processes of teaching and learning, with a view to monitoring and improving the process of education taking place, is an integral part of the BN curriculum. The findings obtained to date suggest that, whilst the students value some aspects of learning biological sciences with medical students, they are anxious about the effectiveness of the teaching methods being employed; the difficulty of what they are learning and the depth and level of knowledge required in order to deliver safe competent nursing care. They are also concerned about the medical bias of the content that they are being taught and its relevance for them as nurses. This paper will set the biological sciences component of the course in context within both the BN and the medical curriculum. The methods being used to evaluate the teaching and learning processes and the results of these evaluations will be discussed and the implications of the students' experiences will be explored.