An evidence-based program to improve analgesic practice and pain outcomes in residential aged care facilities

Pain is common in individuals living in residential aged care facilities (RACFs), and a number of obstacles have been identified as recurring barriers to adequate pain management. To address this, the Australian Pain Society developed 27 recommendations for comprehensive good practice in the identification, assessment, and management of pain. This study reviewed preexisting pain management practice at five Australian RACFs and identified changes needed to implement the recommendations and then implemented an evidence-based program that aimed to facilitate better pain management. The program involved staff training and education and revised in-house pain-management procedures. Reviews occurred before and after the program and included the assessment of 282 residents for analgesic use and pain status. Analgesic use improved after the program (P<.001), with a decrease in residents receiving no analgesics (from 15% to 6%) and an increase in residents receiving around-the-clock plus as-needed analgesics (from 24% to 43%). There were improvements in pain relief for residents with scores indicative of pain, with Abbey pain scale (P=.005), Pain Assessment in Advanced Dementia Scale (P=.001), and Non-communicative Patient's Pain Assessment Instrument scale (P<.001) scores all improving. Although physical function declined as expected, Medical Outcomes Study 36-item Short-Form Survey bodily pain scores also showed improvement (P=.001). Better evidence-based practice and outcomes in RACFs can be achieved with appropriate training and education. Investing resources in the aged care workforce using this program improved analgesic practice and pain relief in participating sites. Further attention to the continued targeted pain management training of aged care staff is likely to improve pain-focused care for residents.

A qualitative analysis of how parents assess acute pain in young children

An accurate and comprehensive pain assessment is crucial for adequate pain management in pre- and early verbal children during painful medical procedures. This study used an inductive approach to explore the processes involved in parental pain assessment and to develop a new model of Parental Assessment of Acute Child Pain. Participants were 19 parents of children aged under 3 years who had previously or were potentially about to experience an intravenous cannula or nasogastric tube insertion. Parental affect regulation, while witnessing their child in acute pain/distress, appeared to be critical to the processes involved in assessing their child’s pain.

Supporting staff to identify residents in pain: A controlled pretest-posttest study in residential aged care

Practical strategies are needed to improve pain awareness among aged care staff and promote a systematic approach to pain identification using evidence-based tools. The purpose of this study was to evaluate a pain identification tool for use by nursing and non-professional staff in residential aged care facilities (RACFs). A controlled pretest-posttest intervention design was conducted in two RACFs in Brisbane, Australia. Completed surveys were returned by 216 staff and 74 residents at baseline and 218 staff and 94 residents at 3-month follow-up. Chart audits were conducted on 308 residents at baseline and 328 at follow-up. Groups were compared on: (1) staff knowledge and attitudes regarding pain, perceived confidence and skills for pain assessment, and perceived quality of pain management, (2) frequency of pain assessments and use of pain interventions, and (3) residents’ perceptions of the quality of pain management. Both groups had high knowledge scores and reported high levels of confidence, skills and perceived quality of pain management at baseline and follow-up. The intervention group showed significant improvement in routine pain assessment and use of non-drug pain interventions. However, due to unexpected changes in control group conditions, both groups increased episodic pain assessment. Overall, staff believed the intervention was clinically useful and fostered a team approach to pain assessment. We found the introduction of pain identification resources with implementation strategies to support frontline staff was partially effective in improving staff and resident outcomes. Nonetheless, our findings confirm the need for change and importance of translational pain research in RACFs.

Phantom limb pain: A nursing perspective

Phantom limb pain (PLP) is a neuropathic pain condition occurring after amputation of a limb. PLP affects amputees’ quality of life and results in loss of productivity and psychological distress. The origin of pain from a non-existing limb creates a challenging situation for both patients and nurses. It is imperative to provide patients and nurses with the knowledge that PLP is a real phenomenon that requires care and treatment. This knowledge will lead to reduced problems for patients by allowing them to talk about PLP and ask for help when needed. Understanding of this phenomenon will enable nurses to appreciate the unique features of this form of neuropathic pain and apply appropriate techniques to promote effective pain management. Performing accurate and frequent assessments to understand the unique characteristics of PLP, displaying a non-judgemental attitude towards patients and teaching throughout the peri-operative process are significant nursing interventions.

Investigating the effect of Eye Movement Desensitization and Reprocessing (EMDR) on postoperative pain intensity in adolescents undergoing surgery: A randomized controlled trial

Aim To investigate the efficacy of Eye Movement Desensitization and Reprocessing for postoperative pain management in adolescents. Background Eye Movement Desensitization and Reprocessing is an inexpensive, non-pharmacological intervention that has successfully been used to treat chronic pain. It holds promise in the treatment of acute, postsurgical pain based on its purported effects on the brain and nervous system. Design A randomized controlled trial was used. Methods Fifty-six adolescent surgical patients aged between 12-18 years were allocated to gender-balanced Eye Movement Desensitization and Reprocessing (treatment) or non-Eye Movement Desensitization and Reprocessing (control) groups. Pain was measured using the Wong-Baker FACES® Pain Rating Scale (WBFS) before and after the intervention (or non-intervention for the control group). Findings A Wilcoxon signed-rank test demonstrated that the Eye Movement Desensitization and Reprocessing group experienced a significant reduction in pain intensity after treatment intervention, whereas the control group did not. Additionally, a Mann–Whitney U-test showed that, while there was no significant difference between the two groups at time 1, there was a significant difference in pain intensity between the two groups at time 2, with the Eye Movement Desensitization and Reprocessing group experiencing lower levels of pain. Conclusion These results suggest that Eye Movement Desensitization and Reprocessing may be an effective treatment modality for postoperative pain.

The Evaluation of an Interdisciplinary Pain Protocol in Long Term Care

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents. Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data. Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group. Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group. Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities. Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews. Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol. Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.

Assessing pain in preterm infants in the neonatal intensive care unit:moving to a 'brain-oriented' approach

Preterm infants in the neonatal intensive care unit undergo repeated exposure to procedural and ongoing pain. Early and long-term changes in pain processing, stress-response systems and development may result from cumulative early pain exposure. So that appropriate treatment can be given, accurate assessment of pain is vital, but is also complex because these infants' responses may differ from those of full-term infants. A variety of uni- and multidimensional assessment tools are available; however, many have incomplete psychometric testing and may not incorporate developmentally important cues. Near-infrared spectroscopy and/or EEG techniques that measure neonatal pain responses at a cortical level offer new opportunities to validate neonatal pain assessment tools.

Positioning Clinical Nurse Specialists and Nurse Practitioners as Change Champions to Implement a Pain Protocol in Long-Term Care

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain: randomized controlled trial.

INTRODUCTION: In recent decades the treatment of non-specific low back pain has turned to active modalities, some of which were based on cognitive-behavioural principles. Non-randomised studies clearly favour functional multidisciplinary rehabilitation over outpatient physiotherapy. However, systematic reviews and meta-analysis provide contradictory evidence regarding the effects on return to work and functional status. The aim of the present randomised study was to compare long-term functional and work status after 3-week functional multidisciplinary rehabilitation or 18 supervised outpatient physiotherapy sessions. METHODS: 109 patients with non-specific low back pain were randomised to either a 3-week functional multidisciplinary rehabilitation programme, including physical and ergonomic training, psychological pain management, back school and information, or 18 sessions of active outpatient physiotherapy over 9 weeks. Primary outcomes were functional disability (Oswestry) and work status. Secondary outcomes were lifting capacity (Spinal Function Sort and PILE test), lumbar range-of-motion (modified-modified Schöber and fingertip-to-floor tests), trunk muscle endurance (Shirado and Biering-Sörensen tests) and aerobic capacity (modified Bruce test). RESULTS: Oswestry disability index was improved to a significantly greater extent after functional multidisciplinary rehabilitation compared to outpatient physiotherapy at follow-up of 9 weeks (P = 0.012), 9 months (P = 0.023) and 12 months (P = 0.011). Work status was significantly improved after functional multidisciplinary rehabilitation only (P = 0.012), resulting in a significant difference compared to outpatient physiotherapy at 12 months' follow-up (P = 0.012). Secondary outcome results were more contrasted. CONCLUSIONS: Functional multidisciplinary rehabilitation was better than outpatient physiotherapy in improving functional and work status. From an economic point of view, these results should be backed up by a cost-effectiveness study.

Knowledge and attitudes of Registered Nurses toward pain /

This research provided relevant data to support pain research literature that finds nurses do not have the knowledge base that they require to sufficiently provide effective pain management. The data demonstrated that nurses have mixed attitudes toward pain. These two findings have been observed in the literature for more than 20 years, but were important results for the hospitals and the nurses involved in the study. The purposes of this study were to identify the level of knowledge and attitudes in a sample of nurses fi-om the surgical and medical units in three hospitals, and determine whether a difference between these two groups existed. The institutional resources to support pain relief practices provided by each hospital were also documented. Data were collected using a convenience sample from the medical and surgical units of three hospitals. Ofthe 1 13 nurses who volunteered to participate, 78 worked in surgical units and 35 worked in medical units. Demographic data were collected about the participants. The established instruments used to obtain data about knowledge and attitude included: (a) Nurses Knowledge of Pain Issues Survey, (b)Attitude to Pain Control Scale, and (c) Andrew and Robert Vignette. Data collected were quantitative along with two open-ended questions for a rich, qualitative section. Inadequate knowledge and outdated attitudes were very evident in the responses. Data from the open-ended questions described how nurses assessed pain and the most conmion problems caring for patients in pain. Nursing practice implications for these hospitals involve initiating a process to develop an educational pain program for nurses throughout the hospital. Utilizing findings from other studies, the program should have an interdisciplinary approach to the planning, implementation, evaluation, and ongoing support. This study supports the belief that inadequate pain management has been attributed to many factors, most importantly to a lack of knowledge. Pain is a costly, unnecessary complication for the patient as well as the hospital. It follows then, that it is in the best interest of all involved to implement an educational pain program in order to influence practice.

But the Pain Remains: A Response to Verpaelst

Commentaire / Commentary

Designing a questionnaire to gather carer input to pain assessment for hospitalized people with dementia

We describe development of a questionnaire to elicit pain symptoms and experience, for use by people with dementia or their carers, at hospital admission. The questionnaire provided contextual information to support professionals’ use of the Abbey Pain Scale, a validated tool used by nursing staff internationally. Appropriate information and physical design were required in order, not only to create an approachable questionnaire for patients and carers, but also to ensure fit with hospital processes. Fit with hospital process had significant influence on the final form of the questionnaire, compromising some aspects of design for patients and carers, but this compromise was considered essential to ensure pain management procedures were supplemented by wider, contextual information.

The problem of postoperative pain: issues for future research

Uncontrolled postoperative pain continues despite abundant research in the area. The purposes of the paper are to review how past research influences our understanding of pain in the postsurgery context and to argue for a methodological shift towards naturalistic inquiry. Such a shift incorporates the complexities of pain assessment and management in the clinical practice environment. Decisions regarding pain are often examined outside of the contextual concerns of clinical practice. Research approaches have involved analyses of nurse and patient-related factors associated with pain. These approaches do not account for complex interactions that occur between nurses, patients and the dynamic environment in which these interactions take place. The failure of research to address the context of pain decisions has several implications. It limits our understanding of why pain continues despite ongoing research and it does not enable evaluation of clinical strategies to improve pain decision-making and pain outcomes for patients.

Patients' decision-making strategies for managing postoperative pain

Despite technological advances, many postoperative patients continue to suffer unrelieved pain. The aim of this study was to identify the strategies used by postoperative patients to bring about pain management decisions. A single-group noncomparative study design was chosen using observations as the means of examining pain activities in 2 surgical units of a metropolitan teaching hospital in Melbourne, Australia. A total of 52 nurses and 312 patients participated in the study, and 316 pain activities were observed. The most common strategy used was patients acting as a passive recipient for pain relief (60%), whereas problem solving (23%) and active negotiation (17%) were less commonly used. Patients in this study were admitted for surgical treatment of a particular condition, and their subsequent pain was specifically related to this acute event. Therefore, the lack of familiarity of the situation and the severity of pain experienced may have encouraged passivity. Patients may have also felt uncertain about how to approach the pain decision, preferring to defer to nurses. Because increased pain levels can be associated with fear, patients could have been unwilling to speak with nurses to discuss their need for pain relief.

Nurses' reassessment of postoperative pain after analgesic administration

Objectives: To identify when and how nurses reassess patients' pain after analgesic administration in the postoperative context.
Methods: Fifty-two nurses were observed caring for postoperative patients (N = 364) in 2 surgical settings in a major metropolitan hospital. Seventy-four observation periods of 2 hours duration were studied. The research assistant observed nurses' activities in caring for the allocated patients'. detailing behavioral and verbal responses onto audiotape.
Results: Of the 316 pain activities Ihat occurred in 74 observation periods. 14 (4.4%) were reassessments after analgesic administration. Four themes were evident from the 14 reassessments: opportunistic reassessment. the use of simple questioning, a focus on surgical wound pain not procedural
pain, and nurse-initiated reassessment.
Conclusions: Despite the focus on meeting standards of care in the area of pain management, there was an extraordinary lack of patient reassessment by nurses after the administration of analgesics. Given Ihe raised awareness internationally on assessment generally and a lack of evidence focused on reassessment after an intervention, this may explain why research is failing to identify shifts in pain severity scores and indeed patient pain.