Pain assessment and management in older hospitalised patients: observation shows common themes relating to nurse–patient communication, pain management strategies, organisational aspects of care and the complex nature of pain
- Correspondence to
: Professor Pat Schofield
School of Health and Social Care, University of Greenwich, Avery Hill Campus, Eltham, London SE9 2UG, UK;
Commentary on Manias E. Complexities of pain assessment and management in hospitalised older people: a qualitative observation and interview study. Int J Nurs Stud 2012;49:1243–54
Implications for practice and research
Staff need more education around identification of pain and options for management among the older population.
Pain assessment methods should be brief and simple, followed by an algorithm for management.
The need to explore organisational barriers which inhibit effective management and to develop more creative ways of overcoming such barriers.
The need to evaluate treatment pathways.
This study was conducted within two geriatric units in a public teaching hospital in Australia. The authors identify the need to explore pain assessment and management, a complex phenomenon that makes up the decision-making process and includes environment, communication and other previously unexplored influencing factors. We are aware that 50% of older adults in the community experience pain and this increases to 80% in care homes.1
The study is described as ‘naturalistic observational research.’ The researcher aims to observe the behaviour of participants within their own environment without any manipulation of the environment. Such observation can be overt or covert, in that the participant may or may not be aware that they are being observed. Thirty-four nurses were recruited of a total of 44 eligible nurses and 285 eligible patients of a total of 342 agreed to participate. The authors conducted several periods of observation, each 3 h in duration, over a 24 h period to observe how pain assessment and management were carried out with these patients. In addition, interviews were conducted with participating nurses to clarify what was being observed.
Four themes emerged from this study; first, nurses tend to use simple questions when asking older adults about their pain experience. In spite of the plethora of pain assessment tools that have been developed for measuring pain, for whatever reasons, simple pain questioning appears to be the preferred approach taken by participants in this study. Second, organisational aspects of care delivery appear to heavily influence the choice of management strategies. For example, during periods of lower staff numbers, simple analgesics were often given due to the complexities associated with the administration of opioids. Third, dealing with pain in the older population is challenging; this is often due to the multiple comorbidities that exist with this group and, subsequently, the presentation of multiple pain syndromes such as acute or chronic pain. Furthermore, fears associated with opioid prescribing are often seen among healthcare professionals and this study is no exception.
This study has adopted an interesting approach to data collection which has not been widely used in the field. There have been a number of studies which have examined nurses’ attitudes and barriers towards pain assessment in the older population.2 Many studies have made recommendations regarding the most appropriate pain assessment approaches, and the American Geriatric Society and the British Pain Society have developed guidelines based on this evidence.3 ,4 However, there are two key issues to consider. First, the most comprehensive and effective pain tools will not be applied if they are too complex and time consuming for nurses in everyday practice who face the demands of few staff to deal with very ill patients with complex needs. Second, the study reinforces the issues underpinning poor staff knowledge and education which have been highlighted many times before. In addition, the issues that surround qualitative research in terms of generalisability must be considered, while an interesting study, it cannot be applied across all settings and countries. Nevertheless, the findings are similar to many other studies in the field that suggest pain management of older adults in hospital settings is suboptimal.4 It is difficult to be specific as to why: lower educational levels, inadequate staffing and inappropriate organisational policies are all factors to consider. But even the best knowledge may not necessarily be translated into practice when there are so many competing demands on the nurses.