Imagine finding that you are losing your independence and find yourself in a long-term care facility unable to speak, relying on others to bathe, feed and, dress you, and you are no longer are in control of administering your own medications. How do you convey your pain to the nurse? Can anyone see you are in pain? Pain is not always subjective, some residents in LTC have the cognitive ability to report pain, this is not always the case.
Cognitively impaired patients with pain are among the most difficult to assess and treat appropriately as they present unique challenges. Cornally & Egan report, “unresolved pain can have profound physical and psychosocial consequences for older people, such as depression and anxiety, loss of function, sleep disturbances and decreased socialization.”. Several other barriers to pain management in LTC exist; the article “Identifying barriers to pain management in long-term care” breaks down these barriers into groups to better organize and share the data with most significance.
The study provides and understanding of pain, perceptions and attitudes of pain, as well as, the most common barriers that affect pain management in hopes to aid in optimizing pain management in LTC (Cornally & Egan, 2013). The purpose of this paper is to reiterate the findings of the research including the main elements from the study to empower nurses to take charge and become informed about the importance of pain management and the common barriers to the delivery of optimal pain management in LTC.
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Research Question
Could requiring ongoing pain education for all healthcare workers, with an emphasis on nursing recognizing barriers to managing pain, optimize pain assessment and management in LTC? Many elements revolve around ineffective pain management in LTC, this study broke the barriers down into three groups, patient, organizational and caregiver-barriers. Patient-related barriers had the overall highest mean among the three groups.
Two recognized barriers with the highest mean in this group were, trouble evaluating pain in the cognitive impaired, as well as, having a patient population that struggles to properly identify their pain on the pain scale. These lead to under rating of pain and under dosing of medications in these patients. Organizational barriers exist, with the second highest mean between the three groups. Several identified barriers in this group were related to a dearth of opportunity to collaborate directly with the palliative team regarding patient pain management, and nursing staff shortages.
The staff nurse is at the patient bedside most, having the ability to collaborate with the entire pain management team could benefit the patient as well as improve quality of care. With a nursing staff shortage nurses time at the bedside is limited leaving the nurse less time to thoroughly assess pain, offer support, provide non-pharmacological interventions or provide adequate patient teaching. Lastly, in caregiver-related barriers there seems to be a large problem with misinterpreting signs of pain, for signs of agitation, leading to improper medication administration and possibly untreated pain.
Research Design
The research design used in “Identifying barriers to pain management in long-term care” was a quantitative, cross-sectional, descriptive design. Questioners were used to assess LTC professional’s perception’s on pain management, demographics of healthcare staff, and perceived barriers related to providing optimal pain management.
The study also uses literature review as a secondary source of data in order to compare their research results with results from a similar, but larger study. The Quantitative portion of the study examines and measures quantifying relationships among the demographic variables and provides means and standard deviations relating to the questioner responses. Descriptive statistics are used to easily display the data and plays as a strength in this study. A weakness I noted encompasses location; the author used this design mostly out of easy accessibility of their target population making it convenient for the researcher, however, the data may not be as relevant in all parts of the world.
Sample
The sample used in this study were healthcare professionals including nurses, healthcare assistants, and clinical managers. The sample included 2 private LTC facilities and 3 public located in Ireland. Several facilities were used to improve generalizability of data, create a variation of responses and to decrease the risk of uncommon standards disturbing the results of the study.
The main characteristic the sample had in common was all participants were working in LTC at the time of the study, otherwise, all participants came from different backgrounds, had different levels of education, experience, and were of all age’s male and female. According to the findings, participants were mostly female staff nurses, mostly full-time in LTC setting, and majority were between the age of 40-49.
Furthermore, the highest level of education reported from participants was diploma. Of participants questioned 72% report they have had some form of continuing education on pain management since graduating nursing school. The sample size in this study was small from the beginning with 138 questioners sent out, only 60% were returned. A larger sample would have been ideal for more accurate data however, the author does use secondary sources to validify the findings in this study.
Data Collection
Primary and secondary data were collected for the purpose of the study. Prior to research ethical approval was given “by the clinical research ethics committee of the Cork Teaching Hospitals” (Cornally & Egan). Primary sources consisted of self-report questioners that were previously used in a similar study that the researcher revised to better fit staff working in LTC settings.
The target population studied were easily reachable nurses working in LTC including staff nurses, healthcare assistants and clinical managers. Of the 138 Questioners sent out, 83 were returned and not all questioners were completed in their entirety. All questions asked of participants were multiple choice; the first portion of the questioner focused on barriers to pain management using the likert scale to provide a numerical value for responses.
The second portion focused on demographic variables such as gender and age of participants. “To improve content validity, additional questions were added to reflect barriers specific to LTC alluded to in other studies” (Cornally & Egar, 2013); these other studies consisted of the secondary data used in conjunction with the primary data to add validity to the study as several of the findings correlate with larger studies.
Limitations
The sample used in this study were all from the same geological area. Education requirements are different around the world. What may pertain to nursing in Ireland may be very different in the United States. This hurdle could be overcome by expanding the sample to other geographical areas. There was no control group in the study to make comparisons if implementation of continuing education on pain management would have any impact on providing optimal pain management. In addition, not all questioners were completed in their entirety, therefor introducing bias among the sample. With the study being of smaller scale and only using one method of data collection the findings should be interpreted with care.
Findings
Results show that patient-related barriers were among the highest group of barriers perceived to hinder optimal pain management, with assessing the cognitively impaired patient being the most difficult perceived barrier of all. It was also found that patient related barriers were rated higher among nursing staff who reported having continuing education in pain management.
Assessing pain in the cognitively impaired may take the nurse longer than a patient without impairment adding more time on to her assessment; it was found that nursing staff shortage is also a barrier to effective pain management. In long term care the nurse will more than likely encounter cognitively impaired patients more than not. If staff is scarce the nurse may not have adequate time to properly assess each patient, in turn delivering sub optimal care due to time constraints. Communication was also found to play a role in barriers to pain management in several ways.
Staff felt they were powerless to communicate with pain management teams to collaborate on patient care, poor communication between healthcare staff, and inadequate time for patient teaching. This study provides a plethora of data to support but not fully answer the question at hand, could requiring continuing education in pain management with an emphasis on identifying barriers, improve pain management in LTC? From a nurses’ perspective it only makes sense to identify barriers so that we may approach all aspects that hinder providing quality optimal care.
Summary
In order to successfully provide optimal pain management, nurses have many hats that must be worn. Hat 1, nurse hat, assess the patient’s pain level, provide non-pharmacological interventions if necessary and carry out physician orders when available. Hat 2, communication hat, communicate to physician as well as ancillary staff, delegate if necessary. Hat 3, teaching hat, educate staff as well as patient and family on pain management. Hat 4, student hat, nurses must always be learning too, continuing education in pain management could improve nurse’s ability to better identify and treat pain. By also learning how to also identify the barriers to providing pain management, the nurse has the tools to make change and improve patient care.
