targeting pain in older people in the acute care ... - Keele University

TARGETING PAIN IN
OLDER PEOPLE IN THE
ACUTE CARE SETTING
Isabel Higgins
Professor of Nursing Older Person Care,
Collaborating Centre for Older Person care: RCGHA
School of Nursing and Midwifery, University of
Newcastle & CPOD Hunter New England Health

TARGETING PAIN TEAM
‣ Caroline Phelan CNS
‣ Fiona Hodson CNC 3
‣ Peter Summons Senior lecturer TUN
‣ Jeanene Douglas CNS
‣ Linda Ritchard CNC 3
‣ Debbie Bruce CNS OPAC
‣ Glody Mabbott RN
‣ Pauline Dobson CNC 3

Funding support
‣ Nursing and Midwifery Office NSW Health
‣ Department of Medicine, John Hunter
Hospital, Hunter New England Health,
New South Wales, Australia.

The Campus
‣ Environmental “Bush-Land” campus
‣ Large grounds

The Location
‣City/beach University

The location

The location

The location

The location

The problem of pain
‣ Pain is common in older people (Ferrell et al., 1995
Madjar & Higgins, 1996, 2004)
‣ Persistent pain is common (Ferrell et al., Madjar & Higgins,
1996, 2004)
‣ Multiple sources and types of pain are common
(Madjar & Higgins, 1996, 2004)
‣ Hospitalised older patients experience high
levels of unrelieved pain (Yates et al., 1998; NICS, 2003)

The problem of pain
‣ There are many barriers to assessment of pain
in older people
• Older people under-report their pain
• Fear being labelled a complainer
• They regard pain as a part of growing old
• Fear of addiction
• Perceive that health care workers too busy
• No expectation for pain relief
• Poor knowledge of staff about pain and pain relief
• Attitudes of staff towards older people and pain
(Blomquist et al., 2003; Brockopp et al., 1996; Madjar & Higgins, 1996, 2004)

The problem of pain
‣ Assessment of pain is rarely documented (Idval et
al., 2002)
‣ Staff often underestimate and under-treat pain in
the older person (Idval et al., 2002)
‣ Precipitating factor for delirium (Inouye, 2001)
‣ Pain may hinder recovery and prolong
hospitalization
• associated with depression, anxiety, cognitive
impairment, decreased appetite, weight loss, and
disturbances to sleep, gait, general activity, mood and
relationships with other people.
Strassels, Chen & Carr, 2002

The problem of pain
‣ Organisations do not make pain
management part of their core business
‣ Health professionals outside of pain
services do not assess or document pain
NICS, 2003

Setting for the study
‣ Large 600 bed tertiary referral hospital in
regional NSW Australia
‣ 32 bed mixed medical and surgical ward
‣ Specialising in neurosurgical and neuromedical
patients
‣ Incorporating a stroke unit

Purpose of the study
‣ To profile the management of pain in older
people in the acute care setting

Aims of the study
‣ To determine whether a multidisciplinary
education program designed to focus on pain
management in older people improves the
detection and management of pain in this
group
‣ To evaluate the project using pre and post
audit mechanisms and qualitative interviews
with patients and staff

Study design
‣ Pre post audit evaluation study on one ward
‣ Six phases
• Pre study chart audit (n=20)
• Clinical guideline development
• Multidisciplinary pain education program development
• Promotional media development “Targeting pain”
• Post chart audit (n=20)
• Patient interviews (n=4) & survey (n=10)
• Focus group with staff (n=3)

Education program
‣ Multidisciplinary
‣ Targeted all discipline groups
‣ For nurses relied on train the trainer
following 20% target
‣ Focused on pain assessment and
management
‣ Documentation
‣ Range of assessment tools provided

Pain let me know

Division of Medicine
Division of Medicine
Currently Targeting
Currently Targeting

Chart audit data
‣ Age
‣ Gender
‣ Relevant medical history
‣ Diagnosis
‣ Pain assessment
‣ Analgesia, nature and type, efficacy
‣ Nurse initiated strategies

Participants
‣ Older adults over 65 years admitted to
neuro medical/surgical ward
‣ Able to give informed consent
‣ Consenting staff:
• Nurses
• Physiotherapists
• Speech pathologists
• Medical officers

Data analysis
‣ Descriptive statistics - chart audit data
‣ Content analysis - qualitative data

Findings – chart audit
‣ Increased pain assessment from pre chart audit
by nurses
‣ Increased documentation in progress notes and
observations charts
‣ Increased use in analgesics – paracetamol
‣ Efficacy noted
‣ Non pharmacological approaches noted pre or
post audit

Chart audit
70%
60%
50%
40%
30%
20%
10%
0%
Pain Assmnt on
Admission
Pain Assmnt
during Admission
Analgesia given in
last 24hrs
Documentation of
Efficacy
Multimodal
Analgesia Used
Pre Education Audit
Post Education Audit

Patient survey data
‣ 50% of patients received information about pain
management
‣ The average pain score was 6.4
‣ 40% of patients said pain interfered with ADLs
‣ 30% of patients said they did not have to ask for
analgesia
‣ 50% of patients waited less than 10 minutes for
pain relief when it was requested.
‣ 70% of patients were satisfied with pain
management

Patient interview
‣ There was a high degree of satisfaction
with care and attention to pain
‣ The badges worn by nursing staff were
noticed by family and staff:
• “it sort of allows you to talk about pain”
‣ Patients use a range of strategies at home
to relieve pain including distraction

Focus group interview
‣ The badges were useful because they drew attention to
pain
‣ Posters were not noticed as readily as the badges
‣ Participants suggested self directed learning packages
allow staff to pace their own learning
‣ Case based scenarios were thought to be an appropriate
approach to learning about pain
‣ Short in-service approaches were not as effective as
extended education programs
‣ A range of strategies are used by nurses to alleviate pain
including positioning and re positioning the patient

Findings - focus group
‣ I remember the in-service but…I don’t remember taking
anything away from it…I mean you know, we got the
badge and we were told to be more on the lookout for
patient’s pain. And that’s what I did.
‣ And that’s what you did. So, was there a presentation
around what sorts of pain tools to use?
‣ I don’t remember.
‣ It wasn’t something that like stuck in my mind, and I
thought was really good or really bad, I just…

Discussion
‣ The findings of this study show a slight improvement in
the assessment and management of pain in older
people.
‣ Using an educational approach supported by visual
media may be effective. In particular, the use of badges
serve to profile pain as a focus of care.
‣ Patient survey data suggest that patients continue to
have high levels of pain despite their reported
satisfaction.
‣ There may be a range of self initiated pain relief
strategies used by patients that nurses could facilitate
during hospitalisation.
‣ Alternative educational approaches/strategies to pain
education were suggested by participants.

Recommendations
‣ The pilot study highlighted several design issues
including the need to;
• refine the audit tool to ensure validity of data collected
• engage medical and allied Health staff in the research process
from the outset
• review and re design the education program and general
approaches used to include non pharmacological approaches to
pain management, case studies, self directed learning
supplemented with extended education days.
• encourage use of algorithms
• redesign badges to be more visually appealing
• explore alternative approaches to placement of targeting signs
such as computer screen saver.
• develop localised pain guidelines for the management of pain in
older people in the acute care setting

References
‣ Blomqvist, K, (2003) Older people in persistent pain: nursing and paramedical staff perceptions
and pain management. Journal of Advanced Nursing,41, 575-584
‣ Brockopp, D., Warden, S., Colclough, G. & Brockopp, G. (1996). Elderly people’s knowledge of
and attitudes to pain management. British Journal of Nursing, 5(9). 556-562.
‣ Chodosh J., Ferrell B., Shekelle M., & Wegner M. (2001. Quality indicators for pain management
in vulnerable elders. Annals of Internal Medicine 135(8): 731-735.
‣ Ferrell, B. A., Ferrell, B. R. & Rivera, L. (1995). Pain in cognitively impaired nursing home
patients. Journal of Pain and Symptom Management 10(8), 591-598.
‣ Idval, E. & Ehrenberg, A. (2002) Nursing documentation of postoperative pain management.
Journal of Clinical Nursing, 11, 734-742
‣ Inouye, S., Foreman, M., Mion, L., Katz, K., & Cooney, L. J. 2001. Nurse's recognition of delirium
and its symptoms. Archives of Internal Medicine, 161(Nov 12), 2467-2473.
‣ Higgins, I., Madjar, I., & Walton, J. (2004) Chronic pain in elderly nursing home residents: The
need for nursing leadership. Journal of Advanced Nursing. 12, 167-173.
‣ Madjar, I. & Higgins, I. (1996a, August). The adequacy of pain relief measures in elderly nursing
home residents. Poster session presented at the 8th World Congress on Pain, Vancouver,
Canada.
‣ Potter V., Wiseman C., Dunn S., & Boyle F (2003) Patient barriers to optimal cancer pain control.
Psycho-oncology, 12: 153-160.
‣ Strassels, S, Chen, C (2002) Postoperative analgesia: economics, resources use, and patient
satisfaction in an urban teaching hospital, Anesthetics and Analgesia, 94: 130-137.
‣ Yates P., Edwards H., Fentiman B., Najman J., Nash R et al., (1998). The prevalence of pain
amongst hospital in patients. Journal of Clinical Nursing, 7: 521-530.
‣ National Institute of Clinical Studies (2003), Australia.