The purpose of this study was to identify if nurses and personal care assistants were instigating best practice in pain assessment in a low-level residential aged care service.
The researcher compared pain assessment practices of nursing and care staff, to a retrospective audit consisting of 11 standards, designed by the researcher based on The Australian Pain Standards (Australian Pain Society 2005).
A three month review of each resident’s medical records was conducted by the researcher, to observe for pain assessment behaviour of the nursing and care staff that complied or did not comply with the retrospective audit based on The Australian Pain Standards (Australian Pain Society 2005).
From standard four from the 11 standards in the audit; is new acute pain diagnosed promptly and treated appropriately, nine residents with dementia did not meet this standard compared with 22 residents with good cognition that complied with this standard.
Standard five: Was resident’s chronic pain diagnosed promptly and treated appropriately. Nine residents with dementia did not comply, and 50% of these residents displayed non-verbal cues of pain that were not assessed and identified.
Six of the nine residents who had dementia also had a pain diagnosis. Only three residents were assessed with the Abbey Pain Assessment tool by the allied health team, which was identified by The Australian Pain Society (2005) as the gold standard for assessing pain for residents with dementia.
It was evident from this retrospective audit that nursing pain assessment of residents experiencing dementia did not meet The Australian Pain Society (2005) standards for pain assessment, compared to residents that were more cognitively able.
This study found that pain assessment for residents with dementia was less likely to be practiced by nursing and care staff. Whilst it was evidenced in the progress notes that non-verbal cues and behaviours of pain were present in some residents with dementia, it was doubtful that a pain assessment or pain intervention would occur. Barry et al. (2012) similarly found when exploring managers’ beliefs and attitudes towards pain assessment and management of dementia residents that no guidelines or structured procedures for pain assessment were in place for the staff.
In addition, managers had limited knowledge of opioid use and non-pharmacological treatment for residents with dementia (Barry et al. 2012). Barreto et al. (2013) similarly argued that the lack of pain guidelines and protocols could lead to underuse of analgesia for persons with dementia.
It may be lack of knowledge and poor implementation of structured guidelines for pain assessment for dementia residents that may have resulted in the poor compliance with the standards for this research. Further research is required to understand why residents with dementia are more disadvantaged when nurses conduct pain assessments, and/or why nurses don’t complete pain assessments at all.
It was also more likely if a GP was contacted about non-verbal cues of pain, that it was managed as a disruptive behaviour that sometimes required antipsychotics.
The reason for this may be lack of education and knowledge from the nurses and carers of what non-verbal cues of pain means.
There may be a pain culture in the facility that does not recognise and understand non-verbal behaviours of pain. Further research may be required into the GPs knowledge of dementia residents experiencing pain, and the impact this has on pain assessment.
Other researchers have identified that more research is required into GPs knowledge of pain for residents with dementia (Barry et al. 2012; Barreto et al. 2013).
Barreto et al. (2013) stated that GPs are responsible for the residents that they care for and questioned if GPs were aware of the pain status of the residents, why residents with dementia were not prescribed analgesia, and argued that a poor relationship between residential aged care and GPs impacts on pain management outcomes for residents.
Moreover Barry et al. (2012) discovered that nursing home managers found GPs as an obstacle for pain management and were reluctant to prescribe alternative analgesia schedules, and recommended further research into this area.
Guidelines and protocols around pain assessment and pain management need to be embedded into the pain culture of a facility. Nurses and care staff need a structured process they can follow when confronted with challenges of residents experiencing pain.
With regulatory requirements and cumbersome documentation in aged care it is important that pain assessment does not create extra documentation for staff. Pain assessment is required as a method to understand what the resident is experiencing, and to justify decision making around pain management and intervention.
Amy Licheni, RN, Graduate Certificate in Mental Health Nursing and a Master in Health Administration, works in Admissions and ACFI Coordinator at Beaufort and Skipton Health Service.
Gylo Hercelinskyj, PhD, RN and a senior lecturer in Nursing at Australian Catholic University, Melbourne.
References
Barreto, P., Lapeyre-Mastre, M., Vellas , B., & Rolland, Y. 2013. Potential underuse of analgesics for recognized pain in nursing home residents with dementia: a cross sectional study. Pain, 154(11). 2427-2431. doi:0.1016/j.pain.2013.07.017
Barry, H., Parsons, C., Passmore, P., & Hughes, C. 2012. An exploration of nursing home managers’ knowledge of and attitudes towards the management of pain in residents with dementia. International Journal of Geriatric Psychiatry
Clark, L., Fink, R., Penninton, K., & Jones, K. 2006. Nurses’ reflections on a pain management in a nursing home setting. Pain Management Nursing, 7(2). 71-77. doi.10.1016/j.pmn.2006.02.004
Mentes, J., Teer, J., & Cadogan, M. 2004. The pain experience of cognitively impaired nursing home residents. Perceptions of family members and certified nursing assistants. Pain Management Nursing 5(3). doi.org/10.1016/j.pmn.2004.01.001118-125
The Australian Pain Society. 2005. Pain in residential aged care facilities, management strategies. Retrieved from apsoc.org.au
