What is the role of Nursing in pain management?

Pain is a common symptom in long-term care (LTC) residents; however, it goes undetected and untreated in many. For example, Hongyan Li and Lisa Osborne, renowned nursing professionals, describe the details of a project that improved treatment outcomes and quality of life for residents in a recent article published in the reference journal, Nursing: Management of the pain for long-term care residents.

Meet pain management goals

Pain management outcome is one of the essential criteria for providing safe, evidence-based, patient-centred care. To improve the management of nursing care for residents of the CLP centre, the nursing management decided that the first step to improving the quality of care in pain management was to establish a training program. The objective was to ensure that the staff had sufficient knowledge about pain, pain assessment and analgesic medication. Through the education and training of nursing staff, these collaborative activities improved pain management outcomes and the subsequent safety and quality of life for our residents. This program was divided into four parts:

Part I: Understanding pain

The program began by clarifying different definitions of pain. Two widely accepted reports were reviewed and discussed. First, the International Association for the Study defines pain as “an annoying emotional and sensory experience that links with actual or potential tissue damage, or described in terms of such damage”. Nurses define it as “what the person experiencing it says it is and is present whenever the person experiencing it says it is”. Based on these definitions, staff and family members readily accepted that a painful experience is subjective and unique to each person, encompassing more than just tissue damage that triggers a nervous system response.

As a complement to the theory of pain and its effect on the resident, the program addressed different ways of managing pain. Project participants reviewed features unique to CLP centres that made pain management difficult:

• Because of impaired cognitive function, many CLP patients with advanced dementia cannot verbalize their pain. Still, they may express it in other ways, such as showing aggression, acting out, or resisting care. Case studies were used in this informal section.
• Many CLP residents have more than one source of pain, for example, osteoarthritis and post-surgical pain.
• Because of polypharmacy, CLP residents are at increased risk for drug interactions and adverse drug reactions.

After this training, the nursing staff and family members already knew that the definition of pain is different for each resident and that systematic evaluations of the physical and mental state of the residents should be made before administering pain medication if necessary.

Nursing pain management

Part II: Recognize the Consequences

Education focused on the possible effects of pain was a central element of the program. The consequences of pain were classified into three categories:

• Pain is associated with reduced physical ability and mental health. Research has found that pain significantly affects patients’ daily activities and mobility.
• The pain is associated with falls. For example, researchers reported that pain, knee stiffness, and decreased muscle strength limit patients’ physical abilities and increase their risk of falling.
• The pain is associated with depression. Research has shown that persistent pain adversely affects mental health, emotional state, and function.

Part III: Assessing pain in residents with dementia

According to CLP nursing research, residents with and without dementia have similar pain diagnoses. Based on the revised definition of pain, the template endorsed the gold standard of pain assessment: self-assessment. CLP nursing research studies suggested that:

• Nursing staff may not routinely assess patients with dementia.
• Residents with mild dementia have less motivation (intention) to report their pain.
• The nursing staff assumed that residents with dementia could not reliably report their pain.
• Nursing staff focused more on addressing overt behavioural disturbances, considered symptoms of dementia, than on assessing pain.

The widely accepted and evidence-based assessment tools of provocation/palliation, quality/quantity, region/radiation, severity and time scale, or other numerical or descriptor rating scales are often used to assess pain and treatment efficacy. Verbal. Assessment tools such as the Advanced Dementia Pain Assessment Scale or the Non communicative Elderly Pain Assessment Scale are reliable with CLP residents who have advanced dementia when self-assessments are considered unreliable due to cognitive impairment. This section reviewed and addressed the pain assessment process and used validated tools to implement them in clinical practice with residents.

For residents with dementia, staff and family members were encouraged to work together to discern how the resident usually acts and what changes occur when in pain. Improving assessment to differentiate dementia symptoms from pain symptoms helps staff determine when and how to intervene.

Part IV: Nonpharmacological Interventions

In older people, opioids have been associated with multiple psychological and physical adverse reactions, including cognitive impairment, increased risk of falls and fractures, cardiovascular adverse reactions, and even an increased risk of death. In addition, nonpharmacological interventions are effective in reducing opioid use and pain intensity.

future directions

Nursing staff knowledge of pain management increased, and pain management clinical practice improved, as demonstrated by regular administrative quality reviews. For example, one resident’s frequent falls have been reduced since analgesic medication has been adjusted. Despite these promising results, Hongyan Li and Lisa Osborne stress that “a higher degree of statistical evaluation is still needed to assess improvement in pain management.” Looking to the future, both professionals point out that the line to follow will be to “train the staff in the evaluation of the administration of analgesic medication for residents with and without dementia, to improve the safety and quality of our CLP centre”.