Abstract
BackgroundChronic pain affects nursing home residents’ daily life. Pain assessment is central to adequate pain management. The overall aim was to investigate effects of a pain management intervention on nursing homes residents and to describe staffs’ experiences of the intervention.MethodsA cluster-randomized trial and a mixed-methods approach. Randomized nursing home assignment to intervention or comparison group. The intervention group after theoretical and practical training sessions, performed systematic pain assessments using predominately observational scales with external and internal facilitators supporting the implementation. No measures were taken in the comparison group; pain management continued as before, but after the study corresponding training was provided. Resident data were collected baseline and at two follow-ups using validated scales and record reviews. Nurse group interviews were carried out twice. Primary outcome measures were wellbeing and proxy-measured pain. Secondary outcome measures were ADL-dependency and pain documentation.ResultsUsing both non-parametric statistics on residential level and generalized estimating equation (GEE) models to take clustering effects into account, the results revealed non-significant interaction effects for the primary outcome measures, while for ADL-dependency using Katz-ADL there was a significant interaction effect. Comparison group (n = 66 residents) Katz-ADL values showed increased dependency over time, while the intervention group demonstrated no significant change over time (n = 98). In the intervention group, 13/44 residents showed decreased pain scores over the period, 14/44 had no pain score changes ≥ 30% in either direction measured with Doloplus-2. Furthermore, 17/44 residents showed increased pain scores ≥ 30% over time, indicating pain/risk for pain; 8 identified at the first assessment and 9 were new, i.e. developed pain over time. No significant changes in the use of drugs was found in any of the groups. Nursing pain related documentation was sparse. In general, nurses from the outset were positive regarding pain assessments. Persisting positive attitudes seemed strengthened by continued assessment experiences and perceptions of improved pain management.ConclusionThe implementation of a systematic work approach to pain issues in nursing homes indicates that an increased awareness, collaboration across and shared understanding among the team members of the pain assessment results can improve pain management and lead to decreased physical deterioration or the maintenance of physical and functional abilities among NH residents. However, pain (proxy-measured) and wellbeing level did not reveal any interaction effects between the groups over time.Trial registrationThe study was registered in ISRCTN71142240 in September 2012, retrospectively registered.
Highlights
Chronic pain affects nursing home residents’ daily life
The implementation of a systematic work approach to pain issues in nursing homes indicates that an increased awareness, collaboration across and shared understanding among the team members of the pain assessment results can improve pain management and lead to decreased physical deterioration or the maintenance of physical and functional abilities among NH residents
There were significant differences at baseline regarding wellbeing/WHO-5 index (p = 0.003), activities of daily living (ADL)-dependency/Katz-ADL (p = 0.013) and ADCS-ADL (p = 0.032) with higher wellbeing, lower dependency measured with Katz-ADL and higher dependency measured with ADCS-ADL in the comparison group compared to the intervention group
Summary
Chronic pain affects nursing home residents’ daily life. Pain management among residents in nursing homes (NHs) is essential for good quality care [1] and pain assessment is emphasized to be central. According to a recent study [7] the prevalence of pain was higher among residents with cognitive impairment and among residents with a greater degree of ADL-dependency. An important concern is that NH residents’ pain is often unidentified or undermanaged, which negatively impacts their ADLs and cognitive impairment, and their quality of life [2, 4, 6, 8]. According to registered nurses (RNs), identifying pain and indicators of pain is challenging, thereby leaving residents with cognitive impairment at higher risk for under-treatment of pain [14]. NH assistant nurses (ANs) reported [15] that it is difficult to determine whether a person’s behaviours are normal personality manifestations or consequences of pain and that the recognition of pain was often a guessing game
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