Barriers and Facilitators to Nurses' Practice in Assessing and Managing Pain for Older Hospitalized Patients: A Summary Analysis of Four Primary Research Articles

INTRODUCTION
Being in pain is one main reason why an older person (those aged 65 years and over) will initially present to hospital
(Goldberg & McGee 2011). Older people often have multiple pain aetiologies requiring comprehensive assessment (Herr
2011). Misconceptions about pain management in older people are based on poor knowledge, lack of understanding and
myths about old age (Czarnecki et al. 2011). Evidence suggests the characteristics of the health care provider can also
influence pain care provision within the acute care setting (Bartley et al. 2015). Pain is and always remains a deeply
personalised and subjective experience and the multidimensional nature of pain often requires an interprofessional
approach to assessment and management (International Association for the Study of Pain. 2019). The accepted gold
standard for pain assessment was developed over 46 years ago by McCaffery (1968) who provided the seminal statement:
Pain is what the person says it is and exists whenever he or she says it does.
All professionals need to serve as advocates for the person in pain and ensure that pain treatment is based on ethical
principles and evidence-based standards and guidelines (Herr et al. 2011) . Nurses play a critical role in effective pain
management (Kerner et al. 2013) because of their frequent contact with patients in a variety of settings (Slatyer, Williams &
Michael 2015).
Research Question:
What are the barriers and facilitators to nurses’ practice when assessing and managing pain for the older hospitalised
person?
Significance:
The research question is relevant for clinical practice. Comprehensive and systematic assessments for the development of
a care plan is an integral part of nursing (Nursing and Midwifery Board of Australia. 2016). Knowledge on barriers and
facilitators for effective pain management will serve as a ‘road map’ that facilitates the translation of research evidence to
current practice in pain care provision for older people. Appropriate knowledge translation strategies then can be selected
to ensure consistent and quality pain provision to older people.
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SUMMARY ANALYSIS OF FOUR (4) PRIMARY RESEARCH ARTICLES
Paper 1
Gorawara-Bhat, R., Wong, A., Dale, W., & Hogan, T. (2017). Nurses’ perceptions of pain management for older-
patients in the Emergency Department: A qualitative study. Patient education and counseling, 100(2), 231-241
The primary aim of the article is to identify the theme that has been arisen from the perception of the nurse when
they are assigned to take care of the older patient who is suffering from pain. Apart from these, the article also focusses on
the development of the optimal intervention which aims to improve the quality of the assessment of the pain in the older
individual in the emergency department. The article aims to evaluate evidence which can be used during the pain
assessment in the older individual. The methodology that is used in the article to collect the related evidence is the semi-
structured, in-depth interviews with the nurses working in emergency department. The questionnaire is distributed among
the nurses about the assessment of the abdominal pain and other issue. The respondents selected for the experiment are
the nurses working in the Emergency Department. Total 20 number of respondents were selected whose response where
coded, transcribed and then analyzed by using the qualitative method.
By observing the result analyzed from the interview, it is stated that the result mainly focusses on two themes, the
challenges and the strategies which are used for assessing the pain. In the first theme, the “challenge” which are
experienced by the nurses in the pain assessment of the older individual and in the other theme, which is “strategies”. In
the strategies, the strategies to overcome the barrier are mentioned. Four different topologies are formulated by the help of
the 2*2 framework, which includes strategies, challenges, sub themes and their classification which help to determine
appropriate strategy for the challenges.
Paper 2
Fry, M., Chenoweth, L., & Arendts, G. (2016). Assessment and management of acute pain in the older person with
cognitive impairment: A qualitative study. International emergency nursing, 24, 54-60.
Pain In the older individual is commonly observed in the older individual, especially who are suffering from
cognitive impairment and bone fracture. The primary aim of the article is to study the perception of the emergency nurse
while managing the pain of the older individual, who are suffering from long bone fracture and the cognitive impairment.
The research design used in the article is the qualitative research design. The data regarding the perceptions of the nurse
while managing the older individual with pain is collected by the help of the focus group interviews. The questionnaire of the
interview was formulated with the help of the literature which lasted around 35-60 minutes and the response were
recorded. The nurses who have minimum one year experience in the emergency department are included in the
experiment. The total number of respondents who are selected for the experiment are 67 females and 13 males. The time
period of the experiment is the 12 weeks.
Five different themes have been observed by analysing the response of the emergency nurse. The five different
themes included, 1. Ageing process and the pain management, 2. Absence of proper tool for pain assessment of the older
individual, 3. Delivery of analgesia, 4. Policy arriers related to the pain management initiated by the nurses, and 5. Belief in
the championing of the pain management. From the result, it is concluded that the pain assessment and pain management
in the older individual face certain obstacles such as lack of assessment tools in the clinical setting, which can be managed
by using the behavioural assessment tools.
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Paper 3
Manias, E. (2012). Complexities of pain assessment and management in hospitalised older people: A qualitative
observation and interview study. International journal of nursing studies, 49(10), 1243-1254.
In the healthcare setting, it is frequently observed that the complexities of the clinical practice pose a negative
impact on the pain assessment and management in the older individual. The primary aim of the article is to examine the
strategy that is used in the pain assessment and the pain management in the older individual who are admitted to the
geriatric management and the evaluation unit. The participant that are selected for the experiment are the registered nurses
who works In the geriatric evaluation unit, total 34 nurses were selected as respondents. The study design used in the
experiment is the observational study design, which aims to gather information by directly observing the interaction
between the patient and the nurses and after the nurses are interviewed for the follow-up process.
By analysing the observational data and the response of the nurses, four major themes were identified which
includes, communication among the nurses and the geriatric patient, organizational and the environmental aspects of the
patient care, strategies that can be used for the pain management and the complexities associated with the nature of the
pain. From the study, it can be stated that the nurse instead of providing opioid medication to the patient, prefers to wait till
the pain is relived and in addition, the time of the day when the care is provided to the patient also have an impact on the
pain management in the older adults. The findings of the study suggests that the analgesics needs of the older patients are
addressed, especially those with complex nature of pain, communication difficulties.
Paper 4
Brorson, H., Plymoth, H., Örmon, K., & Bolmsjö, I. (2014). Pain relief at the end of life: nurses’ experiences
regarding end-of-life pain relief in patients with dementia. Pain management nursing, 15(1), 315-323.
Older patient is commonly found to be suffering from dementia where they need palliative care. In such cases, the
nurses play an important role in providing better care to the patient by identifying the pain and then assessing and
managing accordingly. The primary aim of the study is to discuss the experience of the nurse in providing end life pain
relive care to the older patent suffering from dementia. The respondents selected for the experiment are the nurse working
in any unit or the registered nurse who are able to provide better information regarding the topic of the study. The study
design used for this method is the qualitative study design and to collect the appropriate information for the nurse semi
structured interviews are conducted. After conducting the interview the results are analyzed by the help of the Burnard’s
content analysis method.
By analyzing the result two primary categories were identified which includes, experience of the nurse associated
to the resources regarding the pain relief of the patient and other is experience of the nurse of the difficulties regarding the
pain relief. It is observed that while providing end of life pain care to the patient, nurse often feels powerless due to the
complications in preparing the medication, inadequate feeling, ethical dilemma and feeling of not being able to engage with
the patient. The factors which are used as resources in the care of the patient are also identified which includes, knowledge
of the nurse, pain assessment tools, professional experience, interpersonal relationship and cooperation.
Results and Discussion
This study had aimed to discuss the barriers and facilitators within the nursing practice while evaluating and
managing the pain of a hospitalized older patients. Four different studies were included that had focused to identify the
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