Introduction
VET-LINK is a multidisciplinary network formed to address Canadian Veterans’ current and emerging healthcare needs through research collaboration (Gibson & Savoie, 2003). It is composed of a network of clinician-researchers working in priority- access veterans’ care facilities across Canada. The initial research themes of the network include pain management.
VET-LINK’s pain research program focuses on needs assessment and practice enhancement initiatives aimed at improving pain management in residential health services for veterans. A previous pain research study at Ste. Anne’s Hospital (Quebec) (Le May & Savoie, 2006) aimed to assist the development of a customized education program for nurses on pain management. That study included interviews with 37 nurses to evaluate their learning needs, values and beliefs regarding pain management of the elderly. The findings suggest that nurses’ primary learning needs relate mainly to pharmacological knowledge, misconceptions, and the measurement of pain in cognitively impaired patients. A conclusion was that even though nurses had sound values regarding pain management of the elderly, their clinical practice might be impaired by their misconceptions.
The purpose of this investigation was to attempt to replicate these findings at other sites so that common educational materials could be developed and shared across veterans’ care institutions. To this end, we conducted a survey of nurses and healthcare providers other than physicians from four VET-LINK research sites. This article presents the results of that survey which addressed the following question: What are the beliefs, values and learning needs of managers, nurses and other healthcare providers regarding the pain management of veterans in healthcare settings?
Methods
Sampling
A convenience sample of 98 healthcare providers responded to the survey. The distribution of the different types of care providers was as follows: 44.1% Registered Nurses (RN); 19.3% allied health professionals (occupational therapists, physiotherapists, and social workers); 16.3% RPN/CPN (nurses’ aids); 15.1% Licensed Practice Nurses (LPN); 7.0% managers. Regarding work experience, 35.2% of the participants had 10 years or less and 64.8% had at least 11 years.
Settings
The participating sites were as follows: Parkwood Hospital, Ontario (n = 36, 326 beds); Camp-Hill Veterans Memorial, Halifax (n=34, 175 beds); Deer Lodge, Manitoba (n= 21, 155 beds); Fredericton Veterans Centre (Veterans Health Unit), Fredericton, New Brunswick (n = 7, 47 beds).
Measurement
The VET-LINK Staff Pain Survey is a 15-question instrument designed according to the main outcomes from the initial nurses’ study and a consultation process between the co-ordinators from the four research sites involved. The survey includes seven questions with a Likert-scale format from 1 (Strongly Disagree, or Not at All) to 5 (Strongly Agree, or Totally), seven short open-ended questions, and one nominal question. Under each Likert-scale question, there was space provided for respondents to write additional comments. A review of the draft survey instrument by persons knowledgeable in gerontological nursing, measurement, and psychogeriatrics addressed its face and content validity, with each item considered relevant to a distinct aspect of pain management.
Data collection procedures
All sites obtained ethical approval from their hospital or an affiliated university. Collaborators at each of the four participating sites in the Vet-Link network distributed the measure to samples of nurses, managers and allied health professionals.
Results
Pain relief of the elderly and beliefs regarding medication
According to the survey results, 72.6% of the respondents agree that it is possible to relieve pain totally in the elderly, and 84.2% believe the elderly when they report having pain. In addition, the majority of respondents (90.1%) reported that they were comfortable with the use of pain medication in the elderly but 61.8% disagreed with the use of PRN (Pro Re Nata = As needed or as requested by the patient) analgesics for these patients. Regarding the use of opioids (narcotics), most of the respondents (80.3%) felt at ease with administering this type of analgesic to relieve veterans’ pain.
Respondents were divided regarding administration of the last dose, with 48.4% agreeing or strongly agreeing that nurses are not afraid of giving the last dose of analgesics to dying patients. The remainder (51.6%) believe that nurses are reluctant to provide analgesics to these patients. However, 58.3% of the respondents in the nursing sub-group indicated that they were not averse to giving the last dose.
Principal misconceptions related to pain management of the elderly
The respondents considered the main misconception shared by nurses (42.4%) and allied health providers (15.8%) to be the belief that the administration of analgesics will lead to confusion, drowsiness and addiction. Nurses and allied health professionals considered this misconception to apply also to physicians (23.1%), families (38.3%) and veterans (29.2%). It is likely that the prevalence of this misconception is among the factors that contribute to inadequate pain management in veterans.
Healthcare providers’ values related to the care of the elderly
Healthcare providers’ main values relating to the care of an elderly were as follows: comfort and self-esteem (29.8%), quality of life and personal well-being (17.9%), and respect of the veterans’ wishes (14.3%). When asked to rate their most important value, 52.3% of the respondents mentioned the respect of the veterans’ wishes.
Learning needs regarding pain management of elderly
A question on the measure asked respondents to rate the most urgent learning needs from a list of 13 items representing the needs identified in the previous study (Le May & Savoie, 2006).
The percentage of respondents that identified specific needs as most important is as follows:
- knowledge about signs and symptoms of pain (21.4%);
- knowledge about narcotics (19.8%);
- pain evaluation in cognitively impaired patients (19.8%);
- knowledge about drugs used frequently with elderly (13.1%);
- end-of-life care (12.0%).
When asked to indicate what were their own most urgent learning needs among the list of 13 needs, respondents indicated the following:
- Knowledge about narcotics (16.2%);
- Evaluation of pain with cognitively impaired (16.2%);
- End-of-life care (14.7%).
Discussion
Overall, the results of the survey replicate and expand on the findings from the initial study by Le May & Savoie (2006). The findings indicate that even though healthcare providers value the comfort of veterans, they still have fears or misconceptions related to pain management that may prevent them from providing, or at least making an effort to provide, optimum pain relief. Such discrepancies between healthcare providers’ values and misconceptions draw attention to the importance of improved education about pain management in the elderly. They suggest a need for curricular modification in undergraduate healthcare programs (nursing, psychology, occupational therapy, medicine, etc) and hospital in-service courses (Canadian Pain Society, 2006).
The discrepancies may also require the participation or at least the collaboration of medical doctors since they are responsible for prescribing pain medication to patients. Indeed, many nurses from the initial study mentioned a need to improve the quality of the communication with doctors and to create improved professional collaboration towards the optimal care for veterans.
Such collaboration is consistent with the Canadian Pain Society’s (CPS) accreditation guidelines on pain management: “Since pain can be a complex multidimensional problem, effective management requires a variety of strategies involving all healthcare professionals. Healthcare professionals should utilize each other’s expertise in working together to help patients and families with their pain management.” (p.19).
Limitations to the research include the survey instrument that was new and piloted in this study. It may need revision in subsequent research in accordance with standard procedures for the development of such measures (e.g., to rectify inconsistencies in item format).
Although the findings were similar across the four sites, the results are limited to the profiles of healthcare providers at the four specified VET-LINK sites. Generalization to the wider population of healthcare providers for the elderly may be speculative.
Cleeland et al. (2003) describes a similar initiative that was undertaken by the Veterans Health Administration to improve pain management of Veterans in the United States (Veterans’ Health Administration National Pain Management Strategy). The purpose of this initiative was to develop a system-wide approach to pain management that would reduce pain and suffering for veterans experiencing acute and chronic pain associated with a wide range of illnesses including terminal illness.
Results of this joint collaborative initiative show significant decreases in pain intensity, and improvement in assessment and care plans for patients suffering from pain. The authors suggested that a program of team formation, goal identification, testing and adaptation of recommended system changes, sharing and feedback of process and outcome can produce significant change in pain management in a major health care organization.
These present findings also suggest the need of healthcare providers to use appropriate tools to assess pain in elderly patients with cognitive impairments. In many instances, expressions of pain by the elderly are confounded with delirium. Tools designed to discriminate between patients who are in a state of confusion and patients who are experiencing pain would be useful for better pain management of this clientele. Validated tools are available such as the Feldt’s Checklist of Non Verbal Pain Indicators (Feldt, 2000) and the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) (Fuchs- Lacelle & Hadjistavropoulos, 2004).
Because the majority of patients entering veterans’ care facilities are over 75 years of age, healthcare providers need a sound knowledge of pain management specific to the elderly in order to facilitate compassionate and effective care (Sloman et al., 2001).
In conclusion, the findings of this study corroborate those of our initial study that there is a pressing need for nursing education on pharmacology in relation to pain management. The results also reinforce the fact that there is more to education than facts alone. In order to change clinical practices, one needs to consider the beliefs and the values of the healthcare providers involved in pain management, and to address misconceptions about pain management practices with elderly. There is also a need for more studies on the impact of interventions aimed at improving pain management in the older adults, including veterans. Such interventions must include all members of the healthcare team, veterans and their families.
From a broader perspective, pain management of the older adult remains poorly handled according to the literature. Many descriptive studies dating as far back as 15 years describe the under treatment of pain and the suffering endured by older people in hospital settings (Bowling & Braune, 1991; Ferrell et al., 1990). Today, that standard paradigm remains almost the same (Gibson et al., 2005). It is against ethical principles to let someone suffer unduly, especially when that person is in a vulnerable position and depends on others to obtain proper relief.
We now need to act to modify clinical practices, by transferring this knowledge to providers caring for older adults and particularly veterans, our population of interest, thus providing them with a better quality of life.