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Long-term Care

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Nurses tend to use individual behavioral and visual cues to assess pain in nursing home residents

One-fourth of nursing home residents who suffer from daily moderate-to-severe pain receive no pain-relieving medication. Nursing home staff rarely incorporate formalized pain assessment protocols in their assessment of residents' pain, which they consider regulatory in nature and ill-suited to the nursing home population. Instead, they use visual and behavioral cues honed from personal knowledge of each resident, according to a study by Katherine Jones, R.N., Ph.D., F.A.A.N., of the Yale University School of Nursing, and her colleagues. The study was supported by the Agency for Healthcare Research and Quality (HS11093).

The researchers analyzed discussions of 21 focus groups involving staff from 12 nursing homes. The discussions underscored the uncertainties of pain assessment and ambiguities of the pain experience. To overcome these ambiguities, nursing home staff used a variety of behavioral and visual cues to assess each resident's pain. Knowing a resident's usual behavior was central to identifying pain cues. However, pain cues were often complicated by challenging resident behaviors (family manipulation or desire for attention), generational attitudes about pain, such as stoicism, and fear of addiction to pain medication.

All levels of staff mentioned the physician as a critical person involved in meeting the pain-management needs of residents. Certified nursing assistants viewed their contributions as minimized by nursing staff and said that they were often reproved or ignored when they reported resident pain. As a result, some had lapsed into silent observation rather than pain relief advocacy.

Formal pain assessment protocols might identify pain missed by nurses' observations, note the researchers. They suggest that use of formal pain assessment protocols in nursing homes might improve if the protocols were refined to incorporate nurses' familiarity with pain cues and their awareness of residents' internal barriers to reporting pain.

See "Pain assessment practices with nursing home residents," by Lauren Clark, R.N., Ph.D., Dr. Jones, and Karen Pennington, R.N., M.S., in the November 2004 Western Journal of Nursing Research 26(7), pp. 733-750.

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