Nurses Knowledge of Pain in the Elderly

Vol. 21 No. 4 April 2001 Journal of Pain and Symptom Management 317 Original Article Nurses Knowledge of Pain in the Elderly Rod Sloman, PhD, RN, Maureen Ahern, MHP, RN, Alex Wright, MappSc(res), RN, and Lynne Brown, MN(Hons), RN Faculty of Nursing, The University of Sydney, Sydney, New South Wales, Australia Abstract The purpose of this study was to investigate nurses knowledge of pain and pain management with respect to elderly persons. Registered nurses at several general hospitals and nursing homes were surveyed by questionnaire concerning their knowledge of pain management in the elderly. The findings indicated a significant knowledge deficit in this area. There were also significant differences in knowledge levels between general hospital nurses and those working in nursing homes. We conclude that more education about pain management in elderly patients is needed for nurses. This deficit needs to be addressed in both undergraduate nursing programs and hospital in-service courses. Presently, the majority of patients entering hospitals are aged 65 years and over. Hence, nurses in all areas of care, not just specifically those working in aged care facilities, need a sound knowledge of pain management of the elderly to facilitate compassionate and effective nursing care. J Pain Symptom Manage 2001; 21:317 322. U.S. Cancer Pain Relief Committee, 2001. Key Words Pain, aged, nurses Introduction Similar to other developed nations, Australia shares trends of an aging population and slowing of population growth. 1 Although Australia has been referred to as a young country, the Australian Bureau of Statistics documents an aging population. 2 There are two facts about this aging Australian population which remain unequivocal. The first is that the percentage of those over 65 years is continuing to increase. In 1976, 9% of the Australian population was 65 years and older. By 1996, this had increased to 12% and it is predicted that by 2016 the percentage will increase to 16%. 3 Secondly, the Address reprint requests to: Maureen Ahern MHP, RN, Faculty of Nursing, The University of Sydney, 88 Mallett Street, Camperdown NSW 2050, Australia. Accepted for publication: May 12, 2000. median age of the population will also increase steadily into the next millennium. 4 While many older Australians live active, healthy, and independent lives, many are reliant on some form of medication including pharmacological pain management strategies. 5 The occurrence of pain in the elderly has been documented in several American studies. 6 8 Nurses are the largest group of health care professionals to provide continuity of care to the aged in both the acute and community settings. In some cases, nurses are the first health professional to identify health problems in this group. They are also in the principal position of having to liaise with general practitioners. As nurses are directly responsible for providing interventions for pain relief, the assessment and management of pain by nurses caring for the elderly is a matter of great clinical importance. 9 Nurses caring for the elderly must have a sound knowledge of pain, its causes, manifes- U.S. Cancer Pain Relief Committee, 2001 0885-3924/01/$ see front matter Published by Elsevier, New York, New York PII S0885-3924(01)00248-2

318 Sloman et al. Vol. 21 No. 4 April 2001 tations, and relief strategies. They need to be able to assess pain in the elderly and be able to implement appropriate interventions for pain. It has been reported that most nursing research in this area has focussed on nurses attitudes to pain in the elderly rather than knowledge. 10 There is very little information available concerning nurses knowledge and skills in managing pain in the elderly. 11 The elderly report acute and chronic pain more frequently than do younger adults. 11 12 This is reflected in the fact that the elderly consume more analgesics than younger people. 13 The elderly suffer from more disorders and more chronic and disabling conditions. 14 They are also more likely to suffer from physiological degenerative conditions associated with pain, such as osteoarthritis. 15 The elderly are hospitalized more often and for longer periods of time than younger people and pain is one of the most common symptoms experienced by these patients. 16 Pain is also very common among elderly persons living relatively independent lives in the community. Many such elderly people suffer from arthritic disorders and resultant impaired mobility. 17 Other conditions such as chest pain, lower back pain, neck pain, abdominal pain, leg ulcers, hemorrhoids, neuropathic pain, and headaches are also prevalent among the elderly. 14 A British study surveyed 208 qualified nurses concerning their knowledge and experience of pain in the elderly. 11 The results of this study showed that there were differences in perceptions between acute surgical and geriatric nurses across a range of questions concerning pain responses in the elderly. Firstly, there was a clear lack of unanimity among the nurses about levels of pain experienced and the amount of requests for pain relief by the elderly compared to young adults. Secondly, there was considerable confusion and uncertainty regarding pain in demented elderly patients, and the nurses in the sample overrated the risk of respiratory depression in the elderly due to opioid medications. Other studies, which did not focus specifically on elderly patients, have also demonstrated a serious knowledge deficit among nurses concerning pain. For example, a survey of 318 Canadian nurses found that they lacked knowledge and understanding concerning the usage, properties, and effects of opioid medication for pain relief, as well as the differences in acute and chronic pain. 10 Furthermore, a survey of faculty from 14 baccalaureate schools of nursing in the United States found that nursing faculty were deficient in knowledge of pain management and that curriculum content relating to pain was less than optimal. 18 A review of 14 nursing textbooks published between 1985 and 1992 found that they almost all used confusing terminology and presented erroneous information concerning opioid addiction. The researchers concluded that there is an urgent need for change in nursing education regarding pain management. 19 A study of 119 registered nurses across four American hospitals found that they tended to underassess severe pain. It was concluded that the under assessment of pain is a serious problem in clinical practice and may reflect a lack of knowledge about pain, analgesic usage, addiction, and the risks of respiratory depression. 9 An Australian survey of 42 nurses concerning their knowledge and attitudes of pain management in four areas within a hospital setting yield findings similar to previous studies in North America, including a poor understanding of opioids and a subsequent underadministration of these drugs. The researcher concluded by stating the importance of education at the various institution levels. 20 The present researchers were unable to find any published Australian studies focusing on nurses knowledge of pain in the elderly. Such a study may suggest curriculum changes to educational courses for student nurses and better care and management of pain in the elderly. The current study was undertaken, therefore, in order to shed light on this area in an Australian context. Methods The aim of the study was to obtain baseline data concerning nurses knowledge and experience of pain and its clinical management in the elderly patient. The research questions were: How informed are nurses about pain and its management in elderly patients? Do nurses who work in different clinical specialty areas differ in their knowledge of pain in the elderly?

Vol. 21 No. 4 April 2001 Nurses Knowledge of Pain in the Elderly 319 Is there a relationship between the nurses level of experience and their knowledge of pain in the elderly? Sample A sample of 300 registered nurses (RNs) was obtained from a variety of randomly selected clinical areas within the Sydney metropolitan region. These areas included critical care, acute surgical, acute medical, community, psychiatric, oncology, general, nursing homes, and hospices (see Section A, Appendix). Only RNs involved in the care of elderly patients were included in the sample. The highest professional educational qualification of subjects was distributed as follows: hospital nursing certificate 29.5%, tertiary diploma in nursing 22.5%, bachelors degree 47.4%, and masters degree 0.6%. The average age of subjects was 38 years and there was an average of 14 years professional nursing experience. Of the respondents, 74.2% worked in general medical/surgical hospitals, 17.2% worked in nursing homes, and 8.6% were psychiatric nurses. These percentages reflect the national nursing workforce proportions. 21 There was a 58% response rate to the questionnaire. Of the respondents, 13.8% were males and 86.2% were females. Follow-up contact was not possible because hospital authorities saw it as an issue of coercion. A questionnaire response rate of around 60% is normal for nursing studies in Australia. This may reflect an attitude of indifference to nursing research by Australian nurses. 22 Instrument A questionnaire entitled Pain in the Elderly (see Section B, Appendix) was designed after a careful scrutiny of the literature in this area by the investigators. The instrument was tested for content validity with a panel consisting of nursing academics at The University of Sydney and Clinical Nurse Consultants, all of whom were specialists from the same type of clinical areas used in the study. In addition, a pilot study was conducted on 27 registered nurses enrolled in a nursing course at the University of Sydney. The pilot study further confirmed the instrument s content validity and ease of application. Cronbach alpha was used to determine internal consistency and was found to be 0.84. Procedure Following liaison with the selected clinical facilities, areas were identified within these facilities in which nurses regularly provide care for elderly patients. All registered nurses working in these areas were requested to participate in the study. The nurses were given the questionnaires, along with return addressed envelopes. In some cases these were distributed to the registered nurses by the hospital nursing administration and in other cases they were distributed directly by a research assistant. Results How Informed Are Nurses About Pain and Its Management in Elderly Patients? The number of true, false, and don t know responses to the knowledge questions in the questionnaire are shown in Table 1, along with the percentage of correct responses. Correct responses ranged from 41.1% for question 10 to 92% for question 2, with the overall average of correct responses being 71%. This result indicates a clear knowledge deficit. The average of correct responses for hospital trained nurses and those with a tertiary qualification was compared by the Student s twotailed t-test statistic, which failed to yield significance (P 0.7). However the sample sizes of the comparison groups were different (n 51 compared to n 123). This could have influenced the observed trends. Do Nurses Who Work in Different Clinical Specialty Areas Differ in Their Knowledge of Pain in the Elderly? The specific areas in which the nurses worked were also found to be significant regarding knowledge of pain management in the elderly. The chi-square results for area of work produced a significant result for each item on the questionnaire (P 0.001). The average of correct responses for each clinical area was compared by t-test and multiple comparison of means and the General group was found to be significantly less knowledgeable than the Palliative Care (P 0.001), the Acute Surgical (P 0.001), and the Aged Care (P 0.05). Figure 1 shows the average of correct responses for each clinical area. It can be seen that those nurses who worked in the area of palliative care gained the highest scores for knowledge of

320 Sloman et al. Vol. 21 No. 4 April 2001 Table 1 Items Used in the Questionnaire to Test the Nurses Knowledge of Pain in the Elderly Showing the Distribution of Responses and the Percentage Who Answered Correctly Question True False Don t Know Correct Answer 1. Pain is a natural accompaniment of the aging process. 42 122 10 69.7% 2. Elderly people experience pain less intensely than young adults. 6 162 7 92.6% 3. Elderly people report pain more often than young adults. 53 110 12 62.9% 4. Research literature suggests that pain in the elderly is commonly under treated. 123 8 45 70.3% 5. Cultural factors influence the expression of pain symptoms. 157 12 6 89.7% 6. The demented elderly patient experiences more pain than the lucid elderly patient. 9 123 32 70.3% 7. The assessment and diagnosis of pain in the elderly is primarily the role of the doctor. 17 155 3 88.6% 8. The goal of pain management for the elderly is to maintain the patient in a pain-free state. 150 20 4 85.7% 9. Strong opioids used for pain control, e.g. morphine, are likely to produce addiction in elderly patients if administered in large amounts. 42 115 18 65.7% 10. It is best to avoid giving strong opioids for pain to frail elderly patients because it can cause respiratory depression. 84 72 19 41.1% 11. It is better to administer opioid analgesia on a prn basis rather than as a fixed schedule. 50 106 19 60.6% 12. Analgesic medication is more effective in controlling pain in young adults than in elderly patients. 18 126 31 71.0% 13. The duration of a given analgesic medication is greater in an elderly person than in a young adult. 41 92 41 52.6% 14. The potency of the pain relief measure selected for the patient should be based on the source of the pain rather than on the patient s report of pain intensity. 34 128 13 73.1% pain in the elderly while those who worked in General wards scored lowest. Is There a Relationship Between the Nurses Level of Experience and Their Knowledge of Pain in the Elderly? Differences in the proportion of responses to each question by years of nursing experience were assessed using the chi-square test for related samples. The results for each question showed years of nursing experience to be a significant factor, with a P 0.001 in each case. As might be expected, the greater the years of nursing experience, the more likely the nurse would be to answer the question correctly. Fig. 1. Average percentage of correct responses per clinical area. Discussion The main finding of this research showed that there was a significant deficit in knowledge regarding the experience of pain and its management in the elderly in the sample of registered nurses who were surveyed. This finding was, of course, based on a relatively small sample of registered nurses (n 174) all of whom were drawn from the Sydney metropolitan region. Thus, it is probably invalid to attempt to generalize the finding to the whole population of Australian nurses who work with the elderly. Nevertheless the findings warn of the possibility that nurses may be inadequately educated in the management of pain in elderly patients. A national crossectional survey would probably yield more definitive information. Pain management is, of course, addressed in the undergraduate curricula of nursing faculties in Australian universities. Pain is, however, rarely taught as a distinct subject; rather it tends to be integrated into other areas of clinical focus. As such, it is difficult to ascertain how many hours of learning the undergraduate student receives concerning pain and its management. This is also true for aged care nursing, as many schools follow a life-span integrated curriculum. The extent to which nursing undergraduates engage in learning about pain in the elderly is, thus, impossible to speculate on with any degree of accuracy. Nurses whose main area of clinical experience was in palliative care were found to score higher in knowledge of pain management in

Vol. 21 No. 4 April 2001 Nurses Knowledge of Pain in the Elderly 321 the elderly. They, of course, specialize in symptom management and many of them would have attended seminars on pain management, although none of the respondents indicated that they had within the last two years. The lowest scoring group was the nurses who worked in general wards. The nurses in this area obtained significantly lower scores for pain knowledge than the nurses who worked in palliative care, acute surgical, and aged care. The number of years of clinical experience as a registered nurse was found to be predictive of the nurse s knowledge of pain in the elderly. The more experienced the nurses were in working with elderly patients the higher they scored in knowledge of pain reactions and pain management in these patients. This it seems supports the popular view that there is no teacher like experience. Knowledge and practice require each other. The delivery of effective pain management to our elderly patients requires theoretical understanding combined with clinical experience. Conclusion The findings of this study support the literature in showing a significant knowledge deficit regarding pain and its management in the elderly. Knowledge levels differ significantly between various clinical specialty areas, with nurses who work in palliative care being the most well informed. There is a positive relationship between years of nursing experience and knowledge of pain in the elderly. There is a need for a more comprehensive study focusing on how nurses acquire knowledge of pain responses and pain management, how they assess pain, and what techniques they use to relieve pain in the elderly patients. It would also be useful to investigate the extent to which pain is addressed in undergraduate nursing courses in Australian universities. Acknowledgments This study was financed by The University of Sydney Research Grant Scheme. Special thanks to Mr. Kerry J. Atkins for assistance with data collection and analysis. References 1. Martin LG. Population aging policies in East Asia and the United States. Science 1991;251:527 531. 2. Australian Bureau of Statistics. Australian demographic trends 1997. Canberra: Australian Government Publishing Service, 1997. 3. Australian Institute of Health and Welfare. Australia s health: the sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: AIHW, 1998. 4. Davis JD. Older Australians. Sydney: Saunders, 1994. 5. Leeder SR. Healthy medicine: challenges facing Australia s health services. Sydney: Allen & Unwin, 1999. 6. Hall WJ. Update in geriatrics. Ann Intern Med 1999;131:824 849. 7. Miaskowski C. Pain and discomfort. In: Stone JT, Wyman JF, Salisbury SA, eds. Clinical gerontological nursing: a guide to advanced practice, 2nd ed. Philadelphia: Saunders, 1999:647 663. 8. Engberg SJ, McDowell J. Comprehensive geriatric assessment. In: Stone JT, Wyman JF, Salisbury SA, eds. Clinical gerontological nursing: a guide to advanced practice, 2nd ed. Philadelphia: Saunders, 1999:63 80. 9. Zalon ML. Nurses assessment of postoperative patients pain. Pain 1993;54:329 334. 10. Hamilton J, Edgar L. A survey examining nurses knowledge of pain control. J Pain Symptom Manage 1992;7:18 26. 11. Closs SJ. Pain and elderly patients: a survey of nurses knowledge and experiences. J Adv Nurs 1996;23:237 242. 12. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc 1990;38:409 414. 13. Rumble RH, Morgan K. Longitudinal trends in prescribing for elderly patients: two surveys four years apart. Br J of Gen Pract 1994;44:571 575. 14. Walker J. Pain in the elderly. In: Carroll D, Bowsher D, eds. Pain: management and nursing care. Oxford: Butterworth-Heinemann, 1993:90 99. 15. Masi AT, Medsger TA. Epidemiology of the rheumatic diseases. In: McCarty DJ, ed. Arthritis and allied conditions: a textbook of rheumatology. 11th ed. Philadelphia: Lea & Febiger, 1989;16 54. 16. Closs SJ. Pain in elderly patients: a neglected phenomenon? J Adv Nur 1994;19:1072 1081. 17. Brodie LJ, Sloman RM. Changes in health status of elderly patients following hip replacement surgery. J Gerontol Nurs 1998;24:5 12. 18. Ferrell BR, McGuire DB, Donovan MI. Knowledge and beliefs regarding pain in a sample of nursing faculty. J Prof Nurs 1993;9:79 88.

322 Sloman et al. Vol. 21 No. 4 April 2001 19. Ferrell BR, McCaffery M, Rhiner M. Pain and addiction: an urgent need for change in nursing education. J Pain Symptom Manage 1992;7:117 124. 20. Heath DL. Nurses knowledge and attitudes concerning pain management in an Australian hospital. Aust J Adv Nurs 1998;16:15 18. 21. Australian Bureau of Statistics. Australia Now A statistical profile: health and the health workforce. Canberra: Australian Government Publishing Service, 1999. 22. Wright A, Brown P, Sloman R. Nurses perceptions of the value of nursing research for practice. Aust J Adv Nurs 1996;13:15 18. Section A Appendix Pain in the Elderly Questionnaire Age Gender: female [ ] male [ ] How many years have you been a Registered Nurse? What is your highest completed nursing qualification? hospital certificate [ ] tertiary diploma in nursing [ ] bachelor degree in nursing [ ] master degree in nursing [ ] doctoral degree in nursing [ ] Which of the following areas of nursing best describes the area in which you work? critical care [ ] general [ ] acute surgical [ ] aged care [ ] acute medical [ ] hospice [ ] community [ ] Administration [ ] psychiatric [ ] nurse education [ ] oncology [ ] Other Have you attended educational sessions on pain management during the last two years? Yes [ ] No [ ] Have you had much experience managing pain in the elderly? Yes [ ] No [ ] Do you have a post-basic qualification in gerontological nursing? Yes [ ] No [ ] Section B (Please read these statements and check your response.) True False Don t Know 1. Pain is a natural accompaniment of the aging process. 2. Elderly people experience pain less intensely than young adults. 3. Elderly people report pain more often than young adults. 4. Research literature suggests that pain in the elderly is commonly under treated. 5. Cultural factors influence the expression of pain symptoms. 6. The demented elderly patient experiences more pain than the lucid elderly patient. 7. The assessment and diagnosis of pain in the elderly is primarily the role of the doctor. 8. The goal of pain management for the elderly is to maintain the patient in a pain-free state. 9. Strong opioids used for pain control, e.g. morphine, are likely to produce addiction in elderly patients if administered in large amounts. 10. It is best to avoid giving strong opioids for pain to frail elderly patients because it can cause respiratory depression. 11. It is better to administer opioid analgesia on a prn basis rather than as a fixed schedule. 12. Analgesic medication is more effective in controlling pain in young adults than in elderly patients. 13. The duration of a given analgesic medication is greater in an elderly person than in a young adult. 14. The potency of the pain relief measure selected for the patient should be based on the source of the pain rather than on the patient s report of pain intensity.