Original Article Barriers to Postoperative Pain Management in Hip Fracture Patients with Dementia as Evaluated by Nursing Staff ---

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From the Department of Nursing Science, University of Eastern Finland, Kuopio, Finland. Address correspondence to Maija Rantala, MNSc, RN, Department of Nursing Science, University of Eastern Finland, Kuopio campus, P.O. Box 1627, FIN-70211 Kuopio, Finland. E-mail: momaatta@student. uef.fi Received March 13, 2012; Revised August 17, 2012; Accepted August 17, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2012.08.007

Maija Rantala, MNSc, RN, P€ aivi Kankkunen, PhD, Tarja Kvist, PhD, and Sirpa Hartikainen

ABSTRACT:

This paper reports a study of the perceptions of nursing staff regarding barriers to postoperative pain management in hip fracture patients with dementia, their expectations, and facilitators offered by their employers to overcome these barriers. Patients with dementia are at high risk for insufficient postoperative pain treatment, mainly owing to inability to articulate or convey their pain experience. Nursing staff have an essential role in the treatment and care of patients who are vulnerable, and therefore unable to advocate for their own pain treatment. Questionnaires with both structured and open-ended questions were used to collect data from nursing staff members in seven university hospitals and ten city-center hospitals from March to May 2011. The response rate was 52% (n ¼ 331). According to nursing staff, the biggest barrier in pain management was the difficulty in assessing pain owing to a patient’s cognitive impairment (86%). Resisting care and restlessness among patients with dementia can lead to use of restraints, although these kinds of behavioral changes can point to the occurrence of pain. There were statistically significant differences between the sufficiency of pain management and barriers. Those who expected pain management to be insufficient identified more barriers than those who expected pain management to be sufficient (p < .001). Further updating education for nursing staff in pain detection and management is needed so that nursing staff are also able to recognize behavioral symptoms as potential signs of pain and provide appropriate pain management. Ó 2014 by the American Society for Pain Management Nursing Pain among individuals with dementia has recently become a topic of great interest (Kunz, Mylius, Scharmann, Schepelman, & Lautenbacher, 2009; Zwaghalen, Hamer, Abu-Saa, & Berge, 2006). However, these studies have been generally focused on assessment of pain in long-term settings (Prowse, 2006). There are very few studies on pain treatment in older persons with dementia (Scherder, Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 208-219

Barriers to Postoperative Pain Management in Patients with Dementia

Herr, Pickering, Gibson, Benedetti, & Lautenbacher, 2009), and only a few studies have been done in acute care settings (Brown, 2004; Prowse, 2006). Considerable numbers of patients who require hip fracture repairs suffer from cognitive impairment and dementia (Marottoli, Berkma, & Coone, 1992; Morrison, Magaziner, Gilbert, Koval, McLaughlin, Orosz, Strauss & Siu, 2003a; Sieber, Mears, Lee, & Gottschalk, 2011). Despite generally successful surgical treatment, hip fracture poses a major threat to life, mobility, and independence (L€ onnroos, 2009; Marottoli et al., 1992). An estimated 1.3 million hip fractures occurred worldwide in adults in 1990 (Gullberg, Johnell, & Kanis, 1997; Johnell and Kanis, 2004), with predictions of the numbers rising to 7.3–21.3 million by the year 2050 (Gullberg et al., 1997). A range of studies have supported the observation that acute pain is poorly detected and assessed, and therefore inadequately treated, in persons with cognitive impairment who have difficulties expressing their pain verbally (Macintyre, Schug, Scott, Visser, & Walker, 2010; Prowse, 2006). Effective pain management promotes effective mobilization and functional independence (Marotolli et al., 1992), with resultant decreased morbidity (Institute for Clinical Systems Improvement, 2008). Reliable pain assessment and effective pain treatment are considered to be complex in this population for many reasons (Prowse, 2006; Scherder et al., 2009). First, individuals with dementia gradually lose their ability to express pain, and second, existing comorbidities and polypharmacy make pain treatment complicated (Macintyre et al., 2010). Additionally, this complexity in pain management also reflects the fact that delirium is common (34%– 61%) following hip fracture (Bj€ orkelund, Hommel, Thorngren, Gustafson, Larsson, & Lundberg, 2010; Holmes & House, 2000), and dementia is the most important risk factor for delirium (Lindesay, Rockwood, & Rolfson, 2002). Delirium is a disturbance in consciousness and cognition, with rapid onset, fluctuating course, and underlying causation (Siddiqi, Hol, Britton, & Holmes, 2007), and it makes pain detection more challenging. Furthermore, severe pain, polypharmacy, and comorbidities include risk factors that are present in developing delirium (Siddiqi et al., 2007). These factors together pose extra challenges for pain detection, assessment, and treatment. The viewpoint of nursing staff is important, because their role is essential in treating postoperative pain in frail patients with an inability to express their pain and other needs clearly. Nurses act as advocates for patients and need to be proactive in ensuring that older people have adequate pain relief (Prowse, 2006). The purpose of the present study was to report the

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perceptions of nursing staff regarding barriers to postoperative pain management in hip fracture patients with dementia, their expectations, and facilitators offered by their employers to overcome these barriers.

LITERATURE REVIEW A systematic search of the Pubmed, Cinahl, and Cochrane databases for the period 2002–2010 was performed to develop the questionnaire. The following search terms were used: barriers, pain management, postoperative, acute, dementia, and older adults. In addition, the reference lists of retrieved articles were used to root out more papers and search terms. Only studies in English, Swedish, or Finnish were included. Inclusion criteria were studies and literature reviews including patients with dementia and an acute care setting. The search from Pubmed yielded 75 results, but 68 results were excluded on the basis of title and of the remaining seven, five studies were included (one article’s focus was not pain, and the other was not a study). The Cinahl database produced seven results, of which five were excluded on the basis of title and of the two remaining, one was a duplicate with the Pubmed search and the other was not a study. No results from the Cochrane database were found. Altogether five studies (Brown, 2004; Coker, Papanaioannou, Kaasalainen, Dolovich, Turpie, & Taniguchi, 2010; Herr, Titler, Schilling, Marsh, Ardery, Clarke, & Everett, 2004; Titler et al., 2009; Titler, Herr, K., Xian-Jin, Brook, Schilling, & Marsh, 2003) were included for the initial development of the instrument. It is important to identify barriers to pain management in hip fracture patients with dementia because it is well known that pain is undertreated in this population (Morrison et al., 2003a; Sieber et al., 2011). Several barriers to optimal pain management have been suggested in the literature as being categorized as caregiver-related, patient-related, and system-related barriers to pain management in hip fracture patients with dementia (Coker et al., 2010; Fox et al., 2004). In previous literature there have been identified some expectations on behalf of nursing staff, such as enhanced multiprofessional cooperation, updated education and adequate staffing to overcome these barriers (Fox, Solomon, Raina, & Jadad, 2004). The employer can facilitate the pain management in patients with dementia by providing working conditions where it is possible to provide qualified pain management (Schafheutle, Cantrill, & Noyce, 2001). The identification of nurses’ expectations and facilitators offered by employers in postoperative pain management in hip fracture patients with dementia could be used to develop strategies to improve pain management.

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Difficulties assessing pain in older people because of cognitive problems were cited by the greatest number of nurses as being a barrier to optimal assessment and management of pain in acute medical units, according to the study by Coker et al. (2010). Other patient-related problems included difficulties in pain assessment owing to sensory problems (Coker et al., 2010). Underdiagnosed and untreated pain may also contribute to increases in distressing behavioral symptoms in patients with dementia (American Geriatrics Society Panel on Persistent Pain in Older Persons [AGS], 2002; Brown 2004; Kovach, Noonan, Griffie, Muchka, & Weissman, 2001). The behavioral signs of pain are often misinterpreted; in such cases, psychotropic drug use can mask typical signs of pain and contribute to under-treatment of discomfort (Husebo, Ballard, & Aarsland, 2011). Additionally, in cases of severe dementia, behavioral signs of pain are not easy to recognize, i.e., behavior needed to be repeated several times and observed in the presence of the same caregiver before it was linked to pain (McAuliffe, Nay, O’Donnell, & Fetherstonhaugh, 2009). Experiences and expressions of pain in patients with impaired cognition are sometimes ignored by nursing staff (Brown, 2004). Coker et al. (2009) noted that other caregiver-related barriers include lack of knowledge, that physician’s reluctance to prescribe adequate pain relief for fear of overmedicating was seen to be a frequent barrier by 37% of the nurses, and that only 1% identified their own reluctance to give pain medication to older patients for fear of overmedicating as a frequent barrier. Careful documentation on behalf of nursing staff about pain is highlighted to guarantee the effective flow of information and continuity of appropriate pain treatment and analgesic administration. According to a review of 1,748 medical records of patients with hip fracture, analgesic administration was seldom followed by reassessment (Titler et al., 2009). Instead, when asking nurses working in acute medical units about the adoption of the opinion that ‘‘documentation on the effects of analgesics in older adults is important,’’ 51% had the opinion of always implementing and 47% sometimes implementing this evidence-based practice, although 92% agreed that it was the preferred method (Coker et al., 2010). Fox et al. (2004) identified several system-related barriers. These included lack of optimal team functioning, barriers to communication, and insufficient time. These barriers pointed to the need for institutional support for pain management. Institutional policies could be put in place that would prioritize pain management and help to overcome some of these barriers (Fox et al., 2004). A perceived lack of time for pain assessment and treatment represented typical barriers to

effective pain management (Bird, 2005; Brown, 2004; Coker et al., 2010; Fox et al., 2004). Multiprofessional team functioning is highlighted (Brown, 2004; Fox et al., 2004) because of the challenges to a more proactive treatment response in this vulnerable group (Scherder, 2009). In a study by Titler et al. (2003) about barriers to pain treatment for older adults hospitalized with hip fractures, nurses reported difficulties in contacting physicians and difficulties communicating with them about type and/or dose of analgesics, as the greatest barriers to pain management. Instead, nurses educated as pain experts were sufficiently available for consultation, and knowledge regarding pain medication was acceptable.

THE STUDY Aim The purpose of this study was to identify barriers to postoperative pain management in hip fracture patients with dementia. Additionally, the aim was to identify nurses’ expectations and facilitators offered by employers to overcome the barriers in pain management. The research questions were as follows: 1. What kind of barriers does the nursing staff identify in postoperative pain management among hip fracture patients with dementia? 2. How are the background variables of the nursing staff related to the identified barriers in pain management? 3. Which expectations and facilitators offered by employers does the nursing staff report as overcoming the barriers in postoperative pain management among hip fracture patients with dementia?

Design A cross-sectional questionnaire study design was used. In addition, open-ended questions were used to find the barriers, expectations, and facilitators offered by employers in postoperative pain management in patients with dementia. Questionnaire Development A systematic search of the literature was performed to develop the questionnaire. In the next phase in developing the questionnaire, and to improve the content validity for use in this study, the newly developed instrument was considered to be appropriate in terms of face validity, an important aspect of the usefulness of the instrument (Burns & Grove, 2009). The usefulness of the instrument was tested by collecting the professional opinions from an expert panel consisting of a pain expert in nursing science and, in the department of clinical pharmacology, two pain resource

Barriers to Postoperative Pain Management in Patients with Dementia

nurses and eight doctoral students in nursing sciences. As a result, some items were modified or deleted, and others were added, to garner a consensus in the content of the questionnaire. A pretest of the questionnaire was conducted in October and November 2010 with nursing staff in a surgical department that was not involved in the main study. Each participant received a folder that contained a participant’s information letter, questionnaire, and postage-stamped envelope. The nursing staff and one surgeon stated on a separate form that the items in the questionnaire were adequate and clearly expressed. A total of 27 questionnaires were distributed and 19 returned, a response rate of 70%. Minimal changes were made in light of the suggestions in the pilot test, and no items in the tool were eliminated or modified based on the pretest. An internal consistency for scale was derived by calculating Spearman correlation coefficients for individual items to the total scale and subscales (Burns & Grove, 2009). When calculating correlation coefficients for individual items to the total scale, there were three correlations of 0.626 and for facilitators offered by employers >0.701. The structured questions about nursing staff expectations and facilitators offered by employer were developed by the pain expert panel described above. Nursing staff have an essential role in pain management in patients with dementia who are unable to advocate their own care. So their expectations considering enhancing pain management produce valuable information. On the other hand, the employer has a pivotal role in organizing pain treatment in such a way that there are prerequisites for qualified pain management, e.g., by providing sufficient staffing and education about postoperative pain management in patients with dementia. Data Collection The survey was conducted from March to May 2011. The inclusion criterion were nursing staff working in surgical units from all university and city-center hospitals where the incidence of first hip fractures was >100 per year. Out of 17 eligible hospitals, altogether 634 nursing staff members treating 70% of all

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patients admitted to the hospital for hip fractures in Finland were canvassed. Of the 634 questionnaires distributed, 340 were returned. Nine were excluded because of no responses to the research questions, so in the final tally 331 questionnaires were analyzed, giving a response rate of 52%. A portion of the questionnaire presented in this paper consisted of four subareas: subarea 1, about nurse characteristics (gender, age, occupation, work experience in current unit and in health care, contract, employment arrangement, and shifts worked) and participation in updating education and the sufficiency of postoperative pain management in patients with dementia; subarea 2, exploring nursing staff’s perceived barriers to postoperative pain management (23 items); subarea 3, exploring their expectations for quality improvement in pain management (five items); and subarea 4, containing four questions about facilitators offered by the employer in pain management. The items were scored on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Ethical Considerations This study was approved by the hospital district of Northern Savo’s Committee on Research Ethics (permission no. 83/2010), and permission to conduct the study was obtained separately from each hospital according its individual procedures. Participation in the study was voluntary, and the nurses responded to the questionnaire anonymously. No one could be identified based on the results. Data Analysis Percentages were used to report the respondents’ characteristics. The normality of the distribution was analyzed by means of histograms. Because the data were normally distributed, and comparisons were performed between two or more independent samples, the two independent samples t test (for dichotomous variables) and analyses of variance (for analyzing differences between more than two samples) were applied. Statistically significant differences were defined as p < .05. Individual items were interpreted so that Likert 1 and 2 indicated disagreement, 3 neither agreement or disagreement, and 4 and 5 agreement. The open-ended questions were analyzed by qualitative content analysis by a principal researcher. The goal of the qualitative analysis was to allow a comprehensive description of perceived barriers, expectations, and facilitators offered by employers from the viewpoints of nursing staff. The analysis focused both on visible, obvious components, referred to as manifest content, and latent content, which meant dealing with relationship aspects and involved interpretation of the

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underlying meaning of the text (Garneheim & Lundman, 2004). The quantitative data were analyzed with the use of SPSS 17.0 for Windows (SPSS, Chicago, IL), and the qualitative data were analyzed using the qualitative data analysis and research software ATLAS.ti 6.2.25.

RESULTS Participants’ Characteristics and Other Background Information The participants were mostly female (96%), registered nurses (77%), and three-shift workers (82%). The median age was 43 (SD 11.53) years. Median work experience in their current unit was 7 (SD 9.42) years and in health care 15 (SD 10.9) years. Most of the participants were full-time workers (88%) and under permanent contracts (82%). One-half of the nursing staff (53%) thought that postoperative pain management was sufficient among patients with dementia. Only 6% of respondents had participated in updating education. Perceived Barriers to Postoperative Pain Management in Hip Fracture Patients with Dementia As presented in Table 1, the major barrier to postoperative pain management as evaluated by nursing staff in patients with dementia, was identified as difficulties in pain assessment owing to a decline in cognition (86%). Availability of pain experts (7%), nonpharmacologic pain relief measures available as supplements to analgesics (9%), and inconsistent instructions about the requested analgesics (13%) were not among the major barriers. Other barriers included insufficient documentation of the effects of analgesics (48%), difficulties assessing pain owing to hearing deficit (45%), and not knowing pain levels owing to inadequate time spent with patients with dementia (52%). More seldomly mentioned barriers as evaluated by nursing staff were nurses’ reluctance to give sufficient pain medication (23%), physicians’ reluctance to prescribe adequate pain relief (22%), and patients’ reluctance to take pain medication (30%) owing to fear of overmedication. There were basically no statistically significant differences (p > .05) in barriers to postoperative pain management in the background variables (hospital, age, working experience in current unit and in health care, occupation, contract, employment arrangement and work shifts, participation in updating education). Statistically significant differences were found between barriers to pain management and sufficiency of postoperative pain management (p < .001). Those

respondents who supposed pain management to be insufficient among patients with dementia identified more barriers (mean 2.8, SD 0.50) in pain management compared with those who thought that pain management was adequate (mean 2.6, SD 0.49). Nursing staff also reported their expectations regarding improving pain management (Table 2). They expected adequate staffing, updating education, consistent practices, guidelines, and enhanced multiprofessional cooperation. The facilitators offered by employers were mostly related to availability of updating education (46%) and implementation of new directions concerning pain management (54%). Almost one-half (47% disagreement) of the respondents considered lack of resources to be the main challenge in proportion of development of pain management to be the biggest challenge.

Other Barriers to Postoperative Pain Management in Patients with Dementia Most of the quotations referred to patient-related barriers in postoperative pain management in patients with dementia. When analyzing the openended questions, first a clear pattern of resisting care emerged. Patients with dementia are sometimes confused and may not understand the meaning of care procedures. This causes a patient to resist care, which can make treatment actions troublesome and analgesics administration challenging. Second, the patient does not always remember the information and instructions given, and as a consequence they are exposed to painful situations. For example, they may try to walk in spite of its being forbidden immediately after surgery. The association between pain and confusion was stated to be bidirectional, so that pain exposes confusion, and confusion in turn can add to the risk of painful situations. Additionally, patients with dementia often have coexistent diseases, and as a consequence they are exposed to polypharmacy. Problems with swallowing were also mentioned as being a barrier to analgesic administration. Table 3 summarizes the responses to the open-ended questions about patientrelated barriers to pain management in patients with dementia. The use of physical restraints was associated with situations where a patient resisted care and was restless. The staff recognized the emotional distress that restraints cause to patients and staff, but felt that without restraints there was a risk that some patients may rip out the intravenous cannula or epidural catheters, causing extra pain or cessation of pain medication. Insufficient time was given as a reason for mechanical restrictors in some comments:

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TABLE 1. Barriers to Postoperative Pain Management in Patients with Dementia (%)

Barriers associated with patients Pain detection and assessment Decline in cognition makes assessment difficulty Inability to identify pain Difficulties in assessing pain because of cultural differences Sensory problems Difficulties in assessing pain because of hearing deficits Difficulties in assessing pain because of visual deficits Attitudes Patients not wanting to bother the nurses or doctors Patients’ willingness to put up with pain Patients’ reluctance to take pain medications because of fear of overdosage Barriers associated with formal caregivers Analgesics administration Nurses’ reluctance to give pain medication for fear for overmedication Physicians’ reluctance to prescribe adequate pain relief for fear for overmedication Antipsychotics are considered before pain medications in restless patients Lack of knowledge about prescribing analgesics Documentation Insufficient documentation on effects of analgesics Lack of a documented pain treatment plan for each patient Attitudes Not knowing how much pain is acceptable to each patient Nonacceptance of pain reports by patients with dementia Barriers associated with system Lack of time Not knowing pain levels because of inadequate time spent with patients Inadequate time to deliver nonpharmacologic pain relief measures Lack of means and resources Unavailability of nonpharmacologic methods supplemental to pain medication Pain experts are not available for consultation Lack of common practices There is a lack of common practices in assessment of pain Not having policies for best practices about pain assessment and management Inconsistent instructions about the administration of requested analgesics

‘‘Giving medication can be difficult, patient resists IM injections, spits the tablets, or takes off intravenous cannula or epidural catheter if you don’t use restraints, e.g., magnet belts or ties with a strap. In the case of restless patients, there is not enough time to be guarding continuously; in such cases we are forced to use physical restraints. Patient who calls out all night restricted to magnet restraint—it’s very heartbreaking to hear.’’

Nursing staff viewed lack of time as being a barrier to high-quality care and pain management. As a consequence, they were worried about the continuity of medication and were forced to use movement restrictors in some case. Also, a restless environment was seen as a barrier to pain management.

n

Disagree

Neither Agree Nor Disagree

325 329 331

7 38 53

7 17 26

86 45 21

331 330

38 74

17 16

45 10

328 328 329

19 23 45

19 21 25

62 56 30

331 331

58 60

18 18

23 22

329 321

60 63

22 22

18 14

330 330

30 51

22 23

48 26

330 329

50 66

20 17

30 21

331 327

26 53

22 18

52 29

327 330

82 85

9 8

9 7

327 328 331

53 60 70

18 22 17

29 17 13

Agree

Caregiver-related barriers included attitudes such as trivializing the pain experience, and lack of empathic listening to cognitively impaired patients and family members. Other Expectations and Facilitators Offered by Employer for Pain Management Some nursing staff expectations were related to appropriate and sufficient analgesic administration. Guaranteeing continuity of pain management is challenging because the length of admission is short and patients suffer from many comorbidities. More updating education was wanted concerning the special characteristics of pain assessment in patients with dementia.

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TABLE 2. Responses of Nursing Staff About Expectations and Facilitators Offered by Employers for Pain Management in Hip Fracture Patients with Dementia (%)

Expectations Enhanced multiprofessional cooperation Updating education Consistent operational practices Guidelines for acute pain management Adequate staffing Facilitators offered by employer New directions are implemented satisfactorily Updating education is available Permanent chances are implemented without major difficulties There are sufficient resources for development of pain management

Facilitators offered by employers were mostly related to availability of consultation with anesthetists and nurses in charge of pain management. Other facilitators mentioned were cooperation and dealing with workplace experiences. Availability of updating education was also named, but some nursing staff mentioned that in practice it is not actually available for staff for many reasons, as mentioned in Table 4.

DISCUSSION The results indicated that a great majority (86%) of the nursing staff considered difficulties in pain assessment because of cognitive impairment in hip fracture patients with dementia to be a barrier to postoperative pain management. A similar finding was reported by Coker et al. (2010). Difficulties in pain assessment can point to the need to use different kinds of pain scales, which should be applied according to the degree of cognitive impairment. The strengths were availability of a pain expert’s consultation (85%), and clear instructions of requested analgesic administration (70%). The nursing staff reported that resisting care and restlessness among patients with dementia can lead to use of restraints, although these kinds of behavioral changes can indicate the occurrence of pain. Although the nursing staff identified several common pain behaviors (e.g., resisting care and confusion) classified by AGS (2002), it seems that these were actually not always associated with pain in practice. This finding concurs with the results of another study by McAuliffe et al. (2009) that behaviors needed to repeated several times and observed by the same caregiver before they were linked to pain. In cases of behavioral signs of pain, physical restraints were used in some cases. Before using restraints, it is

n

Disagree

Neither Agree Nor Disagree

Agree

324 326 324 324 323

1 2 1 1 5

5 5 6 6 12

94 93 93 93 82

326 328 324 327

17 30 38 47

29 24 37 29

54 46 25 24

necessary to make sure that there is sufficient analgesic administration, because multiple behavioral changes, such as restlessness, aggression, and resisting care (AGS, 2002), can be symptoms of pain. An individual with advanced dementia often uses behavior rather than specific verbal complaints to express the presence of symptoms such as pain (Kovach, Noonan, Schildt, Reynolds, & Wells, 2006). Use of restraints has negative impacts (M€ ohler, Richter, K€ opke, & Meyer, 2011) on individuals with dementia, increasing anxiety (Moore & Haralambou, 2007). This can lead to a vicious cycle, because the effect between pain and anxiety is two way. Anxiety is associated with higher postoperative pain intensity (Vivian, Abrishami, Peng, Wong, & Chung, 2009), and pain is associated with distributive and anxious behavior (AGS, 2002). Confusion, and as a consequence such symptoms as resisting care and aggression, which were mentioned as barriers to pain management according to the analysis of open-ended questions, can additionally be the symptoms of an acute confusional state, i.e., delirium. It is notable that it is difficult to make a clear distinction between delirium and dementia, and in many studies the terms are often erroneously used interchangeably (Fong, Sands, & Leung, 2006; Kamerow, 2007). Severe pain and inadequate analgesia are well known to increase the risk of delirium in cognitively intact patients (Morrison et al., 2003a). Additionally, barriers to pain management such as polypharmacy, comorbidities, and physical restraints, also mentioned in the open-ended questions, include risk factors that are present in developing delirium (Siddiqi et al., 2007). Because of the complexity of pain management in patients with dementia, a program of proactive geriatric consultation may reduce the incidence and severity of delirium (Siddiqi et al., 2007) and as

TABLE 3. Answers to the Open-Ended Question About Barriers in Pain Management

Patient-related barriers Patient does not understand that he/she has undergone surgery and resists care, e.g., by trying to rip the catheter out. Patient does not understand the meaning of care, so the caregiver has to change diaper or perform repositioning against patient’s will. Unfamiliar persons around, lack of confidence, and as a consequence patients are frightened and resist care. Physical restraints are used sometimes, when the patient is resistant to care and confused. Confusion is often misunderstood because undertreated pain is associated with confusion. Patient does not understand the instructions or is disoriented and does not remember to mind the operated leg. In some cases of applying femoral nerve block, the individual with dementia does not remember the movement restrictions and that the leg was operated on, as a consequence walks out, because the hip is not painful anymore. Many people have several medicines prescribed and they are often confused; it is very challenging to reconcile the pain medication, who knows the interactions of different combinations of medicines. Comorbidities are common / polypharmacy / interactions. Swallowing the analgesics is sometimes troublesome; in such cases the appropriate way to administer analgesics is to find alternative ways, e.g., by grinding the pills. System-related barriers Lack of time; there is shortage of staff; there is sometimes no possibility to check previous medication, only those prescribed in hospital, but if this is not enough? The lack of time causes, e.g., the use of restraint in restless patients, to prevent extra pain in case the patient tries, e.g., rip out the catheter or twiddle with her wound. Restless environment, rooms with many patients, women and men are placed in the same rooms. Confused patients are generally treated in bathrooms or in linen storages. There is a need for special units that are tailored for patients with dementia. Caregiver-related barriers The attitudes of staff are the biggest challenge; this includes diminishing the pain experience and ignoring the needs of patients with dementia and family members. The individuality of the patient should be respected.

Barriers (Manifest Content) Resisting care, restlessness

Themes (Latent Content) Unrecognized behavioral signs of pain, confusion  Additional risk in use of physical restraints  Causes extra risk of painful situations

Obliviousness and confusion

Coexistent diseases and concurrent medication

Polypharmacy and problems in swallowing  Difficulties in analgesic prescription and administration

Swallowing Lack of time

Risk to continuity of the medication, use of physical restraints

Restless environment, segregation

Increased anxiety, increased pain intensity

Attitudes

Barriers to Postoperative Pain Management in Patients with Dementia

Original Quotations

Pain experience is ignored  Insufficient pain management

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TABLE 4. Responses Regarding Expectations and Facilitators Offered by Employers for Pain Management Quotations Expectations for pain management Analgesics administration without delays. Regular, continuous analgesic administration, tailored to the patients. There is a need for sufficient medication before operation to prevent confusion, as a precaution to ensure qualified postoperative pain management.

Analgesic administration  without delays  regularly, continuously  before operation Surgery without delays Continuity of pain management in follow-up treatment Uniform instructions, in-service education Availability of pain experts, possibilities to consult doctors In-service education for pain experts, cooperation with peers, social support and discussions, dealing with best practices

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Best practice in pain management is surgery without delays; nowadays hip fracture patients have to wait for operation up to 2 days. How to guarantee the continuity of pain management in follow-up treatment, because the treatment period is typically only 1–2 days after surgery? There is a need for uniform instructions for pain management and inservice education about pain assessment in noncommunicative patients. Facilators offered by employer In our hospital it is possible to consult an anesthetist and two pain experts, if necessary. We have the opportunity to get acute pain management consultation 24/7, i.e., you can phone either the doctor responsible for pain medication or the nurse who is a pain expert in the hospital. We have one nurse as a pain expert and she tours in different units. In-service education, but it is mainly allocated for pain experts. There is updating education available, but we have no opportunities owing to lack of deputy personnel or time. Cooperation with all caregivers, social support, and discussion with peers. Dealing with experiences that have been used successfully.

Expectations/Facilitators

Barriers to Postoperative Pain Management in Patients with Dementia

a consequence undertreated pain in patients undergoing surgery for hip fracture. According to nursing staff the availability of pain experts for consultation (85%) was a major strength in pain management. Consultation with an anesthetist in case of problems was possible around the clock, and nurses who were pain experts were also available. This result contradicts earlier findings by Titler et al. (2003), in which nurses reported difficulties contacting physicians and difficulties communicating with them about type and/or dose of analgesics as the greatest barriers, but it concurs with the availability of nurses as pain experts, which was not reported as a problem for pain management among patients with hip fracture. The expectation of enhanced multiprofessional cooperation (94%) warrants further examination, because it contradicts the opinion of availability of pain experts for pain consultation. It may be that cooperation was seen more widely by nursing staff, because acute pain management for older people is an area where sharing of knowledge and resources between pharmacists, doctors, nurses, researchers, and the wider multidisciplinary team is essential, because no one discipline can achieve good pain management outcomes alone (Prowse, 2006). The complexity of postoperative pain management in patients with dementia who do not understand the instructions given is represented by the comment that ‘‘if [the] patient is confused and fully painless, the pain is not working anymore as a warning signal to painful situations and he/she can be exposed to painful situations.’’ Because patients with dementia are sometimes disoriented, it can lead to resisting care or trying to walk even though it is forbidden immediately after surgery, which causes more risk of extra pain. Moreover, the incidence of coexistent diseases in individuals with dementia is challenging owing to polypharmacy, which may increase the risk of interactions when administering analgesics (Macintyre et al., 2010). This can be the reason for the findings in this study of nurses reluctant to give pain medication (23%) and physicians reluctant to prescribe adequate pain relief (22%) for fear of overmedicating. In open-ended questions, nursing staff members mentioned certain pharmacologic pain treatment principles, such as analgesic administration without delays, regularitty, and continuity, to be among expectations for sufficient pain management among patients with dementia. According to newly developed guidelines, surgery without delays is the best analgesic for hip fractures (Griffiths et al., 2012). In the open-ended questions, there was a comment related to surgery without delays.

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The need for updating education and consistent operational practices were both among the major expectations (93%). Although a large number of international guidelines are available, Finnish nursing staff had the expectation of a need for consistent guidelines for acute pain management in patients with dementia, because no guidelines exist for nursing staff in Finnish. However, the existence of guidelines does not mean that they are implemented in practice, because according to international studies pain remains undertreated and the evidence-based guidelines are rarely followed (Coker et al., 2010; Grall, 2011; Morrison, Magaziner, McLaughlin, Orosz, Silberweig & Siu, 2003b; Titler et al., 2003). One option is to organize updating education where these guidelines are implemented in practice. According to the present study the updating education was available, but it was mainly directed to pain experts. Study Limitations One of the limitations was that pain management appeared to be a complex phenomenon, and the structured questions about barriers in pain management did not extensively explore the situation that the individual with dementia experiences and what the challenges are from the viewpoints of nursing staff regarding sufficiency of pain assessment and management. One potential limitation was the use of a newly developed instrument because no validated instruments were available. The analysis of open-ended questions produced new information on the topic of interest. Another possible limitation was the potential for systematic dropout of respondents. When testing the reliability of the scale, some low correlations in the ‘‘perceived barriers’’ subscale could reduce the reliability of that scale. Two of three items (willingness to put up with pain and not wanting to bother caregivers) where low correlations existed may not be suitable for this content, because this scale was developed for identifying barriers in pain management in the cognitively impaired at a stage of dementia. An additional limitation was the large numbers (up to 37%) of ‘‘neither agree nor disagree’’ opinions for some items on the questionnaire. The trustworthiness of qualitative content analysis always represents some level of interpretation (Graneheim & Lundman, 2004). Open-ended questions provided, in addition to barriers, expectations, and facilitators offered by employers, general information about the quality of care when treating patients with dementia in acute care settings. Some comments were not very informative, being as little as one word per quotation. In some cases, when analyzing the text, it was difficult to interpret in what way the comment was related to pain management. In the

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open-ended questions, it was also difficult to interpret the association between dementia and delirium, and in some cases there were doubts that these terms were used interchangeably.

CONCLUSION The complexity of reliable pain assessment and effective pain management in patients with dementia makes it challenging. There is a need for consistent guidelines and practices, multiprofessional cooperation, and updating education to enhance the treatment of pain in this vulnerable population and to overcome existing barriers in pain assessment and treatment. The major barrier to effective pain management was stated to be difficulties in assessing pain because of a decline in cognition. Updating education is needed about interpreting the behavioral signs of

pain, avoiding unnecessary suffering and using restraints in patients with dementia resisting care or being aggressive, and applying different kinds of pain scales according to the degree of cognitive impairment. Observations of key behaviors associated with postoperative pain in hip fracture patients with advanced dementia may result in better pain relief. The goal for future research is to learn whether targeted interventions for enhanced recognition of pain results in better patient outcomes in pain management, and learn the challenges in postoperative pain management in patients presenting with dementia or delirium. The findings of this study can also be used in practice and in further studies focusing on pain management among patients with dementia. In addition, the results can be used while developing acute pain–specific behavioral assessment strategies when dementia is present.

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Barriers to postoperative pain management in hip fracture patients with dementia as evaluated by nursing staff.

This paper reports a study of the perceptions of nursing staff regarding barriers to postoperative pain management in hip fracture patients with demen...
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