Complexities of pain assessment and management in hospitalised older people: a qualitative observation and interview study.

BACKGROUND: Pain continues to be a common problem for older hospitalised patients, but little is known about how the complexities of actual clinical practice affect pain assessment and management in these patients.
OBJECTIVE: To examine how pain was assessed and managed in older patients who were admitted to geriatric evaluation and management units. DESIGN, SETTING AND PARTICIPANTS: A naturalistic observational research design was used involving observations of interactions between nurses and patients, and follow-up interviews with nurses. Three observation periods were conducted between midnight and midday, which commenced at 03:30, 07:30, and 10:30, and three observation periods were conducted between midday and midnight, which commenced at 15:30, 18:30, and 22:30. Between 12 and 13 observations were conducted for each observation period, each ranging from 2 to 3h. The study was undertaken in two units, each located in an Australian public teaching hospital. Participants included registered nurses employed in the units, and patients in their care.
RESULTS: Four major themes were identified: communication among nurses and between older patients and nurses; strategies for pain management; environmental and organisational aspects of care; and complexities in the nature of pain. Nurses tended to use simple questioning with patients about the pain experienced. Despite the availability of 'as required' opioid medication for breakthrough or incident pain, nurses often preferred to wait to determine if pain was relieved following administration of fixed-dose paracetamol. Time of day impacted on how pain was managed due to availability of nursing staff. It was unit policy for doctors to reduce medications prescribed, which often extended to analgesics, and nurses were left to deal with patient tensions in addressing analgesic needs. Complexities were associated with the nature of pain experienced, in terms of perceived level of tolerable pain, the simultaneous presence of chronic and acute pain, location of pain, and differentiation of pain from discomfort.
CONCLUSIONS: This study demonstrated the intricacies associated with how analgesic needs are addressed in older patients, especially those with communication deficits, the complex nature of older patients' painful experiences, and the precarious balance of attempting to treat pain effectively while avoiding adverse effects of analgesics.