Frequency and type of chronic pain care approaches used for elderly residents in Japan and the factors influencing these approaches

Authors

  • Yukari TAKAI,

    Corresponding author
    1. Graduate School of Health Sciences, Tokyo Medical and Dental University, Tokyo and
      Yukari Takai, Graduate School of Health Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan. Email: yukagh@tmd.ac.jp
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  • Yoko UCHIDA

    1. School of Health Sciences, Faculty of Medicine, Gunma University, Gunma, Japan
    Search for more papers by this author

Yukari Takai, Graduate School of Health Sciences, Tokyo Medical and Dental University, Tokyo 113-8519, Japan. Email: yukagh@tmd.ac.jp

Abstract

Aim:  To assess the frequency at which various chronic pain care (CPC) approaches were used while managing older residents of the Health Service Facilities for the Elderly Requiring Care (HSFERC) in Japan and to assess the factors related to nurses and care workers that influence this care.

Methods:  A descriptive study design was used. The population comprised 31 nurses, 92 care workers, and 18 residents with chronic pain in eight HSFERC centers located in three provincial cities in Japan. A questionnaire was formulated by using the data collected by a literature review to assess the frequencies at which various CPC approaches were applied and the factors that might influence this care.

Results:  The most frequently preferred CPC approaches were gentle handling and support while providing daily care, listening attentively, and providing a recreational activity. The factors that affected the provision of CPC were the qualifications, years of experience of aged care, and experience of studying about chronic pain. The nurses tended to have a misconception regarding the manner in which the residents complained of pain and their pain sensitivity. Furthermore, organizational strategies for pain management were not reported by the nurses and care workers.

Conclusions:  In order to provide effective and active CPC, ongoing education about pain and cooperation between nurses and care workers to manage residents' pain are highly recommended.

INTRODUCTION

Under the Long-term Care Insurance System in Japan, Health Service Facilities for the Elderly Requiring Care (HSFERC) plays a unique role in providing daily care, education, and support to older residents who are expected to return home after hospitalization. The nurses and care workers who work in such facilities are expected to provide appropriate care and support to residents with various health problems.

Pain is a common experience among residents and can lead to serious problems for them. Older residents tend to have age-related osteoarthritis or spinal stenosis, which often leads to chronic and persistent pain. Moreover, such pain is known to lead to depression, greater disability (Schuler, Njoo, Hestermann, Oster & Hauer, 2004), anxiety, sleep disturbance (Cadogan et al., 2008), and a reduced quality of life (Zanocchi et al., 2007).

There has been some research exploring the prevalence of pain among elderly Japanese persons. Approximately 60–70% of the elderly living in the community suffer from pain (Akamine & Masaki, 2002; Kasai & Tajita, 2001). However, there has been no research to measure the prevalence of pain in Japanese nursing homes. Outside Japan, an increasing number of studies have explored pain prevalence in nursing homes. Studies using data from the Minimum Data Set (MDS) reported that ∼20–30% of residents suffered from pain (Reynolds, Hanson, DeVellis, Henderson & Steinhauser, 2008), compared to studies using the self-reports of residents and interviews, which reported a higher proportion (∼70%) of residents complaining of pain (Boerlage, van Dijk, Stronks, de Wit & van der Rijt, 2008; Tse, Pun & Benzie, 2005). This difference might be related to the method of data collection (Leong & Nuo, 2007).

The MDS needs information regarding the actual complaint of pain from residents and/or a careful pain assessment by caregivers to rate residents' pain. However, nurses and care workers sometimes point out that they cannot assess the pain of residents properly (Bergh & Sjöström, 1999). Often, it is reported that residents do not actively complain of pain because of various reasons (AGS Panel on Persistent Pain in Older Persons, 2002). These factors can lead to difficulty in assessing the pain of residents, which also can lead to a greater difficulty in managing their pain.

Pain management in nursing homes often is considered to be problematic because of numerous barriers. According to a previous study, such barriers can occur among health-care professionals, patients and family members, and health-care systems (Hanks-Bell, Halvey & Paice, 2004). Allcock, McGarry and Elkan (2002) found barriers in health-care systems such as an absence of written policy regarding pain management, standardized pain assessment tools, and specialist knowledge regarding pain management for residents in nursing homes. Another study found that nurses and certified nurse assistants experienced barriers such as a lack of time and unheard attitudes about residents' complaints of pain (Weiner & Rudy, 2002). However, there has been no research exploring the relationship between care provision and the factors related to nurses and care workers who work in facilities providing care for residents in Japan.

There is some research studying pain relief strategies for the elderly that has been carried out by nurses and other health providers. Nurses provided various strategies to manage chronic pain among the elderly such as medication, mediating contact with other health-care professionals, rest, and providing care in a gentle way (Blomqvist, 2003). Tse et al. (2005) reported that residents used pain relief strategies, including non-pharmacological treatments such as massage with analgesic ointment/oil, and they perceived them as very effective. However, there have been no research studies on pain relief strategies in nursing homes in Japan. Therefore, the purpose of this research was to assess the following: (i) the chronic pain care (CPC) approaches that were used by the nurses and care workers to alleviate pain or prevent the occurrence of pain in the residents of HSFERC centers in Japan; (ii) the frequency with which these approaches were used; and (iii) the factors related to the nurses and care workers that influenced CPC provision. The findings thus obtained may lead to suggestions for improving the CPC offered to such residents.

METHODS

Definitions

Chronic pain was defined as “. . . pain that has lasted 6 months or longer, is ongoing, is due to non-life threatening causes, has not responded to currently available treatment methods, and may continue for the remainder of the patient's life” (Dunajcik, 1999, p. 471).

Chronic pain care was operationally defined in this study as the care provided by nurses and care workers in an attempt to relieve and alleviate pain or to prevent the occurrence of pain in residents who are suffering from chronic pain.

Design, setting, and participants

A descriptive study design was chosen. Convenience sampling was used so that the directors of the HSFERC would agree to participate in this study. Eight facilities, located in three provincial cities in Japan, agreed to participate.

The participants of this study were the nurses and care workers who directly catered to residents with chronic pain at the participating HSFERC centers and the residents were those who experienced chronic pain and received care.

Japanese nursing qualifications recognize four categories: public health nurses, midwives, registered nurses, and certified practical nurses (Japanese Nursing Association, 2006). Registered nurses and certified practical nurses participated in the present study.

Those care workers that are recognized in Japan comprise certified care workers and home helpers of levels 1 and 2. Certified care workers accounted for most of the professional participants in this study. Certified care workers are professionals who have passed the State Examination for Certified Care Workers. They provide personal care, including assistance in bathing, meals, and other activities, and also provide care guidance to care workers (Ministry of Health, Labour and Welfare, n.d.). Care workers in Japan have various levels of education. Some have received a university education to become a certified care worker, while some of them only have completed a 3 month training program to be a home helper, level 2.

The residents were selected according to the inclusion criteria, as follows: (i) aged >65 years; (ii) experienced persistent pain for >6 months; (iii) cognitively intact and with the ability to communicate verbally; and (iv) provided consent to participate in this study. All the participating residents met these criteria.

We attempted to gather all the residents who might have been eligible to participate in this study. The staff members at the facilities, such as nurses, care workers, physical therapists, occupational therapists, and/or managers, were asked to provide the researchers with information about the residents. Those residents who had a new injury, whose condition was deteriorating, or who were admitted to hospital during this study were excluded from the study.

Data collection items

Nurses and care workers

The questionnaire that was administered to the nurses and care workers consisted of four parts. First, in order to explore their background, there were questions pertaining to the type of license, age, sex, working style, and educational experience with chronic pain. Those with aged care experience were asked to choose one from “less than 2 years”, “2 years”, “3–4 years”, or “5 years or more,” according to the developmental levels of nursing experience (Benner, 2001).

Second, the nurses and care workers were asked about the frequency of CPC provision to a selected resident in the last 4 weeks by rating it on a five-point Likert scale from 1 (never) to 5 (always). Information on CPC was collected by a literature review (Allcock et al., 2002; Blomqvist, 2003; Davis & White, 2001; Fukai, 2006; Herr & Mobily, 2004; Sato, Takahashi, Honma, Aizawa & Ikeda, 2005; Seomun, Chang, Lee, Lee & Shin, 2006; Takahashi, 2006; Tse et al., 2005). The definition of chronic pain in this study was given in the questionnaire. The nurses and care workers also were asked to write down any other CPC approaches they had used while administering care for the residents. For testing purposes, an example of the questionnaire was completed by the staff members at one of the participating facilities and at another two institutions prior to this study to ensure that the questionnaire was clearly written and explained.

Third, the nurses and care workers were asked about the possible factors that could influence CPC provision to the residents. They were asked to answer 10 statements including “The residents have no pain when they do not complain of pain”, “I have an ability to fulfill my own role regarding pain management”, and “Elderly people have lower pain sensation than younger people”. These questions were developed by using information collected by a literature review (Clarke et al., 1996; Davis, Hiemenz & White, 2002; Endo, Matushita, Imai, Nishiwaki & Hasegawa, 2003; Hanks-Bell et al., 2004; Hess, 2004; Molony, Kobayashi, Holleran & Mezey, 2005; Weiner & Rudy, 2002) and by using a four-point Likert scale, ranging from 1 (disagree) to 4 (agree). Three items were reverse-scored: 4 (disagree) to 1 (agree) (see Table 4).

Table 4.  Comparison between nurses and care workers regarding the awareness of residents' pain and pain care
BeliefNursesCare workersP-value
MedianMeanSDMedianMeanSD
  • *

    P < 0.05;

  • **

    P < 0.01;

  • ***

    P < 0.001 (Mann-Whitney's U-test). 1, disagree; 2, tend to disagree; 3, tend to agree; 4, agree.

  • †Reverse-scored items: 1, agree; 2, tend to agree; 3, tend to disagree; 4, disagree. NS, not significant.

Residents have no pain when they do not complain of pain32.900.9233.260.90*
There is adequate collaboration among staff members regarding pain management in our facility32.830.8332.710.93NS
I have an ability to fulfill my own role regarding pain management32.710.6422.430.74NS
Elderly people have lower pain sensation than younger people32.530.9033.130.86**
I have more than three pain alleviation skills2.52.360.9121.640.63***
I have an ability to alleviate residents' chronic pain22.290.6421.900.67**
I have adequate knowledge regarding chronic pain and chronic pain management22.170.8311.590.73**
I have an ability to distinguish between acute pain and chronic pain22.100.7011.500.64***
I am satisfied with my own care of residents' pain21.840.5221.770.68NS
There is insufficient time to treat residents' pain because of a heavy workload21.740.7322.050.89NS

The nurses and care workers were asked questions regarding the organizational factors that might influence CPC provision. These factors, identified by a literature review, were the existence of a guideline for pain assessment and/or management and recent participation in an in-service education program on pain (Allcock et al., 2002). The nurses and care workers also were asked about their perceptions regarding organizational strategies for reducing the incidence of falls among residents, as this could compare to pain management in the facilities.

Residents

Data on the residents, such as their age, sex, the care requirement level, diagnosis, and the length of institutionalization, were collected by the researchers from the residents' records. To measure the condition of the residents, as well as their activities of daily living (ADL), depressive state, and health-related quality of life, we used the Barthel Index, the 15-item Geriatric Depression Scale (GDS-15), and the Short-Form-36 Health Survey (SF-36 v2), respectively.

The Barthel Index was developed to measure functional independence in personal care and mobility (Mahoney & Barthel, 1965) and its applicability to the institutionalized elderly in Japan was shown (Kirino, Yajima, Nitta & Nakajima, 2003). The GDS-15 is a short-form interview battery and a score of ≥5 indicates possible depression (Wolters Kluwer Health, 2009). The SF-36 v2 was developed as an indicator of health status and covers six domains: physical functioning, role limitations, bodily pain, social functioning, general mental health, role limitation, and vitality and general health perceptions. Its applicability to the Japanese population has been shown (Fukuhara, Ware, Kosinski, Wada & Gandek, 1998).

Data collection procedure

The nurses and care workers were asked to choose one of the residents most familiar to them from the participating residents and to complete a questionnaire. The purpose and methods of the study were explained, either under the direction of a researcher and/or by the provision of written material to the nurses and care workers working at the participating facilities. If they agreed to participate in this study, they were requested to fill in a questionnaire, enclose the completed questionnaire in an envelope without revealing their name, and mail it to the researchers or put it in the box provided at the nursing station.

The residents who met the inclusion criteria also were informed of the purpose and methods of the study. After receiving written consent for participation from the resident, a researcher read each item of the questionnaire and filled in the answer of the resident. The researcher interviewed the residents by using the GDS-15 and SF-36. For the Barthel Index, the researcher directly observed the residents and also consulted the nursing home staff members in order to confirm the abilities of the residents in relation to ADL.

Data analysis

Descriptive statistical values were calculated. The association between the frequency of CPC and the characteristics of the nurses and care workers and the factors related to them were examined by using the χ2-test or Spearman's Rank Correlation. A significant association between the variables and the frequency of the item of care was tested by the two-sided Mann-Whitney's U-test to evaluate the differences between the pairs of groups. We adopted a significant probability as P < 0.05. All the statistical analyses were carried out by using SPSS version 15.0 J for Windows (SPSS, Tokyo, Japan).

Ethical considerations

A written consent form was obtained from the director of each facility. All the participants, including the residents, nurses, and care workers, were provided written material stating the purpose and methods of this study, the risks and benefits, the voluntary nature of participation, and the right to refuse or withdraw participation at any time during the study. A written consent form was also obtained from the residents. For the nurses and care workers, filling in a questionnaire and sending it to the researchers was taken as consent to participate. The data were handled confidentially and only used for this study. Gunma University Research Ethics Committee and the ethics committees of those participating facilities that had one, approved this study.

RESULTS

Participants

A total of nine units at eight facilities with 410 institutionalized residents and 188 nurses and care workers who worked in these units participated in this study. The response rate of the nurses and care workers was 69.7% (131 questionnaires were received). After eliminating those questionnaires with a substantial amount of missing data, 123 completed questionnaires were analyzed. Finally, 31 nurses and 92 care workers were included in this study. The ratio of nurses to care workers participating in the study was 1 : 3, which was the same as the ratio criteria for nurses and care workers under the Long-term Care Insurance System in Japan (Japan Association of Geriatric Health Services Facilities, 2007). Details of the nurses and care workers are shown in Table 1.

Table 1.  Characteristics of the participating nurses and care workers
CharacteristicTotal (n = 123)Nurse (n = 31)Care worker (n = 92)P-value
N%N%N%
  • **

    P < 0.01;

  • ***

    P < 0.001 (χ2-test). NA, no answer; NS, not significant.

Occupation      
 Nurse3125.2 
 Care worker9274.8 
License type      
 Registered nurse1310.61341.9 
 Practical nurse1814.61858.1 
 Certified care worker6754.56772.8 
 Home helper level 132.433.3 
 Home helper level 21512.21516.3 
 NA75.777.6 
Age (years)      **
 <252217.913.22122.8 
 25–293427.6412.93032.6
 30–393427.61341.92122.8
 40–491613.0825.888.7
 ≥50129.839.799.8
 NA54.126.533.3
Sex      ***
 Female9073.23096.86065.2 
 Male3326.813.23234.8
Aged care experience (years)      NS
 <22117.1412.91718.5 
 2129.813.21112.0
 3–42923.6825.82122.8
 ≥56048.81754.84346.7
 NA10.813.200.0
Experience of studying chronic pain      NS (0.056)
 Yes2520.31032.31516.3 
 No7359.31341.96065.2
 Unknown2117.1722.61415.2
 NA43.313.233.3

A total of 18 residents who met the study criteria agreed to participate in this study. The pain intensity of the residents was identified by using the SF-36 v2, which queried their pain during the previous 4 weeks. The number of residents who rated their pain as “very severe”, “severe”, “moderate”, “mild”, “very mild”, and “absent” was 1, 7, 5, 3, 2, and 0, respectively. The residents also had a tendency toward depression and ADL dependency. Details of the residents are shown in Table 2.

Table 2.  Background of the residents who received chronic pain care
CharacteristicResidents (n = 18)
  • Higher scores indicate higher health-related quality of life. ADL, activities of daily living; GDS, Geriatric Depression Scale; SF-36, Short Form-36 Health Survey.

Age: years, mean (SD)82.2(5.3)
Sex: N (%)  
 Female14(77.8)
 Male4(22.2)
Period of institutionalization: months, median8.0
ADL (Barthel Index; full score: 100): score, mean (SD)56.7(25.4)
Depressive mode (GDS-15; full score: 15): score, mean (SD)8.7(3.9)
Health-related quality of life (SF-36 v2; full score: 100)  
 Physical functioning: score, median5.0
 Role physical: score, median65.7
 Bodily pain: score, mean (SD)44.6(23.8)
 General health perceptions: score, mean (SD)40.4(19.3)
 Vitality: score, mean (SD)41.5(26.7)
 Social functioning: score, median50.0
 Role emotional: score, median100.0
 Mental health: score, median69.4
Level of bodily pain during the past 4 weeks (SF-36 v2): N (%)  
 Very severe1(5.6)
 Severe7(38.9)
 Moderate5(27.8)
 Mild3(16.7)
 Very mild2(11.1)
 None0(0.0)
Duration of pain experience: months, median84.0
Pain sites: multiple answers  
 Lower extremities14
 Upper extremities11
 Lower back9
 Chest2
 Back2
 Head1

Frequency of use of chronic pain care approaches

The most frequently used CPC approaches for the participating residents were “gentle handling and support when providing daily care” (mean [M] = 3.7, standard deviation [SD] = 1.3), “listening attentively” (M = 3.5, SD = 1.3), and “providing a recreational activity” (M = 3.0, SD = 1.2). The least frequently used CPC approaches were “administering an opioid analgesic” (M = 1.2, SD = 0.6), “using an alternative therapy” (M = 1.2, SD = 0.7), and “administering analgesics as needed” (M = 1.3, SD = 0.7) (Table 3). The Cronbach's alpha for the questionnaire that examined the frequency of CPC provision in this study was 0.86.

Table 3.  Comparison between nurses and care workers regarding the frequency of providing chronic pain care
Chronic pain care approachNursesCare workersP-value
MedianMean ± SDMedianMean ± SD
  1. Mann-Whitney's U-test; NS, not significant.

Using gentle handling and support when providing daily care43.7 ± 1.343.4 ± 1.3NS
Listening attentively33.5 ± 1.143.5 ± 1.3NS
Reporting the resident's pain to other professionals for analgesic medication33.1 ± 1.532.7 ± 1.5NS
Facilitating adequate rest when in pain33.0 ± 1.233.4 ± 1.4NS
Providing a recreation activity32.9 ± 1.233.1 ± 1.3NS
Transferring slowly and/or with several staff members32.8 ± 1.532.9 ± 1.5NS
Monitoring the side-effects of analgesic medication22.4 ± 1.411.9 ± 1.30.040
Changing the position of the resident when in pain32.3 ± 1.022.3 ± 1.3NS
Applying transdermal analgesic anti-inflammatory drug22.3 ± 1.322.4 ± 1.3NS
Educating the resident on the cause of pain or how to avoid pain22.3 ± 1.011.7 ± 0.90.006
Providing assistive devices22.2 ± 1.322.5 ± 1.6NS
Administering an analgesic suppository or applying analgesic ointment22.2 ± 1.511.7 ± 1.2NS
Maintaining a quiet and undisruptive environment21.9 ± 1.022.1 ± 1.1NS
Massaging11.9 ± 1.111.8 ± 1.1NS
Encouraging and teaching exercises11.7 ± 1.111.6 ± 1.0NS
Applying heat or cold compresses11.7 ± 1.011.4 ± 1.0NS
Seeking family support11.6 ± 0.811.7 ± 0.9NS
Administering a placebo medication11.5 ± 1.211.8 ± 1.3NS
Assisting the resident in bathing when in pain11.5 ± 0.911.4 ± 0.8NS
Using an alternative therapy11.4 ± 0.811.2 ± 0.6NS
Administering analgesics as needed11.2 ± 0.611.3 ± 0.8NS
Administering an opioid analgesic11.1 ± 0.011.2 ± 0.6NS

Some nurses and care workers reported CPC approaches other than those listed in the questionnaire. Four staff members stated that they “attempted to communicate more with the resident”. The other strategies included “helping this resident communicate with other residents”, “using more physical contact such as holding hands or massaging in the manner in which this resident's family member would have massaged”, “assisting this resident in consuming health drinks”, and “not provoking this resident who is easily prone to mood swings” (one answer each).

Factors affecting the provision of chronic pain care to residents

The association between CPC provision and staff characteristics or the barriers that might be related to the provision of care was examined. Six variables (qualifications, aged care experience, previous study of chronic pain, skills in pain alleviation techniques, ability to fulfill one's role in pain management, and a lack of time to provide pain management strategies) were mildly-to-moderately associated with the provision of CPC. A further statistical analysis was carried out by using the Mann-Whitney's U-test to evaluate the differences between the two groups.

First, the qualifications of the nurses or care workers significantly influenced the provision of “monitoring the side-effects of an analgesic medication” and “educating a resident about the cause of pain or how to avoid pain”; these approaches were more frequently used by the nurses than by the care workers (P < 0.05) (Table 3). Moreover, the number of nurses who stated that they had more than three pain alleviation skills, the ability to alleviate the chronic pain of residents, adequate knowledge about chronic pain, and the ability to assess acute and chronic pain was significantly higher than the number of care workers possessing these abilities (P < 0.05) (Table 4). In contrast, the number of care workers who disagreed with the notions that “the residents have no pain when they do not complain of pain” and “older people have lower pain sensation than younger people” was significantly higher than the number of nurses who disagreed (P < 0.05) (Table 4).

Second, the provision of some CPC approaches differed significantly between the staff members who had >3 years of experience in caring for the elderly and those who had <3 years of experience (P < 0.05) (Table 5, part 1), between the staff members who had previously studied chronic pain and those who had not (P < 0.01) (Table 5, part 2), between the staff members who were skilled at more than three pain alleviation approaches and those who were not (P < 0.05) (Table 5, part 3), between the staff members who thought that they possessed the ability to efficiently play a role in pain management and those who thought that they lacked this ability (P < 0.05) (Table 5, part 4), and between the staff members who believed that there was insufficient time to treat the pain felt by the residents and those who believed otherwise (P < 0.05) (Table 5, part 5).

Table 5.  Comparison of the frequency of providing chronic pain care by different variables
Variable NMedianMean ± SDP-value
  • *

    P < 0.05;

  • **

    P < 0.01;

  • ***

    P < 0.001 (Mann-Whitney's U-test).

1. 3 years of experience     
 Reporting the resident's pain to other professionals for analgesic medicationYes8633.0 ± 1.5*0.019
No3322.3 ± 1.4
 Monitoring the side-effects of analgesic medicationYes8622.3 ± 1.4**0.005
No3211.5 ± 1.0
 Administering an analgesic suppository or applying analgesic ointmentYes8112.0 ± 1.4*0.027
No3011.4 ± 0.9
 Seeking family supportYes8611.8 ± 0.9**0.007
No3211.3 ± 0.6
 Assisting the resident in bathing when in painYes8911.5 ± 0.9*0.031
No3311.1 ± 0.4
2. Study about chronic pain     
 Changing the position of the resident when in painYes2532.9 ± 1.2**0.009
No or unknown9422.2 ± 1.2
 Educating the resident on the cause of pain or how to avoid painYes2522.4 ± 1.0**0.002
No or unknown9411.7 ± 0.9
 Assisting the resident in bathing when in painYes2522.0 ± 1.3***<0.001
No or unknown9411.2 ± 0.6
3. To have more than three pain alleviation approaches     
 Monitoring the side-effects of analgesic medicationYes2032.6 ± 1.4*0.019
No9011.9 ± 1.2
 Educating the resident on the cause of pain or how to avoid painYes2132.4 ± 1.0**0.005
No9211.7 ± 0.9
 Applying heat or cold compressesYes2112.0 ± 1.3*0.030
No8911.4 ± 0.9
 Assisting the resident in bathing when in painYes2121.9 ± 1.0***<0.001
No9211.3 ± 0.8
 Using an alternative therapyYes2111.5 ± 0.9***0.001
No9111.1 ± 0.5
4. Efficiently playing my role in pain management     
 Using gentle handling and support when providing daily careYes5844.0 ± 1.2*0.026
No6143.4 ± 1.4
 Facilitating adequate rest when in painYes5843.3 ± 1.3**0.007
No6132.7 ± 1.2
 Monitoring the side-effects of analgesic medicationYes5822.4 ± 1.4**0.002
No5811.7 ± 1.2
 Administering a placebo medicationYes5612.0 ± 1.5*0.046
No6011.5 ± 1.0
 Encouraging and teaching exercisesYes5511.9 ± 1.1***0.001
No6011.4 ± 0.8
 Assisting the resident in bathing when in painYes5811.6 ± 0.9**0.002
No6211.2 ± 0.5
 Administering analgesics as neededYes5211.5 ± 1.0*0.011
No6211.1 ± 0.4
5. The lack of time for pain management     
 Using gentle handling and support when providing daily careYes9543.5 ± 1.4**0.006
No264.54.3 ± 0.9
 Reporting the resident's pain to other professionals for analgesic medicationYes9432.6 ± 1.5*0.020
No2533.4 ± 1.5
 Seeking family supportYes9411.6 ± 0.9*0.028
No2421.9 ± 0.9

The responses of the nurses and care workers with regard to organizational factors and the care system at their facility also were explored. Systematic strategies to prevent falling by residents were recognized by more than half of the staff in this study (94 participants, 76.4%). However, the existence of pain scales and pain management guidelines and recent participation in an in-service education program on pain were not recognized by most of the staff (Table 6).

Table 6.  Awareness of organizational strategies for pain management among nurses and care workers
StrategyYesNoUnknownNo answer
N%N%N%N%
Organizational strategies for reducing the incidence of falls among residents9476.464.91713.864.9
Recent experience of in-service education for pain32.411391.975.775.7
Availability of a pain management guideline21.63629.38165.943.3
Availability of a pain scale00.04133.37762.654.1

DISCUSSION

In this study, we used the data from nurses and care workers in eight HSFERC centers in Japan. We explored the frequency of CPC approaches for the participating residents and the factors related to the nurses and care workers that might influence the provision of care.

Most of the residents who received CPC from the nurses and care workers in our study reported moderate-to-severe pain. However, analgesic medication and alternate therapies that could alleviate the pain were not used frequently by the nurses and care workers. This might be because the data included responses from care workers. However, in Japan, care workers often need to provide medication to residents because no nurse is available at night (Hayashi, 2003). It could be said that residents might be at risk of severe pain and that health professionals should be aware that this could lead to serious problems for the residents.

Although the most frequent components of CPC for the residents were the provision of gentle daily care, listening attentively, and the provision of recreational activities, these seemed to have little direct and active effect in alleviating the pain of the residents. The application of these strategies might relate to the tendency of residents for severe ADL dependency and depressive status.

There could be various reasons for the low usage of pain medication in the facilities such as a difficulty in assessing the residents' pain, the cost of medications in the Long-term Care Insurance system, hesitation in using analgesic medication in the elderly, and insufficient knowledge about pain assessment and pain management among the staff. The combination of non-pharmacological and pharmacological management has been found to be extremely important (Registered Nurses Association of Ontario, 2007). Nurses and care workers need to select appropriate CPC approaches for residents. Accordingly, guidelines or checklists for pain management can be helpful in making decisions regarding pain care (AGS Panel on Persistent Pain in Older Persons, 2002; Registered Nurses Association of Ontario; The Australian Pain Society, 2005). The implementation of a guideline can lead to better pain management outcomes in nursing homes (Resnick, Quinn & Baxter, 2004). However, before adopting any available guidelines, Japanese nurses and care workers should be aware of the differences between countries in the role of nurses and in policies.

When the nurses were compared with the care workers in this study, the care workers tended to have a more appropriate understanding of the pain experienced by the older residents. The answers from the care workers regarding the pain experience of the residents were likely to be correct because there was no difference in pain sensitivity between the elderly and young persons (Kanner, 2001), and the hesitation of the residents in reporting pain was noted. The issue of the nurses experiencing difficulty in understanding the residents' condition has been noted in some studies in Japan (Harada, Tutumi, Nakatani, Nakao & Takano, 2005; Inaba, Huruya & Ogiwara, 2006). It might be because a small number of nurses need to take care of a large number of residents in the HSFERC. The findings of the present study also suggest that the lack of time seems to be an area of concern in the provision of CPC. Nurses might tend to focus on medical procedures or diseases and might not have enough time or skills to assess residents' pain. Nurses in the HSFERC might need more support.

There was a significant difference between the nurses and care workers in the frequency of practising some approaches, such as monitoring side-effects and educating the residents. This might be related to the difference in professional status between the nurses and care workers. However, there were far more care workers than nurses in the HSFERC centers and, in some of the facilities, no nurses were available at night. The monitoring of side-effects is important for older residents experiencing pain because of their higher frequency of adverse drug reactions (Horgas & Yoon, 2008). Therefore, close working coordination between the nurses and care workers in managing the pain in residents and the leadership of nurses in pain management are strongly recommended.

The more experienced staff provided more CPC for the residents in this study. Benner (2001) stated that nurses with >3 years of experience in similar fields could understand the situation of patients holistically and at a deeper level. Therefore, nurses with experience might be able to assess the condition of a resident more comprehensively. Less experienced staff might need support to manage the pain of residents (e.g. job orientation including a pain management lecture).

The nurses and care workers in this study stated that there were no pain management strategies, such as guidelines and pain scales, although there were organizational strategies for the prevention of falling among residents. Moreover, most staff members had not undergone an in-service education program regarding pain recently. The difference in organizational strategies for pain management and fall prevention might derive from the promotion of the “No Physical Restraint Campaign” in 1999 in Japan (Takasaki, Misutani, Mizuno & Takayama, 2005). This might have provided a strong impetus for facilities to manage residents' falls more effectively. Institution-wide approaches to pain management are extremely important (The Australian Pain Society, 2005). The issue of pain management in the HSFERC urgently needs to be explored in more detail.

This study has certain limitations. The number of nurses and care workers catering to HSFERC residents was small. Moreover, the number of residents that participated was also small. This was a result of one of the inclusion criteria of this study, which was that the resident should be able to communicate with the researchers; however, 93.5% of the HSFERC residents were suffering from dementia (Ministry of Health, Labour and Welfare, 2009). Therefore, it could be difficult to generalize our results. Furthermore, we focused on only 22 CPC approaches. There might be numerous other approaches that nurses need to practise such as strategies for pain assessment and the evaluation of the effects of care practises. Therefore, a further study is required to explore more comprehensive strategies of pain management at HSFERC centers.

CONCLUSIONS

In this study, we assessed the various CPC approaches that were used by the nurses and care workers at HSFERC centers in Japan and the possible factors influencing CPC. The most frequently used CPC approaches for the residents in this study included gentle handling and support while providing daily care, listening attentively, and offering recreational activities. The factors that affected the provision of CPC were qualifications, experience of aged care (≥3 years), and experience of studying about chronic pain. The nurses tended to have a misconception regarding the manner in which the residents complained of pain and their pain sensitivity. Furthermore, organizational strategies for pain management were not reported by the nurses and care workers. In order to provide effective and active CPC, ongoing education about pain and cooperation between nurses and care workers to manage residents' pain are highly recommended.

ACKNOWLEDGMENTS

We are extremely grateful to all the study participants, the directors and staff of the participating facilities, and Professor Misako Koizumi for extending support and advice during the study. This research was conducted as a part of a Master's thesis at Gunma University in Japan.

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