Methods: Data were collected from 12 nursing homes in Colorado. A total of 21 focus groups were held and attended by both nurses and nursing staff. Qualitative coding techniques were used for data analysis. The duration of each focus group was 1.5 hours. Three topics were discussed from a standardized agenda: 1) pain assessment, 2) pain treatments (pharmacologic and non-pharmacologic) and 3) any ideas for improving for pain-related knowledge in nursing homes. The coded transcripts were analyzed for themes according to cultural consensus theory.

Findings: Four themes were identified: 1) an underlying uncertainty in assessing residents' pain, 2) a reliance on a staff relationship-centered approach, 3) behavioural and visual cues that alert staff to pain and 4) resident characteristics important to assessment that included challenging behaviour and generational attitudes about pain and addiction. Nurses were uncertain in pain assessment due to their difficulty in disentangling the symptoms of physical pain from sadness, loneliness and depression. They overcame the ambiguities of residents' report of pain by relying on relationship-centered cues. Changes in residents' general behaviour sparked suspicion of pain, but nurses rarely asked about pain directly or used formal pain assessment. Pain cues were sometimes complicated by communication problems due to cognitive or other impairment, pain exaggeration or tolerance due to previous drug abuse, challenging behaviour such as attention seeking or family-manipulation, and generational attitudes such as stoicism and fear of addiction. Both nurses and certified nursing assistants agreed that physician's resistance to ordering pain medication is a critical problem with nursing home pain management.

Conclusion: The researchers note that one of the major limitations with reliance on behavioural cues and intuition in assessing pain is the time required to know the resident. They suggest that regular standardized pain assessment measures would identify pain that would otherwise elude nurses. Standardized pain measurement also has the advantages of being easily applied by new staff and would provide a quantified measure which can facilitate communication across caregiver categories. However, pain assessment measures may be more comprehensive if they acknowledge a relationship-based approach and incorporate the nurses' familiarity with the resident.

Reference: Clark, L., Jones, K., Pennington, K. (2004) Pain Assessment Practices with Nursing Home Residents. Western Journal of Nursing Research 26(7), 733-750.

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