Measures to Improve Nurses' Pain Management

Pain is the most common medical issue that older people face in a long-term care facility. Registered nurses have a critical role in helping residents manage their pain. This research looked at measures to improve pain management practices in long-term care facilities in Ontario. The site for this research was a chosen long-term care facility in Ontario, Canada, a 160-bed nursing home for the elderly that provides various nursing and medical care services. Semi-structured focus group interviews lasting about an hour were done. This study's population consisted of 45 nurses. The researcher chose a sample of 25 registered nurses using a purposive sampling strategy. The data was reviewed using qualitative data analysis to detect recurring concerns. This research revealed the necessity of identifying measures to improve pain management and reinforcing good practices in long-term care homes; better pain management practices are necessary to manage pain in a long-term care home. This study demonstrated the importance of recognizing and overcoming measures to improve pain management and reinforce good practices in long-term care homes. Therefore, improved measures to improve pain management practices are required to manage pain in a long-term care home effectively. Education about safe pain management will help to prevent the undertreatment of pain and its negative consequences. The overall benefits of measures to improve pain management practices in long-term care homes expand nurses' clinical knowledge in the care of residents living in nursing homes.


INTRODUCTION
Almost everyone experiences pain at some point in their lives.Pain is frequently classified as either acute or chronic.Acute pain, such as postoperative pain, fades as healing occurs.Chronic pain is long-lasting and can be classified as cancer-related pain or non-malignant pain, such as arthritis, low-back pain, and peripheral neuropathy.The author drew on the body of knowledge concerning chronic pain; however, this study focused on the evidence supporting measures to improve nurses' pain management in Long Term Care homes (Wells et al., 2008).According to Wahdaniyah et al. (2023), physical conditions that residents undergoing chemotherapy may experience include pain, allergies, hair loss, weakness, and decreased appetite.Pain is a feeling created by an injury or damage to any area of the human body.It is caused by four processes: transduction, transmission, perception, and modulation (Urden et al., 2013).Pain management minimizes the afflicted person's pain experience or reduces pain to a bearable degree.Effective pain treatment comprises both pharmaceutical and non-pharmacologic nursing methods.Multidisciplinary efforts are required; nonetheless, nurses play a significant and complex role in pain treatment in long-term care homes and hospitals (RNAO, 2013).Multidisciplinary efforts are required by nurses and other healthcare professionals to deal with pain (RNAO, 2013).Nursing interventions such as continuous assessment of the effect of pain treatment, standardized pain assessment, and the proper use of pharmacological and non-pharmacological pain relief strategies are the foundations of effective pain management (Saslansky et al., 2014).Long-term care residents need access to adequate pain treatment.Nurses must have the correct attitude, beliefs, and abilities to deliver excellent pain treatment.

Background of the Study
Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional result of tissue damage (Saslansky et al., 2014).As a result, building efficient pain management pathways is crucial to improving pain management and providing proper nursing care.This may be performed by determining the nurses' perception of the older person's pain expression and pain treatment components in a long-term care facility.There is strong and incontrovertible evidence that the Canadian population is ageing at an unsustainable pace compared to present social and healthcare services (Fleckenstein, 2013).According to (Statistics Canada, 2013), the fastest-growing age group is senior citizens (65 and above).In 2011, five million Canadians were 65 years old or older (Statistics Canada, 2013) this number of elderly Canadians is predicted to quadruple over the next 20 years.By 2051, about one out of every four Canadians would be older than 65 (Statistics Canada, 2013).
Nurses are the primary healthcare professionals in Ontario's long-term care home facilities (Busby & Robson, 2013).Adequate pain management knowledge and comprehension and clinical decision-making based on research data are therefore required to improve nursing practice and promote good health outcomes in Ontario's long-term care home settings (Busby & Robson, 2013).Furthermore, the complex health needs of older people in long-term care homes necessitate nurses with specific pain management competence, as well as reliable assessment and clinical decisionmaking skills, to care for older people who may require healthcare but are unsure how to meet their health needs (Busby & Robson, 2013).Inadequate sleep can cause agitation, delirium, distraction, and pain sensitivity, which can exacerbate pain intensity.As a result, the relationship between pain and sleep quality continues to be triggered (Kocasli et al., 2023).Inadequate sleep can cause agitation, delirium, distraction, and pain sensitivity, which can exacerbate pain intensity.As a result, the relationship between pain and sleep quality continues to be triggered (Kocasli et al., 2023).Furthermore, although healthcare delivery is vital, there may be a persistent obstacle to pain treatment among the elderly's health demands (Busby & Robson, 2013).
Many seniors in long-term care homes have several diseases, such as drug misuse, physical problems, and mental health issues.These people usually originate from areas with inadequate health promotion and illness-preventive practices due to a lack of knowledge and low finances (Statistics Canada, 2013).Furthermore, a broad collection of people, including a multi-professional group, are directly or indirectly involved in pain management in long-term care facilities.Nurses take the lead in pain treatment in long-term care homes compared to other multidisciplinary team members.This is due to nurses being close to residents.They are in a position to reduce pain and increase comfort by evaluating and creating pain-relieving care methods, recording, and monitoring (Almost, et al., 2013).Nurses also provide emotional and personalized care to elderly residents in long-term care institutions.In high-stress circumstances, nurses coordinate care by sending older individuals to pain management specialists or doctors (Almost et al., 2013).

Purpose of the Study
This research aimed to look at measures to improve pain management practices in Ontario long-term care facilities.This study also looked into nurses' perspectives on ways to improve pain management in long-term care homes.

METHOD
In this study, a qualitative research technique was applied.The research methodology outlines the study's design, sampling, and sample characteristics.Additionally, the tools, data-collecting procedures, and analytic methods utilized to meet the research goals of this study are presented.The research used a qualitative approach, including nonexperimental, exploratory, and descriptive methodologies.The research methodology is a scientific strategy for addressing a problem that comprises a method for designing the study and acquiring and evaluating data (Baybutt & Chemlal, 2016).According to Birchenall and Adams (2014), the research methodology educates the reader on how the study was performed; in other words, what the researcher did to discover answers to the research issue or answer the research question.The qualitative research approach was suited for this study since it sought to comprehend measures to improve pain management for older people in long-term care homes.

Research Design
A research design is a collection of plans or recommendations for carrying out research or the basics of carrying out a study (Polit, Beck, & Polit, 2016).A non-experimental, qualitative, exploratory, and descriptive design was used in this investigation.The experimental design is a method of comprehending and being aware of a situation, community, person, or phenomenon under study (Brink, Van der Walt, & Van Rensburg, 2014).To convey a picture of a particular circumstance, social location, or connection, the descriptive design focused on 'how' and 'why' inquiries (Brink, Van der Walt, & Van Rensburg, 2014).The study used a qualitative, exploratory, descriptive research approach.

Research Setting
The selected long-term care facility has 160 beds and offers 24-hour nursing and personal care and access to the family doctor and other health specialists.Since its inception in 2004, the chosen long-term care facility has given nursing services to the elderly.In addition, it provides a versatile and pleasant living setting.

Sampling and Sample
Sampling refers to the selection of certain participants in studies from the overall population and the process used to generate a sample (Babbie & Mouton, 2012).Because of the qualitative character of this study and the necessity to acquire detailed information related to the research questions and goals, the researcher picked study participants using a non-probability sampling method.The sampling technique utilized was non-probability sampling, defined as any sort of sampling in which the items or participants chosen are not decided by the statistical concept of randomness (Baybutt & Chemlal, 2016).A vital element of the non-probability sampling approach is that samples are carefully picked depending on the researcher's subjective judgement.Therefore, participants for this research were chosen using non-random approaches using purposeful sampling.

Data Collection
According to Silverman (2015), data are gathered to understand the participants' experiences better and document the interpretations that participants have created of their experiences.The researcher utilized a semi-structured data collecting technique, such as focus groups, to lead the data collection method, implying that only broad recommendations were used to steer the data collection method.This strategy is justified because it allows for more in-depth, substantial, and deliberate replies.Experiences are no longer primarily dependent on predetermined responses, and they are appropriate for descriptive investigations due to the abundance of different information they present (Silverman, 2015).The data was acquired with the assistance of a scriber who made notes on all replies so that the researcher could conduct the focus group discussion.Participants provide meaningful self-disclosure in an ideal focus group interview and effectively analyse their experiences (Cottrell, 2014).According to Polit, Beck and Polit (2016), group interviews establish meaning when participants participate in conversations and a substantial amount of engagement on a topic in a short period.They also argue that the focus group interviews are high quality since participants can voice their opinions.The conversations highlight parallels and variations in the members' viewpoints on a particular subject.

Ethical Considerations
The research was approved by the University of South Africa's College of Human Sciences Research Ethics Review Committee (HSHDC/739/2017).The study adhered to the Code of Ethics for Human Subjects Research.The long-term care home administration and all participants signed a written agreement.Participants were also assured of their anonymity and confidentiality.The researcher obtained approval from all key stakeholders, including UNISA's CREC and the longterm care home (research setting).Before data collection began, all participants provided written, informed consent.Furthermore, participants were informed that they could withdraw from the study at any time without penalty.Participants were given codes throughout the data collection process to ensure anonymity and confidentiality.Research ethics comprises concepts, norms, and values that guide proper behaviour in research choices (Babbie & Mouton, 2012).It may also relate to applied ethics, which attempts to preserve study participants' well-being (Terre Blanche, Durrheim, & Painter, 2014).Furthermore, Saldana (2014) asserts that ethics include self-determination, privacy, anonymity, secrecy, correct choosing, fair treatment, and protection from pain and injury.

RESULTS AND DISCUSSION
A theme is a ticket that represents a method of reporting large amounts of data in a simple condensed format (Tracy, 2013).The data revealed the following themes: developed within the sub-categories and categories of the data.The researcher identified measures to improve pain management as a theme.Participants stated that measures to improve pain management are an important component of their nursing activities.They recommended various measures to improve pain management practices that residents, nurses and administrators can implement that may improve pain management.Two subthemes emerged from the data: organizational initiatives and interprofessional collaborations.

Subtheme 1. Organisational initiatives
According to Terre Blanche, Durrheim and Painter (2014), pain management initiatives refer to the appropriate interventions developed to control pain.Registered Nurses Association of Ontario (RNAO), 2013), claims that organisations must know that all residents have the right to the best pain management possible by making pain assessment and management a priority.Six categories emerged from the data and more details about each follow:

Category 1.1: Enhance communication
Participants identified enhancing communication as a significant element in improving pain management practices.They recommended that communication practices, such as adequate communication with residents during pain assessment and with nurses during the end-of-shift report, could be beneficial.The statements below confirm the findings: "Maintaining open and effective communication between nurses during the end of shift report could help in improving pain management" (FG3, 35 years, Female).
"During pain assessment, I need to communicate with residents in a way a resident can relate to by asking simple and easy pain assessment questions" (FG1, 32, Male).
The findings were supported by several studies which indicated that improvement is seen when teams embody open communication in pain management (Grove, Gray, & Burns, 2015).According to LoBiondo-Wood and Haber (2016), communication skills are crucial and a significant component of the nursing profession.Nurses' roles include speaking to residents of varying educational, cultural and social backgrounds, and nurses must do so in an effective, caring and professional manner; especially when communicating with residents and their families (LoBiondo-Wood & Haber, 2016).

Category 1.2: Provide ongoing training for nurses
In all the focus groups, participants recommended the need to provide staff with ongoing training opportunities and support in handling complex cases.They believed that this could contribute to nurses' future growth.All participants emphasised the need to understand and be aware of existing protocols.The statements that follow confirm the finding: "You can only know what you are taught and prepared for; our management must arrange in-service training on pain management to help us improve our skills" (FG2, 45 years, Female).
"I need to be trained on the new methods and kept up to date with the latest developments and protocols" (FG1, 42 years, Female).
Several studies confirmed that long-term care practitioners need ongoing training in pain management (Kaasalainen, et al., 2013).Empowering in-service training can improve pain management and achieve a greater quality of life for residents (Tse & Ho, 2014).The orientation of new staff to the organisation's pain management policies, procedures and practices and ongoing professional development is a necessity (RNAO, 2013).

Category 1.3: Increase family involvement in pain management initiatives
Participants suggested that enhanced family involvement in pain management initiatives may improve pain control practices.They believed that nurses needed to engage the family in decision-making, including potential pharmacologic treatments.They recognised the contribution of the family in the provision of essential pain control measures, especially for residents with cognitive impairment.The following statements are the verbatim quotes that support the findings: "Family members are a good source of healthcare information during the admission process; they also validate information, I just think that we need to get them more involved when planning pain interventions, to improve the outcomes" (FG3, 40 years, Female)."I will recommend getting valuable information concerning past pain management history from a family member of residents who are cognitively impaired" (FG2, 36 years, Female).
"Another way is to include family members in annual case meetings to get their support of the pain management plan" (FG1, 36 years, Male).
The findings are supported by Ferrell and Coyle (2014), who say family members play an important role in addressing aspects where they feel nurses are not meeting their pain management expectations.Jones and Sharpe (2014), posit that family meetings between the resident, family and nurses are important in sharing health information, clarifying the goals of care, discussing the interpretation of pain, discussing the intended pain management plan, prognosis and developing a plan of care for the resident.In addition, Chaghari, Saffari, Ebadi and Ameryoun (2017), indicated that doing the intake/admission assessment with the family encourages collaboration and effective pain management practices.

Category 1.4: Provide adequate resources for optimal pain assessment
Participants recommended that nurses need adequate resources to use on cognitively impaired residents, and they should be skilled in using them.The participants also suggested that strengthening culturally congruent pain assessment tools will enhance the quality of pain management.The statements below confirm the findings: "In cognitively impaired residents, I need to be provided with the resources to identify pain and the use of the pain assessment tools" (FG2, 38 years, Female).
"To improve pain management, I need adequate pain assessment resources, so our management needs to make a provision for resources to provide optimal pain care, which will reduce the challenges I face" (FG3, 36 years, Female).
"Many of our nurses and residents are from different cultures; to improve pain management, it is very important to develop a cultural resource for pain assessment" (FG2, 40 years, Female).
Older adults with advanced dementia cannot report pain because of cognitive and verbal deficits; hence, there is a need to develop a method of identifying pain in this population (RNAO, 2013).According to Corbett, et al. (2016), pain assessment in cognitively impaired elderly persons remains difficult and identifying pain continues to be a daily challenge for nurses.The findings were supported by RNAO (2013), who agrees that using a systematic, organisational strategy to assess and manage pain through best practice guidelines and resources would enhance pain assessment.

Category 1.5: Implement a reasonable workload for nurses
Participants suggested that using the self-scheduling system by nursing staff can improve the morale of nurses and, subsequently, pain control practices.They expressed the need for the organisation to implement acceptable, universal resident' and nurse ratios to improve the quality of care, including pain control.The following verbatim quotes support this finding: "If our management explores the use of self-schedule for nurses, this will positively increase nurses' morale and sense of belonging.As a result, it gets out the best from nurses when they are managing residents' pain" (FG3, 37 years, Female).
"We need to use standardized residents and nurse's ratio when booking nurses for the shift, to reduce nurses ' workload" (FG1,38 years,Female).
It is affirmed by Jamison and Edwards (2014), that there are proven benefits in implementing a method that determines the skill levels of nurses and balances it with a reasonable number of nurses.According to RNAO (2013), a reasonable workload is required for nurses to assist in providing sustainable pain management for older people.Furthermore, employers have a responsibility to provide nurses with reasonable workloads.as well as nurses' strengths and limitations in pain management.Despite advancements in pain medicine, effective pain management is proportional to clinical as well as cultural factors.These issues must be identified and addressed because optimal pain management is required to avoid complications such as dependency and loss of function in older adults.

Limitation
According to the study's results, enhancing referrals to other health providers and upgrading an existing multidisciplinary team might help improve pain treatment.However, this research focused on nurses' pain management procedures at a single long-term care home facility in Ontario, Canada.Consequently, the results cannot be generalized to the other institutions.A more extensive study of a representative sample of long-term care home facilities in the province would be necessary for generalization.Another disadvantage of this research was that it did not incorporate comments on pain management from residents.

Table 1 .
Measures to Improve Pain Management