Registered Nurses’ Perception of Pain

Pain is the most common medical issue that older people face in a long-term care facility. Nurses have a critical role in helping residents manage their pain. This research looked at registered nurses’ perception of pain practices in long -term care facilities. 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. A qualitative research technique was applied in this study. 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 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 and overcoming registered nurses’ perception of pain practices in long -term care homes are necessary to manage pain. This study demonstrated the importance of registered nurses’ perception of pain to effectively manage pain and reinforce good practices in long-term care homes. Therefore, improved registered nurses’ perception of pain practices is required to manage pain in a long-term care home effectively. The overall benefits of registered nurses’ perception of pain practices in long -term care homes expand nurses' clinical knowledge in the care of residents living in nursing homes.


INTRODUCTION
A pain sensation is caused by an injury or damage to any part of the human body.Transduction, transmission, perception, and modulation are the four processes that cause it (Registered Nurses Association of Ontario (RNAO), 2013).The aim of this study was to look at registered nurses' perception of pain practices in long-term care facilities.Assessing pain for adequate pain management is a challenge.However, it is an essential practice as good pain management in early stages can have long-term benefits for resident of long-term care home (Abidin, Yunita, & Rachmad, 2022).Pain management minimises or reduces a person's pain experience to a bearable level.Effective pain management includes both pharmaceutical and non-pharmacologic nursing interventions.Although multidisciplinary efforts are required, nurses play an important and complex role in pain management in long-term care homes and hospitals (RNAO, 2013).Nurses and other healthcare professionals must work collaboratively to treat pain (RNAO, 2013).Nursing interventions such as continuous pain assessment, standardised pain assessment, and the proper use of pharmacological and nonpharmacological pain relief.

Background of the Study
The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional result of tissue damage (Fleckenstein, 2013).As a result, developing effective pain management pathways is critical to improving pain management and providing appropriate nursing care.In a long-term care facility, this can be accomplished by determining the nurses' perceptions of the older person's pain expression and pain treatment components.There is compelling evidence that the Canadian population is ageing at an unsustainable rate in comparison to current social and healthcare services (Busby & Robson, 2013).Senior citizens are the fastest-growing age group, according to (Statistics Canada, 2013) (65 and above) reported that five million Canadians were 65 or older in 2011.
Nurses are the primary healthcare providers in long-term care homes (Almost, et al., 2013).To improve nursing practice and promote good health outcomes in long-term care home settings, adequate pain management knowledge and comprehension, as well as clinical decision-making based on research data, are required (Almost, et al., 2013).Furthermore, nurses with specific pain management competence, as well as reliable assessment and clinical decision-making skills, are required to care for older people who may require healthcare but are unsure how to meet their health needs in long-term care homes (Almost, et al., 2013).Furthermore, despite the importance of healthcare delivery, there may be a persistent barrier to pain treatment among the elderly's health demands (Almost, et al., 2013).Many seniors in long-term care facilities have a variety of diseases, including drug abuse, physical problems, and mental health issues.These people are typically from areas with insufficient health promotion and illness prevention practices due to a lack of knowledge and resources (Baybutt & Chemlal, 2016).Furthermore, a diverse group of people, including a multiprofessional group, are involved in pain management in long-term care facilities, either directly or indirectly.In comparison to other multidisciplinary team members, nurses take the lead in pain treatment in long-term care homes.This is because nurses are close to the residents.They can alleviate pain and increase comfort by evaluating and developing pain-relieving care methods, recording, and monitoring (Birchenall & Adams, 2014)

Purpose of the Study
This research aimed to look at nurses' perceptions of pain in long-term care facilities.The goal was also to advise older persons on proper pain management strategies.

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 (Polit, Beck, & Polit, 2016).According to (Brink, Van der Walt, & Van Rensburg, 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 nurses' perceptions of pain 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 a study (Babbie & Mouton, 2012).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 (Silverman, 2015).The descriptive design focused on' how' and' why' inquiries to convey a picture of a particular circumstance, social location, or connection (Silverman, 2015).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, 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 (Cottrell, 2014).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 nonprobability 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 (Polit, Beck, & Polit, 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 registered nurses chosen using nonrandom approaches using purposeful sampling.The inclusion criteria 1. Registered Nurses who have worked in the long-term care home.2. Who have managed resident pain.The exclusion criteria 1.Who have not managed pain of residents.

Data Collection
According to (Saldana, 2014), 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 (Saldana, 2014).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 analyze their experiences (Tracy, 2013).According to (Babbie and Mouton, 2012), group interviews establish meaning when participants participate in conversations and a substantial amount of engagement on a 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
Research ethics comprises concepts, norms, and values that guide proper behaviour in research choices (Cottrell, 2014).It may also relate to applied ethics, which attempts to preserve study participants' well-being (Terre Blanche, Durrheim, & Painter, 2014).Furthermore, (Grove, Gray and Burns, 2015), asserts that ethics include self-determination, privacy, anonymity, secrecy, correct choosing, fair treatment, and protection from pain and injury.

RESULT AND DISCUSSION
How nurses perceive pain may influence their behavior in pain assessment and management (Swakhalen, Hamers, Peijnenburg, & Berger, 2017).As such, nurses need to have a good perception of pain to achieve effective pain management.According to (Chatchumni, Namvongprom, Eriksson and Mazaheri, 2016), differences in the interpretation of patients in pain affect the outcome of the pain assessment.The participants' accounts of their perceptions of residents in pain and pain management were condensed into two subthemes.These subthemes were: the meaning of pain to nurses and its influences on understanding residents' pain.The subthemes and categories of Theme are presented in Table 1.

Subtheme 1: Meaning of pain to nurses
In this subtheme, two categories emerged: recognition and interpretation of pain and legislative framework for pain management.Each category is discussed in the subsequent sections.All three focus groups' contributions are indicated in the quotations as FG1 referring to focus group one, FG2 referring to focus group two, FG3 referring to focus group three, and FG4 referring to the three additional participants.

Category 1.1: Recognition and interpretation of pain
All participants from the focus groups described how they recognized and interpreted pain.They used cues such as facial expressions like a grimace or frown, clenched jaw, quivering chin, or lack of interest in any activity.Nurses mainly used medical terms to express their interpretation of pain.They agreed that the interpretation of residents' pain was subjective and based on the individual resident's complaint.All the participants mentioned various methods by which they recognize pain.Participants explained.
"I know my residents are in pain when they frank their faces and they are uncomfortable" (FG2, 36 years, Female)."…when I see them in discomfort and irritable" (FG1, 38 years, Female)."…when I notice that they are feeling anxious and avoiding daily activities" (FG4, 40 years, Female).

"I identify my resident's pain through pain assessment and close observation, which enable me to know when things are becoming abnormal to residents" (FG3, 36 years, Male).
Pain recognition is the first step in ensuring residents' pain is managed effectively.If the pain is not recognised, it is difficult to assess and manage (Rasmi Issa, Awaje, & Khraisat, 2017).According to Lichtner, et al., (2016), understanding overall residents' pain experiences in long-term care homes includes investigative work and putting a picture together of an individual's pain pattern.Consequently, many healthcare facilities consider nurses' pain interpretation as the fifth vital sign (Kosier, Berman, & Snyder, 2013).Pain interpretation by nurses is used as a routine check-up in health care; it is a fact that pain is subjective and pain interpretation by nurses covers physiological, behavioural, socio-cultural, and emotional aspects (Kosier, Berman, & Snyder, 2013).

Category 1.2: The legislative framework for pain management
Participants stated they used a legislative framework for pain management that includes the residents' rights to pain control and an interdisciplinary approach to pain management.Participants elaborated on their experiences related to collaboration with other healthcare professionals in delivering direct services and supporting residents in their pain management decisions and actions based on clinically accepted guidelines.
"Our policy on pain management is that all residents be assessed for pain during admission" (FG3, 38 years, Male)."The long-term care policy stipulates that all nurses follow and use the pain guidelines during pain assessment, which can be found in random assessment indicator computer" (FG2, 39 years, Female).
According to RNAO, ( 2013), pain legislative frameworks are systematically established statements to assist nurses in assessing pain during and after admission into a long-term care home.These statements provide evidence-based recommendations for nurses who are assessing and managing pain.RNAO (2013), stated that every resident of a longterm care home has a written pain management plan of care.According to Aziato and Adejumo (2015), each resident must be assessed for pain on admission and be reassessed quarterly and during any change in health status.

Subtheme 2: Influences on understanding residents' pain
Data showed that nursing background influenced nurses' understanding of residents' pain.In this subtheme, two categories emerged: biomedical influences and cultural influences on understanding residents' pain.These categories are described next: Category 2.1: Biomedical influences Data showed that nurses' views of pain are influenced by the biomedical perspective, which is based on the understanding that pain or any other diseases are malfunctioning of the body.According to the participants, the pain has a pathological reason which can be described in terms of human anatomical and physiological functions.Some attributed the pain to physical malfunction and pathological procedures connected with disease and cell degeneration.The verbatim quotations supporting this follow: "I know pain is caused by disease and degeneration of cells in old age people" (FG1, 36 years, Female)."I know injury causes pain, accidents, illness and may lead to complications" (FG2, 38 years, Male)."If residents are in pain, their blood pressure and pulse would be elevated.I know residents cannot be in pain and be laughing" (FG3, 40 years, Male).Bendelow ( 2013), agrees with these findings; the biomedical perspective only considers the physiological causes of pain, which does not always take emotional aspects of pain causes into consideration.

Category 2.2: Cultural influences on understanding residents' pain
Participants stated that the resident's cultural background might influence the way they interpret pain.They claimed that some cultures tolerate pain better than others, which determines how they express pain.Participants said some of their residents would not express their pain because they believed their pain was due to old age.All the participants agreed that their ability to break through nursing cultural barriers is the key to providing effective pain management.Participants pointed out that cultural differences affect residents' and nurses' responses to pain.The relationship between pain perception and culture is shaped by the cultural experiences of nurses and residents.The quotes below confirm the findings: "I believe that if residents are in pain, they will be able to communicate the location and intensity of the pain" (FG1, 34 years, Female).This finding was supported by Raman (2015), who found that culture affects a person's approach to pain management and the amount of pain deemed abnormal.Nurses' understanding of deficits, biases, and attitudes thus influence the assessment and management of the residents' pain (Undari-Schwarts, 2017).According to (Reade, 2018), an increase in Canadian ethnic diversity implies that nurses are frequently required to meet the needs of residents from different cultures and offer culturally relevant pain management.Culture influences pain management interventions in terms of what is regarded as 'normal' and 'abnormal', determining the cause of pain, and influencing the decision-making in determining the best method to be adapted for controlling pain (Reade, 2018).Raman (2015), emphasises the need for nurses to create cultural abilities and culturally appropriate interventions for individuals from culturally varied communities.This process requires nurses to learn how to conduct a comprehensive, culturally sensitive pain assessment to determine the specific needs and appropriate interventions for the people targeted.

CONCLUSION
According to the findings of this study, employers in Canada must provide adequate guidelines on pain management measures.Nurses are required to practise within the legal framework that governs pain management (RNAO, 2013).According to the data, the meaning of pain to nurses influences their perception of pain.The nurses were heavily influenced by the biomedical interpretation of pain, such as body malfunctioning and pathological processes associated with diseases.Nurses appeared to be more knowledgeable about the biomedical dimension of pain management than the behavioural dimension.This distinction was stronger among experienced nurses than among newly trained nurses (Prem, et al., 2017).According to the study findings, nurses lack cultural assessment tools to perform a cultural assessment of pain.Because of their prior knowledge of pain, participants stated that different nurses from different cultures perceived pain differently.According to Yennurajalingam (2018), nurses must be aware that in many cultures, discussing pain as an act of bad lifestyle practised by the resident is considered inappropriate and culturally insensitive.Many cultures have different cultural beliefs about the meaning, origin, and role of pain, which can influence how residents interpret and perceive pain.The net result of cultural differences in pain response is that some residents overestimate or underestimate the severity of their pain, which may affect pain management (Yennurajalingam, 2018).
The findings of our study could help long term care homes managers in developing continuous education and staff development training programs on assessing and managing pain for residents.Establishing continuous education, workshops, professional developmental lectures focusing on pain evaluation and treatment for both acute and chronic pain, as well as training courses on how to use pain assessment tools and other behavioural pain indicators, especially for nonverbal residents are highly recommended.Also, findings could be used to develop an evidence-based standard pain management protocol tailored to effectively assess and promptly treat the pain of critical care residents and emphasizing the importance of alternative and complementary medicine of pain (Kocasli, Oner Karaveli & Bal, 2023).

Limitation
According to the findings of the study, increasing referrals to other health providers and upgrading an existing multidisciplinary team may help improve pain treatment.This study, on the other hand, concentrated on nurses' pain management procedures at a single long-term care home facility.As a result, the findings cannot be applied to other institutions.For generalization, a larger study of a representative sample of long-term care home facilities in the province would be required.Another disadvantage of this study was that it did not include resident comments on pain management.

"
Sometimes when my residents express, they are in pain, they need a companion from me because they are feeling lonely" (FG2, 37 years, Female)."Since many of my residents are from different cultural backgrounds some are from Indian, China, Jamaica, Poland and Greece they express pain based on what is accepted in their culture and because on many occasions we do not understand the meaning, it gives us different perception" (FG2, 38 years, Male)."Understanding residents' pain differs from nurse to nurse because we are from different cultural backgrounds, I found this common among other nurses from another unit during the medical review of resident's file" (FG3, 45 years, Female).

Table 1 .
Nurses' perception of pain