ASPMN 2019 Position Statement: Pain Assessment in the Patient Unable to Self-Report

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses

BACKGROUND

Pain management of sedated and ventilated patients in intensive care units lacks consistency.

OBJECTIVES

To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives.

METHODS

A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to.

OUTCOME MEASURES

Demographics, training, governance, clinical practice, knowledge, and attitudes.

RESULTS/FINDINGS

108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness."

CONCLUSION

The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management.

IMPLICATIONS FOR CLINICAL PRACTICE

Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.

Pain in non-communicative older adults beyond dementia: a narrative review

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

A Scoping Review on Nurse's Pain Management of Older Patients with Dementia in a Hospital Environment

OBJECTIVES

Hospitalized persons living with dementia often experience unrelieved pain. Unmanaged pain during hospitalization has a significant negative effect on quality of life for persons living with dementia. Despite the central role of nurses in pain management, little is known about how nurses manage pain in this patient population in the hospital environment.

DESIGN

A scoping review explored the nurses' pain management practices when caring for persons living with dementia in a hospital setting.

DATA SOURCES AND REVIEW/ANALYSIS METHODS

After an extensive search for all available evidence on how nurses manage pain in hospitalized persons living with dementia, data were extracted on pain management methods that included assessment, intervention, effectiveness of pain management, and the barriers nurses encountered when managing pain. A descriptive content analysis was used to extract data from qualitative studies.

RESULTS

Six articles published between 2016 and 2021 met the inclusion criteria; four utilized qualitative methods, and the others used mixed-methods and quantitative study designs. A narrative description of the findings was summarized after data were categorized into pain management data elements and barriers nurses encountered when managing pain. Barriers were grouped into the subcategories of communication challenges (nurse to patient), information sharing (nurse to nurse), lack of knowledge, time constraints, and nursing stressors.

CONCLUSION

We identified six articles that met our inclusion criteria, highlighting a noticeable gap in the literature. Managing pain in this population is complex and lacks organizational support. Review findings indicate that pain management methods lack consistency and standardization, making it difficult to assess their effectiveness. Nurses also described knowledge deficits resulting in practice gaps that, when combined with barriers and challenges, result in underrecognized and undermanaged pain.

Position Statement: Range Orders in the Management of Pain

American Society for Pain Management Nursing (ASPMN) supports safe medication practices and the appropriate use of pro re nata (PRN) range orders for analgesics in the management of pain within the scope of nursing practice. Although range orders may apply to many medications prescribed as PRN, the focus of this ASPMN position statement is on PRN analgesic medication. PRN range orders are commonly used to provide flexibility in dosing to meet the analgesic requirements of an individual patient. There are many patient-specific factors that require professional clinical assessment when administering medications to patients. Unfortunately, several myths persist regarding The Joint Commission's (TJC) standard around the implementation of range orders leading many to assume that range orders are not supported or safe. On the contrary, if utilized in a consistent and appropriate manner, PRN range orders can allow nurses to provide optimal pain management while still providing safe administration (Paquette et al., 2022).

Oral symptoms in dying nursing home patients. Results from the prospective REDIC study

BACKGROUND

The mouth is a central organ for communication and fluid intake, also for dying nursing home patients. This study describes the prevalence and severity of oral symptoms from nursing home admission until the day of perceived dying and the day of death.

METHODS

A prospective, longitudinal cohort study including 696 patients who were admitted to 47 Norwegian nursing homes in 35 municipalities. During the first year of their stay, 189 died (27%), of whom 82 participants were assessed on the day they were perceived as dying and 134 on the day of death. Mouth care, nutrition, and bedsores were assessed with the Residents' Assessment Instrument for nursing homes (RAI-NH) and palliative care (RAI-PC). Pain intensity was assessed with the Mobilization-Observation-Behaviour-Intensity-Dementia-2 Pain Scale (MOBID-2).

RESULTS

The proportion of patients with ≥ 6 oral symptoms increased from 16% when perceived as dying to 20% on the day of death (P = 0.001). On the day of death, xerostomia (66%), dysphagia (59%), and mastication problems (50%) were the most frequently observed oral symptoms. Only 16% received mouth care every hour and 12% were in pain during this procedure. Compared to people without dementia, those with a diagnosis of dementia at admission (N = 112, 86%) had xerostomia and mastication problems more frequently (50% vs. 73%; 32% vs. 56% (P = 0.038), respectively) on the day of death.

CONCLUSIONS

The high extent of oral symptoms such as xerostomia, dysphagia, and mastication problems underline the need for systematic assessment and improved oral palliative care for dying nursing home patients with dementia.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01920100 08/08/2013. First submission to BMC oral 15/03/2023.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

Investigation of pain associated with endotracheal aspiration and affecting factors in an intensive care setting: A prospective observational study

BACKGROUND

Endotracheal aspiration is a painful nociceptive procedure. There is still a gap in the literature on studies to determine the pain level and nursing interventions for aspiration.

OBJECTIVES

This study evaluated pain during endotracheal aspiration and examined the factors affecting pain.

METHODS

This prospective observational study was conducted with 105 inpatients meeting the inclusion criteria in the internal intensive care unit of a public hospital. Two hundred ten aspiration procedures were monitored for pain and other variables. ASPMN 2019 Position Statement recommendations were followed in designing the study and determining the procedure. The pain score range obtained from The Critical Care Pain Observation Tool was 0-8. A score of 2 or more is considered to indicate the presence of pain. The primary outcome measures were pain associated with endotracheal aspiration and affecting factors in this study. The generalised linear mixed model established for aspiration procedure-associated pain and affecting factors was analysed.

RESULTS

Patients' mean pain score was 1.24 ± 2.05 before, 3.07 ± 2.17 during, and 2.35 ± 1.94 after aspiration and 0.89 ± 1.40 at 15 min after aspiration. The pain rate was 26.1% before, 71% during, and 60.9% after the aspiration procedure and 18.8% after 15 min. There was a statistically significant difference between all pain scores evaluated. The difference in aspiration-related pain scores by age, respiratory diseases, sedation status, aspiration pressure, and tube diameter was statistically significant.

CONCLUSIONS

The pain score due to aspiration procedure increased significantly in intensive care unit inpatients and is an important risk factor for patient safety. More focus is needed on the causes and measures of aspiration-related pain.

Psychophysics of Pain: A Methodological Introduction

For over 100 years, psychophysics ..÷ the scientific study between physical stimuli and sensation ... has been successfully employed in numerous scientific and healthcare disciplines, as an objective measure of sensory phenomena. This manuscript provides an overview of fundamental psychophysical concepts, emphasizing pain and research application..÷defining common terms, methods, and procedures.Psychophysics can provide systematic and objective measures of sensory perception that can be used by nursing scientists to explore complex, subjective phenomena..÷such as pain perception. While there needs to be improved standardization of terms and techniques, psychophysical approaches are diverse and may be tailored to address or augment current research paradigms. The interdisciplinary nature of psychophysics..÷like nursing..÷provides a unique lens for understanding how our perceptions are influenced by measurable sensations. While the quest to understand human perception is far from complete, nursing science has an opportunity to contribute to pain research by using the techniques and methods available through psychophysical procedures.

Best Practices in Pediatric Oncology Pain Management

ABSTRACT

Pediatric oncology patients are vulnerable to pain that may be caused by the disease or its treatment, and this symptom can be challenging to manage. This article focuses on the importance of pain control, pain assessment and treatment, and special considerations in pediatric oncology pain management, including preparing children for painful procedures and the family's role in managing pain.

Elderspeak communication and pain severity as modifiable factors to rejection of care in hospital dementia care

Background

Rejection of care (RoC) occurs when persons living with dementia (PLWD) withstand or oppose the efforts of their caregiver. Improvements in hospital dementia care are needed, and one way to address this need is by identifying factors that lead to RoC, particularly those that are modifiable. Elderspeak communication is an established antecedent to RoC among PLWD in nursing homes. The purpose of this study was to extend these results to acute care settings by determining the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD.

Methods

Care encounters between nursing staff and PLWD were audio‐recorded, transcribed verbatim, and coded for semantic, pragmatic, and prosodic features of elderspeak. RoC behaviors was scored in real‐time using the Resistiveness to Care Scale. A Bayesian repeated‐measures hurdle model was used to evaluate the association between elderspeak and both the presence and severity of RoC.

Results

Eighty‐eight care encounters between 16 PLWD and 53 nursing staff were audio‐recorded for elderspeak and scored for RoC. Nearly all (96.6%) of the encounters included some form of elderspeak. Almost half of the care encounters (48.9%) included RoC behaviors. A 10% decrease in elderspeak was associated with a 77% decrease in odds of RoC (OR = 0.23, 95% CI = 0.03, 0.68) and a 16% decrease (eβ= 0.84, CI = 0.73, 0.96) in the severity of RoC. A one‐unit decrease in pain severity was associated with 73% reduced odds of RoC (OR = 0.27, CI = 0.12, 0.45) and a 28% decrease (eβ= 0.72, CI = 0.64, 0.80) in the severity of RoC.

Conclusions

Both elderspeak by nursing staff and RoC by PLWD are present and pervasive in acute care. Pain and elderspeak are two modifiable factors of RoC in hospitalized PLWD. Person‐centered interventions are needed that address communication practices and pain management for hospitalized PLWD.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments

BACKGROUND

Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale.

PURPOSE

The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit.

METHODS

Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management.

RESULTS

There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

Palliative Care and Dementia: What All Advanced Practice Nurses Should Know

Dementia is a progressive, incurable condition that causes limitations in life and should be recognized as a life-limiting condition. Health care professionals should understand its trajectory to better manage symptoms and to provide early and ongoing advance care planning. Advanced practice registered nurses are uniquely qualified to work with patients and their families to identify care preferences and then to align treatments to them. Palliative care and hospice are important interventions that should be integrated into the management of patients with dementia. Additionally, early integration of palliative medicine can better manage symptoms and lessen the strain on loved ones.

Pain-related health care costs for long-term care residents

Background

We tested for differences in direct health care costs among long-term care (LTC) residents age 65 and older with clinically significant pain (CSP) and with no pain or non-daily mild pain (NP/NDMP). We are not aware of any other large scale investigation that examined the cost of pain in LTC environments.

Methods

Population-based administrative health data from Saskatchewan, Canada for 2004 to 2015 were used to compare direct health care costs for CSP and NP/NDMP groups up to one year after admission to LTC. Total accumulated costs for hospitalization, physician services, LTC, and prescription drugs were calculated in 2015 Canadian dollars. Group differences were tested using generalized linear models with generalized estimating equations.

Results

Amongst 24,870 LTC residents, 8289 (33.3%) were censored due to death or discharge in the 365-day study observation period. Of the 16,581 (66.7%) observed residents, 5683 (34.3%) had CSP at admission. Residents (66.3% female) had a mean age of 85 years (SD = 7.4). The mean annual total direct health care cost per resident was higher among the CSP group (CAD $8063) than the NP/NDMP group (CAD $6455). This difference was found even after including LTC costs, and for each cost component (i.e., CSP residents had higher hospitalization, physician, and prescription drug costs). Similar results were obtained after controlling for demographics, comorbidities, physical and cognitive impairment, prior health care costs, and facility characteristics.

Conclusion

The higher costs incurred by CSP residents compared to NP/NDMP residents are likely underestimated because pain problems are often missed in residents with dementia, who comprise a large portion of the LTC population. Improved pain care can reduce such costs and improve quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02424-2.

Assessment of pain in patients with primary immune deficiency

BACKGROUND

Primary immune deficiency (PID) patients may develop acute or chronic pain. Pain has not been studied in this population until now.

OBJECTIVES

This study systematically assessed the pain of various durations in PID patients using validated pain questionnaires.

SUBJECTS AND METHODS

A Short-Form McGill Pain Questionnaire (SF-MPQ), already validated in the Arabic language, was used to ascertain the characteristics and severity of pain. Additionally, an Arabic version of the Neuropathic Pain Questionnaire-Short Form (NPQ-SF) was employed to evaluate neuropathic pain in the same group of patients.

RESULTS

Forty-six patients participated in the study. The mean age of the patients was 25 years. The most commonly diagnosed PID was a common variable immune deficiency (32.6%), followed by severe combined immune deficiency (19.57%). Based on the SF-MPQ, the pain was experienced by 30.4 % of the subjects who participated in the study; 57% of whom were on regular pain medications. The most common site reported for pain was the abdomen (35.7%). The mean duration of pain was 36.1 days ± 34.6 days. The most common comorbidities in these patients were bronchiectasis, followed by immune thrombocytopenic purpura, and scoliosis. None of the PID patients had significant neuropathic pain based on NFQ-SF.

CONCLUSION

To the best of our knowledge, this is the first study to assess the prevalence as well as the severity and duration of pain in PID patients. There were significantly more subjects who had continuous pain. Treatment of pain in PID patients will have a significant effect on improving their quality of life.

Interprofessional Healthcare Students' Attitudes, Skills, and Knowledge After Comprehensive Pain Assessment Training in Verbal and Nonverbal Patients

A comprehensive pain assessment is the first step in safe, effective pain management. Few studies have explored variations of strategies and measures for multidimensional pain assessment education in both verbal and nonverbal patients. In this retrospective cohort study, interprofessional health care students enrolled in a palliative care curriculum completed a pain assessment training, which taught the PQRSTA ("palliating factors, precipitating factors, previous treatments, quality, region, radiation, severity, temporal factors and associated symptoms") mnemonic as a strategy for assessing pain in verbal patients and the Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures for nonverbal patients. The purpose of this study was to compare the change in attitudes, self-perceived skills, and knowledge regarding pain assessment before and after the training. Attitudes and self-perceived skills were assessed in the pretraining and posttraining survey, which was analyzed using χ2 test or Fisher exact test. Students' knowledge responses were analyzed using Wilcoxon signed rank test to assess accuracy of responses compared with the expert defined score. One hundred eighty-two students were included. Results showed a statistically significant improvement in attitudes related to applicability of pain measures and self-perceived skills. Overall, data did not support an increase in knowledge using the PQRSTA mnemonic, or Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures. Future pain trainings should consider training on only 1 nonverbal pain measure, incorporating bedside assessments, and integrating real-time feedback.

Hospital Admissions Associated With Cancer Pain in Older Adults With and Without Dementia

BACKGROUND

Neoplasm-related pain is often suboptimally treated, contributing to avoidable suffering and increased medical resource use and costs. We hypothesized that dementia may contribute to increased resource use and costs in patients hospitalized for neoplasm-related pain in the United States.

AIMS

To examine how persons with cancer and dementia use medical resources and expenditures in US hospitals compared to ondividuals without dementia.

DESIGN

This study examined a retrospective cohort.

SETTING

Admissions to US hospitals for neoplasm-related pain from 2012-2016 PARTICIPANTS/SUBJECTS: METHODS: Data were obtained from the 2012-2016 National Inpatient Sample (NIS). The sample included hospital admissions of individuals aged 60 or older with a primary diagnosis of neoplasm-related pain. Dementia was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), and ICD-10-CM diagnosis codes. Primary outcomes were number of admissions, costs, and length of stay (LOS). Descriptive statistics and multivariable regression models were used to examine the relationships among dementia, costs, and LOS.

RESULTS

Of 12,034 admissions for neoplasm-related pain, 136 (1.1%) included a diagnosis of dementia and 11,898 (98.9%) did not. Constipation was present in 13.2% and 24.5% of dementia and nondementia admissions, respectively. The median LOS was 4 days in persons with dementia and three in those without. Mean costs per admission were higher in persons without dementia ($10,736 vs. $9,022, p = .0304). In adjusted regression results, increased costs were associated with nonelective admissions and longer LOS, and decreased costs with age above the mean. In contrast, decreased LOS was associated with age above the mean and nonelective admissions. Dementia was associated with neither endpoint.

CONCLUSION

This study provides nurses and other health care professionals with data to further explore opportunities for improvement in cancer pain management in patients with and without dementia that may optimize use of medical resources.

Experimentally evoked pain in Alzheimer's disease

BACKGROUND

Pain continues to be underrecognized and undertreated in Alzheimer's disease (AD) while existing guidance about pain assessment and management in dementia is not widespread. Brain regions involved in pain processing and modulation are damaged during AD, and the pain experience in AD is not well understood. Experimental pain studies using psychophysics can further our understanding of the pain experience in AD, which may lead to improved assessment and management of pain in people living with AD.

OBJECTIVE

A systematic review was conducted to explicate the current understanding of experimentally evoked pain in AD from primary research using psychophysical methods.

DATA SOURCES

Peer-reviewed publications were found via PubMed, CINAHL, and PsycINFO. A total of 18 primary research, peer-reviewed full articles that met inclusion criteria were included, representing 929 total participants.

CONCLUSIONS

Experimentally evoked pain in people with AD demonstrates that despite cognitive impairment and a reduced ability to effectively communicate, individuals with AD experience pain similar to or more unpleasant than cognitively intact older adults. This may mean amplified pain unpleasantness in people with AD.

IMPLICATIONS FOR PRACTICE

Our current best practices need to be widely disseminated and put into clinical practice. Self-report of pain continues to be the gold standard, but it is ineffective for noncommunicative patients and those unable to understand pain scales or instructions because of memory/cognitive impairment. Instead, pain treatment should be ethically initiated based on patient reports and behaviors, caregiver/surrogate reports, review of the medical record for painful conditions, analgesic trials, and regular reassessments.

Policy Implications for Pain in Advanced Alzheimer's Disease

Untreated pain in people with Alzheimer's disease continues to be a serious public health problem. Pain is a subjective and complex experience that becomes increasingly challenging to assess as cognition declines. Our understanding of pain processing is incomplete, particularly for special populations such as people living with Alzheimer's disease, and especially in the advanced stages of the disease. Pain-processing networks in the brain are altered in Alzheimer's disease, yet evidence suggests people living with Alzheimer's disease do not experience less pain. Rather, their pain is not adequately recognized or treated. Although scholarly publications provide important assistance, recent widespread reports and guidelines do not include sufficient guidance, especially as Alzheimer's disease progresses to the last stages. Additionally, current pain measurements may not accurately evaluate pain in this condition, and the existing definitions of pain are not adequate when considering the effects of Alzheimer's disease on pain-processing in the brain. There is a need for new, widespread policies, guidelines, and definitions to help clinicians adequately manage pain in people with Alzheimer's disease. These will need to hinge on continued research because it remains unclear how Alzheimer's disease impacts central pain processing, pain expression, and communication of pain. In the meantime, policies and guidelines need to highlight current best practices as well as the fact that pain continues in Alzheimer's disease.

The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review

BACKGROUND

Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes.

OBJECTIVES

To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children.

DESIGN

Systematic literature review.

DATA SOURCES

The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020.

REVIEW METHODS

We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded.

RESULTS

In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions.

CONCLUSIONS

Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.

Model of Empathic Pain Assessment and Treatment in Persons With Dementia

The current article presents an evidence-based model for understanding clinical empathy's relationship with the assessment and treatment of pain in persons with advanced dementia. A literature review informed creation of an interdisciplinary conceptual framework of clinician empathy in pain assessment and treatment among persons with advanced dementia. Driven by observation of behaviors indicating pain in persons with dementia unable to self-report, the model represents the cognitive, affective, ethical, and behavioral components of clinical empathy involved in assessing and treating pain, relevant patient outcomes, and contextual factors influencing empathy and outcomes; and provides a framework for testing clinical empathy interventions to improve adverse outcomes in persons with advanced dementia. Understanding the relationship between clinician empathy and the assessment and treatment of pain in persons with advanced dementia may improve care quality and help reduce pain behaviors in this patient population. This model may be used to inform pain research in persons with dementia and develop clinical interventions and clinician education programs. [Research in Gerontological Nursing, 13(5), 264-276.].

Interprofessional Collaboration and Involvement of Parents in the Management of Painful Procedures in Newborns

Introduction: Newborns are subject to many painful procedures. Pharmacological and non-pharmacological approaches alone are not enough, and it is necessary to consider other contributing elements such as the environment, interprofessional collaboration and parental involvement. The aim of this feasibility study was to explore interprofessionality and the role of parents in improving the management of painful procedures in newborns and pain management strategies. Materials and Methods: a pre-post feasibility study using a mixed method approach was conducted. Questionnaires, interviews and focus groups were used to describe the parents' views on their child's pain management and involvement in care as well as to explore the level of interprofessionality and feasibility. Results: Collaboration between physicians and nurses improved following the implementation of a complex interprofessional intervention involving professionals, parents and newborns. In spite of improving professional collaboration in procedural pain management, parents were attributed a passive role or only marginally involved in in the infant's pain management. However, parents stated-as elicited by the questionnaires and interviews-that they wished to receive more information and be included in painful procedures executed on their infant. Discussion: Management of painful procedures in neonates needs to be changed. Interprofessional collaboration contributes to improved procedural pain management in neonates. It is essential to include parents as active members in the interprofessional healthcare team.

Utilization of Health Care Resources by Long-term Care Residents as a Function of Pain Status

OBJECTIVE

We estimated the association between the presence of pain and health care utilization among older adults residing in long-term care (LTC) facilities.

MATERIALS AND METHODS

Using administrative health data maintained by the Saskatchewan ministry of health and time-to-event analyses with multivariable frailty models, we tested for differences in health care use (hospitalization, physician and specialist visits, and prescription drug dispensations) as a function of pain status among LTC residents after admission to an LTC. Specifically, we contrasted LTC residents with daily pain or less than daily pain but with moderate or severe intensity (ie, clinically significant pain group; CSP) to residents with no pain or nondaily mild pain (NP/NDMP group).

RESULTS

Our cohort consisted of 24,870 Saskatchewan LTC residents between 2004 and 2015 with an average age of 85 years (63.2% female; 63.0% in urban facilities). Roughly one third had CSP at their LTC admission date. Health care use after admission to LTC was strongly associated with pain status, even after adjusting for residents' demographic and facility characteristics, prior comorbidities and health care utilization 1 year before the study index date. In any given quarter, compared with NP/NDMP residents, those with CSP had an increased risk of hospitalization, specialist visit, follow-up general practitioner visit, and onset of polypharmacy (ie, 3 or more medication classes).

DISCUSSION

To our knowledge, this is the first large-scale project to examine the utilization of health care resources as a function of pain status among LTC facility residents. Improved pain management in LTC facilities could lead to reduced health care use.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.