Pain Assessment and Management in Care Homes: Understanding the Internal and External Context Through a Scoping Review


 Background: Internationally, 2-5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the internal and external contexts that might influence its management.Methods: We conducted a scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment or management for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were screened, and website searches carried out of key organisations, to ensure relevant evidence was retrieved, including grey literature. As per the methodolocal framework, stakeholder evidence from 16 local care home managers was also accessed, to undertand their current perspectives.Results: Inclusion criteria were met by 109 studies. Three overarching themes were identified: staff variables and beliefs, pain assessment, and interventions. Evidence from the review indicated a lack of training and staff confidence in relation to pain assessment and management in care homes. This was particularly the case for residents with dementia, who cannot always verbalize their pain, and may resort to behavioral manifestations to try and communicate their distress.Conclusions: This review has highlighted that training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way. Internal and external contexts need further examination in order to integrate recognition and assessment of pain, and its management, to the benefit of residents.


Introduction
Internationally, 2-5% of people live in residential or nursing care homes, with almost 60% of residents being over 85 years of age [1]; many live with multi-morbidities, including severe cognitive impairment [2].
Pain is frequently considered an expected part of old age and morbidity, and as a consequence is often under-reported by care home residents, or may go unrecognized by care staff [3].
The International Association for the Study of Pain (IASP) [4] estimates that 20% of the adult population are living with chronic pain. They consider pain to be individual and subjective, and assert that the inability to communicate pain verbally, for example in people with dementia, does not negate the possibility of pain being present, and the need for treatment [4].
Where the presence of pain cannot be verbalized, pain behaviors may include guarding, agitation, facial expression, or altered mobility [4]. However, it is unclear how well such factors are understood and, where pain is identi ed as the probable cause of such behaviour, whether this is acted upon by care home staff [5]. In addition, where pain is recognized and treated, the IASP advises caution with older people, who are generally less tolerant of analgesia, and may experience side effects such as sedation or confusion if the analgesia type and dose are not chosen with care [4]. In addition, over or misprescribing may lead to drug related problems for nursing home residents [6]. Non-pharmacological treatments or adjuncts are therefore worth considering for treatment of pain in older age. In addition to such concerns, the in uence of emotional state on pain is a signi cant factor, which is not always acknowledged [7].
While appropriate assessment of pain is an essential step to effective treatment [8], and various pain assessment tools have been developed [9], pain assessment and management in care homes is complex. To further understand these complexities, we undertook a scoping review to explore the internal and external contexts which may in uence pain assessment and management for care home residents.

Review category
This scoping review was carried out using the methodological framework of Levac et al. [10] involving six stages noted in Table 1.  Data extraction and quality assessment Data from individual studies or reports were extracted onto a pre-designed table, and cross-checked by two reviewers (JP & SA). We did not aim to produce a detailed quality appraisal of included studies or exclude studies on the grounds of quality [12], but noted any quality limitations to further inform the review.

Analysis methods
We conducted a thematic analysis of the papers reviewed, and an analysis of stakeholder evidence from 16 care homes. We sought to identify common themes across studies and stakeholder evidence, and group these themes into areas of shared interest across and between all evidence sources. In particular, all data were examined to identify organisational factors, such as internal and external barriers or facilitators that might either help or hinder pain assessment and management. Links and implications for policy, practice and research were sought within the analysis process (Levac et al., 2010: Stage 5).

Findings
Overview 109 studies were found that ful lled all inclusion criteria. An overview of these studies is presented in Appendix 3. Due to the large number of studies, each tabulated 'included study' (IncS) was allocated a number (e.g. IncS 1, 2 etc) for identi cation within the following text. Full references details for included studies are presented below the main reference list.
There was a diverse geographical spread across 17 countries, indicating a global interest and potentially concern about the issues surrounding pain assessment and management in care homes.

Methods and appraisal of included studies
Research methods used were diverse, including 13 RCTs, 18 non-randomised trials (typically pre/post-test studies), 16 qualitative studies, 30 of cross-sectional design, and 13 systematic reviews. Where studies were longitudinal (mainly RCTs) the longest duration of follow up was 6 months. While the majority of studies clearly detailed the methods used, study limitations largely related to methodological issues (e.g. cross sectional design) or small participant numbers. The di culties inherent in including care home participants in reseach, who by the nature of their situation are vulnerable, was not widely acknowledged.

Analysis
Our analysis provided a breakdown of topics of interest across and between studies, and revealed six initial themes: Staff variables in relation to pain assessment and management (e.g. experience, quali cations etc.) Beliefs and perceptions relating to pain (staff, residents, relatives) Pain assessment tools Pain assessment and management for nursing care home residents with cognitive impairment Pain intervention e cacy/effects (pharmaceutical/non pharmaceutical)

Pain training interventions and their outcomes
These six themes were further amalgamated into three broader overarching themes or categories: Staff variables and beliefs, Pain assessment, and Interventions, as illustrated in Fig. 2 below. Due to some studies being multifaceted, results from a particular study may appear in more than one category.

Staff variables and beliefs
There were a number of included papers (n = 17) that explored the training level and experience of health care staff, and the impact this had on pain recognition and practices relating to pain management.
For example, Takai et al. (IncS 94) reported a relationship between increased nursing experience and lower pain prevalence in residents, and a relationship between the years of staff experience and the utilization of non-drug methods to treat it, being more frequently used by those with greater pain experience and training (IncS 95).
Experience tended to affect judgements: Alm & Norbergh (IncS 3) found that nurses with less experience had less con dence in making a judgement about pain themselves; however Baeza et al. (IncS 6) reported that care home staff with more experience tended to feel more stressed when not knowing the cause of pain for residents with dementia, and thereby less able to make their own judgement.
One systematic review (IncS 5) reported a correlation between less experienced staff and the verbally disruptive behaviour of residents, which may have been a manifestation of untreated pain.
Findings were also reported relating to staff turnover, type of working contract, and relationships with pain assessment and management, with evidence that pain assessment and management was performed better when there was lower staff turnover, and staff were hired permanently, and had longer tenure time (IncS 5, 16,29,39).
Care homes where staff had higher quali cations appeared to perform better in pain assessment and management, and give better quality of care (IncS 14, 15, 100). In addition, while some GPs lacked knowledge about pain assessment themselves, they valued the role of nurses and other caregivers (IncS 53), even although some staff perceived GPs as disinterested in relation to pain (IncS 78).
Care home staffs' beliefs and perceptions exerted an in uence on pain management, as examined in 40 of the included papers. For example, several papers reported that when staff felt more con dent about the identi cation of pain, they were more certain in relation to its management (IncS 10, 44, 62). However, when staff considered pain to be part of ageing, they were less likely to identify pain in a resident (IncS 62). It was also reported that those residents who thought that pain was part of getting older were in uenced by staff attitudes towards treatment, potentially resulting in reduced therapy options (IncS 104).
There was evidence that many staff did not agree with the statement that pain is part of aging and cannot be treated (IncS 8); however, with regard to residents with dementia, 50% of staff did consider pain as part of aging in this population (IncS 14).
When exploring nurses' knowledge and attitudes to pain assessment in people with dementia, Burns & McIfatrick (IncS 13) reported that even amongst those with very recent training in pain assessment, it was still considered to be a "guessing game"; such beliefs had the potential to result in a higher prevalence of untreated pain in residents with dementia (IncS 94). However, when staff were familiar with residents, they found it easier to interpret non-verbal cues of pain (IncS 49, 61, 68, 104), and potentially differentiate it from other forms of distress (e.g. emotional distress).

Barry et al. (IncS 7)
found that relatives who visited care homes more often considered that pain was being noted and treated to a greater extent by the staff. Also, relatives visiting their relatives frequently were more likely to interpret (and report) behavior changes as signs of pain (IncS 37), and thereby felt more actively involved in their care (IncS 24, 59).
Staff beliefs and concerns about the safety of using opioid analgesic were highlighted in several studies (IncS 9, 14, 53, 59, 76). These concerns related to either addiction beliefs, or fears about increased confusion and sedation; drug utilization was also reduced when either nurses or residents refused to use or take certain medications, even when their use may have been bene cal.
There were some ndings relating to staff perceptions about why residents might not report pain: for example in one paper it was suggested that staff were unsure if residents were displaying pill-seeking behavior because they wanted attention, rather than being truly in pain (IncS 30). In other papers, it was felt that residents might not be reporting pain because they were concerned about potential loss of independence (IncS 61, 76) or did not want to be seen as complainers or di cult residents (IncS 59, 61, 104).

Pain assessment
Of the included studies, 16 examined the use of pain assessment tools; in general these did not appeared to be widely utilized (IncS 10, 31, 52), with some GPs in particular having little knowledge of speci c tools to assess pain in care home residents (IncS 53). In one of these studies, detailing results from 810 participants across 7 European counries, it was reported that 58% of staff did not use any tool to assess pain in their daily practice (IncS 108). In other studies, although staff had knowledge of the tools, they reported problems interpreting them (IncS 97, 109), or felt them to be time consuming (IncS 42, 79, 84), However, when staff were trained in the utilization of tools, their use was more likely (IncS 97), and with increased usage, staff appeared to recognise their value to a greater extent (IncS 72). The impact on residents of tool usage was highlighted in several studies. For example, the proportion of residents with pain appeared to increase, because pain questions were being asked (and recorded) more frequently, and also pain was being treated to a greater extent (IncS 74, 83). The use of tools was considered to increase awareness, and render staff more sensitive and responsive to residents' pain-related behaviour (IncS 69).
The most commonly researched tool in the included studies was the Pain Assessment in Advanced Dementia scale (PAINAD). Where used, pain assessment tools that were found to be helpful included the Pain Assessment Checklist for seniors with Limited Ability to Communicate (PACSLAC), DOLOPLUS-2, Pain Assessment in Non-Communicative Elderly Persons (PAINE), and the Pain Assessment for the Dementing Elderly (PADE). In contrast, the Abbey Pain Scale, while commonly used in practice, was found to be inaccurate when assessing pain intensity compared with staff estimated pain intensity, and it was also considered to be lacking in direction about precision of usage (IncS 94).

Interventions
Of the 22 studies examining pain treatment interventions, most were shown to produce effective results. Where pain management practice improvements were made, analgesic and non-pharmaceutical treatment use increased and pain scores were shown to reduce (e.g. IncS 19,36,87). However, a systematic review (IncS 89) reported that pain scores deteriorated (increased) where there was a high turnover of staff, and lack of physician support.
Over half of the pain intervention studies (n = 13) were related to non-pharmaceutical treatments, and

Consultation with stakeholders
Evidence from the eld research carried out at 16 care homes is summarized in Table 3, and con rms many of the above points, including staff views regarding lack of eduation and training, lack of systematic use of pain assessment tools, and nearly all mangers expressing the need to improve pain assessment and management in their care home. Table 3 Summary of evidence from stakeholders Discussion This review has examined evidence relating to pain relief in care homes, and sought to understand the internal and external contexts that might in uence the assessment and management of pain for residents. As such, it ful ls the requirement of a scoping review to map the current state of evidence, rather than produce a detailed critical appraisal [12]. To our knowledge, such a broad scoping review has not been previously undertaken.
By including multiple research designs and methods, this review gives a comprehensive overview of ndings from a diverse range of research studies. It updates, incorporates, and broadens the focus of the 13 included reviews, which examined narrower perspectives (e.g. management of speci c types of pain, such as musculo-skeletal: IncS 34, or cancer-related pain: IncS 90, and reviews speci c to dementia: IncS 14,50,76,80).
Care home staff knowledge and training (or lack of it) occurred as a common thread across the different themes identi ed in the review. It was clear that training staff in the assessment and management of pain, and training in the use of appropriate pain assessment tools, in addition to experience and knowledge of residents, did reap bene ts for residents in terms of greater comfort and quality of life, and helped staff to identify treatment options. However, a report by the International Longevity Centre (ILC) [13] argues that a lack of funding for training above and beyond essential or mandatory training exists. It is unclear what regulatory bodies for care homes in other countries (if in existence) advise; however, in the UK, recent reports published by the Care Quality Commission (CQC) show little or no focus on pain [14]. Where training does take place, it is often focussed on the need to ful l other mandatory CQC requirements, rather than a commitment towards workforce development [13]. Prescribing for older people generally is recognised as complex, and staff education is essential to improve outcomes [15]. Areas that would bene t from training programmes for care home staff are summarised in Table 4. Table 4 Training programme recommendations Lack of training may account for reduced staff knowledge and/or concerns about the use of opioids for older people. The differing views of experts may add to this confusion: according to Guerriero [16], guidelines should recommend opioid use as a rst line treatment for moderate to severe persistent pain in older adults, whereas the American Geriatrics Society [17] advise more caution due to the potential side effects (disorientation, potential respiratory suppression, constipation etc). The World Health Organisation (WHO) pain ladder, which advocates stepping up to opiod use if pain is not controlled, has not been validated for non-cancer chronic pain [18], and may contribute to inappropriate prescribing if used in non-cancer pain [18]. However, current NICE guidance [19] does not rule out opioid use if other drugs prove ineffective, and also advocates the use of non-pharmaceutical treatments to augment or compliment medication. More detailed guidance is clearly needed for staff involved in the care of older people with chronic pain.
With further regard to staff training, Wright [20] argues for care assistants to have greater access to training, considering it a key factor in attracting and retaining suitable employees. This is consistent with WHO guidelines relating to health staff retention [21], which state that nancial incentives alone are insu cient to retain staff. Frogner & Spetz [22] also take up the theme that improved education and training for staff, alongside higher wages, and higher overall sta ng levels, are necessary to combat and lower staff exit rates. The high turnover of staff in care homes has been called the 'elephant in the room' by Wilson [23], given that approximately 25% of staff leave in any one year [13]. This makes sustainability of any improvement in the assessment and management of pain less likely, unless there is regional support for training and retention.
Unfortunately, working in the care home sector may not viewed as career choice for many quali ed nurses, even though there are many more beds in nursing homes than in acute care hospitals, and the care needs of residents are increasingly complex [24,25]. Whilst the di culty of recruitment and high turnover of staff is therefore frequently acknowledged as problematic, the evidence from this review shows a correlation between high turnover of staff and less well controlled pain; this would appear to contravene a duty of care. It has also been suggested that older people cared for at home may have less pain and greater comfort than those being cared for in care homes [26].
On a more positive note, this review has also highlighted that more experienced staff, familiar with their residents, are more likely to include non-pharmaceutical measures in the management of pain (IncS 1, 20, 28,36,62,101). That said, the use and effectiveness of non-pharmaceutical treatments can be aided by appropriate assessment prior to, and following, interventions. It is evident that in order to overcome barriers relating to pain assessment, such as the use of tools to augment observational judgment, the mechanisms by which the integration of new practice occurs needs to be understood to a greater extent [27]. If staff can see the value and rewards associated with using a pain assessment and management framework (e.g. increased resident comfort), then shifts in attitudes and norms can occur more readily [27]. Pain in frail older people needs to become part of the regulation of care homes, although it has been argued that this may not happen until care homes adopt an electronic minimum data set or equivalent tool [28]; this has gained more interest recently, stimulated by conversations as a result of the Covid-19 pandemic [28].
Further points of relevance highlighted by the review include the need for clear communication and support from external professionals, including greater access to GPs, and the value of including the views of relatives regarding the detection of pain.
It could be argued that highlighting the skill required to deliver quality care to residents, and the importance of good pain assessment/management, may help to attract nurses and care staff into a career with frail older people in care homes. The value placed on such care by the public and politicians has certainly been highlighted during the COVID19 pandemic [30], and may provide a timely platform from which to launch recruitment drives.

Review strengths and limitations
It is acknowledged that the review may not have captured all relevant material. Searches, screening, and study selection are all open to error or bias. However, the rigorous methods utilised, including blind screening and cross-checking, have served to minimise these limitations. The broad nature of the review, including seeking care home staff opinions, has enabled an expansive view of the available knowledge rather than a narrower or con ned analysis.

Conclusions
This review has highlighted that training and explicit guidelines for the appropriate assessment and treatment of pain remain a current requirement for care home staff. Due to budget limitations, such training may need to be funded by external sources, in the interest of resident well-being, staff satisfaction, and overall care home performance. Knowledge of the issues that face care home staff and their residents can help other professionals, external to the care home environment, to target their input in the most appropriate way. Internal and external contexts need further examination in order to co-create a framework that integrates the assessment of pain and its management, to the bene t of patients.

Key points
There is a need for pain assessment and management training for all staff in care homes, including training relating to residents with dementia Funding for this training needs to be facilitated, potentially by external agencies Clearer, updated pain treatment guidelines for older adults may assist staff decision-making Raising the importance of good pain assessment and management in care homes may alter staff perceptions relating to the presence of pain in older people and particularly those with cognitive impairment Pain assessment and its management will not improve in care homes where there remains a high turnover of staff