title: Systematic pain assessment in nursing homes: a cluster-randomized trial using mixed-methods approach.
abstract: Chronic pain affects nursing home residents' daily life. Pain assessment is central to adequate pain management. The overall aim was to investigate effects of a pain management intervention on nursing homes residents and to describe staffs' experiences of the intervention.
  
  
  
  A cluster-randomized trial and a mixed-methods approach. Randomized nursing home assignment to intervention or comparison group. The intervention group after theoretical and practical training sessions, performed systematic pain assessments using predominately observational scales with external and internal facilitators supporting the implementation. No measures were taken in the comparison group; pain management continued as before, but after the study corresponding training was provided. Resident data were collected baseline and at two follow-ups using validated scales and record reviews. Nurse group interviews were carried out twice. Primary outcome measures were wellbeing and proxy-measured pain. Secondary outcome measures were ADL-dependency and pain documentation.
  
  
  
  Using both non-parametric statistics on residential level and generalized estimating equation (GEE) models to take clustering effects into account, the results revealed non-significant interaction effects for the primary outcome measures, while for ADL-dependency using Katz-ADL there was a significant interaction effect. Comparison group (n = 66 residents) Katz-ADL values showed increased dependency over time, while the intervention group demonstrated no significant change over time (n = 98). In the intervention group, 13/44 residents showed decreased pain scores over the period, 14/44 had no pain score changes ≥ 30% in either direction measured with Doloplus-2. Furthermore, 17/44 residents showed increased pain scores ≥ 30% over time, indicating pain/risk for pain; 8 identified at the first assessment and 9 were new, i.e. developed pain over time. No significant changes in the use of drugs was found in any of the groups. Nursing pain related documentation was sparse. In general, nurses from the outset were positive regarding pain assessments. Persisting positive attitudes seemed strengthened by continued assessment experiences and perceptions of improved pain management.
  
  
  
  The implementation of a systematic work approach to pain issues in nursing homes indicates that an increased awareness, collaboration across and shared understanding among the team members of the pain assessment results can improve pain management and lead to decreased physical deterioration or the maintenance of physical and functional abilities among NH residents. However, pain (proxy-measured) and wellbeing level did not reveal any interaction effects between the groups over time.
  
  
  
  The study was registered in ISRCTN71142240 in September 2012, retrospectively registered.
authors.affiliation: Department of Health and Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden. anna-greta.mamhidir@hig.se.|Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. anna-greta.mamhidir@hig.se.
authors.forename: Anna-Greta
authors.initials: AG
authors.lastname: Mamhidir
authors.affiliation: Department of Health and Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden.|Department of Neurobiology, Care Sciences and Society (NVS), Aging Research Center (ARC), Karolinska Institutet and Stockholm University, Stockholm, Sweden.
authors.forename: Britt-Marie
authors.initials: BM
authors.lastname: Sjölund
authors.affiliation: Department of Health Care Sciences of Ersta, Sköndal University College, Stockholm, Sweden.
authors.forename: Birgitta
authors.initials: B
authors.lastname: Fläckman
authors.affiliation: Department of Neurobiology, Care Sciences and Society (NVS), Aging Research Center (ARC), Karolinska Institutet and Stockholm University, Stockholm, Sweden.|Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Wimo
authors.affiliation: Department of Neurobiology, Care Sciences and Society (NVS), Aging Research Center (ARC), Karolinska Institutet and Stockholm University, Stockholm, Sweden.|Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.
authors.forename: Anders
authors.initials: A
authors.lastname: Sköldunger
authors.affiliation: Department of Health and Caring Sciences, Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden.|Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.|Nursing Department, Medicine and Health College, Lishui University, Lishui, China.
authors.forename: Maria
authors.initials: M
authors.lastname: Engström
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D059350:Chronic Pain / Q000175:diagnosis / Q000523:psychology / Q000628:therapy; D016000:Cluster Analysis; D005260:Female; D006707:Homes for the Aged / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009735:Nursing Homes / Q000706:statistics & numerical data*; D017063:Outcome Assessment, Health Care; D059408:Pain Management; D010147:Pain Measurement / Q000379:methods / Q000523:psychology / Q000706:statistics & numerical data
keywords: Cluster- randomized trial; Mixed-methods; Nursing homes; Pain assessment; Pain intervention