The Sustainability of Evidence-based Pain

Management Practices in Aged Care.

Ms Helen Mary Holloway

BHSc, BSc, GradDipBioethics, MScMed (PainMgt).

A thesis submitted for the degree of Doctor of Philosophy at

The University of Queensland in 2018
Faculty of Health and Behavioural Science
School of Nursing, Midwifery and Social Work.
 Abstract.
Despite there being acknowledgement by the aged care industry of the presence of
complex persistent pain in older people living in residential care facilities (RCFs),
pain continues to be under-recognised and poorly managed. This is particularly the
case for residents from culturally and linguistically diverse (CALD) groups and those
living with dementia. Some initiatives in this area include the development of multiple
assessment tools, advancement of pharmacological and non-pharmacological
strategies, the development of best practice guidelines and increased education.
However, little advancement has been made in establishing and sustaining best
practice in this area of care. There is also a lack of research examining how
knowledge and best practice, on a broader scale, are sustained within RCFs,
through ongoing learning.

Using a mixed methods approach, this research, conducted in two phases, aimed to
identify what factors impact on organisational knowledge and the sustainability of
evidence-based (EB) pain management practices in aged care. Phase One was
conducted in an RCF that had previously implemented the Australian Pain Society’s
(APS) best practice guidelines (Goucke et al., 2005) and it investigated what
individual and organisational factors impact on the ability of the direct care staff
(registered and enrolled nurse, allied health and care workers) to undertake EB pain
management practices. Phase Two was conducted in two Registered Training
Organisations (RTOs) in Queensland and it investigated, how current education
practices for workers with Certificate III in Aged Care (the primary workforce),
influence their ability to conduct EB pain management practices.

Organisational learning theory (OLT) was utilised in this research, specifically the
organisational learning theoretical framework as proposed by Argote and Miron-
Spektor (2011). This framework provided the tool for analysing how factors from the
external environmental context (e.g. government policy and legislation) and internal
contextual factors (organisational and individual), influence the way in which
knowledge about pain management practices is attained, retained and transferred
(Argote & Miron-Spektor, 2011).

The findings of this research indicate that, two years after implementation of EB pain
management strategies, best practice was not sustained and a number of resident,

i
staff, organisational and system factors, influenced the maintenance and utilisation
of organisational knowledge. This research also found, that Certificate III care
workers obtained only basic knowledge of pain identification and management
practices in the course, through one hour of education, primarily provided in the
palliative care module. They received limited education or mentoring in these
practices and processes, once they were employed in a care worker role. Clinical
Facilitators (CFs) involved in care worker training, typically had a Certificate III in
care work only and had varying levels of experience and knowledge in pain
management practices and processes. The teaching methods utilised in the workers’
education were didactic, with use of workbooks or a power point presentation.

The results indicate there are significant individual and organisational factors that
impact the sustainability of EB pain management practices in aged care. Inadequate
maintenance of best practice, affects the older person’s quality of life and contributes
to unnecessary suffering. Whilst many of these factors have previously been
documented in the literature as impacting on pain management processes in RCFs,
there appears to have been minimal advances in resolving the issues. Knowledge
regarding pain identification, assessment and management, may be attained through
education and the provision of guidelines. However, the utilisation, retention, and
transference of this knowledge within aged care facilities, appears to decline after
initial implementation. If best practice is to be sustained, managers and clinical
leaders in RCFs, need to utilise a framework or model, such as provided in the
organisational learning theoretical framework, to identify potential barriers and
facilitators, consider what happens beyond the initial implementation phase and
strategically plan how the RCF can sustain knowledge and best practice, given their
current human and physical resources. The aged care industry, nursing as a
professional body and the public at large, needs to pressure the government to
improve staff ratios and skill mix. There also needs to be a pressure placed on the
government and training providers, to improve the standard of education offered in
the Certificate III/IV aged care training material. Improved education for care workers
in pain management (and other clinical areas), would better equip them, for work in
the current aged care environment, where care that is more complex is required for
older people now being admitted to RCFs.

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If we do not make some considerable efforts to address the ongoing poor recognition
and management of pain in RCFs, then we will continue to fail in our duty of care to
one of the most vulnerable groups in our population. Older people have the right to
have their pain managed appropriately.

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 Declaration by author.

This thesis is composed of my original work, and contains no material previously

published or written by another person except where due reference has been made
in the text. I have clearly stated the contribution of others to the jointly-authored
works that I have included in my thesis.

I have clearly stated the contribution of others to my thesis as a whole, including

statistical assistance, survey design, data analysis, significant technical procedures,
professional editorial advice, financial support and any other original research work
used or reported in my thesis. The content of my thesis is the result of work I have
carried out since the commencement of my higher degree by research candidature
and does not include a substantial part of work that has been submitted to qualify for
the award of any other degree or diploma in any university or other tertiary institution.
I have clearly stated which parts of my thesis, if any, have been submitted to qualify
for another award.

I acknowledge that an electronic copy of my thesis must be lodged with the

University Library and, subject to the policy and procedures of The University of
Queensland, the thesis be made available for research and study in accordance with
the Copyright Act 1968 unless a period of embargo has been approved by the Dean
of the Graduate School.

I acknowledge that copyright of all material contained in my thesis resides with the
copyright holder(s) of that material. Where appropriate I have obtained copyright
permission from the copyright holder to reproduce material in this thesis and have
sought permission from co-authors for any jointly authored works included in the
thesis.

iv
 Publications included in this thesis.

No publications included.

Submitted manuscripts included in this thesis.

No manuscripts submitted for publication.

Other publications during candidature.

Peer reviewed publication.

Holloway, H., Parker, D. & McCutcheon, H., (2018). The complexity of pain in aged
care. Contemporary Nurse, 54:2, 121-125, DOI: 10.1080/10376178.2018.1480399

Conference abstract.

Holloway, H. (2012). Barriers and facilitators to pain assessment in individuals with

moderate to severe dementia living in residential aged care, paper presented to
Emerging Researchers in Ageing. Brisbane, QLD, 19-20th of November 2012.

Contributions by others to the thesis.

Professor Helen McCutcheon and Professor Deborah Parker have contributed to this
thesis through the conception and design of this project and to the work and writing
represented and reported in this thesis, through critically revising the sections of this
document in order to contribute to the interpretation of results. It is also
acknowledged that Associate Professor Christine Neville contributed to the early
conception and design of this research and Mrs Diane Josey contributed to the
professional editing.

v
Statement of parts of the thesis submitted to qualify for the award of another degree.

No works submitted towards another degree have been included in this thesis.

Research involving human or animal subjects.

Ethics approval was sought from The University of Queensland Behavioural & Social
Sciences Ethical Review Committee for both Phase One (#2012000433) and Phase
Two (# 2015000051) (Appendix 1). These were obtained after approval from the
Residential Care Facility and Registered Training Organisations was granted (Letters
of Support in Appendix 2).

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 Acknowledgements.

In a thesis journey of this length (7 years) there are many people who you meet
along the way contributing in small and big ways. First acknowledgement always
must go to God, who is always there to strengthen and guide me. Brett, my husband,
who continues to let me follow my dreams of studying and no matter where he is in
the world supports my pursuits, loves me and always offering great IT support. There
were many days when if it wasn’t for his computer knowledge, I would have lost my
sanity. To my cats Oscar (deceased) and Imoen thanks for spending the many hours
lying beside the computer keeping my company whilst I worked.

To my Mum, Dad, sisters (PJ, Cassandra (and family), Danielle), Shirley, Bron and
Tim, thanks for your encouragement and support in the many ways you have
provided it. To my extended family aunts, uncles and cousins on both sides, thank
you. A particular mention needs to go to Vicki and Bob Hinrichsen (and the boys),
who housed and supported me for many years. I will never forget Vicki our nights of
sitting together at the kitchen table studying with cups of tea followed by a “chick
flick”! To all of my friends, church families and colleagues (of which there are too
many to mention individually). Thank you for your encouragement, prayers, support,
cups of tea, time outs, chocolates, biscuits, sport updates, lunches and dinners. You
all know who you are. Your support has been unmeasurable. One special mention
however, does have to go to Steve Bade, who saved my hard drive at one very
crucial moment.

To my eye specialists Associate Professor Michael Coote, Dr D’Mellow and their

teams, and optometrist Nic Karanges. Thanks for keeping my eyes in top shape so I
could keep writing and finish this thesis. Your professionalism, care and medical
skills helped make the difficult journey with my sight, much easier. Grant Sutherland
(physio) must also be thanked for helping me get physical function back.

To all of the participants, managers, nurses, allied health members, care workers,
students, Clinical Facilitators (and by proxy residents). Thank you so much for your
contribution to this research. I couldn’t have done it without your input. Your passion
for each of your areas of practice make a difference to each and every person.

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Last but of course never least. To my supervisors. Christine Neville thank you for
walking the early part of the journey with me. To Professor Helen McCutcheon thank
you for coming on board when you did and being such a great guide. Your
knowledge, input and support really made the difference to the completion of this
project. It has been nice working with you. To Professor Deb Parker. You have been
with me from the start. I have so appreciated your guidance, support, patience and
the many hours that you have spent reading my material. Your passion for palliative
care for older people, makes working with you such a great experience. It has been
good to get to know you over the last seven years. To my reviewers Professor
Elisabeth Beattie and Dr Andrea Petriwskyj, thank you for taking the time to read my
work and for your invaluable input. Thanks to all other staff at UQ school of Nursing,
Midwifery and Social work for help and support. Finally, thanks to Diane Josey for
editing.

Dedication.

This thesis is dedicated to older people, particularly those living in residential care,
living with persistent or poorly managed pain. You are not forgotten.

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 Financial support.

This research was supported by general research support funding from the
University of Queensland, School of Nursing, Midwifery and Social Work.

Keywords.

Aged care, evidence-based practice, knowledge, organisational learning, pain,

sustainability.

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 Australian and New Zealand Standard Research Classifications (ANZSRC).

ANZSRC code: 111001 Aged Care Nursing 100%

Fields of Research (FoR) Classification

FoR code: 1110, Nursing 100%

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 Table of Contents
Abstract. ...................................................................................................................... i
Dedication ................................................................................................................ viii
List of figures & tables. ..............................................................................................xv
List of abbreviations used in the thesis.................................................................... xvii
Chapter One: Introduction and Background to Project. .............................................. 1
1.1 Introduction. ...................................................................................................... 1
1.2 Background. ...................................................................................................... 1
1.3 Significance....................................................................................................... 5
1.4 Research questions. ......................................................................................... 5
1.5 Summary........................................................................................................... 6
Chapter Two: Literature Review. ................................................................................ 7
2.1 Introduction. ...................................................................................................... 7
2.2 Pain. .................................................................................................................. 8
2.2.1 Acute vs persistent pain. .............................................................. 10
2.2.2 Pain in older people. .................................................................... 11
2.2.3 Pain in people with dementia. ...................................................... 11
2.2.4 Culturally and linguistically diverse (CALD) Individuals and pain. 13
2.3 The identification, assessment and management of pain. .............................. 14
2.4 Pain assessment and management resources for aged care. ........................ 15
2.5 Barriers to pain assessment............................................................................ 17
2.5.1 Resident barriers. ......................................................................... 17
2.5.2. Staff barriers................................................................................ 21
2.5.3 Facility barriers. ............................................................................ 22
2.5.4 System barriers. ........................................................................... 25
2.6 Facilitators of pain assessment. ...................................................................... 27
2.7 Implementing evidence-based (EB) practice................................................... 28
2.8 Sustaining EB pain management practices in RCFs. ...................................... 30
2.9 Summary......................................................................................................... 31
Chapter Three: Theoretical Framework.................................................................... 33
3.1 Introduction. .................................................................................................... 33
3.2 Theoretical frameworks and paradigms. ......................................................... 33
3.2.1 Positivist and post positivist paradigms. ....................................... 34

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 3.2.2 Constructivist-interpretivist. .......................................................... 35
3.2.3 Critical theory. .............................................................................. 35
3.2.4 Pragmatism. ................................................................................. 35
3.3 Consideration of theoretical underpinning for the proposed research. ............ 36
3.4 Theories. ......................................................................................................... 39
3.5 Organisational learning and organisational learning theory (OLT). ................. 40
3.5.1 Organisational learning. ............................................................... 40
3.5.2 Organisational learning theory (OLT). .......................................... 41
3.5 Research questions. ....................................................................................... 46
3.6 Summary. ........................................................................................ 46
Chapter Four: Methodology. ..................................................................................... 47
4.1 Introduction. .................................................................................................... 47
4.2 Ethics. ............................................................................................................. 48
4.3 Research methods used in organisational learning (OL) research. ................ 48
4.4 Triangulation. .................................................................................................. 49
4.5 Phase One. ..................................................................................................... 50
4.5.1 Aim of the proposed study............................................................ 50
4.5.2 Methodology. ................................................................................ 50
4.5.3 Part 1 – Audit of residents’ charts. ............................................... 52
4.5.4 Part 2 - Interviews with RCF direct care staff. .............................. 54
4.6 Phase Two. ..................................................................................................... 56
4.6.1 Participants. ................................................................................. 58
4.6.2 Documentation. ............................................................................ 64
4.7 Analysis........................................................................................................... 64
4.8 Summary......................................................................................................... 66
Chapter Five: Results – Phase One. ........................................................................ 67
5.1 Introduction. .................................................................................................... 67
5.2 Results Phase One - Part One........................................................................ 67
5.2.1 Facility audit. ................................................................................ 68
5.2.2 Audit of resident files. ................................................................... 69
5.2.3 Assessment on admission............................................................ 73
5.2.4 Regular pain assessment. ............................................................ 77
5.2.5 Episodes of Pain. ......................................................................... 79

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 5.2.6 Pain management strategies. ....................................................... 80
5.3 Results Phase One - Part 2. ........................................................................... 82
5.3.1 Staff interviews. ............................................................................ 82
5.3.2 Themes and subthemes from interviews. ..................................... 85
Internal organisational contextual factors. ............................................................. 86
Theme Three – Knowledge and experience of carers........................... 92
5.4 Summary......................................................................................................... 93
Chapter Six: Results – Phase Two. .......................................................................... 95
6.1 Introduction. .................................................................................................... 95
6. 2 Student/new care worker. .............................................................................. 95
6.2.1 Recruitment. ................................................................................. 95
6.2.2 Demographic information. ............................................................ 98
6.2.3 Student/New Care Worker - Questionnaire responses. ............. 100
6.2.4 Diary entries at TP2 and TP3. .................................................... 111
6.2.5 Interviews at TP2 (student) and TP3 (new care worker). ........... 116
6.3 Clinical facilitators (CFs). .............................................................................. 126
6.3.1 Clinical Facilitator Questionnaire Data. ...................................... 126
6.3.2 Interviews – Clinical Facilitator. .................................................. 135
6.4 Document analysis. ....................................................................................... 141
6.5 Summary....................................................................................................... 143
Chapter Seven: Discussion and Conclusion. ......................................................... 145
7.1 Introduction. .................................................................................................. 145
7.2 Aim of the research. ...................................................................................... 146
7.3 Individual factors impacting direct care staffs’ ability to conduct EB practice. 147
7.3.1 Resident. .................................................................................... 147
7.3.2 Direct care staff/students/new care workers/CFs. ...................... 152
7.4 Organisational factors impacting direct care staff ability to conduct EB practice.
............................................................................................................................ 160
7.4.1 Environmental context (external to the organisation). ................ 160
7.4.2 Organisational context (internal). ............................................... 162
7.5 Education practices and age care workers and their ability to conduct EB pain
management practices. ....................................................................................... 178
7.6 Limitations. .................................................................................................... 183

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 7.7 Recommendations to improve evidence-based pain identification, assessment
and management practices in RCFs. .................................................................. 185
7.8 Plans for dissemination of results. ................................................................ 187
7.9 Future research............................................................................................. 188
7.10 Conclusion. ................................................................................................. 188
References. ............................................................................................................ 192
Appendices. ........................................................................................................... 210
Appendix 1: Ethics approval- Phase One and Two. ............................................ 211
Appendix 2: Letters of support- Phase One and Two ......................................... 213
Appendix 3: Phase One- Pain Practices Audit Tool (PPAT). .............................. 216
Appendix 4: Phase One– Participant information and consent. .......................... 231
Appendix 5: Phase One- Demographic questionnaire and interview questions. . 236
Appendix 6: Phase Two- Participant information and consent. ........................... 240
Appendix 7: Phase Two- Student quesionnaires. ............................................... 249
Appendix 8: Phase Two- Student interview questions. ....................................... 258
Appendix 9: Phase Two- Clinical facilitator questionnaires. ................................ 259
Appendix 10: Phase Two- Clinical facilitator interview questions. ....................... 266

xiv
 List of figures & tables.
List of figures.
Chapter 3.
Figure 3.1 Organisational learning theoretical framework. ....................................... 42
Chapter 4.
Figure 4.1 Explanatory sequential mixed methods design for Phase One. .............. 52
Figure 4.2 Non-randomised convergent triangulation for Phase Two. ..................... 57
Chapter 5.
Figure 5.1 Admission assessments. ......................................................................... 75
Figure 5.2 Regular pain assessments. ..................................................................... 76
Figure 5.3 Episodes of pain...................................................................................... 78
Chapter 6.
Figure 6.1 Recruitment and retention of student/new care worker participants in
Phase Two. .............................................................................................................. 97

List of tables

Chapter 4.
Table 4.1 Inclusion/exclusion criteria for staff participation in Phase One. ............... 54
Table 4.2 Inclusion/exclusion criteria for students/CFs Phase Two. ........................ 58
Table 4.3 Schedule of data collection points for student/new care workers in Phase
Two. ......................................................................................................................... 62
Chapter 5.
Table 5.1 Age of residents in the facility. .................................................................. 69
Table 5.2 Length of stay (weeks and years). ............................................................ 70
Table 5.3 Resident comorbidities. ............................................................................ 71
Table 5.4 Dementia types. ....................................................................................... 72
Table 5.5 History of persistent pain and known pain behaviours. ............................ 73
Table 5.6 Pharmacological and non-pharmacological strategies used in the facility.80
Table 5.7 Age range of direct care staff. .................................................................. 83
Table 5.8 Themes and subthemes of barriers to pain assessment. ......................... 86
Table 5.9 Themes for facilitators of pain assessment. ............................................. 91

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Chapter 6.
Table 6.1 Student demographic information–gender and age.................................. 98
Table 6.2 Student nationality at Time Point 1. .......................................................... 99
Table 6.3 Responses to knowledge and belief questionnaire between TP1, TP2 and
TP3......................................................................................................................... 102
Table 6.4 Responses to the Modified Student Pain Management Survey between
TP1 and TP2. ......................................................................................................... 106
Table 6.5 Responses to the Modified Student Pain Management Survey between
TP1, TP2 and TP3.................................................................................................. 108
Table 6.6 Responses to knowledge and attitudes to pain in the elderly between TP1
vs TP2 and TP1 vs TP2 vs TP3 ............................................................................. 110
Table 6.7 Themes and subthemes from diaries at TP2 and TP3. .......................... 112
Table 6.8 Themes and subthemes of interview at TP2 and TP3. ........................... 117
Table 6.9: Demographic information of Clinical Facilitators. ................................... 128
Table 6.10 Clinical Facilitator responses to Knowledge and belief of Pain in the
Elderly Questionnaire. ............................................................................................ 130
Table 6.11 Clinical Facilitator responses to Modified Pain Management Clinical
facilitator survey. .................................................................................................... 132
Table 6.12 Clinical Facilitator responses to knowledge and attitudes survey
regarding pain. ....................................................................................................... 134
Table 6.13 Themes and subthemes from CF interviews. ....................................... 135

xvi
 List of abbreviations used in the thesis.
ACFI Aged Care Funding Instrument
AACQA Australian Aged Care Quality Agency.
AD Alzheimer’s disease
AH Allied Health
AIN Assistant in Nursing. May also be known as personal care assistants
(PCA), multi skilled care worker (MSCW), personal care worker (PCW).
APS Australian Pain Society
BPSD Behavioural and Psychological Symptoms of Dementia
CALD Culturally and linguistically diverse
CM Care Manager
CN Clinical Nurse
CNS Central Nervous System
DT Diversional Therapist
EB evidence-based
EBPRAC Establishing Best Practice in Residential Aged Care
EN Enrolled Nurse
GP General Practitioner
M-BPV Modified Brief Pain Inventory
NP Nurse Practitioner
OLT Organisational Learning Theory
PAINAD Pain Assessment in Advanced Dementia.
PPAT Pain Practices Audit Tool
PRACMS Pain in Residential Aged Care Management Strategies.
PRN When necessary
PT Physiotherapist
RCF Residential Care Facility
RN Registered Nurse.
RTO Registered Training Organisation
TENs Transcutaneous Electrical Nerve Stimulation
TP Time Point
vs Versus

xvii
 Chapter One: Introduction and Background to Project.
1.1 Introduction.
In Australia, older people may require care services because of the presence of
multiple comorbidities and the need for support. Care services can be provided in the
community, in the individual’s own place of residence, or in a residential care facility
(RCF). There are a number of different providers of aged care services in Australia:
not-for-profit, for profit or government organisations. All these organisations need to
be accredited by the Australian Aged Care Quality Agency (AACQA) and compliant
with the Department of Health (DoH). The use of evidence-based (EB) practice in
aged care, can contribute to the delivery of quality care and assist RCFs to achieve
and maintain their accreditation status.

The direct care workforce in RCFs comprises Nurse Practitioners (NP), Registered
Nurses (RNs), Enrolled nurses (ENs), Allied Health (AH) practitioners and care
workers also known as Assistants in Nursing (AINs) (Mavromaras et al., 2017). AINs
in Australia, are unregulated and have a minimum qualification of a Certificate III in
Aged Care (now known as a Certificate III in Individual Support, CHC33015
(Department of Education and Training [DET], 2018). They provide the majority of
direct care in RCFs in Australia (making up 70% of the direct care workforce)
(Mavromaras et al., 2017). There are no minimum ratios or skill mix mandated for
RNs, ENs or AINs to residents/clients. Since 2003, there has been a gradual but
significant decline in the number of RNs employed in the aged care sector, despite
the increased complexity of care required for individuals being admitted into RCFs
(Hillen, Vitry, & Caughey, 2017; Mavromaras et al., 2017). This is a concern for the
delivery of EB quality care.

1.2 Background.
Pain is common amongst the residents living in aged care and has been estimated
to be present in as high as 40-83% of any aged care population (Corbett et al., 2012;
Hanlon, Perera, Sevick, Rodriguez, & Jaffe, 2010; Savvas & Gibson, 2015; Takai,
Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010).

1
Pain is defined as,

An unpleasant sensory and emotional experience associated with actual or

potential tissue damage, or described in terms of such damage. The inability
to communicate verbally does not negate the possibility that an individual is
experiencing pain and is in need of appropriate pain-relieving treatment. Pain
is always subjective
(International Association for the Study of Pain (IASP), 2018).

The classification of pain is based on factors such as anatomy, severity, length of

time present and cause (Turk & Okifuji, 2010). Commonly used terms include acute
or persistent, cancerous or non–cancerous, nociceptive or neuropathic. Persistent
(chronic) pain, is pain that persists long after tissue healing. It may be the result of
trauma or a disease process. In persistent pain, the nervous system becomes over
sensitised. This over sensitisation may be further contributed to, by the psychosocial,
emotional, physical and spiritual characteristics of the individual experiencing the
pain (Turk & Okifuji, 2010).

The Australian Bureau of statistics (ABS) (2011), found that people over the age of
75 reported the highest rates of severe/very severe pain. This age group also has
the largest number of comorbidities, with approximately 50% of the 65–74-year-old
age group and 70% of the 85 plus age group having more than five comorbidities
(ABS 2010). Increasing age and multiple comorbidities, frequently means complex
pain that is often difficult to manage. This is not only because of the presence of
mixed pain types, but also because multiple comorbidities, requiring polypharmacy,
result in an increased risk of interactions, inappropriate prescribing and side effects.
This is particularly relevant for the older person who may already have a reduced
ability to metabolise and utilise medications because of age related changes (Nobili,
Garattini, & Mannucci, 2011; Rastogi & Meek, 2013).

Pain can affect the older person physically, psychologically, spiritually, emotionally,
socially or financially. Some of the effects of poorly managed pain for the older
person, and particularly for those with dementia, include depression, decreased
mobility, deconditioning, falls, decreased socialisation, withdrawal, sleep deprivation,
increased confusion and increased behaviours of need (Kaye, Baluch, & Scott, 2010;

2
Molton & Terrill, 2014). The effect is significant on the older person’s quality of life,
already impacted by multiple comorbidities.

Since the 1990s, it has been well documented nationally and internationally, that
pain in individuals living in RCFs is poorly identified, assessed and managed
(Achterberg et al., 2013; Bjoro & Herr, 2008; Ferrell, 1995; Ferrell, Ferrell, &
Osterweil, 1990; Goucke, 2018; Hadjistavropoulos et al., 2007; Hanlon et al., 2010;
Horgas & Elliott, 2004; McAuliffe, Brown, & Fetherstonhaugh, 2012; Scherder et al.,
2009). There are a number of explanations given why pain, acute or persistent, is
poorly assessed and managed in this group.

The presence of multiple comorbidities (including dementia) and geriatric syndrome,

adds levels of complexity to the pain being experienced by an older person. A
culturally and linguistically diverse (CALD) background, means the presence of
language and cultural barriers. A number of barriers at the resident, staff, facility and
system levels have also been identified (Bruneau, 2014; Caughey, Vitry, Gilbert, &
Roughead, 2008; Department of Health and Ageing, 2008; Goucke, 2018; Hillen et
al., 2017; Schofield et al., 2012). All of these, individually or collectively, can affect
the pain assessment and management process.

There have been a number of international resources developed to improve care in

the area of pain assessment and management in older people and people living with
dementia (Abdulla et al., 2013; American Geriatric Society [AGS], 2002; AGS Panel
on the Pharmacological Management of Persistent Pain in Older Persons, 2009;
Ferrell et al., 2009; Hadjistavropoulos et al., 2009; Schofield et al., 2012).

In Australia, assessment tools, guidelines and educational resources have also

been developed, in attempts to improve EB pain management practices. They
include the Abbey Pain Scale (Abbey et al., 2004) and the Pain in Residential Aged
Care: Management Strategies (PRACMS), which provided best practice strategies
(Goucke et al., 2005) (with a revised edition in 2018 (Goucke, 2018)). The Pain
Management Guidelines (PMG) for Aged Care: An Implementation Kit to accompany
the PRACMS, was developed to assist facilities to implement the best practice
guidelines (Edith Cowan University, 2007). These were distributed to every RCF in
Australia from 2006 and 2008 by the Department of Health and continue to be

3
accessible through the Australian Government’s Department of Health, the
Australian Pain Society and Caresearch websites.

The 27 best practice strategies (identified in the 2005 PRACMS document (Goucke
et al., 2005)), were utilised as the framework for the Establishing Best Practice in
Residential Aged Care (EBPRAC) Pain Management project that ran from 2007 –
2009 (Savvas, Toye, Beattie, & Gibson, 2014b). The Australian Government
Department of Social Services (now the Department of Health), funded this project in
an attempt to increase the use of EB pain management practices in RCFs and
improve the quality of life of the older person. The project utilised a change
management framework, pre and post auditing, education and training sessions for
all staff across multiple sites, to improve pain management practices (Savvas et al.,
2014b). The long-term sustainability of these implemented best practices (>2 years)
has never been evaluated.

The successful implementation and sustainability of EB practices in an RCF

environment can depend on a number of factors being in place. These include: a
receptive context; the use of an implementation model e.g. Promoting Action in
Research Implementation in Health Research (PARiHS); education on the benefits
of changing practice; adequate resources (human and material); suitably skilled staff
and ongoing education. An organisation and leadership group that are engaged and
committed to best practice and supporting all staff, has also been identified as
important. Examination of the best EB practice guidelines provided by policy makers,
government departments or the organisation, and adaptation at the local level, is
essential. Barriers to the implementation and sustainability of EB practice may exist,
but identifying and addressing any potential barriers prior to implementation, may
help increase compliance with the new practice. Prompts, such as posters reminding
residents to report pain, or for all staff to observe for signs of pain and report it, can
contribute to creating and maintaining a pain vigilant culture. Finally, systems need
to be in place to continuously monitor the new practice and allow for feedback to the
staff on performance and how they are meeting outcomes (Colón-Emeric et al.,
2016; Goucke, 2018; Hagedorn et al., 2006; Kredo et al., 2016; Masso & McCarthy,
2009; Rycroft-Malone, 2004; Wiltsey Stirman et al., 2012). Examination of these
factors also means, that the organisation considers the ongoing maintenance of the

4
knowledge of the task, how this knowledge will be retained and shared amongst
existing and new staff (Argote & Miron-Spektor, 2011; Virani, Lemieux-Charles,
Davis, & Berta, 2009).

1.3 Significance.
The identification, assessment and management of pain in the older person living in
RCFs, has to contend with many complex challenges. Multiple factors (at resident,
staff, facility and system level) have been known to impact the implementation of
pain management practices in aged care (Achterberg et al., 2013; Bruneau, 2014;
Goucke, 2018; Veal et al., 2018). These factors could also potentially impact
sustainability.

The need for research in this area was identified in the literature and confirmed,
when the researcher was working as a Clinical Nurse in the aged care sector and
observed inadequate pain identification, assessment and management practices,
continuing more than two years after best practice guidelines were implemented
during the EBPRAC pain management project (Savvas et al., 2014b). The impact of
these poor practices on the older person were significant and resulted in an altered
lifestyle and a significant burden of psychological, emotional and spiritual suffering.
In addition, the Commonwealth Government funded several projects in an attempt to
establish best practice in RCFs in Australia (Masso, Westera, Quinsey, Morris, &
Pearse, 2011). Research is required to determine the long-term sustainability (>2
years) of the practices implemented, and the factors that have influenced their
sustainability.

This thesis seeks to examine the factors influencing the sustainability of EB pain
management practices in an RCF.

1.4 Research questions.

1. What individual factors impact the ability of direct care staff to conduct
evidence-based pain identification, assessment and management practices for
older people in RCFs?
2. What organisational factors impact the ability of direct care staff to conduct
evidence-based pain identification, assessment and management practices for
older people in RCFs?

5
 3. How do current educational training practices for care workers, influence their
ability to conduct evidence-based pain identification, assessment and
management practices for older people in RCFs?

In this thesis, Chapter Two presents a review of the literature on pain, pain in the
older person and people with dementia, barriers and facilitators to pain identification,
assessment and management. Chapter Three, discusses the theoretical
underpinnings of the research project, with Chapter Four focussing on the research
methodology for Phase One and Phase Two. Phase One evaluated the sustainability
of EB pain management practices, in a facility that had previously implemented best
practice during the EBPRAC project. Phase Two, conducted with two Registered
Training Organisations (RTOs), examined the education and training of Certificate III
Aged Care students, in pain identification, assessment and management, and the
transfer of that knowledge into the workplace. Chapter Five presents the results and
analysis from Phase One and Chapter Six provides the results and analysis from
Phase Two. Chapter Seven provides the discussion, recommendations, limitations
and conclusions of this research.

1.5 Summary.
Ongoing poor pain management practices in aged care result in needless suffering
and have a negative impact on the quality of life of the older person living in
residential care. A number of resources have been produced nationally and
internationally, to improve practice in this area of care. Whilst there is evidence
available on how guidelines should be implemented, there is less evidence available
about the factors that promote organisational learning and help sustain practice in
residential care. This research aims to identify some of the factors influencing best
practice sustainability.

6
 Chapter Two: Literature Review.
2.1 Introduction.
Translating, implementing and sustaining best practice for the identification,
assessment and management of pain in RCFs is important. Older people being
admitted to these facilities often have complex health conditions and poorly
managed complex persistent pain, leading to a poor quality of life. Under
assessment and poor management, is common in this population and is attributed to
a number of individual and organisational barriers (Achterberg et al., 2013; Bruneau,
2014; Savvas & Gibson, 2015; Veal et al., 2018). There is also a lack of significant
research in this area regarding pain and the older person, pain in people with
dementia and older people form CALD groups, which may also contribute to poor
assessment and management practices in aged care. Further research is also
required, to improve the validity and reliability of both verbal and non-verbal pain
assessment tools in these groups and to assess the effectiveness of non-
pharmacological and pharmacological strategies (analgesia and adjuvant therapies),
for older people living with persistent pain and multiple comorbidities (Achterberg et
al., 2013; Bruneau, 2014).

There is also a lack of knowledge and research concerning the translation,

implementation and the long-term sustainability of EB practices in RCFs (Verbeek,
Zwakhalen, Schols, & Hamers, 2013). The research that is available, informs us that
sustaining change after the implementation of best practice, is challenging and there
are a number of factors that can contribute to the success or failure of the change
(Wiltsey Stirman et al., 2012). It has been proposed, that barriers to the
implementation of EB practice, may be overcome by the use of an implementation
strategy and there are a number of theories, models or frameworks available that
could be utilised for this purpose (Nilsen, 2015). Using an implementation strategy,
provides an organisation with the opportunity to look at the evidence to be
implemented, the context into which this evidence is being introduced, the individuals
who will receive the information, the resources available to enable the change and
potential barriers that may inhibit implementation (Marchionni & Ritchie, 2008;
Nilsen, 2015). The implementation strategy (i.e. the theory, model or framework),
could also be utilised during the implementation phase to evaluate progress and
post-implementation of the practice, to gauge sustainability of practice strategies.

7
The following chapter will review pain, pain in older people and people with
dementia, pain in CALD groups, pain identification, assessment and management
strategies, and known barriers to and facilitators of pain management practices in
RCFs. The chapter will conclude with discussion of the current EB pain management
guidelines available, and approaches that could be used to help organisations
sustain best practice.

2.2 Pain.
Pain is a subjective personal experience, influenced by a number of factors. An
individual’s anatomy and physiology, age, gender, genetics, cultural and ethnic
background, spiritual beliefs, coping skills, emotions, social skills and expectations,
mental health, education level, life experiences and previous or current pain
experiences, are some of the factors identified. All, or some of these factors, can
impact on the individual’s interpretation of the pain and its verbal or non-verbal
expression (Coghill, 2010; Cope, 2010; Hadjistavropoulos, Hunter, & Dever
Fitzgerald, 2009).

Pain is not a normal process of ageing, however, it is more common in older people
than younger because of a higher prevalence of multiple diseases, geriatric
syndrome, injury or psychosocial factors (Herr, 2011; Molton & Terrill, 2014). The
highest levels of debility and pain are often seen in the 65+ age group, some of
whom will be living in RCFs. These individuals are often in long-term care because
of chronic health conditions, dementia and substantial disability (Australian Institute
of Health and Welfare [AIHW], 2012; Goucke, 2018; Hillen et al., 2017). Husebo et
al., (2012), puts the prevalence of pain in this population as high as 83%. The higher
incidences of pain in older people in RCFs, have been identified in those individuals
who have communication problems, such as those with dementia (Goucke, 2018).

Pain can be classified in different ways: acute, persistent, nociceptive, neuropathic,

central or peripheral. It may also be described by what is causing the pain i.e. cancer
or ischaemia (Turk & Okifuji, 2010). Individuals may also verbalise about the quality
of the pain they are experiencing in various ways, such as: aching, throbbing,
burning, stabbing or shooting (Fillington, 2010; Molton & Terrill, 2014). This is
because, pain is not only a physical experience, but integrates a number of

8
biopsychosocial, emotional, behavioural and cultural factors, that can act together to
moderate the individual’s experience and expression of pain.

Pain is processed in the central nervous system (CNS). In the brain there are a
complex set of neural networks that communicate between each other to process
incoming painful stimuli and to modulate output. Whilst a number of regions in the
brain have been identified as important to pain processing, two areas that have been
clearly identified, are the medial and lateral pain systems. The medial pain system
plays a central role in the neuro-endocrine, motivational/affective and
cognitive/evaluative centres for pain (Achterberg et al., 2013). These are the areas
where memory, emotions, expectations, learning and autonomic responses occur.
The lateral pain system is involved primarily in the sensory/discriminative
assessment of pain, that is, the qualities, intensity and position of pain (Achterberg et
al., 2013; Ciampi de Andrade et al., 2011; Lorenz & Hauck, 2010; Molton & Terrill,
2014). These are also the areas that are affected during the disease process of
dementia, particularly Alzheimer’s disease (AD) (Husebo, Achterberg, & Flo, 2016).

As pain is a subjective experience, for another person to understand the experience,

the person in pain needs to verbalise the presence of pain, describe its duration,
location, intensity, its characteristics (i.e. burning, shooting, aching) and its impact on
their quality of life. Even then, the full complexity of the pain experience may not be
articulated, because verbal self–expression can be modulated by cultural,
psychosocial, emotional or spiritual factors (Craig, 2015). Self-reporting of pain
requires an individual to pay attention to the task, consider the situation and report
on the multidimensional nature of the experience within their own context, putting the
experience into a few sentences so that another person can understand. It is a
complex cognitive task (Craig, 2015; Garland, 2012). The subjectivity and complexity
of the pain experience, is why verbal self-report remains the most accurate method
of identifying and assessing pain (Corbett et al., 2012).

In addition to the verbal expression of pain, there are some behavioural (non-verbal
communication) aspects of pain, which can be observed by others (Corbett et al.,
2012; Keefe, Somers, Williams, & Smith, 2011). Such pain behaviours may include,
facial expressions, vocalisations, changes in body positioning (limping, posturing or
guarding), changes in normal behaviour (withdrawal from socialisation), or changes

9
in physiological signs (sweating, pallor) (Achterberg et al., 2013).These behaviours
may be indicators to an observer, of the presence of pain and the only way that a
person with dementia, other neurological or sensory deficits, can communicate with
others that something is wrong (Keefe et al., 2011). However, these behaviours may
also be altered or absent in people with persistent pain, or people from different
social or CALD backgrounds (Brady, Veljanova, & Chipchase, 2019; Dansie & Turk,
2013; South East Melbourne Medicare Local [SEMML], 2015).

2.2.1 Acute vs persistent pain.

Differences exist between the experience of acute pain and the experience of
persistent pain, based on duration pf the pain experience and changes in tissue,
neural and muscle pathophysiology (Turk & Okifuji, 2010).

Acute pain is usually the result of illness, injury or surgery and the experience and
expression of acute pain can be influenced by biopsychosocial and behavioural
factors. With acute pain, damage to the tissues results in inflammation and activation
of peripheral nociceptive receptors, which may or may not involve stimulation of the
CNS processing pathways, depending on the extent of the damage. In acute pain
after the tissue has healed, pain typically resolves (Turk & Okifuji, 2010).

Persistent pain may be provoked by an acute injury, surgery or illness, but extends
over a longer period of time than acute pain and may never completely resolve.
Other physiological, environmental, psychosocial, emotional, cultural and spiritual
factors may continue to impact on the individual, particularly as pain persists. The
result is that the peripheral and central nervous system becomes over sensitised. As
the pain continues, further modification and sensitisation of the peripheral and CNS
can occur that may contribute to the development of pain with a mixed pathology.
That is nociceptive and neuropathic pain. Without appropriate biopsychosocial
management, the result can be further disability, as well as psychosocial and
emotional deterioration, with individuals often developing anxiety and depression
(Turk & Okifuji, 2010). This process then becomes cyclic. With altered physical and
mental health, individuals further disengage from activity, resulting in more pain,
leading to further sensitisation of CNS, leading to increase in pain and further
disability (Karp, Shega, Morone, & Weiner, 2008; Turk & Okifuji, 2010).

10
2.2.2 Pain in older people.
For an older person, persistent pain of a mixed pathology can be a significant part of
their everyday life. This is often the result of one or multiple medical conditions, for
example, osteoarthritis, cardiac disease, diabetes or cancer, geriatric syndrome and
aged related physiological changes (Hillen et al., 2017; Karp et al., 2008; Molton &
Terrill, 2014). The consequences of untreated or poorly treated pain for an older
person is an altered quality of life. Depression, reductions in mobility and
socialisation, sleep disturbances, falls, anxiety, cognitive impairment, increased use
of health resources, change in nutritional intake and behaviours, are just some of the
known consequences of undertreated pain. This is particularly true for individuals
living in RCFs and especially for those with dementia (Ciampi de Andrade et al.,
2011; Molton & Terrill, 2014). These factors can also contribute to further cognitive
decline and functional disability.

2.2.3 Pain in people with dementia.

In 2012, more than half of the population (52%) living in residential aged care in
Australia, had a diagnosis of dementia (Australian Institute of Health and Welfare
[AIHW], 2016). Individuals with the inability to verbally communicate, such as those
with dementia, have been identified as the group in RCFs that are significantly under
assessed and undertreated (Husebo et al., 2012). As noted previously, age related
neurological changes, biopsychosocial and behavioural factors affect the processing,
experience and expression of pain. Dementia, particularly as it advances, further
alters the pain experience (Ciampi de Andrade et al., 2011; Molton & Terrill, 2014).

Memory, language and interpretation skills are required to understand, evaluate and
express feelings of pain (Cunningham, McClean, & Kelly, 2010; Lukas et al., 2012).
A decline in cognitive function in individuals suffering from dementia, eventually
results in a loss of spontaneous verbal expression of pain, which includes expression
of its severity, location, what it feels like and frequency (Lukas et al., 2012).
Individuals with dementia, may be unable to find a word to describe the pain and/or
recognise or understand what they are feeling (Cunningham et al., 2010).

Neuropathological changes in dementia and pain processing, mean that the

expression of pain is different for the different dementia types and during the
different stages of dementia (Achterberg et al., 2013; Scherder et al., 2009). This is

11
perhaps due to the changes in the medial and lateral areas of the brain, affecting the
sensory/discriminative, cognitive/ evaluative and affective/motivational components
of the pain processing system (Achterberg et al., 2013; Cunningham et al., 2010;
Scherder et al., 2009). The changes in the processing of pain in the person with
dementia, can also be complicated by central and peripheral neurophysiological
changes that occur in the older person (Karp et al., 2008). For example, the
transmission and integration of input from a peripheral pain stimulus, may be
reduced in AD (Scherder et al., 2009).

The lack of spontaneous verbal expression of pain, means that many health
professionals, mistakenly believe that the person with dementia does not experience
pain (Molton & Terrill, 2014). Functional magnetic resolution imaging scans have
shown that, when comparing the pain experiences between individuals with and
without AD, the individual with AD had more areas of brain activity in the sensory,
affective and cognitive processing regions of their brain, than the person who was
cognitively intact (Cole et al., 2006; Scherder et al., 2009). This means that, in actual
fact, the people with dementia experience more pain than those without dementia,
but cognitive changes mean they are unable to evaluate or express it.

Health professionals therefore, require an alternate method of detecting the

presence of pain, if a person lacks the ability to verbalise about its presence. Over
the past 30 years, a significant body of research has taken place regarding the
development of observational behavioural assessment tools for use in assessment
of pain in people with dementia (Corbett et al., 2012). Although every attempt should
be made to obtain a verbal response, in some individuals with moderate dementia
and in those with severe dementia, an accurate verbal response may not be possible
(Achterberg et al., 2013). Currently, the best method for identifying pain in a person
with moderate to severe dementia, is through observing changes in behaviour at rest
and during activity, via a proxy. Key areas of behaviour that have been identified as
related to the pain experience in people with dementia are: facial expressions,
vocalisation and verbalisations, changes in normal behaviour such as engagement in
activities or interactions with others, guarding or changes in body positioning (Cervo
et al., 2007; Cunningham et al., 2010; Hadjistavropoulos et al., 2014; Herr, Coyne,
McCaffery, Manworren, & Merkel, 2011; Husebo et al., 2012).

12
While there are generalised behaviours that may indicate that an individual with
dementia is experiencing pain, the expression of pain by a person with dementia,
can also be specific to the individual (Jones & Mitchell, 2015). For example, the
resident may wander in a different way or at a different pace, be agitated or
aggressive (Flo, Gulla, & Husebo, 2014; Kales, Gitlin, & Lyketsos, 2015). Therefore,
the AINs or significant others (proxies), who have a close relationship with the
resident, are best suited to identifying changes in behaviour that may indicate the
presence of pain. AINs are the most closely involved with the individual during
periods of care, when pain may be aggravated by movement (Goucke, 2018). This
means, that the AIN is also often the best person to undertake the formal pain
assessment, as they have a personal knowledge of the individual and can detect
subtle changes in their behaviour (Douglas, Haydon, & Wollin, 2016; K. Holloway &
McConigley, 2009).

However, van Herk et al. (2009), suggest proxy reporting is not without its problems
and can be an unreliable way of detecting the intensity of pain. Therefore, pain
assessment tools may only be beneficial in detecting the presence of pain. They
suggest, that for both formal and informal carers, education about pain identification
and persistent pain (including its non-pharmacological management), may assist in
improving pain management for people with dementia (van Herk et al., 2009).

2.2.4 Culturally and linguistically diverse (CALD) Individuals and pain.

Further complexity is added to the conducting of best practice pain identification,
assessment and management strategies in RCFs, when the resident is from a
culturally and linguistically diverse (CALD) background. These individuals may be
living with or without dementia. Currently, CALD individuals make up 18.3 % - 20%
of the residential population of Australian RCFs (Goucke, 2018; Productivity
Commission, 2016).

A person’s cultural background, determines how they will experience, express and
communicate verbally or non-verbally about their pain experience (Peacock & Patel,
2008). Each culture and language have a specific way of expressing pain and
distress, based on sociocultural factors, mistrust of and previous experiences with
health care professionals, religious beliefs and how individuals and families interpret
the meaning of pain (Campbell & Edwards, 2012; SEMML, 2015). Difficulty also

13
arises as English is often not their first language and even if English had been learnt
after migration to Australia, older people often revert to the language of their
childhood (ABS, 2012; Federation of Ethnic Communities'Councils of Australia
[FECCA], 2015). Verbal communications, behaviours or lack of expression of pain,
may be misinterpreted by direct care staff, resulting in inadequate or inappropriate
pain assessment and management (Peacock & Patel, 2008).

2.3 The identification, assessment and management of pain.

The identification of pain in the older person can occur in three ways. There is a
group among older people living in RCFs, who will verbally self–report the presence
of pain. There is a second group of older people, who will not spontaneously verbally
report the presence of pain. This might be due to cultural, psychosocial factors, or
inappropriate myths or beliefs about the pain they are experiencing. Direct care staff
need to consistently ask these individuals if they have any pain and observe them for
known pain behaviours during care, in order to trigger conversation (Goucke, 2018;
Veal et al., 2018). The third group of older people, consists of those that do not have
the capacity to verbalise. They rely on the proxy observer (direct care staff) to
identify pain related behaviour or specific individual behaviour (Herr, 2011; van Herk
et al., 2009).

Subsequent assessment of pain can be conducted using a number of

unidimensional, multidimensional or observational tools, depending on the verbal or
non-verbal capacity of the older person, or the phase of assessment. The Australian
Pain Society (APS) recommends unidimensional verbal or numerical rating scales,
for assessing the intensity of pain and the “Modified Verbal Brief Pain Inventory”
(MvBPI) to assess the multidimensional nature of pain, for individuals able to
verbalise. For older people unable to verbalise and those with dementia, the “Abbey
Pain Scale” (Abbey et al., 2004) or the PAINAD (Warden et al., 2003) tool, have
been recommended. These tools look at the physical behaviours that may be
expressed when a person with altered cognitive function experiences pain. The most
recent edition of the APS, PRACMS guidelines also provide an example of a pain
monitoring sheet (Goucke, 2018).

The management of pain, centres on evaluation of the information collected through

the pain assessment tool, taking into consideration the potential causes, the medical

14
and pain history of the individual and the conducting of a systematic physical
assessment. The information can then be used to develop a plan of care, that uses a
combination of pharmacological (simple analgesics, opioids, adjuvant therapies) and
a variety of non-pharmacological strategies, which should include physical,
psychosocial and spiritual strategies (Goucke, 2018). A combination of strategies
such as is listed above, supports a biopsychosocial approach, which is important
when caring for an older person with complex persistent pain (Goucke, 2018;
Painaustralia, 2017).

However, in the older person, extra precautions need to be taken when

implementing pharmacological strategies. Older people living with multiple
comorbidities are subsequently taking multiple medications, which may increase the
risk of side effects and drug interactions. In addition, due to ageing, the older person
will have altered physiology in relation to the metabolism and secretion of
medications (Abdulla et al., 2013; Fine, 2012; Kaye et al., 2010). There is a lack of
substantial research in the use of these analgesic and adjuvant medications in the
over 65 age group, in older people with multiple comorbidities and people with
dementia, which may be contributing to ongoing poor management of pain (Abdulla
et al., 2013; Crome, 2007; Fine, 2012).

Non-pharmacological strategies such as heat packs, transcutaneous electrical nerve

stimulators (TENs) and massage, predominantly used in RCFs (and supported by
funding through the ACFI), are passive strategies which may offer comfort, but do
little to change the central sensitisation experienced by individuals living with
persistent pain (Goucke, 2018; Makris, Abrams, Gurland, & Reid, 2014). These
modalities also need to be used with caution in people who are unable to verbalise
(such as people with dementia), as verbal feedback is required for staff to evaluate
the effectiveness of the strategy. Older people with moderate to severe dementia
may not have the capacity to provide this detail (Goucke, 2018).

2.4 Pain assessment and management resources for aged care.

More attention is being paid nationally and internationally to pain assessment and
management in older people, particularly those with dementia (Charette & Ferrell,
2011; Cunningham et al., 2010; Goucke, 2018; Herman, Johnson, Ritchie, &
Parmelee, 2009; Herr et al., 2011; Husebo et al., 2012; McAuliffe, Nay, O'Donnell, &

15
Fetherstonhaugh, 2009; Takai et al., 2010) more than ever before. A number of
resources have been developed, to improve and implement best practice pain
management principles for the care of the older person in pain (Goucke, 2018;
Schofield et al., 2012).

International resources include:

• The Management of Persistent Pain in Older Persons (American Geriatric

Society Panel on Persistent Pain in Older People, 2002).
• Pharmacological Management of Persistent Pain in Older Persons (AGS Panel
on the Pharmacological Management of Persistent Pain in Older Person,
2009).
• Guidance on the Management of Pain in Older People (Abdulla et al., 2013).
• Pain Assessment in the Patient Unable to Self-Report (Herr et al., 2011).
• The Assessment of Pain in Older People: UK National Guidelines (Schofield,
2018).
• An Interdisciplinary Expert Consensus Statement on Assessment of Pain in
Older Persons (Hadjistavropoulos et al., 2007).

Within Australia, initiatives that are specifically targeted at RCFs include:

• Pain in Residential Aged Care Facilities: Management Strategies, (PRACMS)

(Goucke, 2018).
• The PMG Kit for Aged Care: An Implementation Kit to Accompany the
Australian Pain Society's Pain in Residential Aged Care Facilities: Management
Strategies (PMG Kit) (Edith Cowan University, 2007).
• Guidelines to a Palliative Care Approach in Residential Aged Care (2006) and
the Palliative Care Approach Toolkit (2015) (Department of Health., 2012).

The distribution of the first edition of the PRACMS (Goucke et al., 2005) and the
PMG kit (Edith Cowan University, 2007) in 2006–2007, was followed by funding in
the first round of the Department of Health (DoH) EBPRAC projects in 2007-2009.
The EBPRAC pain management project, used a change management framework to
implement the best practice principles in five RCFs across Australia. The outcome of
this project was that in the short term (up to 12 months), best practice principles

16
were maintained through increased compliance to the 27 best practice principles
provided in the first edition of the PRACMS (Goucke et al., 2005). The greatest
improvement was seen in increased identification of pain and increased use of
assessment tools for residents that could verbalise (Savvas et al., 2014b). However,
the long-term sustainability of the implemented changes in clinical practice (>2
years) has not been evaluated.

Despite the increased focus on pain assessment and management in aged care, the
production of clinical guidelines, increased education and a number of observational
assessment tools, poor assessment and management practices continue and the
translation of best practice principles into aged care has been limited both nationally
and internationally (Herr, 2011; Lukas et al., 2013; Veal et al., 2018; Verbeek et al.,
2013). The reason for ongoing poor practice may be related to one or more barriers
that have been previously identified in the literature (Achterberg et al., 2013;
Bruneau, 2014; Veal et al., 2018).

2.5 Barriers to pain assessment.

Barriers can be categorised under individual or organisational factors. Individual
factors can be related to the resident or staff, whereas organisational factors can
include internal facility contextual factors or wider aged care system factors. Other
factors responsible for poor pain assessment and management practices include:
lack of scientific research into pain and the older person, and pain in the person
living with dementia; pharmacological strategies for the older person; and validation
of pain assessment tools (Achterberg et al., 2013; Bruneau, 2014).

2.5.1 Resident barriers.

While spontaneous verbal report is the best way to identify the presence of pain,
often-older people are reluctant to spontaneously self-report. This means that people
who are caring for these individuals, need to be proactive and ask the individual,
during care time, if there is any pain present (Goucke, 2018; Veal et al., 2018).

There are a number of reasons why older people may not report that they are
experiencing pain. Stoicism, cultural or religious beliefs, fear of disease progression,
fear of analgesia (particularly opioids and addiction), are some of the attitudes or
beliefs older people may have regarding pain. If they have had previous encounters

17
with health professionals who have not believed their reports of pain (common,
particularly with persistent pain), or fear that if they report the pain then they may
have to undergo many tests/investigations to find a cause (which costs money), can
also prevent the older person from reporting pain. The presence of other symptoms
of comorbid conditions which create more anxiety or concern for the older person,
may mean that pain is not significant enough for that person to report it (Bruneau,
2014; Kaasalainen et al., 2010; Narayan, 2010; Savvas & Gibson, 2015; Tracy &
Morrison, 2013; Veal et al., 2018).

Other barriers relate to the physiological changes in the older person as they age.
Neurophysiological changes in the peripheral or CNS, decreased production of
neurotransmitters and even mild cognitive impairment, may alter pain processing
(Karp et al., 2008). Changes in the senses, hearing or vision, mean that questions
used during assessment may not be heard or may be misunderstood (Closs, 2007;
Tracy & Morrison, 2013). Assessment may also be impeded if the word used to ask
the older person about the presence of pain, does not match how the older person
describes their pain (Herr, 2011). For example, if direct care staff ask the older
person if they have any ‘pain’, but the word the older person uses to describe their
pain is ‘ache’, then the older person may deny the presence of pain.

As noted previously, more than 50% (AIHW, 2016) of individuals living in RCFs in
Australia have a type and degree of dementia. As dementia progresses, the ability of
the person to self-report about their pain, is gradually lost (Herr, 2011). This is a
primary barrier to the identification, assessment and management of pain (Bjoro &
Herr, 2008; Bruneau, 2014). Even though a resident may retain some residual
verbal skills in the early to moderate stages of dementia, this does not mean that
they actually comprehend what is being spoken or asked of them. Then as dementia
progresses, individuals gradually lose the ability of higher executive brain functions,
like evaluating and interpreting information, verbal communication skills, memory or
emotions (Corbett et al., 2014; Scherder et al., 2009). This means that they may not
be able to respond to even simple questions asked about the presence of pain, or
convert what they are experiencing into words (Cunningham et al., 2010).

For those individuals with dementia, the experience of pain may also be different
because of the type of dementia they are living with and the degree of alteration in

18
memory (Álvaro González, 2015). Pain may not be as distressing in different types of
dementia and it is therefore difficult to identify and assess (Álvaro González, 2015;
Corbett et al., 2014). This is related to changes in the brain involving the
affective/motivational component of the pain system, which modifies pain by
involving emotion, memory, expectation and learning. This has an impact on the
expression of pain, as the anxiety and expectation associated with pain is not there
in individuals with dementia (Álvaro González, 2015). This particularly applies to
older people living with AD (Ciampi de Andrade et al., 2011).

Behaviours and pain.

Some individuals living with dementia demonstrate common pain behaviours and
others have very individualised behaviours, as previously discussed in this chapter
(Cunningham et al., 2010; Horgas & Miller, 2008; Kales et al., 2015). If all direct care
workers in a facility, are not aware of these more individualised behaviours, then an
individual may be inappropriately diagnosed as exhibiting changes in behaviour that
relate to neuropsychiatric symptoms of dementia, instead of pain (Husebo, Ballard,
Sandvik, Nilsen, & Aarsland, 2011; Jones & Mitchell, 2015; McAuliffe et al., 2009).
An individual may be given psychotropic medication instead of analgesia, resulting in
sedation, but continue to experience pain (Jones & Mitchell, 2015).

The staffing model used to provide care in RCFs, may influence the detection of
pain, particularly in the case of people living with dementia. How AINs are allocated
to work in the facility, whether assigned to the same residents for a period of time
(relationship centred care) or rotating assignment, can influence the detection of
changes in behaviour (Castle, 2011). For a change in behaviour to be detected, the
changed behaviour may need to be repeated several times with the same AIN before
a concern may be raised (Corbett et al., 2012). AINs are also known to utilise their
knowledge of a resident and noted changes in their normal behaviour, as ways of
detecting when the resident may be ill or in pain, rather than identifying the pain
through established pain behaviours (K. Holloway & McConigley, 2009). If the AINs
are not consistently with the same resident, then they are unable to get to know the
normal behaviour of the resident. They therefore may not identify changes in
behaviour that may indicate pain. This may then delay pain assessment and
subsequent management.

19
In addition, the difficulty in caring for individuals with dementia, is that behaviours
being exhibited may indicate the presence of pain, or they may also be indicators of
a number of other problems, including hunger, thirst, infection, boredom,
overstimulation, anxiety, depression or constipation (Hadjistavropoulos et
al.,Hadjistavropoulos et al.,Hadjistavropoulos et al.,Hadjistavropoulos et al.,2009;
Horgas & Miller, 2008; Jansen et al., 2017). The assessment of pain is only one of a
number of assessments that may be undertaken when there is a change in the older
person’s behaviour. Concern about other medical problems such as infection or
constipation, may mean that pain assessment is one of the last assessments to be
undertaken (Charette & Ferrell, 2011). The reasons for this are unclear but may be
related to the ease of assessment and management of other conditions, compared
to the time that is required to do a comprehensive pain assessment, evaluate the
data, and develop a management program, which may include contacting a general
practitioner (GP). Another problem may be the lack of knowledge about pain in
people with dementia (Achterberg et al., 2013).

Potential comorbidities such as delirium or depression may further complicate

matters and make the detection of pain more challenging. Delirium can be the result
of infection, pain, polypharmacy or illness (Hadjistavropoulos et al., 2009). During
episodes of delirium (which can be superimposed on dementia), the individual can
present with hyperactive, hypoactive or mixed delirium signs and symptoms.
Identifying, assessing and managing pain in this situation is difficult because of
further rapid decline in pre-existing cognitive function (Paulson, Monroe, & Mion,
2014).

The same can be said for depression, which may also be superimposed on
dementia. Depression is common in older people living in aged care facilities
because of the presence of chronic disease, disability and frailty, altered
socialisation, pre-existing psychological disorders and persistent pain (Kok &
Reynolds, 2017). The presence of depression may interfere with the assessment of
pain, as changes in behaviour such as withdrawal, altered eating habits and sleep
patterns, are common symptoms of both persistent pain, dementia, and/or
depression (Corbett et al., 2014; Hadjistavropoulos et al., 2009).

20
2.5.2. Staff barriers.
Barriers relating to staff primarily arise because of lack of knowledge about the
identification, assessment and management of pain, particularly in CALD groups and
people with dementia (Bruneau, 2014; Ciampi de Andrade et al., 2011; Douglas et
al., 2016; Kaasalainen et al., 2010; Tracy & Morrison, 2013; Veal et al., 2018). This
deficit in knowledge has been related to insufficient or inadequate education (Ciampi
de Andrade et al., 2011; Kaasalainen et al., 2010; McAuliffe et al., 2009). In addition,
even with provision of education and improvement in knowledge of the assessment
and management of pain, direct care staff need to be able to integrate new
knowledge and skills, with pre-existing practices and knowledge, undertake critical
reflection of their practice and change behaviour (Masso, McCarthy, & Kitson, 2014).
This is a process that takes time and in RCFs is dependent on competing priorities,
facility culture, organisational learning, managerial support and clinical leadership
(Cammer et al., 2013; Colón-Emeric et al., 2016; Masso et al., 2014).

The current workforce structure and physical environments in RCFs, means that
direct care staff are often time poor, have many competing priorities and find it
difficult to provide safe quality care (Cammer et al., 2013; Masso et al., 2014). This
often restricts their ability to undertake additional tasks (Masso et al., 2014). It has
been shown that if AINs are patient with the older person and allow time for them to
process verbal and visual cues, particularly for the individual with mild to moderate
dementia, then the individual may verbally respond to questions, particularly if closed
ended questions are used (Tracy & Morrison, 2013). This also applies to that group
of residents who do not spontaneously report pain because they do not want to be a
bother to the nurses, because they are so busy (Veal et al., 2018). If time is taken by
AINs to enquire about the presence of pain, even for the older person who can still
verbalise, then more episodes of pain may be reported.

Inaction of the clinicians (i.e. RN or GP) may also be a barrier. AINs may report to
the RN that a resident has complained of pain, or there has been a change in the
resident’s behaviour. However, the RN may fail to follow up on the concern raised
and conduct further assessments (Douglas et al., 2016; Kaasalainen et al., 2010).

One of the reasons for this inaction may be related to the unscheduled nature of
episodes of pain and the workload of the RN. RNs have on upward of 59

21
residents/shift to care for, according to research by Willis (2016). Many of these older
people have complex health care needs or require end-of-life care. Time constraints
and competing priorities, mean that care relating to unscheduled activities is often
missed, or action to address the problem is often delayed (Willis et al., 2016).

Communication problems between RNs and the GPs have also been identified.
Either the GP does not accept the RN reports, or they are slow to respond (Peisah,
Weaver, Wong, & Strukovski, 2014; Veal et al., 2018). This seeming inaction by the
GP, may be contributed to by a lack of supporting evidence from a pain assessment
or pain monitoring chart, conducted with the resident about the pain they are
experiencing. Evidence is required for the GP to make an informed choice regarding
which strategies are the most appropriate to use (Peisah et al., 2014). Lack of
knowledge by the GP about pain in the older person, pain in the older person with
dementia, management of persistent pain in the older person and current EB pain
management practices, may also contribute to inaction (Peisah et al., 2014; Veal et
al., 2018).

Direct care staff (RNs/ENs/AINs), have also been known to undervalue an older
person’s verbal report of pain, believing that they, the carers, are more objective, and
are the better judges of the level of pain being experienced by the individual
(Bruneau, 2014; K. Holloway & McConigley, 2009). Direct care staff subjectivity, may
also be a barrier to the reliability and validity of the information collected, during
either the identification or the assessment phase. Factors such as the length of time
the direct care staff member has known the resident, been working at the facility or in
aged care, may influence their assessment or report. Direct care staff may also
assume that the lack of outward signs of the presence of pain (despite a verbal
report), may mean that the older person is not really in pain, but just seeking
attention or analgesia. This therefore can impact the direct care staff’s decision
making, about what management strategies may be offered or implemented (Bjoro &
Herr, 2008; van Herk et al., 2009).

2.5.3 Facility barriers.

Barriers also exist at facility or organisational level. An organisation’s commitment to
best practice care, in regards to pain assessment and management at all levels, is
particularly important (Verbeek et al., 2013). For implementation and sustainability of

22
best practice principles in pain identification, assessment and management, it has
been recommended, that there needs to be full management support, provision of
resources, identification of barriers to organisational learning and knowledge
retention, implementation of strategies to overcome barriers and ongoing planned
education, be provided (Fleiszer, Semenic, Ritchie, Richer, & Denis, 2015b; Virani et
al., 2009; Wiltsey Stirman et al., 2012).

The number of staff exiting and entering a facility, poses a significant barrier for the
maintenance of best practice (Mavromaras et al., 2017). A high staff turnover means
that there is a constant need for education, mentoring and knowledge transfer of
tasks, procedures and processes (Virani et al., 2009). New staff need to learn about
the behaviours of the residents (particularly those with dementia, and the CALD
groups), that may indicate the presence of pain (van Herk et al., 2009). This may
take time and require the carer to work consistently with the same resident over a
period of days, weeks or months (Castle, 2011).

Staffing numbers and skill mix in RCFs is also a barrier. Mavromaras et al., (2017),
reported that 70% of staff working in aged care were unlicensed personal care
workers (AINs). The ratio of registered staff to unregistered care workers is high, with
usually one or two RNs covering an entire facility. Unlicensed care workers receive
minimal training on the identification, assessment and management of pain. Task
related education (such as learning about showering, dressing etc.) takes priority (K.
Holloway & McConigley, 2009; Kaasalainen et al., 2010).

There is also an increasing number of CALD migrants working in RCFs (32% of the
workforce in RCFs were from migrant backgrounds in 2016) (Mavromaras et al.,
2017). Whilst this can be of benefit to a work place in helping communicate with
CALD residents and creating a multicultural workplace, it is not without its problems.
Cultural and social differences exist in the experience and expression of pain, along
with individual differences (SEMML, 2015). Direct care staff who are unfamiliar with
the differences in the expression of pain in different cultures, may either overlook
verbal complaints of pain, or disregard pain behaviours (Bourgeault, Atanackovic,
Rashid, & Parpia, 2010).

23
A lack of access to or use of valid and reliable pain identification and assessment
tools, may also be a barrier (Bruneau, 2014; Douglas et al., 2016; McAuliffe et al.,
2012), although in Australia the Department of Health and the Aged Care Funding
Instrument (ACFI) guidelines, require that an APS recommended pain assessment
tool be used. Even if a reliable tool is available, knowledge of use of that tool may be
poor and therefore assessments are completed inappropriately, e.g. not completing
a pain assessment during movement (Goucke, 2018). The ACFI is the primary
funding instrument for aged care, developed by the Australian Government
Department of Health (Department of Health: Ageing and Aged Care, 2017). It does
not recommend specific pain management tools to use during the assessment of
pain, but refers people back to the PRACMS (Goucke, 2018; Goucke et al., 2005) or
the PMG kit (Edith Cowan University, 2007) for best practice tools. The publishing of
the first edition of PRACMS (Goucke et al., 2005) and the PMG Kit for Aged Care
(Edith Cowan University, 2007), was aimed at improving Australian RCF access to
valid pain assessment tools. The most recent edition of the PRACMS is only
available as a hard copy currently, and needs to be purchased from the Australian
Pain Society (Goucke, 2018).

Variability in the physical layout of each facility, communication processes and

resources, may also impact the identification, assessment and management of pain
(Cammer et al., 2013; Masso et al., 2014). The physical layout of the facility as a
home-like environment, with single rooms and large common areas, means that
residents are not visible all the time (Cammer et al., 2013). Care such as that
required for activities of daily living (showering, toileting and dressing), must be
delivered in each resident’s room. This means that care staff (AINs), can be away
from other residents for extended periods of time, making care and observation of
these residents intermittent. Workflow and processes may mean, that identifying
episodes of pain is not always possible.

Nurses’ stations are often located in common care areas, away from individual
resident rooms. Each resident in their room is not visible from the nurses’ station, or
from other individual resident’s rooms, making it difficult to observe all residents, all
the time (Cammer et al., 2013). Care must also be delivered with privacy and dignity

24
in mind, requiring doors of rooms to be closed during delivery of care. This also
restricts observation of each resident.

Due to the area and room layout of facilities and requirements of routines and
workflow, pain identified during care may not be documented or reported for some
time. Direct care staff are unable to leave the floor to document findings or locate a
RN to report too. By the time staff go to document or communicate any findings, a
significant time may have passed since the observed event. Staff may have forgotten
the detail of what was observed and when it occurred (Pelletier, Duffield, &
Donoghue, 2004; Willis et al., 2016). In addition, AINs may lack the language and
literacy skills, to be able to adequately document the required information (A.
Pearson & Peels, 2009).

Alternatively, the RN may not be available to report any observed changes too.
Qualified nursing staff to resident ratios are poor, with the norm (not the ideal), being
one RN upward of 50 residents (including residents with complex, high care needs),
per shift (Willis et al., 2016). Due to work requirements, they are often performing
clinical or administrative tasks away from nurses’ stations throughout the day
(Henderson, Willis, Xiao, & Blackman, 2017; Willis et al., 2016).

In addition, every facility has a different physical and organisational environment,

staffing structure, skill mix, and utilise different communication practices (Cammer et
al., 2013; Masso et al., 2014). Pain management guidelines and resources are
typically generic documents, that do not provide strategies on how to adapt best
practice guidelines to the local organisational environment (Goucke, 2018). For
example, how to implement the best practice guidelines to meet the needs of a
CALD resident population, or how to strategically implement best practice strategies,
given the lack of human and physical resources available in RCFs. This perpetuates
the underutilisation of best practice strategies.

2.5.4 System barriers.

System barriers that exist in the aged care industry, include the ratio of staff to
residents, time constraints, the ACFI, the availability of medical staff and access to
specialised medical services (Mavromaras et al., 2017; Peisah et al., 2014; Reed,
2015).

25
The ratios of RN, EN, AH practitioners and AINs to residents have decreased over
the last 13 years. There has been an increase in the number of AINs and a decrease
in the number of RN staff (Mavromaras et al., 2017). Mavromaras et al. (2017) noted
in their report, that RNs make up approximately 15% of direct care workers, ENs
10%, AH workers 1.4 %, and AINs approximately 70%. Nurse practitioners now also
have a small presence in some facilities. These ratios vary between metropolitan
and rural aged care facilities and between different organisations (Mavromaras et al.,
2017).

The impact of a reduction in RN staff, results in an increase in the demand on the

RNs that are present in the facility, for the completion of complex clinical care,
leadership, administration and documentation duties, to ensure funding is achieved
and maintained (Willis et al., 2016). This means that there is a reduction in the time
available to appropriately deliver quality, safe care. In many circumstances, clinical
care is often missed because of competing demands (Henderson et al., 2017;
Kaasalainen et al., 2010). This leaves RNs time poor to fully implement EB practice
guidelines and to monitor the practices of AINs.

Medical support in the RCFs is often poor, with limited availability of medical officers
to the RCFs, depending on the GP model of service delivery (Reed, 2015). GPs may
attend the RCFs at random times, without interacting with the RN, which means
there is no communication between direct care staff and the GP (R. Pearson, Mullan,
Ujvary, Bonney, & Dijkmans‐Hadley, 2018). This is a problem, particularly if the older
person is not able to verbalise concerns or issues because of cognitive or physical
impairment, relying instead on a proxy reporting. This could potentially result in a
resident being in pain for longer or being inappropriately managed. Alternatively,
there may be poor interactions (communication) between the GP and direct care
staff, meaning that GPs are not willing to utilise resources that are available, or listen
to RN opinions about the resident (Veal et al., 2018). More recently, there have even
been concerns raised by GPs, that it is often difficult to locate staff in the facility, or
the only available staff member available during their site visit, is an AIN, who is
inadequately prepared to provide detailed information on a residents health status
(R. Pearson et al., 2018).

26
The ability of the RCFs to access Specialised Pain Services is also restricted.
Access to the type of service is particularly needed since RCFs are caring for older
people often with complex, persistent pain. As residents may be unable to leave the
RCFs due to their physical disabilities or dementia, they cannot access specialist
pain management, except perhaps through palliative care services (Gibson, 2007;
Goucke, 2018). However, in one state in Australia, access has improved with the
introduction of telehealth (Australian Medical Association., 2012). Within one
persistent pain service provider in Australia, a GP phone advice line has been
developed. This allows the GP to set up a phone consultation time and to develop a
plan of care for the older person living in RCF, with the guidance of pain
management specialist (Queensland Health, personal communication, January 20th,
2016).

2.6 Facilitators of pain assessment.

Only a few facilitators have been identified as promoting best practice (Abdulla et al.,
2013; Bruneau, 2014; M. Burns & McIlfatrick, 2015). Specifically, for pain
management practices in aged care, education strategies utilised for improving the
knowledge and experience of direct care staff in pain identification, assessment and
management, have brought about, short term changes in practice (Ghandehari et al.,
2013; Hadjistavropoulos et al., 2016; Savvas et al., 2014b).

For the implementation of any best practice guidelines in health care organisations, a
further number of different strategies have proved beneficial. Education of all staff,
including clinical and managerial leaders, reviewing facility operations (policies,
procedures and processes) and clinical practice, reviewing organisational
communication strategies, and changing government standards (Colón-Emeric et al.,
2016; Goucke, 2018; Kaasalainen et al., 2010; Masso et al., 2014).

It has been recognised that education of staff at all levels, management, clinical,
support services and GPs, will improve the recognition, assessment and
management of pain in the older person living in an RCF (Achterberg et al., 2013;
Clark, Jones, & Pennington, 2004; Gordon & Dahl, 2004; Kaasalainen et al., 2010;
McAuliffe et al., 2009; Zwakhalen, Hamers, Peijnenburg, & Berger, 2007).
Internationally, it has been recognised, that purely improving the knowledge of staff
in aged care facilities is only part of the answer. There needs to be a strategic plan

27
developed by a facility or organisation, to translate knowledge into practice at an
organisational level, address the multilevel barriers that exist and make a shift in
organisational culture (Kaasalainen et al., 2010). For best practice pain management
in aged care, that means creating a ‘pain vigilant culture’ (Goucke, 2018, p. 26).

2.7 Implementing evidence-based (EB) practice.

Best practice guidelines consist of a synthesis of the best available research and
clinical practice evidence (Graham, Tetroe, & Group., 2007). They are often devised
by an expert working party, made up of a combination of researchers, clinical health
staff, consumers and policy makers who agree by consensus as to what evidence to
include in the guidelines (N. Burns & Grove, 2005). Best practice guidelines, help the
clinician to make appropriate clinical decisions for a specific clinical problem and
deliver sound EB practice and standardised care for the organisation (Berta et al.,
2005; N. Burns & Grove, 2005). Implementing best EB practice, is also important for
‘clinical governance, legal, professional and ethical reasons’ (Aveyard & Sharp, 2009
p. 127).

The provision of best practice guidelines alone is not, however, sufficient to improve
knowledge and changes in practice, as evidenced by this statement from Berta et al.,
(2005, p. 283), ‘best practice guidelines are not self-implementing’. To implement
guidelines into clinical practice, consideration needs to be given, to how these
guidelines may be implemented and how knowledge can be translated from
guidelines to clinical practice.

Knowledge translation is a complex process that involves, in this case, converting

newly acquired information into a context that is applicable to clinical care (Canadian
Institute of Health Research, 2008). Put simply, this is putting the research into
practice, to improve the quality of the care being delivered (Straus, Tetroe, &
Graham, 2009). Knowledge translation or knowledge transfer has evolved into a field
known as implementation science. Implementation science (and research), is
defined as ‘the scientific study of methods to promote the systematic uptake of
research findings and other EB practices into routine practice, thereby improving the
quality of effectiveness of health services’ (Eccles & Mittman, 2006, p. 1).

28
However, translating research into practice and creating a sustainable change is not
a simple process. There are multiple factors, which will influence the uptake of the
new knowledge and practice being implemented. These include the skill of
individuals (direct care workers) to be able to, systematically review the literature and
evidence being provided, the context into which the knowledge is being introduced
(including the organisational culture), management structure and support of the
clinical staff. The format that the evidence is provided in, can influence knowledge
uptake. Other factors include the resources and time available for the already busy
clinical staff, to integrate the evidence into practice. Trying to merge new information
with what is already known, when there are many other priorities that are competing
for the staff’s attention in aged care, can prove challenging. Having staff resources
available to help facilitate the change and meet the different learning needs and
styles of the individual staff member, will impact on how knowledge is retained and
transferred (Argote, 2013; Masso et al., 2014; Perry et al., 2011; Straus et al., 2009;
Virani et al., 2009).

Numerous theories, models and frameworks, have been used in planning,

implementing and evaluating EB practice over the last ten years. In using an
implementation strategy, as the foundation for the introduction of a new practice, it is
believed that the process of translating research in to practice, may be guided and
clinical leaders can gain an improved understanding of ‘what influences
implementation outcomes, whilst simultaneously evaluating the change in staff
practices’ (Nilsen, 2015, p. 54). Theories that have originated in psychology,
sociology and organisational theory are increasingly being used to underpin
implementation studies (Nilsen, 2015).

A review by Cammer et al. (2013) and Masso, McCarthy and Kitson (2014),
identified factors that could facilitate practice change. They are the following:

• All staff having the same common goal and communicate in the same manner
about the new practice being implemented;
• Identifying and addressing competing priorities, showing staff how to integrate
practice change into busy schedule to minimise the burden of a new task;
• Developing a pathway from EB knowledge to practice, so that connections
can be made to pre-existing knowledge and practice;

29
 • Identifying the benefits of making the change to practice;
• Providing staff with the knowledge and support systems, to empower them to
take action (Cammer et al., 2013; Masso et al., 2014).

Cammer et al. (2013) noted, that assessment of the environment into which a new
practice is to be implemented, should be undertaken prior to implementing the
change. This ensures that impediments in the environment may be identified and
modified, and strategic plans implemented to support staff in making the practice
change (Cammer et al., 2013).

2.8 Sustaining EB pain management practices in RCFs.

Over the last 20 years, there have been a number of EB resources and clinical
practice guidelines that have been developed internationally and nationally for use in
aged care (Abdulla et al., 2013; Goucke, 2018; Kaasalainen et al., 2010; Savvas et
al., 2014b; Schofield et al., 2012). However, the implementation of guidelines has
been inadequate or ineffective. This is evidenced by the ongoing international and
national literature that discusses the under recognition and inappropriate
management of pain in aged care. These documents continue to offer strategies to
improve pain management practices in the aged care population (Abdulla et al.,
2013; Douglas et al., 2016; Goucke, 2018; Hadjistavropoulos et al., 2016; Jones &
Mitchell, 2015; Kaasalainen et al., 2010; Painaustralia, 2017; Savvas & Gibson,
2015).

Strategies used to improve implementation, including the translation of research into

clinical guidelines, implementing guidelines into practice (such as in the EBPRAC
pain management project) and identifying barriers to implementation, have
demonstrated that in the short term there is adoption of changes in practice (Nilsen,
2015; Savvas et al., 2014b). However, where the current research gaps lie, is in the
use of the different implementation theories, frameworks and models in RCFs; in
examination of the long- term sustainability of changes in practice; and the different
strategies that are utilised to maintain and promote changes in practice (Douglas et
al., 2016; Slaughter, Estabrooks, Jones, Wagg, & Eliasziw, 2013; Wiltsey Stirman et
al., 2012).

30
The reasons for lack of research in the above areas may include: the difficulty of
converting best practice guidelines to local contexts; different organisational and
staffing models; availability of resources; differences in the values, missions and
goals of care of a facility; and different resident profiles (for example a higher number
of CALD groups) (Slaughter et al., 2013). Other reasons for lack of research in this
area, may be related to funding for longitudinal data collection in aged care and the
increased burden longitudinal research would place on an industry that is already
under resourced (Slaughter et al., 2013).

It is essential that, with the expected increase in the aged care population both here
in Australia and internationally, particularly the expected increase in people with
dementia, strategies for addressing the known barriers to pain identification,
assessment and management, are developed (AIHW, 2017). This includes
examining, how knowledge is translated from research into practice, how strategies
for the implementation and sustaining of best practice in aged care are identified and
utilised. This will assist us in ensuring that quality care is delivered, best practice is
implemented and needless suffering in the older person is minimised (Slaughter et
al., 2013; Verbeek et al., 2013).

2.9 Summary.
This chapter has highlighted that pain is complex, and that ageing and comorbidities
increase that complexity. There are multiple biopsychosocial, environmental and
behavioural factors, that can influence the older person’s pain experience and the
expression of it. The presence of persistent pain, often found in older people
because of comorbid disease and dementia, further influences this experience and
quality of life.

A significant number of individual and organisational barriers have been identified as

impacting the implementation and execution of EB pain management practices in
RCFs, both here and internationally. The development of best practice guidelines
and education packages, have been the primary strategies used to improve EB
practice in this area. However, the ongoing poor identification, assessment and
management of pain in older people living in RCFs, continues. Given the number of
different individual and organisational barriers that are present, education alone is
not sufficient to overcome these factors and to sustain EB practice. A number of

31
frameworks and implementation models have been developed to help organisations
implement best practice. RCFs could utilise these frameworks and models, to
effectively implement and sustain new practices.

32
 Chapter Three: Theoretical Framework.
3.1 Introduction.
It is important that research be underpinned by theory, to assist researchers to
develop research questions and hypotheses, define and relate concepts that may
explain and predict observed behaviours, within a specified context (Johnston, 2014;
Weible, 2014). Theory can also provide a guide for every step of the research
process, determining whether a deductive or inductive approach to the research will
be used, thus influencing the methodology (Johnston, 2014; Taylor, Kermode, &
Roberts, 2006). Without an underpinning theory, the information obtained from the
research can lack significance, validity and not be replicable (Johnston, 2014).

This chapter discusses the theoretical framework underpinning the examination of

factors that impact the sustainability of EB pain management practices in RCFs. It
will focus on the post-positivism paradigm and organisational learning theory (OLT).

3.2 Theoretical frameworks and paradigms.

The term ‘theoretical framework’, is often used interchangeably with the term
‘paradigm’ or ‘conceptual framework’. A paradigm is a ‘broad overarching intellectual
framework or architecture of assumptions, used for examining an area of scientific
inquiry’ (Carpiano & Daley, 2006, p. 565). A paradigm guides the researcher in their
‘philosophical, epistemological and ontological thinking’ (Grant & Osanloo, 2014;
Guba & Lincoln, 1994, p. 13). ‘An individual’s past experiences, attitudes, beliefs,
social and cultural positioning’ (Denzin & Lincoln, 2011, p. 721), influence this
thinking. These factors will influence the validity, quality and quantity of their
knowledge (epistemology) and how they comprehend what exists in reality
(ontology) (Denzin & Lincoln, 2011; O'Leary, 2010). The choice of paradigm will
determine the researcher’s purpose, incentive and expectations in the research
project (Mackenzie & Knipe, 2006).

There are a number of different paradigms referred to in the literature. These include
positivist, post-positivist, pragmatist, critical (transformative), constructivist-
interpretivist, functionalist, radical humanist, structuralism, total quality management,
continuous quality improvement, emancipatory, normative, post-modern, social
constructivist and deconstructivist paradigms (Kaplan et al., 2010; Karataş-Özkan &
Murphy, 2010; Mackenzie & Knipe, 2006). The choice of paradigm used for a
33
research project, is influenced by the field in which the research is conducted
(management, business, health, social, psychological etc.), as well as the research
question being asked.

The paradigms of positivism, post-positivism, constructivism-interpretivism, critical

theory and pragmatism, are discussed in more detail in the following sections, as
they are used frequently in nursing research and more recently in organisational
learning research (Denzin & Lincoln, 2011; Popova-Nowak & Cseh, 2015). This will
be followed by a more in-depth discussion, of the use of post-positivism in this
research project.

3.2.1 Positivist and post positivist paradigms.

Positivist.
The positivist paradigm, has its philosophical, epistemological and ontological
position based in ‘scientific realism. According to this paradigm, science is the only
way to know the truth about the world. Knowledge is gained through what can be
observed or measured quantitatively. This applies even to the social world (Aliyu,
Bello, Kasim, & Martin, 2014; Mackenzie & Knipe, 2006). Research undertaken
under the positivist paradigm, involves testing a theory using hypotheses (O'Leary,
2004). The methodology used is prescriptive and the researcher does not interact
with the subjects. This ensures that the researcher’s values and prejudices, do not
have any impact on the information collected (Mackenzie & Knipe, 2006).

Post-positivist.
The post–positivist paradigm, developed post World War II, deviates from the black
and white position of positivists, by believing that there may be many different
realities and they may be vague and inconstant (O'Leary, 2004). Objectivity on the
part of the researcher may be difficult, as their knowledge, values and beliefs can
affect the research being conducted. This then impacts on how knowledge is gained
from observing human behaviour in a social world, as instinct may also play a part in
information gathering (subjectively) (Mackenzie & Knipe, 2006; O'Leary, 2004). Post-
positivists believe that the complete truth can never be found (Creswell, 2013).
Quantitative and qualitative methods are used in data collection and whilst not as
prescriptive as positivist methods, researchers still aim to use a systematic and
rigorous approach (O'Leary, 2004).

34
3.2.2 Constructivist-interpretivist.
The constructivist-interpretivist paradigm, is based on attempting to understand
human knowledge and behaviour and ontologically understanding, that reality is
socially created (Cohen, Manion, & Morrison, 2007; Mackenzie & Knipe, 2006).
Researchers rely on the participants to help them understand the situation. They are
also aware of how their previous experiences and knowledge impact the research
(Creswell, 2013; Mackenzie & Knipe, 2006). The methods to be used during this
process can be mixed, quantitative or qualitative.

3.2.3 Critical theory.

The critical theory paradigm, has its philosophical, epistemological and ontological
perspective based in a reality where knowledge is shaped by an individual’s culture,
gender, social, political, economic and ethnic stance (N. Burns & Grove, 2005).
Critical theory, examines potential power imbalances that may occur among the
participant group and through the research, provides ways for the power imbalance
to change (Weaver & Olson, 2006). There is a significant link between the
researcher and the subjects, such that the values of the researcher can impact on
the information obtained (Denzin & Lincoln, 2011).

3.2.4 Pragmatism.
Pragmatism is primarily a philosophy utilised in mixed methods research. It focuses
on the question being posed by the researcher, rather than on the method in which
data will be collected. However, it utilises multiple qualitative and quantitative
methods in an attempt to understand the problem (Creswell, 2013). Creswell (2013),
provides a good overview of pragmatism, when he indicates that it is not committed
to one philosophical view and reality; but rather researchers can choose the methods
that will best answer their question and they will decide what and how to research,
based on the intended consequences (outcomes). In pragmatism, research occurs in
a variety of different contexts and allows the researcher to consider the world from a
number of different viewpoints and rules, using different methods to answer their
proposed research question (Creswell, 2013).

Each of these paradigms was considered, to determine which paradigm would best
suit this research project and align with the researcher’s epistemological and
ontological beliefs. Consideration was also given to the paradigm, that would guide

35
the methodology to be used during the research project, that is, to examine the
sustainability of EB pain management practices in aged care (Mackenzie & Knipe,
2006).

3.3 Consideration of theoretical underpinning for the proposed research.

Following careful consideration, it was decided that positivism, critical theory,
constructivism–interpretivism and pragmatism, were not suitable paradigms for this
project. Positivism was not suitable, because the factors that influence the
sustainability of EB practice (barriers and facilitators previously identified, particularly
the human and social factors associated with RCF staff), cannot be comprehensively
understood using only quantitative methods. To obtain a better understanding of the
behavioural factors influencing the sustainability of EB pain management practices,
the use of qualitative methods and interaction with RCF staff and Certificate III/IV
care worker students, would be required. However, the researcher’s subsequent
formation of a relationship of trust with the individual participants over time, might
encourage participants to provide more accurate responses to questions regarding
their behaviours related to practice. Therefore, the researcher is unable to keep
herself separate from the participants.

Critical theory, which examines the power differences that may occur within a group,
was also deemed unsuitable for this current study (N. Burns & Grove, 2005). While
social injustice or power related factors between the different levels of staff may
influence pain management practices in some organisations, the sustainability of EB
practice is not solely related to power struggles or to social injustices within the aged
care workplace.

Whist the constructivist-interpretivist paradigm examines knowledge and behaviour

in social/work situations, it is more directed at examining what individuals make of
their experiences within phenomena and what the reasons are for their behaviour
(Creswell, 2013; Plack, 2005). In this research project, the aim is to identity
‘commonalities and patterns in the data’ regarding the sustainability of EB practice,
not to focus on individual staff viewpoints Houghton, Hunter, and Meskell (2012, p.
35), so that future action plans regarding the sustainability of EB practice, might be
directed at addressing those factors. In addition, the process of pain identification,
assessment and management, involves a number of processes that are not solely

36
related to human behaviour (e.g. use of appropriate assessment tools) or the human
experience. There have been a number of barriers and facilitators of the pain
management process, previously identified and documented (Achterberg et al.,
2013; Bruneau, 2014; Goucke, 2018; Veal et al., 2018; Wiltsey Stirman et al., 2012).
These barriers and facilitators are complex and require different methodologies
(using both quantitative and qualitative data), to obtain better knowledge and
understanding of the phenomena.

Pragmatism, whilst utilising mixed methods, was also deemed not suitable. Whilst it
is recognised that care in RCFs occurs in different social, political and historical
contexts, these are not the only factors that are impacting EB pain management
practices in RCFs (Creswell, 2013). Human behaviour (both staff and resident), the
availability of human and physical resources, other external and internal
organisational factors and how the organisation continues to learn, retain and
transfer knowledge, may also impact practice and influence the sustainability of best
practice. The researcher needs to obtain a better understanding, of how all these
different factors impact care outcomes.

The post-positivist paradigm enables the use of quantitative and qualitative data to
provide a more critical examination of the complexities of human behaviour,
associated in this case with the conducting of pain management practices (Sharma,
2010). Post-positivists believe, that there are multiple realities and these are often
influenced by the context in which the events (in this instance health care) occur and
that the real world is not understandable or predictable (O'Leary, 2007, 2010).

Context in RCFs is very important, as this impacts on the culture of the organisation,
staff, leadership, resource availability, organisational structure, processes, learning
and capacities (Virani, 2012). The reality in aged care is, that there are multiple aged
care providers, in which the internal organisational context will differ (Virani, 2012).
These factors will affect the implementation and sustainability of EB practice.

Reality is also impacted on, by the individuals working within in the particular context.
These individuals bring different cultural, social, emotional and psychological factors
with them into the work place on a daily basis (Virani, 2012) . Questions related to

37
workplace practices and processes, may be influenced by these factors and give the
researcher a different perspective on what is happening.

In post-positivism, objectivity is important, but the researcher is aware that their

personal attributes can influence the information that is obtained. In this project, the
researcher is aware of the impact that her previous experience and values as a
clinical nurse in persistent pain management, with a specific interest in the older
people in RCFs and dementia, could have on this project. The researcher
understands, that complete objectivity will be difficult but achievable, by adherence
to post-positivist research methods.

Use of the post-positivist paradigm, means that both quantitative and qualitative
methods can be used to test the research questions. The project will use these
methods to systematically collect and analyse data from representative samples of
staff from an RCF, that has implemented EB pain management practices, from
students/graduates undertaking a Certificate III in aged care, and from CFs from two
Registered Training Organisations (RTOs).

To ensure that objectivity is maintained during the research project, triangulation will
be used, as this facilitates the use of either multiple theories, methods, investigators,
or data sources and provides a systematic process to examine and describe the data
and reduce bias (Houghton et al., 2012; Sharma, 2010). In this project, triangulation
will be achieved using quantitative (audits and questionnaires) and qualitative
(interviews, diary entries, document analysis) methods.

Whilst the post-positivist paradigm provides the architectural framework for a study, it
does not make specific assumptions that are required to study the phenomenon
surrounding the sustainability of best pain management practices in RCFs. However,
a theory sits within the framework of a paradigm and provides the researcher with a
structure to allow study of the phenomena in question and any relationships
occurring between factors. The theory assists with the ‘development of hypotheses,
systemising knowledge, explaining phenomena and predicting conclusions’
(Carpiano & Daley, 2006, p. 2). The following section will discuss the theories
considered for use in this research.

38
3.4 Theories.
Various theories have been used previously to plan and study improved patient care.
These included ‘process theories’ and ‘impact theories’ (Grol, Bosch, Hulscher,
Eccles, & Wensing, 2007, p. 95). Process theories look at the steps involved in the
implementation of new practice processes and how those steps impact the recipients
(Grol et al., 2007). Impact theories look at how barriers and facilitators may impact
the change being implemented and define theories and conventions about how an
implemented intervention, will enable practice change (Grol et al., 2007; Grol,
Wensing, Bosch, Hulscher, & Eccles, 2013).

There are several theories which either target the individual or professional group
and the context in an organisation. Theories that target the individual, or specific
professional groups, include cognitive, educational and motivational theories. These
focus on how individuals use their cognitive and psychosocial skills and practise their
behaviours in their daily professional lives (Grol et al., 2007; Grol et al., 2013).
Theories that target social interaction, examine how individuals within the context
being studied, influence the change being implemented within the organisational
context, and examine how each individual affects other individuals within associated
networks and teams. Theories of social interaction, include the theory of
communication, social learning theory, social network and influence theories,
theories related to teamwork, professional development and leadership (Grol et al.,
2007; Grol et al., 2013). Lastly, theories that focus on examination of the
organisational environment include theory of innovative organisations, theory of
quality management, theories of integrated care, complexity theory, organisational
learning theory and theories of organisational culture. All of these theories look at the
internal context of an organisation, its culture, processes, team structure,
collaboration and division of work (Grol et al., 2007; Grol et al., 2013).

The theory chosen for this research is organisational learning theory (OLT). This
theory provides structure for obtaining a deeper understanding of the complex and
multifaceted issues, related to the implementation and sustaining of EB practice,
organisational learning and knowledge about practices (Argote, 2013).

39
3.5 Organisational learning and organisational learning theory (OLT).
3.5.1 Organisational learning.
Organisational learning has been defined as, ‘a modification in the organisations
knowledge that occurs as the organisation attains experience’ (Argote, 2013; Argote
& Miron-Spektor, 2011). Changes in knowledge may include changes in thinking or
conduct and can be overt, implied or difficult to identify (Argote, 2011). Experience is
obtained as individuals within the organisation, perform the tasks and utilise the tools
(translating knowledge into action), then evaluate the actions and outcomes. This
platform (formed by the people utilising the tools and completing the tasks), is the
place where knowledge is shared between individuals and the team (Ratnapalan &
Uleryk, 2014). As knowledge is obtained through ongoing task performance, it is
established in individuals, policy and procedure guidelines, routines, and in the
interactions and relationships that are formed between three components –
members, tasks and tools (Argote & Miron-Spektor, 2011). This then impacts on the
organisational environment, knowledge and ongoing practices (Argote & Miron-
Spektor, 2011). Continuous organisational learning, is essential for the delivery of
safe EB practice, particularly where a shared knowledge of roles, practices and
communication strategies is required (Ratnapalan & Uleryk, 2014).

The term ‘organisational learning’, originated in the 1950s with a debate between
economists and behaviourists, about the complexity of learning within an
organisation. Interest in the area of organisational research has subsequently
increased with an increase in research in the field in the last 50–60 years. The fields
of business, psychology, sociology, health, engineering and management, have all
embraced organisational learning, with the focus being on the outcomes of learning,
creating, retaining and the transferring knowledge within an organisation (Argote &
Miron-Spektor, 2011; Schulz, 2005). In health care, there has been little substantial
empirical research on organisational learning. However, it is being acknowledged, as
an important framework for health care, including in RCFs, where the organisation
and staff are working towards a common goal of safe, EB quality care for the
residents (Ratnapalan & Uleryk, 2014; Virani et al., 2009).

40
3.5.2 Organisational learning theory (OLT).
OLT, ‘relates to the acquisition, interpretation, retrieval and use of knowledge within
the organisational setting, with the view to satisfy one or more organisational
objectives’ (Virani et al., 2009, p. 90). The purpose of OLT, is to ‘understand the
processes that lead to (or prevent) changes in organisational knowledge, as well as
the effects of learning and knowledge on behaviours and organisational outcomes’
(Schulz, 2005, p. 441). This includes ‘workplace socialisation, meaning-making and
power relations’ (Dee & Leišytė, 2016, p. 275). Given the myriad of barriers and
facilitators that have already been identified as inhibiting pain management practices
in RCFs, and the implementation of EB practice in aged care, OLT is appropriate to
underpin this research project and provide the structure to identify the external and
internal factors that impact the sustainability of best practice.

OLT development has been complex and has spanned seven decades (since the
1950s) (Argote, 2011; Schulz, 2005). Theory development has been influenced by
organisational performance and research in organisational learning, in the business,
economic, industrial, technical, manufacturing, psychological, anthropological and
social fields. Each field has used a different research methodology and proposed a
different theoretical model. Some of these OLTs have been based in cognitive theory
(experiential learning theory or adaptive & generative learning theory), or behaviour
theory (assimilation theory), depending on the organisational outcome focus (Argote,
2013; Argote & Miron-Spektor, 2011). At present there is no one unified OLT and
debate continues as to whether one should be developed, or whether each discipline
should adapt its own theory, depending on organisational requirements (Argote,
2013).

Argote and Miron-Spektor (2011), attempted to unify OLT concepts and proposed a
theoretical framework which can assist organisations or researchers to analyse
organisational learning (Argote, 2011). This theoretical model, is based on
‘organisational experience, the context, organisational learning processes and
organisational knowledge’ (Argote, 2011, p. 1126).

The OLT framework shown in Figure 3.1 examines the contexts and networks that
are formed and within which, organisational learning occurs, and knowledge is
developed. Organisational experience is obtained, as the individuals within the

41
organisation undertake their duties and responsibilities. These individuals interact
within a context to create knowledge (Argote, 2013; Argote & Miron-Spektor, 2011).

Learning occurs in a context and in this framework, context includes both the
external environment and the organisation. ‘The context interacts with the
experience gained by the staff performing the tasks, and so, knowledge is created’
(Argote & Miron-Spektor, 2011, p. 1125). The context in which organisational and
individual learning occurs is important and should be considered during
implementation of any new practice and when planning strategies to sustain the
practice (Fleiszer et al., 2015b; Virani, 2012; Wiltsey Stirman et al., 2012). These
considerations include, examining the external environment and organisational
factors for potential barriers to practice change (Virani, 2012; Wiltsey Stirman et al.,
2012).

Legend
- indicate the interaction
between the context and
knowledge.
- indicate the continuous
learning circle that occurs
when building organisational
knowledge.

FIGURE 3.1 Organisational learning theoretical

framework.
(Argote & Miron-Spektor, 2011, p.1125).

The environmental context, refers to elements that are external to the facility or
organisation (Argote, 2013; Argote & Miron-Spektor, 2011). In the case of RCFs in
Australia, this relates to the Australian Aged Care Quality Agency (AACQA) and the
Aged Care Funding Instrument (ACFI), and to legislation such as the Aged Care Act
1997, which regulates the quality and type of care delivered. Relationships with the

42
wider aged-care community including other facilities, membership with health-related
professional bodies, such as the Australian College of Nursing or the Australian
Association of Gerontology, Australian nursing unions and relationships with different
education providers, may also contribute to workplace knowledge. These agencies
and groups, may also contribute to the potential barriers and facilitators of
organisational learning and the implementation and sustainability of EB practice,
through either the legislation or their own policies, procedures and processes.

The concept of organisational context encompasses a variety of factors including,

the characteristics of a facility or organisation. These may include its physical
structure, staffing, resources, culture, processes, policies and procedures,
communication resources and strategies, leadership, values, mission and goals of
care, motivations and quality improvement practices (Argote & Miron-Spektor, 2011;
Kaplan et al., 2010; Virani, 2012). In aged care, the context understandably varies
between organisations, facilities within organisations and independent standalone
facilities.

Within the organisational context, there are active and inactive elements that will
influence organisational and individual learning and knowledge attainment (Argote &
Miron-Spektor, 2011). In Figure 3.1, these are depicted as the ‘active and latent
contexts’ (Argote & Miron-Spektor, 2011, p. 1125). These concepts were derived
from a previous theory of small groups and complex systems (Arrow, McGrath, &
Berdahl, 2000; McGrath & Argote, 2002).

The active context refers to the individuals in the organisation, the clinical,
environmental, administrative and maintenance staff, volunteers, the residents and
the residents’ significant others. Interactions occur between these groups, when
using tools associated with pain management practices and performing pain
management related tasks (Argote & Miron-Spektor, 2011). The latent context
includes organisational structure and culture, physical resources, (for example the
pain assessment tools available to complete the tasks), policies, procedures and
processes, funding, staff models and skill mix. It also relates to whose responsibility
it is to perform the task. In relation to pain identification, assessment and
management, tasks can be carried out by care workers (AINs), Registered nurses
(RNs/ENs), or Allied Health (AH) practitioners (Argote & Miron-Spektor, 2011).

43
The latent context can influence the active context. Lack of assessment tools, or
limited pharmacological and non-pharmacological resources, will affect how the staff
member can complete pain assessment and management tasks (active context).
The composition of staff within the organisation and their allocated roles, also affects
the active context. If, for example, there is an inadequate number of, or no RNs/ENs
available, then this will influence how frequently pain assessment tasks are
completed and the response time to delivery of pain management strategies.

The culture of the organisation can also impact organisational knowledge and the
implementation and sustainability of EB practice. If the culture of the organisation
(latent context) is supportive and nurturing, then organisational learning and
outcomes are supported. However, if the culture of the organisation is one where
staff feel unsafe, then this acts as a barrier to organisational learning (Argote, 2013;
Argote & Miron-Spektor, 2011).

As staff interact with each other (active context), the residents and their significant
others when undertaking the pain identification, assessment and management tasks,
and utilise the assessment tools and care plans to deliver care, they collaborate and
communicate with different members of the team, and so networks are formed.
Organisational learning theory acknowledges, that networks are set up between all
the different factors within the organisational context. Networks can be formed
between the members (the staff, resident and their significant others), the members
and the tools (which individual member is utilising what tool to undertake a particular
task); and between the members and the tasks, (which member of the team is
allocated to which task). Networks can also be formed between the tools and the
tasks (including, what tools are used to perform which task) and between the
members, tasks and tools (which individual, which task with what tool) (Argote &
Miron-Spektor, 2011). ‘The members, tools and tasks and their networks, are the
primary mechanism in organisations through which organisational learning occurs,
knowledge is created, retained and transferred’ (Argote & Miron-Spektor, 2011, p.
1125). Learning is continuous throughout the life of the organisation and the
organisation must be active in embracing change and continually improving service
delivery (Ratnapalan & Uleryk, 2014). The arrows in Figure 3.1 show this continuous
learning cycle.

44
Within organisational learning, knowledge is retained and individuals (members) are
the primary channels through which learning occurs. The main source of knowledge
regarding the resident and their care needs in RCFs, is the direct care staff,
particularly the AINs, who work with the residents for extended periods of time every
day (Caspar, Ratner, Phinney, & MacKinnon, 2016). However, knowledge can also
be retained in tools, such as those used in pain assessment, in guidelines, policies
and procedures or in routines within the organisation. These tools can help trigger
previously retained staff knowledge and also be involved in the transfer of knowledge
between staff members (Argote & Miron-Spektor, 2011). Knowledge is therefore
acquired by learning and through the interactions between the members, tools and
tasks. It is subsequently, embedded in the organisation and affects future learning
(Argote & Miron-Spektor, 2011).

The retention and transference of knowledge utilising organisational memory, is

important for the continual delivery of quality care and the performance of the
organisation. Knowledge retained mostly in its members can be impacted by staff
turnover, organisational contextual factors such as the structure and layout of the
worksite, the culture of the organisation, motivations of individuals within the team,
human and material resources, education provision and leadership (Argote & Miron-
Spektor, 2011; Virani, 2012).

The circle of learning (shown in Figure 3.1) that occurs between the members, tools
and the experience gained through performing the tasks, can occur at the individual
or organisational level (Argote & Miron-Spektor, 2011). This is important, as the aim
of implementing any new information, is to change an individual’s knowledge and
practice (Masso & McCarthy, 2009). Individual learning is important for team and the
wider organisational learning. However, it is not enough to sustain organisational
knowledge. This is because the individual would be required to transfer their
knowledge to every single active or latent context. In addition, on occasions
education occurs within particular groups within the team, e.g. only RN staff or only
AINs. This may result in information not being shared between the different staff
groups (Argote & Miron-Spektor, 2011; Ratnapalan & Uleryk, 2014).

Sustaining EB practice in RCFs, therefore requires careful thought and planning and
consideration of all the concepts and factors described in the OLT framework, that

45
can impact learning, knowledge, implementation and sustaining of a new practice
(Virani et al., 2009). Consideration of all the factors and concepts described in OLT
and planning and implementing a practice change that identifies and addresses
these factors, will ensure that changes and knowledge are entrenched into the
organisational memory for use in producing, recalling and conveying knowledge in
the future (Argote, 2013; Virani et al., 2009).

This thesis seeks to examine the factors influencing the sustainability of EB pain
management practices in RCFs using OLT.

3.5 Research questions.

1. What individual factors impact direct care staffs’ ability to conduct evidence-
based pain identification, assessment and management practices for older
people in RCFs?
2. What organisational factors impact direct care staffs’ ability to conduct
evidence-based pain identification, assessment and management practices
for older people in RCFs?
3. How do current educational training practices for aged care workers, influence
their ability to conduct evidence-based pain identification, assessment and
management practices for older people in RCFs?

3.6 Summary.
The use of the post-positivist paradigm to undertake research in organisational
learning, provides an opportunity to explore the establishment and sustainability of
EB practice using a realist objective position. OLT used as the underpinning theory
in this research project, has a different definition, in accordance with the field of
interest, so consequently, there is not one unified theory. However, in health care
research, OLT as proposed by Argote & Miron-Spektor (2011), can be used as one
theoretical framework to analyse the sustainability of EB practice in aged care. In the
next chapter, the methodology used during Phases One and Two of this project will
be discussed.

46
 Chapter Four: Methodology.
4.1 Introduction.
This research, conducted in two phases, examined the factors that affected the
sustainability of EB pain identification, assessment and management practices in
RCFs in Australia.

While both phases addressed the research questions, Phase One focused on
research questions one and two, and Phase Two on research question three.

1. What individual factors impact direct care staffs’ ability to conduct evidence-
based pain identification, assessment and management practices for older
people in RCFs?
2. What organisational factors impact direct care staffs’ ability to conduct
evidence-based pain identification, assessment and management practices for
older people in RCFs?
3. How do current educational training practices for aged care workers influence
their ability to conduct evidence-based pain identification, assessment and
management practices for older people in RCFs?

The aim of Phase One, was to audit an RCF that had implemented the ‘Pain in
Residential Aged care Facilities: Management Strategies [PRACMS] (Goucke et al.,
2005), best practice principles in the identification, assessment and management of
pain. In returning to a facility that was known to have previously implemented best
practice strategies as part of the EBPRAC project, the purpose was to examine
whether previously implemented strategies had been sustained, thereby
demonstrating continuous organisational learning and knowledge retention. In
addition, the purpose was to identify factors associated with the external contextual
environment (aged care systems), or the internal organisational context (the
residents, staff, or the facility), that may be inhibiting or contributing to, sustained
practice change.

Phase Two, examined how aged care workers were educated and trained in pain
identification, assessment and management skills, by two Registered Training
Organisations (RTOs), identified as RTO A and RTO B and examined how these
skills were then translated into the workplace. The certificate course provided by the

47
RTOs, was based on the Australian Government, Department of Education and
Training Certificate III in Aged Care (now known as Certificate in Individual Support).

These phases are discussed sequentially.

4.2 Ethics.
Ethics Approval.
Ethics approval was sought from The University of Queensland Behavioural & Social
Sciences Ethical Review Committee for both Phase One (#2012000433) and Phase
Two (# 2015000051) (Appendix 1). After approval from the RCFs and RTOs was
granted, (Letter of Approvals in Appendix 2), ethics approvals were granted.

Conflicts of Interest.
There is no known conflict of interest. The researcher was not a member of staff of
the organisation involved in Phase One. Neither was the researcher a member of
staff of either RTO A or RTO B in Phase Two.

4.3 Research methods used in organisational learning (OL) research.

Just as issues have been identified with the concept of one unified Organisational
Learning Theory (OLT), there is ongoing debate around the possibility of unification
of research methods in organisational learning (Argote, 2013; Popova-Nowak &
Cseh, 2015). This lack of unification in methods and theory is not without its
problems, as it makes the interpretation of results from any research difficult to
transfer across different fields, for example from the managerial to the service
industry. Argote (2011), discussed organisational learning, concluding that there is a
lot of research that still needs to be undertaken in many of its areas, utilising different
research methods, as each organisation exists with a different reality.

There is a lack of literature relating to organisational learning and OLT and the field
of healthcare, particularly aged care (Nuño-Solinís, 2017). Papers discussing the use
of OLT in health care, have examined how OLT can be used to embed practice
guidelines or EB practice into health care and the long-term care environment. They
also discuss the different organisational and individual factors that can impact
practice and the implementation of new EB practices (Berta et al., 2005; Ratnapalan
& Uleryk, 2014; Virani et al., 2009). However, in other fields (anthropology,
psychology, sociology, management), there has been a significant amount of

48
research into organisational learning (Argote, 2013; Nuño-Solinís, 2017). A review of
empirical research in organisational learning, found that a mixture of both
quantitative or qualitative methods and multiple or mixed methods have been used to
investigate the multiple facets associated with organisational learning (Argote, 2011;
Easterby-Smith, Li, & Bartunek, 2009).

In organisational learning research, both quantitative and qualitative methods have

been used. Quantitative methods (questionnaires or audits), have been used to
‘establish patterns, relationships and variations in organisational processes‘ (Nyame-
Asiamah & Patel, 2009, p. 11). Qualitative methods, allow more detailed information
to be collected, with the researcher able to investigate the viewpoints of individuals
functioning within a particular context being studied. In organisational learning
research, qualitative research methods, have been used to ‘develop strategies, plan
changes, improve performance, manage knowledge and information technology, and
examine issues related to learning’ (Nyame-Asiamah & Patel, 2009, p. 11). However,
using both qualitative and quantitative methods is not without its problems, as they
come from different epistemological positions (Popova-Nowak & Cseh, 2015).

When conducting empirical research into subjects such as organisational learning,

various underpinning methods are acceptable. The choice of methods for this
particular research project, is the mixed data collection method, using both
quantitative and qualitative methods, as this is also appropriate to the post-positivist
stance being assumed in this work (Plack, 2005).

However, to maintain validity under the post-positivist paradigm and OLT, a process
needs to be incorporated that allows for verification of the data being collected.
Triangulation of data with the use of different data collection methods, is one strategy
that can be used. This strategy allows the use of more than one approach to
collecting the same data. This is important particularly in this research, where
questions are being asked regarding the multiple factors impacting on sustaining EB
practice (Heale & Forbes, 2013).

4.4 Triangulation.
To maintain validity and reliability in the post positivist paradigm, the method of
triangulation of either theory, data collection, researchers or data analysis, can be

49
employed (Creswell, 2013). In this research project, there were multiple methods of
data collection used. Use of quantitative and qualitative methods including, audits,
questionnaires, document analysis, interviews and diaries used in this research,
results in across-method triangulation, where methods from different research
traditions are used in the one study (Green & Thorogood, 2011; Heale & Forbes,
2013). In this research there was also within-method triangulation used, whereby two
or more research methods were used to measure the same variable (Green &
Thorogood, 2011). For example, different questionnaires on knowledge, attitudes
and beliefs about pain and pain practices, student diaries and interviews, analysis of
documents (policies, procedures, patient records, databases, education material),
were used to ascertain direct care staff and student care worker knowledge about
pain identification, assessment and management in older people, people with
dementia and practices in the aged care environment. These methods described
above, were used concurrently or consecutively, to capture the data.

The limitations of triangulation include, researcher bias in data selection, the

selected methods for data collection may be incorrect or incorrect for the question
being asked, or the researcher fails to detail how triangulation was attained. This
consequently can impact on the validity of the project. There could also be
incompatibility of the use of triangulation within the research paradigm and
replication of any part or the whole research project may also be difficult (Casey &
Murphy, 2009).

4.5 Phase One.

4.5.1 Aim of the proposed study.
The aim of Phase One was to review the sustainability of implemented EB pain
management practices in an RCF. Specifically, this phase addressed Research
Questions One and Two, to identify the individual and organisational factors
impacting pain identification, assessment and management practices.

4.5.2 Methodology.
This study was conducted in a facility that had previously implemented best practice
principles during the EBPRAC pain management project (Masso et al., 2011; Savvas
et al., 2014b). The 27 best practice principles were outlined in the 2005 edition of the
PRACMS guidelines (Goucke et al., 2005).

50
An explanatory sequential mixed method research design was used in Phase One
(Creswell, 2013). In this design, quantitative data was collected initially, using a
designed audit tool (Appendix 3). This tool was developed from the 27-best practice
strategies from the PRACMS guidelines (Goucke et al., 2005). The data were then
analysed. Qualitative data was then collected through participant interviews, five
months after the audit data was collected and analysed. Documents pertaining to the
practice were also collected, to build on the quantitative results and attempt to
explain them in more detail (Creswell, 2013). Access to the facility education data
base, was also granted to the researcher, during the initial audit period.

Quantitative data gained through the audit (Part 1), needed to be collected first, to
determine what best practice pain management strategies were still being utilised
within the facility. Quantitative methods included, the use of an audit tool (Appendix
3), collection of demographic data of the residents and examination of electronic
databases recording education provision and attendance. This audit took place over
three days in May 2012. Qualitative data (Part 2) (including demographic data of
staff), was collected from conducting interviews with staff, over a two-day period, five
months (Oct 2012) after the audit data was collected and analysed. The policy and
procedure documents were also examined, post analysis of the quantitative data.
The purpose of the interviews was to identify external and internal contextual factors
that affected the staff’s ability to conduct EB pain management practices. Figure 4.1
will illustrate the research design for Phase One.

51
 FIGURE 4.1 Explanatory sequential mixed methods design for Phase One.

4.5.3 Part 1 – Audit of residents’ charts.

Individuals with moderate to severe dementia who had died at the RCF since the
EBPRAC pain management project was completed (June 2009), were the focus of
the retrospective chart audit. A specific focus on people with moderate to severe
dementia was considered appropriate for this chart audit. Such residents constitute
the most vulnerable population in aged care and will demonstrate the presence of
pain either through verbalisation (if the capacity to verbalise is still present), or
through pain related behavioural changes. Both of these factors related to the
communication of pain by people living with dementia, are well-documented in the
literature (Herr, 2011).

The aim of the chart audit was to identify when regular pain assessments were
conducted and care plans evaluated; and in the case that episodes of pain were
identified, when they were assessed and if a new pain management strategy was

52
implemented. Whenever a change in care plan/management was implemented, the
resident should have had a follow up evaluation assessment to review the
effectiveness of the new strategy. The chart audit examined information for the 6
months prior to the death of the resident and was conducted using the Pain
Practices Audit Tool (PPAT) (H. Holloway, 2012) (Appendix 3). Two external experts
reviewed the audit document and made suggestions to improve the tool. These
improvements were incorporated into the final document.

In addition, demographic data about the age, gender, length of time in the facility,
comorbidities, persistent pain and dementia type of the deceased residents, were
also collected.

Inclusion criteria-Resident.

A diagnosis of moderate to severe dementia and death since June 2009 were the
requirements for residents’ inclusion in the audit.

Exclusion criteria.
All residents without dementia and those with dementia but who had died prior to
June 2009.

Audit.
The charts (n=17), were examined over a three-day period in May 2012, for the
following documentation:
• Demographic information.
• Clinical information – comorbidities, persistent pain, dementia type.
• Progress notes for documentation regarding: identified pain, completion of a
pain assessments, verbal reports or behaviours that may indicate the
presence of pain.
• Formal pain assessments: on admission, every 3 months (as per best
practice guidelines) and if a review was required because of medication
changes, hospitalisation or if pain was suspected, episodes of pain.
• Progress notes and care plans were examined for pain management plans,
as changes in management, would require a pain assessment to determine
effectiveness of treatment changes.

53
 The facility provided a list of deceased resident names during the researcher’s
attendance at the facility, based on the inclusion criteria. The researcher was given
access to the facility archives. Seventeen (n=17) deceased residents, were selected
from the period of June 2009–December 2009, 2010, 2011; and from January 2012
to October 2012 (researchers’ attendance dates at the facility) that met the inclusion
criteria, as the number of resident charts exceeded the data capacity of the
researcher. This allowed for the auditing of charts for the three years post best
practice implementation.

The audit tool also allowed for auditing of wider facility policy/procedures and of the
education database provided at the facility.

4.5.4 Part 2 - Interviews with RCF direct care staff.

A convenience sample of RCF staff (n=13) from the facility were used for this part of
the study. Inclusion and exclusion criteria are available in Table 4.1 below. The RCF
staff, were recruited through the researcher, who liaised with the Care Manager (CM)
and Clinical Nurse (CN) of the facility, prior to attending the facility. These individuals
were provided with a list of the inclusion criteria and were asked to facilitate rostered
staff being available on the day the researcher attended the facility (two days in
October 2012). Once recruited, the staff were provided with an informed consent
document (Appendix 4), in which the requirements of participation were clearly
explained.

Table 4.1 Inclusion/exclusion criteria for staff participation in Phase One.

Inclusion criteria Exclusion criteria

• All staff categories care worker, Enrolled nurse, • Not involved in direct
Registered nurse, Allied health and managerial.
care of residents.
• Employed at the facility during the implementation
of the EBPRAC project.

• Employed at the facility post the implementation of

the EBPRAC project.

• Involved in the direct care of the residents.

54
Demographic data was collected through a questionnaire, that was conducted at the
commencement of the interview. This document included questions about age,
gender, and ethnic background, previous experience and qualifications in aged care
and job experience (Appendix 5).

The same staff were interviewed regarding their knowledge of pain identification,
assessment and management processes and more generally about the identification
of facilitators or barriers to pain management practices. The interview process took
approximately 30 minutes and was conducted in person at the facility, in a room
made available away from the care areas on the day. The RN/CN interview was
conducted by phone. The interviews were recorded on two digital recording devices,
fully transcribed and analysed by the researcher.

The questions utilised during the interview were semi-structured and based on the
results of the quantitative data from Part 1 (the audit of residents’ charts). The
purpose of the interview was to determine the knowledge of the staff regarding pain
identification, assessment and management practices and the individual and
organisational factors (barriers and facilitators), that influenced the sustainability of
best practice. These questions varied according to the role of the staff member in the
organisation and whether the staff member had been present during the EBPRAC
project (i.e. RN/AIN) (Appendix 5).

Analysis.
Data collected from the residents’ chart audits were entered into an SPSS database
(version 24) and basic descriptive statistical analysis was undertaken. For questions
where non-numerical data was collected, a narrative explanation of the data will be
presented.

Demographic data collected from staff0, were entered into SPSS (version 24) and
basic descriptive statistical analysis undertaken. Interviews completed and recorded
on a digital device were transcribed by the researcher and analysed using thematic
analysis (Bradley, Curry, & Devers, 2007). This involved manual coding (Bradley et
al., 2007). As the purpose of staff interviews was to identify individual and
organisational factors that impact on the sustainability of EB pain identification,
assessment and management practices, interview data was coded with this purpose

55
in mind. Therefore, pre-set codes were listed as barriers or facilitators. Interview data
were then categorised under these two headings. Themes were identified by the
frequency of word occurrence within the text (more detail regarding theme and
subtheme development, is provided in the respective results chapters).

4.6 Phase Two.

4.6.1 Aim of the proposed study.
Phase Two evaluated the current training of Certificate III care workers in pain
management practices. It was aimed at addressing Research Question 3.

4.6.2 Methodology.
Two Registered Training Organisations (RTOs) within Queensland were approached
for this phase of the research project. Training modules delivered in these courses
are based on the Australian Government CHC 30208 (CHC 33015
https://www.myskills.gov.au/courses/details?Code =CHC30212], with local
adaptation depending on course structure and length. Phase Two developed from
the data analysed from Phase One, which demonstrated that the majority of care
workers working in the RCF could not remember anything about their education
regarding pain identification, assessment and management during their certificate
course. In addition, AINs are now the primary workforce in aged care, delivering
most of the care and we need to obtain a better understanding of their knowledge
about complex areas of care, such as that required in pain management. It is
therefore important to determine what level of information the Certificate III for Care
worker training provides, in this area of clinical care. As all courses are based on the
framework provided by the Australian Government, it was deemed that evaluation of
Certificate III training could occur in any state or territory.

A non-randomised convergent triangulation design was chosen, because the same

Clinical Facilitators (CFs), worked with different part-time and full-time student
groups. Both quantitative and qualitative data were collected at approximately the
same time. This was to ‘demonstrate more valid results by finding agreement across
different research strategies’ (Turner, Cardinal, & Burton, 2015, p. 248). The aim of
Part Two, was to examine, how current educational practices influence AINs’ ability
to conduct EB pain management in aged care. The quantitative data collection was
aimed at obtaining demographic information about the students’ and examining the

56
students’ knowledge prior to the commencement of the certificate studies,
throughout the study period and post-graduation, by using questionnaires. To allow
for a deeper understanding of knowledge attainment and the transference of that
knowledge into the workplace, qualitative data was also collected. Figure 4.2 shows
a diagram of the proposed research design.

Figure 4.2 Non-randomised convergent triangulation for Phase Two.

57
4.6.3 Participants.
Registered Training Organisation (RTO).
Two RTOs in Queensland that offered the Certificate III in Aged Care, offered to
participate in this phase of the research. These organisations had been informed
about the project through one–to–one meeting with the managers. Participants
included students undertaking Certificate III in Aged Care (CHC 30208) (now
superseded by Certificate in Individual Support) and the CFs who were instructing
the students. The inclusion and exclusion criteria can be seen in Table 4.2.

Table 4.2 Inclusion/exclusion criteria for students/CFs Phase Two.

Inclusion criteria Exclusion criteria

• Certificate III aged care students – part time/full Nil

time

• Graduate Certificate III aged care students (new

care workers) part time/full time

• Clinical facilitators – part time/ full time employed

by the RTO

Students.
Students were enrolled either part time or full time in the Certificate III in Aged Care
(CHC 30208) in 2015/2016. Students were recruited during the first week of their
course, through face-to-face contact. The researcher attended a training session,
after being granted permission by the RTO. Students were informed about the
project, provided with an information and consent form to complete at that time
(Appendix 6). They were provided with time to complete and return the consent form
and ask any questions. The purpose of this method of recruitment, was to provide
students with information regarding the project and give the students an opportunity
to participate, if they chose. The total number of students present during these
information sessions was not recorded, as participation in the project was voluntary.
Their CFs were not present in the room during the time of consent either, to ensure
both anonymity of the student and so that students known to have participated in the

58
project did not receive any extra tuition or favouritism regarding pain identification
assessment and management education, during the teaching period. Sixty-seven
students were recruited across five different student groups and two RTOs.

Students completed their training in pain identification, assessment and

management provided by the RTOs (noted in this research as RTO A and RTO B).
In the current course structure, students learn about pain identification, assessment
and non-pharmacological management strategies, primarily in the module entitled
Palliative Care Approach and End of Life Care. The pain component of this module
was approximately one hour of teaching time in class and then the practical
component of identifying and reporting pain was addressed as an assessment item
(in RTO A only), whilst students were gaining their practical experience at a facility.

Sample Size.
The sample was a convenience sample of students enrolled in the Certificate III in
Aged Care CHC 30208) in 2015/2016 in two RTOs (RTO A and RTO B) in
Queensland. No sample size calculations were conducted, as there was no previous
literature on research conducted with this group.

Data Collection.
The following data were collected from the students/new care workers across three
time points (Appendix 7).

Demographic data.
Demographic data were collected at baseline (Time Point One [TP1]), which
included age range, gender and ethnic background information and addressed
previous experience in aged care, previous qualifications and job experience. The
question was also asked as to why participants had chosen to become aged care
workers.

Questionnaires.
To measure changes in student/new care worker attitude, knowledge and confidence
in pain identification, assessment and management, three questionnaires were used
across three time points.

59
 1. The Knowledge and Beliefs about Pain in the Elderly questionnaire
(Zwakhalen et al., 2007).
2. Modified Pain Management Student Survey (Savvas et al., 2014b).
3. Knowledge and Attitudes Survey Regarding Pain (Ferrell & McCaffery,
2012).

Three tools were chosen, as there was no one tool available to assess
knowledge and attitude towards pain among students/new care workers and CFs
involved in Certificate III training. Results from these questionnaires would be
used to evaluate which tool was the most suitable in the event that a larger study
were to be conducted.

The ‘Knowledge and Beliefs about Pain in the Elderly’ questionnaire had been
developed by Zwakhalen et al. (2007), for a study in an RCF where RNs and AINs
were surveyed. It had 17 questions presented on a five-point Likert Scale (‘strongly
agree’, ‘mostly agree’, ‘mostly disagree’, ‘strongly agree’ and ‘no opinion’) and had
been evaluated for validity and reliability (internal consistency satisfactory, alpha >
0.7) (Zwakhalen et al., 2007).

The second tool was the Modified Pain Management Student Survey, which had
previously been utilised with RNs/ENs, AINs and AH practitioners, during the
EBPRAC pain management project (Savvas et al., 2014b). This tool was modified
because in the original survey, Questions 11 and 12 had been just the one question,
which asked about confidence in using both pharmacological and non-
pharmacological management strategies. However, it was felt that splitting,
questions 11 and 12 provided more accurate data about the participants’ confidence
in performing pain management tasks and their knowledge of pain management
strategies. This survey had 14 questions and participants were asked to complete
the questionnaire using a four-point Likert Scale with ‘strongly agree’, ‘mostly agree’,
‘mostly disagree’ or ‘strongly disagree’. No psychometric tests were available for this
tool.

A ‘Knowledge and Attitudes Survey Regarding Pain’ (Ferrell & McCaffery, 2012),
was included to measure student/new care worker attitudes towards pain in the older
person. This questionnaire required a ‘true’ or ‘false’ response to eight questions.

60
Only eight relevant questions from the original thirty-seven questions were selected
(they were not an intact subscale), as all other questions were concerned with
medication usage, side effects and doses-issues, which were outside the scope of
practice for, care workers in Australia. Questions were modified to make the
questions relevant to the Australian RCF context. The original tool had content
validity, construct validity and test retest reliability (r >0.80 and internal consistency
alpha r > 70) (Ferrell & McCaffery, 2012).

The schedule for the administration of these questionnaires is specified in Table 4.3.
Due to the location of the researcher and the participants, and the variation in
enrolment between part-time and full-time students, questionnaires were distributed
by electronic mail, along with diary entry records (discussed below). Students/new
care workers completed the questionnaire either online or printed it, completed the
document, then scanned and sent it back to the researcher.

It is understood that conducting the questionnaires in this manner, can bring the
reliability of the students’ answers into question, as they may use resources to
provide the appropriate answer. However, following the questionnaire distributed at
time points two and three, diaries were completed and returned and interviews were
conducted, in an attempt to gather supporting evidence regarding their questionnaire
responses about knowledge of pain identification, assessment and management
practices and factors impacting their ability to conduct EB practice.

Diary.
Students were asked to keep a diary of their experiences in identifying, assessing
and managing pain, during their two weeks of practical placement (Time Point Two
[TP2]) and three months post completion of their certificate course (Time Point Three
[TP3]) (Table 4.3), once they had obtained employment in a community or residential
environment. Students/new care workers were provided with either, a paper-based
diary or an electronic copy of a diary, depending on their preference. The diary entry
had a standard format of ‘What happened?’, ‘Who did you tell?’ and ‘What did you
do?’ and a section for reflection on the activity. This format of communication was
discussed with the participants prior to TP2 and TP3. The students were requested
to complete the diary on the day of their observation of the event. Diaries were either

61
 returned electronically prior to the interview or, if hand written, copies were, either
mailed or provided to the researcher on the day of the interview.

Interviews.
Semi-structured interviews, of approximately 30 mins in length were conducted using
predetermined questions (Appendix 8). These questions were based on student
responses to the three pain questionnaires and student/new care worker diary
entries, which were requested to be sent to the researcher prior to the interview. The
questions were directed at examining the participants’ knowledge, attitude,
confidence and skills gained during their practical experience (TP2), and initial care
worker experience (TP3), in the identification, assessment and management of pain.

Interview scheduling times are indicated in Table 4.3 below. These interviews were
conducted in a location and at a time convenient to the student. The interviews were
recorded on a digital audio device. Interviews or meetings were not held at the
participants’ workplaces, to minimise impact on the facility, residents and staff.

Table 4.3 Schedule of data collection points for student/new care workers in
Phase Two.

Time One Time Two Time Three

Commencement Completion Three months post
of course, of course, completion of course
Demographic data X

Knowledge and Beliefs about

Pain in the Elderly
(Zwakhalen et al., 2007) X X X
&
Modified Pain Management
Student survey (Savvas et al.,
2014b) X X X
&
Knowledge and Attitudes
Survey Regarding pain
(Ferrell & McCaffery, 2012) X X X

Diary During practical

placement X

Interview X X

62
Clinical Facilitators (CFs).
Clinical facilitators (n=6), already employed by the RTOs were recruited. During
meetings organised by the Manager/Director of the organisations, they were
informed about the project, the scope of their role if they decided to participate, and
were provided with written information and informed consent documents (Appendix
6). Participation in the project was voluntary.

Questionnaires.
On return of the signed consent form, CFs (n=6), were provided with a demographic
questionnaire sent to the CFs electronically for return electronically, or hard copies of
the questionnaires were provided with a return-stamped envelope. This
questionnaire was similar to the student questionnaire, with an added question
regarding how long they had been working as a CF. The ‘Knowledge and Beliefs
about Pain in the Elderly’ questionnaire (Zwakhalen et al., 2007), was the same as
that given to the students. It had 17 questions presented on a five- point Likert Scale
(‘strongly agree’, ‘mostly agree’, ‘mostly disagree’, ‘strongly agree’ and ‘no opinion’)
and has been evaluated for validity and reliability (internal consistency satisfactory,
alpha > 0.7) (Zwakhalen et al., 2007). The Modified Pain Management Clinical
Facilitator Survey (Savvas et al., 2014b) (as previously discussed and used with the
students), was further modified to remove questions targeting facility knowledge and
to ask more questions regarding their knowledge of pain assessment and
management practices, as it was important to determine the current knowledge level
of the CFs teaching the students. The ‘Knowledge and Attitudes Survey Regarding
Pain’ examining attitude and beliefs, was also included (Ferrell & McCaffery, 2012)
(Appendix 9). This questionnaire was used to measure the CFs’ attitudes towards
pain in the older person and their knowledge and confidence in performing
identification, assessment and management of pain. Considering the role of the CFs,
it was assumed that they would have more knowledge in this area and were likely to
be RNs or ENs. Therefore, 18 questions from the original survey were used, with
more questions being included regarding medication. The psychometric testing of
the original survey was the same as provided in the students’ discussions.

63
Interviews.
CF interviews (30 minutes duration), were conducted, to support the information
provided by the completion of the questionnaires. As questionnaires were
administered individually to each CF, it was recognised that (similar to the students),
CFs may research the questions being asked to provide the correct answer. The
interviews were semi structured and based on their questionnaire responses
(Appendix 10). There were some predetermined questions, which were used to
examine their knowledge and confidence in pain identification, assessment and
management and teaching strategies. Questions were centred on an advanced
understanding of pain identification, assessment tools and management strategies
including, pharmacological and non-pharmacological strategies and knowledge
regarding pain in people with dementia (Appendix 10).

These interviews were conducted in the office at the RTOs or at a place that was
convenient for the participant. It was noted that phone interviews might be required.
Interviews were recorded on a digital device and fully transcribe by the researcher.

4.6.4 Documentation.
Documents pertaining to the training of the students, in the area of pain identification,
assessment and management were obtained from each of the RTOs. This included
workbooks (n=2), learning guides (n=2) and a PowerPoint (ppt) lecture (n=1). These
documents were analysed using document analysis (description included in the
following section). The purpose of collecting these data were to look at the
information and education that was provided to students, regarding pain
identification, assessment and management during their training, as further
evidence. They also form part of the method of triangulation, which correlates with
the positivism paradigm (Bowen, 2009).

4.7 Analysis.
All data, was collected, coded and analysed by the researcher.

Students.
Demographic data collected, was entered into SPSS (version 24), and basic
descriptive statistical analysis undertaken, including frequencies and percentages.

64
For questions where non-numerical data were collected, a narrative explanation of
the data was constructed.

Questionnaire data were entered into SPSS (version 24), frequencies, and medians
calculated. As data was non-parametric, for comparison of participant data against
TP1 and TP2 and TP1, TP2 and TP3, Wilcoxon Ranked sign test and McNemar’s
test were used to analyse data from the questionnaires completed by the students.

Diary entries were analysed using thematic analysis. Interviews recorded on an

electronic device, were transcribed by the principal investigator and analysed using
thematic analysis (Bradley et al., 2007). More detail regarding the development of
themes and subthemes is provided in the relevant chapter.

Clinical Facilitators (CFs).

Demographic data collected were entered into SPSS (version 24) and basic
descriptive statistical analysis undertaken. For questions where non-numerical data
was collected, a narrative explanation of the data was constructed. Questionnaire
responses were entered into SPSS (version 24) and median statistics calculated.
Interviews, recorded on a digital device, were transcribed and analysed by the
principal investigator using thematic analysis (Bradley et al., 2007). As previously
described, more detail regarding the development of themes and subthemes from
the CF interviews, is provided in the relevant chapter.

Documentation.
The documents provided by the organisation were analysed using document
analysis. This allowed for triangulation of data in Phase Two (Bowen, 2009). As the
primary focus of these documents was on pain identification, assessment and
management knowledge and strategies, the overall themes relating to these
concepts were considered.

The documents were initially read through superficially to identify specific areas of
the text relating to the topic of pain. Secondly, the areas identified were more
thoroughly read and coded to identify themes related to the identification,
assessment and management of pain. These documents were considered in light of
the purpose and the audience for which they were intended, the presenter of the
information and the method of teaching (Bowen, 2009).

65
Thematic Analysis.
Thematic analysis utilising hand coding was utilised for the interview data from
Phases One and Two and the diary entries from Phase Two. Hand coding was
chosen as there were small numbers of participants in both phases and to ensure
that data was richly explored (Guest, MacQueen, & Namey, 2012). The OL
theoretical framework (Argote & Miron-Spektor, 2011), was used as a reference
guide during the analysis.

The process used for deductive thematic analysis was as follows:

1. All interviews were read at the end of Phase One and at the end of Time Point
2 and Time Point 3 in Phase Two, to allow for identification of developing
themes.

2. Themes were developed using the OLT framework where initial codes were
individual, organisational and educational factors impacting best practice
sustainability.

3. More in-depth coding then occurred which examined relationships between

themes and subthemes (Bradley et al., 2007) (more detail provided in Chapter
Five for Phase One and Chapter Six, for Phase Two).
4.8 Summary.
Phases One and Two of this project utilised a data triangulation approach involving
mixed methods, to examine factors that impact on the sustainability of EB pain
management practices in aged care. Phase One undertook an audit of a facility that
had previously implemented best practice, to determine what elements of best
practice were being sustained. Interviews of direct care staff followed the audit, to
provide further depth to understanding the individual and organisational factors,
impacting best practice sustainability.

Phase Two specifically examined how Certificate III Aged Care workers were
educated in pain identification, assessment and management and how this
knowledge translated to aged care workplaces. All quantitative data collected were
analysed using SPSS (version 24) and the qualitative data by thematic analysis.
Results from Phase One will be discussed in Chapter Five and those from Phase
Two in Chapter Six.

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 Chapter Five: Results – Phase One.
5.1 Introduction.
Phase One of this study was to undertake a chart audit examining the pain
management practices in an RCF that had previously implemented EB practice
guidelines. This chapter presents the results from Phase One of this study that was
conducted in two parts: chart and facility audits (part one); and staff interviews (part
two).

5.2 Results Phase One - Part One.

Chart audits were conducted for residents who had died between June 2009
(completion of the EBPRAC pain management project (Masso et al., 2011)) and
October 2012, using the Pain Practices Audit Tool (PPAT) (H. Holloway, 2012),
discussed in Chapter Four.

Charts were examined for the following documentation:

• Demographic information.
• Progress notes for documentation regarding identified pain, completion of
pain assessments, verbal reports or behaviours that might indicate the
presence of pain.
• Formal pain assessments: on admission, every 3 months (as per best
practice standards) and if a review was required because of medication
changes, hospitalisation or if pain was suspected (episodes of pain).
• Progress notes and care plans were examined for pain management plans,
as changes in management would require a pain assessment to determine
effectiveness of treatment changes.

The facility provided a list of the names of deceased residents and thirty-five (n=35)
were identified as meeting the inclusion criteria. Permission was given for the
researcher to access the facility archives. Resident charts were not located together
in one paper-based archive file, but were stored in separate clinical, financial, Aged
Care Funding Instrument (ACFI) data and medication/pharmacy archive files. Some
of the documentation was also archived electronically. Once all components of a
resident’s chart were identified and located, they were audited.

67
Six of the thirty-five charts were not able to be located in the archive room, had not
been removed by staff and there was no available record of their location. To audit
the remaining charts (n=29), paper based and electronic documents were read and
pain assessment forms and care plans were located. However, as the first two
paper-based charts were audited, it became evident that previous filing systems
were unstructured and there was no logical order to the filing. Auditing of these
paper-based files took between 2 and 4 hours to complete. Therefore, due to
researcher time constraints (8hrs/day for three days), only seventeen files (n=17)
were audited (59%). These charts were purposively selected from June 2009, 2010,
2011 and 2012. This selection provided charts for residents with various lengths of
stay (31-990 days) and allowed for the auditing of charts of residents who had died
more than 12 months after the completion of the EBPRAC pain management project.

In addition, the facility had in the 6–12 months preceding the audit, introduced
electronic documentation through iCARE and had begun transferring archived
documentation to electronic format. Therefore, some records were located in
archived files on the computer. As for the first two chart audits, the remaining charts
took between two–four hours to complete.

5.2.1 Facility audit.

The audit conducted at the facility level using the PPAT (H. Holloway, 2012),
identified the presence of a pain assessment and management policy and
procedure. The audit also identified the register of staff education and identified one
formal education session in the previous two years, in pain identification,
assessment and management.

The structure of the facility was also considered during the audit, particularly the
main areas related to resident care, as this was pertinent to latent organisational
context. The facility had three wings, with one a secure wing for people living with
dementia. The wings were situated around a central court yard. Residents had single
rooms with ensuites. Each wing had separate rooms with seating (similar to a lounge
room). Staff utility rooms, clinical supply, storage rooms and nurses’ stations were in
more central areas away from resident rooms but overlooked dining and larger
lounge room areas. Management offices were located at the front of the building.

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 5.2.2 Audit of resident files.
Demographic data.
Demographic data were collected from the resident files (n=17), for background
information about age, gender, number of days in the facility, comorbidities (including
persistent pain), dementia type and number of years with dementia.

Age, gender and length of stay.

Residents (n=17), were predominantly female-65% (n=11) and male-35% (n=6). The
average age of the residents was 86 (range 74-100) (Table 5.1). The average age of
females (n=11) was 88 and of males (n=6) was 83. The median length of stay was
between 1 and 3 years. Lengths of stay varied from 31 days to 13 years (Table 5.2).

Table 5.1 Age of residents in the facility.

Age range Gender

Frequency
(Years)
Male Female
70-75 2 1 1

76-80 3 3 0

81-85 2 0 2

86-90 5 0 5

91-95 3 1 2

96-100 2 1 1

Total numbers 17 Males-6 Females-11

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Table 5.2 Length of stay (weeks and years).

Length of stay No of residents Percent (%)

< 4 weeks 3 18 %

4- 26 weeks 0 0

26 – 52 weeks 0 0

1-<2 years 4 23%

2-<3 years 4 23%

3-<4 years 1 6%

4-<5 years 2 12%

5- <8 years 1 6%

8-<11 years 1 6%

11-<13 1 6%

TOTAL 17

Comorbidities.
The comorbidities were divided into disease systems to show the percentage of the
residents diagnosed with a disease in a specific body system (Table 5.3). Forty-
seven percent of the residents (n=8), were also identified as having mobility
problems and as being a falls risk.

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Table 5.3 Resident comorbidities.

Disease system Disease types % of residents

with disease
Neurological Dementia, Parkinson’s Disease, Epilepsy, Peripheral 100% (n=17)
Neuropathy, Transient ischaemic attack
Cardiovascular Ischaemia Heart Disease, Bypass Surgery, Angina, 88% (n=15)
Atrial Fibrillation, Congestive Cardiac Failure, Aortic
stenosis, Hyper/Hypotension, Hypercholesterol,
Varicose Veins, Pacemaker
Musculoskeletal Osteoarthritis, Osteoporosis, Fractures, Rotator Cuff 88% (n=15)
Injury, Lower Back Pain, falls, Impaired Mobility,
Lower limb weakness, Joint Replacement, lumbar
spondylosis
Psychological Depression, intellectual disability, 41% (n=7)
Paranoia/Delusions, Psychoses, Mood Affective
Disorder, Schizoaffective Disorder
Genitourinary Recurrent Urinary Tract Infections, Renal Failure, 35% (n=6)
Penectomy, Incontinence, Transurethral
Prostatectomy, Hysterectomy, Prolapsed Uterus
Endocrine Hyper/Hypothyroidism, Type II Diabetes 35% (n=6)

Gastrointestinal Peptic Ulcer Disease, Bowel cancer, Gastro- 23.5% (n=4)

oesophageal motility disorder, Gallstones
Respiratory Asthma, Chronic Obstructive Pulmonary Disease 23.5% (n=4)

Optical Poor Vision, Blindness 12% (n=2)

Auditory Hearing Loss 12% (n=2)

Immunological Gammopathy, Monoclonal antibody gammopathy 12% (n=2)

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All the residents had dementia and more than three other comorbidities from this list,
with the most common being cardiovascular and musculoskeletal disease. All of the
residents had a medical history that should have alerted a clinician to the possibility
of the presence of pain.

If the type of dementia was identified, this was noted in the audit and can be seen in
Table 5.4. It is noted that 53% of the individuals included in this audit had a
diagnosis of dementia where the dementia type was not specified.

Table 5.4 Dementia types.

Type of dementia Percentage of residents

Probable Alzheimer’s Disease 23.5% (n=4)

Vascular 6% (n=1)

Fronto-temporal 6% (n=1)

Lewy-Body 6% (n=1)

Mixed (Vascular/Probable 12% (n=2)

Alzheimer’s)

Not specified 53% (n=8)

Persistent pain and expression of pain.

Information was collected on whether a diagnosis of persistent pain had been
present prior to admission (Table 5.5). As these residents had a diagnosis of
moderate to severe dementia, resulting in decreased verbal reporting of pain, pain
was more likely identified by changes observed in behaviours. Progress notes and
care plans were reviewed to determine if there was documentation of the type of
pain behaviour displayed i.e., general or specific behaviours. General behaviours
included facial expression, vocalisation, body language changes and behavioural
changes. Five residents had documentation in their care plan or in progress notes,
indicating that pain was expressed with general pain behaviours as described above.

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Only one resident had a specific behaviour identified, which was described as a
vocalisation, repeatedly calling out, “Mummy”.

Table 5.5 History of persistent pain and known pain behaviours.

Questions Yes No Comment

Is there a history of 70.5% (n=12) 29.5% (n=5) Of the five individuals not
persistent pain? identified as having persistent
pain, Medical history should
have alerted staff to the
potential for pain.
Has the cause 100 % (n=12) For the 12 with a history of
been identified? persistent pain
Were behavioural 35% (n=6) 65% (n= 11) For the six residents identified
symptoms as having documented pain
documented that behaviours, these included
may indicate the general and specific pain
presence of pain? behaviours.

The remaining data from the chart audits were collated and flow charts were
developed to show the results. The figures were divided into routine admission pain
assessments (Figure 5.1), routine regular assessments (Figure 5.2) and episodes of
pain (Figure 5.3).

5.2.3 Assessment on admission.

The facility policy and procedure stated that ‘the resident should have a pain
screening form completed within 24 hours of admission, to determine if the residents
have pain, is on analgesia, or is exhibiting behaviours that indicate the presence of
pain. If cognitively impaired use cognitively impaired form in addition to the screening
form ‘(Care Manual Procedure No. 11.1). There were no screening forms located in
any of the resident files. The facility procedure then stated, that ‘if this (screening
form), indicates the presence of pain then a three-day pain assessment should be
commenced’ (Care Manual Procedure No. 11.1, p.1). As no screening forms were
completed, no pain assessments were conducted in the initial 7 days of a resident’s
admission to the facility. However, in seventy percent (70%) of the files examined,

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the resident had a pain assessment conducted 10 to 30 days after admission to the
facility.

Figure 5.1 shows the results of the PPAT audit (Appendix 3), examining pain
assessment on admission to the facility (within 10–30 days). Seventeen resident files
(n=17) were audited. Fifty-nine percent of these residents (n=10), had a pain
assessment completed within 30 days of admission. Of these, one resident (n=1)
was admitted prior to the 2008 period before best practice principles were
implemented. The remainder were admitted after January 2008. Examination of the
assessment tools completed (n=10), showed that the tool was completed correctly
90% of the time (n=9) that is, all sections were completed. Pain assessments should
be completed at rest and on movement and this needs to be noted on the
assessment tool (Goucke et al., 2005). Documentation on the assessment tool,
showed that only 20% (n=2) were conducted at rest and 10% (n=1) were completed
on movement. Thirty percent of the residents (n=3) who had a pain assessment
completed on admission, required follow up by the General Practitioner (GP) and a
review of their current pain management care plan. There was no follow-up
assessment (n=0) conducted to evaluate the effectiveness of any new strategies
implemented.

Of the seventeen resident files that were audited, 41% (n=7) of these residents had a
known diagnosis of persistent pain on admission. However, only five of this group
(n=5), received a formal pain assessment. Of the pain assessments conducted for
this group, only two (n=2) individuals verbalised the presence of pain or
demonstrated behaviours of pain on assessment and were part of the group of three
(noted above), that required follow up by the GP. No follow-up assessments were
conducted to evaluate the effectiveness of any new strategies implemented for this
group.

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Figure 5.1 Admission assessments.

75
Figure 5.2 Regular pain assessments.

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5.2.4 Regular pain assessment.
Regular pain assessments were conducted every 6 months in this facility, in line with the
facility policy (Care Manual Procedure 11.1) and care plan review. Figure 5.2 shows the
results of the audit performed on resident charts, examining the completion of regular pain
assessments. The audit was conducted according to the PPAT, which specified that a
regular assessment should be conducted every three months in line with the first edition of
the PRACMS guidelines (Goucke et al., 2005).

Only 14 of the 17 resident files were audited, as three residents had lived in the facility for
less than 31 days. To locate the documentation related to the completion of the regular
assessment tools, the audit was conducted by going back through resident files from the
date of death, until 6 months prior. If a regular assessment tool was found, this was then
audited for how it was completed (i.e. correctly filled out, at rest or on movement). The
audit showed that only 10 residents (71%) received one regular assessment during that 6-
month period. Six of those residents (60%) had a formal assessment tool completed which
could be identified and located in the file and was completed correctly. For the remaining
40%, it was documented in the progress notes that a pain assessment had been
conducted (for example Abbey assessment tool completed score of 2), but no formal pain
assessment tool was able to be located. Out of the six formal assessment tools completed,
it had been noted that three (50%), had been conducted at rest and only one (16%) on
movement (based on documentation on the tool). For the remaining two (34%), there was
no documentation about what position or activity the resident was in when the pain
assessments were conducted.

Four (40%) of the ten residents who had a regular pain assessment completed required
review by an RN. Of these four, the RN requested that three be reviewed by the GP
(75%). Follow up by the GP resulted in the pain management care plan being revised for
all three residents. However, reassessment of the resident’s pain to determine the
effectiveness of the new strategies implemented, did not occur.

It is noted that only three of the seven (43%) residents who had previously been identified
as having persistent pain, received a regular assessment in the six months prior to their
death. Only one of these three residents (33%) was identified as having pain during the
assessment and was part of the group that required follow up by the GP to receive
changes to their care plan.

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Figure 5.3 Episodes of pain.

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5.2.5 Episodes of Pain.
Figure 5.3 presents the results of the data collected from the chart audit examining
the information that indicates an episode of pain. Resident charts were examined for
the presence of formal pain assessment tools, that were used during any episode of
pain in the six months preceding death. An episode of pain was identified when: the
resident demonstrated changes in behaviour through either known pain behaviours
or agitation, aggression, screaming, change in respiration, sleep disturbances or
wandering; when there was documentation of a verbal complaint of pain (in residents
who could still verbalise); residents had returned from hospital, had a change in
medication, or a fall. All seventeen resident files were audited.

There were 30 episodes identified where a formal pain assessment should have
been conducted because of the reasons stated above. The facility policy stated that
‘a pain assessment should be conducted if there is a change in medication, there is
an indication of increased pain, change in condition or a change in behaviours’ (Care
Manual Policy No. 11, p.1).

Seven (23%) episodes of pain where a formal pain assessment tool was used were
identified. One resident received two assessments in that time for identified episodes
of pain and one resident had three assessments (accounting for five of the total
seven). Five of the seven of those tools were completed correctly (71%). Four of
those tools (57%), were completed at rest and two tools (29%) were completed on
movement (this was based on documentation on the tool as to activity at the time of
the assessment). Six (86%) of this group (who had a formal pain assessment
conducted), required review by an RN. After review by the RN, five (83%) of the six
were then referred on for further review by the GP and changes to their pain
management plan were made. All treatments initiated were evaluated for their
effectiveness through the use of either a formal pain assessment tool (n=3), or
documentation in the progress notes (n=3).

Of the 23 episodes that did not receive a formal assessment, fifteen (n=15) were
reviewed by an RN. After review by the RN, thirteen of these episodes of identified
pain were referred on for further review by the GP. Of the residents reviewed by the
RN and/or the GP, fourteen (93%) had a change made to their pain management
plan. Nine of the treatments were evaluated for their effectiveness and two of these

79
individuals received a formal pain assessment following the changes to the
resident’s pain management plan.

5.2.6 Pain management strategies.

Of the 17 resident charts audited, five residents did not have a pain management
care plan. Of the 12 charts that did include a care plan, both pharmacological and
non-pharmacological strategies were used within the facility. Pharmacological
strategies included non-opioids and opioid analgesia, and adjuvants such as
antidepressants, anti-epileptics and muscle relaxants. All residents were on regular
analgesia and had as required (PRN) analgesia available. Nine of the residents were
also receiving an antipsychotic, either Zyprexa, Seroquel or risperidone. A list of the
pharmacological and non-pharmacological strategies utilised in the facility are in
Table 5.6.

Table 5.6 Pharmacological and non-pharmacological strategies used in the

facility.

Pharmacological Non-pharmacological
Analgesia Adjuvants Reassurance
paracetamol (regular diazepam
Socialisation + cup of tea
and slow release)
oxazepam
Physiotherapy – mobilisation, exercises
Panadeine Forte
Lyrica
Diversional Therapy
Voltaren Gel
Sertraline
Occupational Therapy
meloxicam
Mirtazapine
Massage
Norspan
Duloxetine
Aromatherapy
Durogesic
Heat packs
Endone
Transcutaneous Electrical Nerve
Oxycodone
Stimulation
Kapanol
Repositioning
morphine
Warm Shower

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Facility policy.
The PPAT (Appendix 3) provided the means to evaluate the facility pain
management policy and procedure (Care Manual Policy No 11, p.1 and Care Manual
Procedure 11.1, p.1). The Pain Management Policy (Care Manual Policy 11), defined
pain and referred to the Aged Care Act 1997 and Aged Care Principles 1999. It
identified the beliefs of the organisation to be that ‘all care recipients will receive
appropriate pain management and will be as free as possible from pain’ (Care
Manual Policy No 11, p.1). This was the limit of the policy content.

The pain management procedure added to this policy by nominating when pain
assessments should be conducted-namely that, within 24 hours of admission, a Pain
Screening Form should be completed. If this identified the presence of pain, then a

three-day pain assessment should be undertaken and completed. If pain is

likely and no current management plan is in place, then a GP is to be notified
immediately and asked for a review, then continue with a further three-day
assessment. A three-day pain assessment should also be completed if a
potential for pain is identified, if medications are altered or ceased, an
increase in pain is noted, or a decline in condition or increase in challenging
behaviours. A two-day pain assessment is to be completed on a resident’s
return from hospital (Care Manual Procedure 11.1, p.1).

The care manual did not state, that a pain assessment should be regularly
conducted, but that the pain management ‘care plan should be evaluated 6 monthly
or more often if required’ (Care Manual Procedure 11.1, p.1). The CN informed the
researcher that care plan evaluation involved conducting a three-day pain
assessment, prior to updating the care plan.

The procedure (Care Manual Procedure 11.1), further stipulated who can complete
the pain assessment charts i.e. RNs, ENs or AINs (known as multiskilled care
workers in this facility). The document did state that RNs/ENs must evaluate all
assessments including the pain-monitoring sheets.

Neither the policy (Care Manual Policy 11) nor procedure (Care Manual Procedure
11.1) outlined what pain management strategies were available within the facility,
except for making a reference to alternative therapies and a referral to physiotherapy

81
or occupational therapy. The procedure (Care Manual Procedure 11.1, p.2), did not
specify what the role of these allied health services were. Neither did the
policy/procedure specify which RCF staff were responsible for administering
medication. In this facility, it was the AINs.

Education.
The PPAT tool was also used to evaluate the education matrix provided by the
facility and this will be discussed in the next section under staff education.

5.3 Results Phase One - Part 2.

5.3.1 Staff interviews.
Staff interviews (n=13), were conducted with a range of staff, five months after the
chart audits were completed. This timeframe allowed for analysis of resident chart
audit data, facility policy and of the staff education database. The audit data showed
that best practice principles in pain identification and assessment were only partly
sustained and the primary management strategies utilised were passive strategies
such as TENs and heat packs, as supported by the ACFI. Questions in the interview
were therefore designed in a semi-structured format, to allow for a deeper
exploration of the factors impacting the sustainability of the best practice principles,
previously implemented. Staff who participated included a Care Manager (CM),
Clinical Nurse (CN), allied health staff member (Physiotherapist (PT), Physiotherapy
Aide/Diversional Therapist (DT) and AINs (known in this facility as multi-skilled care
workers). A total of thirteen staff were interviewed (see demographic questionnaires
and interview questions in Appendix 4). The interviews were analysed using thematic
analysis (Bradley et al., 2007) and hand coding and the outcomes are presented in
Section 5.3.2.

Demographic data of interviewees.

All staff interviewed were female and their nationalities were Australian (n=8),
Chinese (n=1), Ghanaian (n=1), New Zealand (n=1), Vietnamese (n=1) and Zambian
(n=1). Staff were asked to nominate their age group from age ranges such as 16-20,
21–30 etc. The results are presented in Table 5.7 below. The largest groups
represented were the 21-30-year olds and the 51-60-year olds.

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Table 5.7 Age range of direct care staff.

Age group range Frequency

16-20 1
21-30 5
31- 40 1
41- 50 0
51-60 4
61-70 2

Staff classification and qualifications.

All of the AINs held at least a Certificate III in Aged Care, two of this group also
holding a Certificate IV. Fifty percent of the AIN group were undertaking further
training, either by completing an EN program or by being enrolled in an
undergraduate nursing degree. Of the Allied Health team, the PT held a Bachelor’s
Degree and a Masters in Sports Physiotherapy and had undertaken some formal
study in gerontology. The DT had previously worked as an AIN and had completed
Certificates III and IV in Aged Care, a Cert IV in Allied Health and was enrolled in an
undergraduate Bachelor of Nursing degree. Of the registered nursing staff, the CN
was a hospital trained RN who held no other postgraduate qualifications. Of the two
ENs, one held a medication endorsement, the other worked in management as the
CM and held a Frontline Management Diploma.

Formal training.
Only one staff member (the CM), had attended formal training in pain identification,
assessment and management. This was provided in a hospital by an external
Recognised Training Organisation (RTO), whilst the staff member was employed by
another provider.

Staff experience.
To gain an understanding of the experience level of the staff caring for the residents
with dementia in the facility, the staff were asked how long that they had been caring
for a person with dementia, not only at this facility, but also in their whole working
life. All staff had over 12 months experience in this area of specialised care. The
average length of time was 8 years 4 months. Their individual experiences ranged
from 1 year 2 months to 10 years.

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Staff education.
Staff were asked how frequently in the last two years they had attended an
education session about the identification, assessment and/or management of pain,
in the person with dementia. Education sessions in this facility were known as
“Toolbox training”. They were short 10 min education sessions, provided at the
commencement of a shift, to inform AINs of new procedures, update skills or revisit
procedures. No records were kept of the staff attending these sessions, or the
content. More than 53% of the staff stated that they had been to one or two toolbox-
training sessions on pain, 31% had not been to any education in the last two years,
8% had been three to five times and 8% more than six times. The individual that
responded with the highest number of attendances at sessions, was the CN who
provided education to the AIN and RN/EN nursing staff.

Access was granted to the facility-training database in the period from June 2009–
October 2012. Evaluation of this database was undertaken utilising the PPAT audit
tool (Appendix 3). Based on the tool’s criteria, not all of the staff had received pain
management education, neither had all staff attended an annual pain
assessment/management update. There had been no education/training provided
regarding assessment tools (particularly relevant since the facility had recently
commenced using electronic documentation, and the pain assessment tools
provided through iCARE, were different from the previously used paper-based tools).
No competency assessments related to pain management practices had been
conducted.

Of the staff interviewed, only one, the CN, had attended a formal training session on
pain assessment and management at the facility during this time. Examination of the
training matrix showed, that only one formal training session on pain management
was held, in March 2010, and four AINs attended. In May 2011, three AINs attended
a session regarding pain management and the use of medication, given to the
registered nursing staff. During the same time, there were no formal sessions held
on pain assessment.

The final question on the demographic questionnaire, asked staff if they knew that
the facility had a pain management policy/procedure. The responses indicated that
77% (n=10) of staff interviewed knew that there was a pain management

84
policy/procedure and what the documents set out for the facility. The remaining staff
did not know of the presence of the policy or procedure.

5.3.2 Themes and subthemes from interviews.

Information collected from the staff interviews were transcribed in full and analysed
using thematic analysis and manual coding (Bradley et al., 2007). The organisational
theoretical framework was used as a reference for analysis. In particular, the internal
and external organisational contextual factors were used as a guide. As the purpose
of staff interviews was to identify individual and organisational barriers and
facilitators to sustaining EB pain management practices, interview data was initially
coded, with this purpose in mind. Second analysis determined themes and
subthemes identified by the frequency of word occurrence within the text. For
example, with regard to barriers related to the resident, terms used by the staff such
as, ‘language is an issue at this centre’; ’If there is a staff member who does not
speak the patient’s language, then we get a relative to come in and translate for
us…it is a long process that can take a hour, hour and a half to do an assessment’
(AIN 227895 p.1: 16), were identified under the theme ‘resident barrier’ and then
subtheme, ’language’.

Barriers.
Four barriers were identified: resident, staff, facility and systems. Each of the themes
identified as barriers had two to four subthemes, seen in Table 5.8.

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Table 5.8 Themes and subthemes of barriers to pain assessment.

Context Barrier Theme Subtheme

Internal 1. Resident Dementia

Organisational
Language/English comprehension
Context
2. Staff Knowledge
Competing priorities
Inaction–RNs/GPs
Language/English comprehension

3. Facility Staffing
Communication
Continuity of care
Environmental 4. Systems Aged Care Funding Instrument (ACFI)
Context Lack of resources

Internal organisational contextual factors.

Theme one - Resident.
Resident related barriers were identified by the staff. Within this category, two
subthemes were recognised: the implications of dementia, language and the
resident’s English comprehension.

Subtheme – Dementia.
In relation to dementia, staff comments were specifically made about the resident
and how their dementia impacted the staff, being able to identify pain and conduct a
pain assessment. For example, ‘with dementia it’s harder than with other residents.
We assess according to the pain score and might be some who are scared of saying
they have pain’ (AIN 648936, p.1:11) or ‘A lot of the residents, some of them can tell
you. In people with dementia I think it is harder’ (AIN 228753, p.1:13) or ‘sometimes
it is hard to tell whether they are happy or in pain’ (AIN, 287669, p.1:10).

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Subtheme - Language/English comprehension resident.
The language/English comprehension barrier, compounded the communication
problem particularly for the person with dementia. Staff comments identified the
difficulty in identifying and assessing pain in the person who spoke English as a
second language, who then also had dementia. This was evident by a statement
from the staff ‘Sometimes we get people in, there is not a staff member who can
speak their language and we will rely on relatives’ (AIN 227895, p.1:16).

Theme two – Staff.

Staff barriers were identified and within this theme, there were four subthemes
identified: knowledge, time, inaction by RNs and GP and language/English
comprehension.

Subtheme - Knowledge – Lack of knowledge/ application of knowledge.

This subtheme identified, that staff did not always have the knowledge, or apply the
knowledge they had obtained about pain identification, assessment or management.
Statements were made by care staff such as ‘As carers we are not educated much
for pain assessment’ (AIN 965252, p.2:13) or ‘It is that level from 1–5, seeing they
are not a 2 but are they a three or a four, as far as the level of pain’ (AIN 672688,
p.1:19). Comments were also made about AINs having the knowledge, but not
applying what they have learnt, as is evidenced by the following comment made by a
more senior AIN, who was also a facility pain champion: ‘People have education but
sometimes they don’t apply it’ (AIN 749566, p.1:11).

A comment by both AINs and an AH staff member, identified that those they report to
and rely on for action (namely the RNs/ENs), do not always have the knowledge
required. Statements such as ‘you assume the RN has a certain amount of
knowledge’ (PT 227869, p.2:16) supported this, as did comments by the care staff
stating that they often reported pain that they had identified whilst attending to the
resident, however, they did not see follow up or a management plan implemented.

Subtheme – Competing priorities.

This subtheme identified by the staff, primarily related to competing priorities. This
actually impacted at all levels of the pain identification and assessment process and
across all staff levels. AINs commented that there are so many things that compete

87
for their attention in the daily routine of care, that pain identification and evaluation of
treatments is often given a low priority. This is evident by statements such as, “We
don’t have time at all”. Sometimes the residents say “Oh I’m in pain” we give them a
PRN, but they are coming (back) to us, but we are busy with other tasks (ÁIN
465346, p.1:13) or ‘If you get busy and distracted and have other things to do which
happens quite a lot’ (AIN 465346, p.2:9). The PT also found time a barrier “I am
required to do all the TENs machines and all the heat packs”, ‘I don’t have time to do
them all’ (referring to assessing and treating residents with complex health related
care for pain management [ACFI]) (PT 227869, p.1:10).

The CN/RN also discussed the problem with competing priorities,

The care staff come to you and report to you that this person has got pain
and you go, yep ok I will deal with that. And then you sort of go off and do ten
other things, and you haven’t done anything by the end of the day. You come
back two days later and you think, I haven’t seen John about his pain (CN
49637, p.2:11).

Subtheme- inaction by RN/GP.

This subtheme of inaction was identified by AINs, the CM and the CN.

AINs reported, that ‘When we report something, they don’t really act on it quickly’
(AIN 965252, p.2:16). The CM and the CN commented that there is a big problem
with RNs being accountable and taking ownership of their actions. The CM felt that
this was related to the facility workforce being largely part-time or casual. ‘We have a
lot of part time RNs. People tend not to take ownership if they are only going to be
here for one or two days’ (CN 549637, p.4:24) or ‘RN’s lack accountability and not
following through the processes etc.’ (CM 874859, p.2:9).

The PT reported, that for a resident that she was caring for with chronic pain, ‘the GP
will not refer her to a chronic pain management clinic’ (PT 227869, p.4:18), despite a
request from the PT to the GP.

Subtheme - Language/English comprehension.

This subtheme centred on barriers surrounding English language skills and English
comprehension of staff. This included understanding both spoken and written

88
language. Statements supporting this theme came from both CM and the CN, ‘As we
have a lot of people with English as their second language, understanding the
information on the assessments…it’s clear that they don’t understand. It’s language
and comprehension’ (CM 874859, p.3:15) and ‘We have a number of cultural groups
and the problem for them is language skills’ (CN 549637, p.6:30).

Theme Three – Facility.

Facility level barriers included staffing, communication and continuity of care. These
factors form part of the latent and active organisational context (Argote, 2013).

Subtheme – Staffing.
There were a number of issues surrounding staffing, that were identified by all levels
of staff interviewed. AINs commented that they often worked short staffed, or they
were often orientating new staff, which took time away from other activities. ‘We are
short staffed and you kind of just rush…so short of staff, running late, running behind
or you are working with new staff and they are kind of slow and you are panicking
you just want to rush on’ (AIN 965252, p.2:14).

Subtheme – Communication.
Communication, both verbal and written, amongst all levels of staff, was identified as
a barrier. However, it was also identified as a facilitator. It was identified that there is
poor communication between the AINs and the RNs. ‘Better communication between
the RNs and the AINs. Everyone is so busy entering data into ACFI and so busy with
other things, that a lot of things get lost along the way’ (PT 227869, p.2:15). Some
staff reported that they were not provided with a verbal handover, even though they
were involved in direct care activities. ‘We don’t get to listen to handover’ (DT
789273, p.2:14) and they had to source the information that they required from the
staff on a resident-by-resident basis, which meant spending time finding direct care
staff.

There were also reports that care staff may verbally hand over an episode of pain
identification to an RN, but then fail to document it, either on a pain assessment
chart or on the electronic notes, which meant that the verbal report was not followed
up. This was identified by the CM. ‘An AIN will verbally report it (to an RN), but don’t

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actually do it in the written format. We are trying to explain that the verbal can fall
down’ (CM 8748859, p.2:11).

Recently the facility had also transferred their previous paper documentation to
electronic documentation. This meant that staff were not able to locate some written
documents, or that different documents were being used for pain assessments, for
example the Abbey Pain Scale (Abbey et al., 2004) and a PAINAD (Warden, Hurley,
& Volicer, 2003) tool.’ Sometimes the pain chart is not in iCare’ (AIN 648936, p.2:13)
or ‘Sometimes the pain chart is different…like we are trained in 1–10 but this one is
1–20’ (AIN 648936, p.1:17). There were also gaps noted in the new electronic
documentation, as evidenced by the statement from the CM, ‘It’s one of the
frustrations of the new system. There are many gaps, a lot of holes’ (CM 874859,
p.3:12).

Subtheme - Continuity of care.

The final subtheme identified under staff barriers, was continuity of care. Some staff
reported they spent a length of time in an area (weeks or months) and others
reported that they were rotated around on a daily basis, in areas designated as the
high and low dementia units. One AIN commented that, ‘Every day we work with
different people. It is hard to get to know them and understand what is required of
our co-workers because of this. There is no consistency in working in areas, we are
always being moved around’ (AIN 228753, p.1:16).

Theme Four – Systems.

The fourth theme identified was system barriers. Subthemes identified here included
the current ACFI and the lack of human resources. However, the ACFI was also
identified as a facilitator (Table 5.9).

Subtheme- Aged Care Funding Instrument (ACFI).

For one member of the Allied Health team, the ACFI was seen as a barrier to the
performance of their job and the provision of EB care to the residents. The PT felt
very strongly about this and stated that, ‘My role is really made limited or difficult, by
the way ACFI treat it (pain) and because of iCare. ACFI does not allow you to do
good pain management. ACFI encourages our residents to be dependent…they (the
facility) get more money if they get D’s for mobility’ (PT 227869, p.1:8).

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Subtheme - Lack of resources.
This subtheme, related to access to Medical Practitioners, Specialist Services,
Registered and Clinical Nurses. As the CN stated, ‘Lack of resources is still our
biggest problem. Lack of human resources… in terms of medical support and clinical
support as well’ (CN 549637, p.11:11). The staff felt isolated and frustrated because
of the lack of support from GP services and specialised medical services, particularly
when dealing with residents with chronic, difficult to manage pain or requiring
palliative care.

Facilitators.
Four themes were identified during staff interviews as facilitators of pain
identification, assessment and management practices and are listed in Table 5.9.

Table 5.9 Themes for facilitators of pain assessment.

Contextual Facilitator Theme
factors

Internal 1. Education
Organisational
2. Communication
Context

3. Knowledge and
experience of carers
Environmental 4. Funding
Context

Theme One – Education.

Education was identified by all levels of staff interviewed, as an important tool for
improving knowledge and therefore facilitating pain identification, assessment and
management. Training identified by all staff as being beneficial, included not only
seminars, but also the short training sessions such as the 10-minute sessions at
handover (toolbox training), and one-on-one training. However, more education was
requested by the AINs. ‘More education for the workers…we need more training’
(AIN 228753, p.3:25 & 29), (More education)…’especially with dementia’ (DT

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789273, p.3:27), more ‘one–on–one training and talking to them about different
manifestations of pain’ (CN 549637 p.3:17).

Theme Two – Communication.

Some forms of communication used in the facility, were identified by the staff as
being beneficial in helping them identify who required more frequent observation,
because they were on a pain assessment chart. Discussion of residents at handover,
and the use of a white board to document who was currently on a pain assessment,
was seen as beneficial. Staff stated that ‘We do a handover; this resident is on a
pain assessment’ or ‘we have a white board…on it is written who has a pain
assessment’. Whilst some staff found previously that there were gaps in the iCare
system, some AINs reported they were able to locate information and documents like
pain assessment tools better. The CM stated that ‘iCare means we can actually
locate information… people cannot lose or misplace them (documents)’ (CM 874859,
p.3:14). Some of the AINs also reported that the Message of the Day on iCare,
helped them to identify who was on a pain assessment.

Theme Three – Knowledge and experience of carers.

The AINs verbalised the general behaviours to look for when trying to identify pain in
the person with dementia: ‘Maybe like facial expressions when you’re bathing them
or changing their clothes, they squeak’ (AIN 965252, p.2:12). Or ‘You’re observing. If
you are a good carer, then you are observing the resident all day’ (AIN 749566,
p.1:10). They were then also able to state the steps to follow, to report the observed
behaviours to the CN, RN or EN.

AINs reported that they learnt most of their skills whilst actually on the job and
working with the residents: ‘I have learnt it from the residents’ (AIN 228753, p.1:16)
or ‘You pick up different things as you go’ (AIN 465346, p.1:13). None of the AINs,
actually reported remembering any content about pain in their Certificate course
(even those who had recently completed the Certificate [within 12 months]).

Theme Four – ACFI.

The CM stated that she found the ACFI beneficial for pain identification, assessment
and management. She stated that ‘because I am looking at the funding, I am looking
for optimising the funding…I am looking at the complex health domain for example,

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pain and what you do for people with chronic pain is one of the components of that’
(874859, p.1:19). This meant that when a resident was admitted to the facility that
the CM ensured that a pain assessment was completed. This was particularly the
case if the resident had a pre-existing condition, such as persistent pain or
osteoarthritis, which meant that pain, was likely. Therefore, the CM would encourage
the RNs to undertake a pain assessment and develop a pain management plan.

5.4 Summary.
The results presented in this chapter, are for Phase One (Part One and Two) of this
research project.

Phase One examined the pain practices of an RCF, that had participated in EBPRAC
project, where PRACMS best practice guidelines (Goucke et al., 2005), were
implemented, two years prior to this research. An audit was conducted to examine the
facility processes and procedures around pain identification, assessment and
management, to determine if EB practices had been sustained. Residents included in
this audit, had a complex health profile, having multiple comorbidities, geriatric
syndrome, dementia and living in the last weeks or months of their life. The audit
determined, that there was inadequate maintenance of EB pain management
practices, with poor assessment on admission, regular assessments which did not
follow best practice guidelines and poor identification and assessment of episodes of
pain. Where new management strategies were implemented, there was poor
evaluation of the outcomes of the new strategy (whether it was
successful/unsuccessful), in managing the resident’s pain. Pain management
strategies utilised, were primarily based on medication and passive strategies such as
TENs, heat packs or repositioning, strategies which are supported by the ACFI.
Policies and procedures provided by the organisation, were poorly followed by staff
and did not meet the suggested requirements for the delivery of EB care, made in the
PRACMS guidelines.

Part Two of Phase One, conducted five months after the chart audit, interviewed
direct care staff. The direct care staff identified a number of barriers, associated with
the resident (dementia and/or language related issues), staff (language, knowledge,
competing priorities, inaction by clinicians), the facility (communication strategies,
staffing levels, skill mix, continuity of care), and system related barriers (ACFI and

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access to resources). Facilitators identified by the staff included, the ACFI,
communication strategies, knowledge and experience of carers, and education
provision, through tool box training. There was a lack of formal regular education
about pain management practices, provided for all direct care staff in the facility, with
only one session in the preceding two years since the EBPRAC project was
completed.

In the following chapter (Chapter six), the results of Phase Two of this research will
be presented. Phase two examined the training provided by two Registered Training
Organisations (RTOs), in the Certificate III/IV for aged care workers (AINs) and their
translating of that knowledge into the aged care workplace.

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 Chapter Six: Results – Phase Two.
6.1 Introduction.
Phase Two of this research was conducted in two Registered Training Organisations
(RTOs) in South East Queensland (SE Qld). The aim of Phase Two, was to identify
how current education and training practices, influence the new aged care workers’
ability to conduct evidence-based pain identification, assessment and management.

6. 2 Student/new care worker.

6.2.1 Recruitment.
Full and part time students from two RTOs - RTO A & RTO B, located in SE Qld,
were recruited during the first week of their Aged care Certificate III course in
February, May, June and July 2015, and February and July 2016. Students were
provided with a copy of the consent and information sheet, which described the aim
of the project, the requirements of participating and risks. Students who agreed to
participate, were consented and provided their contact details to the researcher, to
allow for further communication. The primary method of communication used was
text message, with a follow up email. Students who agreed to participate and were
consented, were contacted within 24 hours, provided with the researcher’s contact
details and the questionnaires for Time Point One (TP1). These were the
demographic questionnaire, the ‘Knowledge and Beliefs about Pain in the Elderly’
questionnaire (Zwakhalen et al., 2007), the Modified Pain Management Student
Survey (Savvas et al., 2014b) and the ‘Knowledge and Attitudes Survey Regarding
Pain’ (Ferrell & McCaffery, 2012) (Appendix 7). They were also provided with a copy
of their signed consent forms within a week. Figure 6.1 shows the recruitment and
retention data from the student/new care worker participants.

Sixty-seven (n=67) students agreed to participate and were consented at Time Point
One (TP1) and at Time Point Three (TP3), nine (n=9) new care workers remained
and participated in the final step. Thirty-five students in total, failed to respond
between the consent and the three time points, despite multiple text messages and
emails being sent (see no further contact boxes, Figure 6.1). Fifteen students in total,
withdrew between consent time and each of the three time points. Reasons for
withdrawal from the project included: unspecified personal reasons, family illness,
study load, moving overseas, moving house, a new baby and work pressures. Eight

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graduated students (care-workers) (n=8), did not take part in TP3. Five (n=5) were
unable to obtain a job in aged care, two (n=2) chose not to seek a job in aged care
but work in another part of the health industry, and one (n=1) chose to do further
study.

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 Withdrew Withdrew Withdrew

11 2 2

Completed Completed Completed

Recruited TP1 TP3
TP2
67 32 9
23

No further No further No further No job in

contact contact contact aged care

24 7 4 8

Figure 6.1 Recruitment and retention of student/new care worker participants in Phase Two.

97
6.2.2 Demographic information.
Demographic information was collected from the students at TP1, on
commencement of their course. Demographic questions included gender, age range,
nationality, indigenous status, role prior to enrolling in the certificate III course, work
status and position in aged care. Additional education/training in pain management
and knowledge of facility pain management policy, were also included. Table 6.1
contains the demographic information for those individuals who completed each time
point.

Table 6.1 Student demographic information–gender and age.

TP1 TP2 TP3

Gender

Male 5 3 1

Female 27 20 8

Age Group

16-20 5 1 0

21-30 5 4 0

31- 40 8 6 3

41- 50 9 8 5

51-60 4 3 1

61-70 0 0 0

Missing 1 1 0

TOTAL 32 23 9

Females were the highest number of participants. The largest age groups
represented were the 41-50-year-old across the three time points (n= 9, n= 8 and n=
5 respectively), followed by the 31-40 age group (n= 8, n= 6, n= 3).

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Students were asked to provide their nationality at TP1. One student declined to
specify their nationality but was of African descent. Australians were the largest
group represented (n=12). Two students held dual Australian citizenship, with
Finland and the United States, respectively. Twenty-three percent (23%) of the
students in the project group, were from a non-English speaking background. The
nationalities of the students at TP1 are presented in Table 6.2. No participants
identified themselves as Aboriginal or Torres Strait Islander.

Table 6.2 Student nationality at Time Point 1.

Nationality Frequency

Australian 12

Australian/Finnish 1

Australian/American 1

British 6

Filipino 2

Indian 2

Kenyan/Irish 1

Maltese 1

Nepalese 1

New Zealand 1

Russian 1

Scottish 1

Thai 1

Not stated (African) 1

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Previous occupation.
Information regarding previous occupation was obtained. There was only one
student currently working within aged care, as an aged care/disability support worker
in the community. The remainder had various jobs in different industries. One
student had previously been an EN but had not practised for more than 10 years.
One student was an internationally trained pharmacist, whose qualifications were not
recognised in Australia. Three individuals were working in aged care as
environmental services staff.

Current position, education and knowledge of pain management.

At the time of undertaking their Certificate, none of the students were currently
working as an AIN in an RCF or community care position. Four of the students did
hold other positions or qualifications. Two students were concurrently enrolled in
undergraduate degrees–one nursing, the other social work. One provided home
support to a client and as has been previously noted, one was an overseas trained
pharmacist, whose qualifications were not recognised in Australia.

Three students acknowledged that they were learning about pain assessment and/or
management during their Certificate course. As none of the students was working in
an aged care facility, the question regarding knowledge of facility pain management
policy, was not relevant at this time point (TP1). The one individual who was working
as a disability support worker, did not have knowledge of the organisational pain
management policy.

6.2.3 Student/New Care Worker - Questionnaire responses.

As no research had previously been conducted examining changes in confidence,
knowledge and attitudes of Certificate III aged care students and early career aged
care workers, in EB pain management practices, three questionnaires were used to
test student/new care worker (and CF), knowledge, beliefs and attitudes, during this
research project. The questionnaire about ‘Knowledge and Beliefs about Pain in the
Elderly’ (Zwakhalen et al., 2007), the Modified Pain Management Student Survey
(Savvas et al., 2014b) and the ‘Knowledge and Attitudes Survey Regarding Pain’
(Ferrell & McCaffery, 2012) were distributed at TP1, TP2 and TP3.

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‘Knowledge and Belief about Pain in the Elderly’ (Zwakhalen et al., 2007).
The Questionnaire – ‘Knowledge and Beliefs about Pain in the Elderly’ (Zwakhalen
et al., 2007), was distributed at the commencement of the Certificate course (TP1),
after completion of the Certificate (TP2) and three months post completion of the
Certificate (TP3). Questionnaire responses were coded and the data entered into
SPSS (version 24). Median responses were determined. At TP2 two questionnaires
were not included due to their not being completed or having significant missing data
(n=21); at TP3 all questionnaires were included (n=9); however, some data was
excluded for specific questions during the analysis because of missing data. Table
6.3 presents a summary of student responses.

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Table 6.3 Responses to knowledge and belief questionnaire between TP1, TP2 and TP3
QUESTIONS T1 v T2 (n=21) T1 v T2 v T3 (n=9)
T1 T2 p- value T1 T2 T3
(CORRECT ANSWERS IN GREEN). p-value
Median Median <0.05 Median Median Median
1.Older people experience pain less intensely than younger people 1 1 0.83 1 1 1 1.0
(1. SD, 2- MD, 3 – NO, 4 – MA, 5 – SA).
2.Pain medication works better in young people than in the elderly 2 2 0.56 1(n=8) 1(n=8) 1(n=8) 0.37
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
3.Pain medication works longer in the elderly than in young people 2 2 0.89 2 2 2 0.91
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
4. Pain medication has more side effects in the elderly than in younger people 2 2 0.59 2 2 3 0.78
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
5.Dementia patients experience less pain than non-dementia patients 1 1 0.03* 1 1 1 0.1
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
6.Assessing pain in a dementia patient is a matter of guessing 2 2 0.56 2 2 2 0.27
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
7.Where I work, pain is assessed correctly 3 4 0.001* 3 4 4 0.004*
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA). (n=20) (n=20)
8.Where I work, pain is treated correctly 3 4 0.001* 3 4 4 0.008*
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA). (n=20) (n=20)
9.Where I work, much attention is given to pain in dementia patients 3 4 0.065 3 4 4 0.002*
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA). (n=20) (n=20)
10. Pain medication should only be administered to patients suffering from severe pain 2 2 0.16 2 1 1 0.78
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
11. Residents are often prescribed too much pain medication 3 2
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA). (n=20) (n=20) 0.002* 3 2 2 0.04*
12. It is better to administer pain medication ‘when necessary’, rather than according to a fixed 2 2 0.85 4 2 3 0.73
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
13. Administering pain medication should be postponed as long as possible, because dementia
patients should receive as little pain medication as possible 1 1 0.86 1 1 1 0.78
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
14. A dementia patient should first report pain before receiving the next dose of pain 1 1 0.80 2 1 1 0.55
medication (1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
15. Pain is part of the aging process (1. SD, 2. MD, 3. NO, 4. MA, 5. SA). 4 2 0.06 1 1 1 0.35

16. Older people are more likely to be affected by pain than younger people 4 2 0.06 4 2 2 0.12
(1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
17. Pain medication, if administered in large quantities, easily leads to addiction among the 3 2 0.013* 3 2 2 0.11
elderly (1. SD, 2. MD, 3. NO, 4. MA, 5. SA).
*statistically significant.
Abbreviations SD- strongly disagree, MD- mostly disagree, NO – no opinion, MA – mostly agree, SA – strongly agree

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Time Point 1 (TP1) versus (vs) Time Point 2 (TP2).
Table 6.3 presents the responses of the students who completed TP2 (n=21), except
in those questions indicated where n =20 because of missing data. The first four
questions related to pain in the young vs the older person. Students completing TP2
questionnaires, did not change their median response between TP1 and TP2. They
strongly disagreed that older people experience pain less intensely than the younger
person, and mostly disagreed that pain medication works less well or longer and has
more side effects, in old people than in young people.

Questions 5–6 were concerned with the students’ knowledge regarding pain in
people with dementia. A Wilcoxon Sign Rank Test showed statistically significant
difference in the responses to Question 5 (indicated by the asterisk). This question
asked if patients with dementia experience less pain than those without dementia.
After completion of their training, students strongly disagreed that people with
dementia do not experience less pain (Z value of – 2.126, N = 21 and an r value of
0.47 with a medium effect). The median score remained unchanged from T1 (Md 1)
to T2 (Md 1).

Questions regarding the work environment and assessment and treatment of pain
(Questions 7–9), showed a statistically significant difference between TP1 and TP2
(indicated by the asterisk). During this time students undertook practical placement
in an RCF and could observe facility practices regarding assessing (Z value – 3.149,
N =21, r value of 0.69 large effect, Median score changing from Md3 at Tp1 to Md4
at Tp2) and treating pain (Z value - 3.226, N= 21, r value 0.70 large effect, Md 3 at
Tp1 to Md4 at Tp2). This was also reflected in some student diaries and interviews,
where students reported they felt that the process to identify, report and manage
pain was adequate within the RCFs where they undertook their placement. However,
despite a change in median score from 3 (no opinion) to 4 (mostly agree) for
Question 9 (much attention given to pain in people with dementia), no statistically
significant difference was seen.

Questions 10–13 focussed on the administration of medication. No students in either

RTOs learnt about medications or their administration during the certificate course.
However, statistically significant difference was shown between TP1 and TP2, for the
question regarding residents being prescribed too much pain medication. Students’

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median opinion changed from ‘no opinion’ prior to practical placement to ‘mostly
disagree’ (Z value – 3.087, N= 21, r value 0.68 large effect, Md 3 at TP1 to 2 at TP2).
No statistically significant difference was seen for the questions regarding
administering medication as necessary, postponing medication administration for
people with dementia, people with dementia reporting pain before medication
administration, or older people being more affected by pain than younger people.
Interestingly, despite a change in median score of 4 (mostly agree) to 2 (mostly
disagree) between TP1 and TP2 regarding pain being part of the ageing process
(Question 15), no statistically significant difference was seen.

In the final question (Question17), students were asked their opinion on whether
administering pain medication in large quantities led to addiction. Significant
difference was seen between TP1 and TP2 with students’ opinions changing from
Md score of 3 at Tp1 to Md 2 at TP2 (Z value of – 2.489, N= 21 and r value of 0.54
with large effect).

Time Point 1 (TP1) versus Time Point 2 (TP2) versus Time Point 3 (TP3).
Nine new care workers (39% of those who completed TP2), progressed to
completing TP3. Five worked in separate RCFs and four were able to obtain a
position in community aged care services. The new care workers successful in
securing a position in community aged care, were retained and the information
collected, as the process of knowledge transfer and learning, was deemed to be
similar in the initial months of their career and also because retention of individuals
to TP3 was difficult (Figure 6.1). Data from TP1, TP2 and TP3, were used to
demonstrate learning and the progression of knowledge for these new care workers.

For the new care workers completing TP3, the questionnaires were distributed three
months post-graduation. All new care workers in this category had a staff position in
either an RCF or community aged care service, prior to completing the Certificate III
course. The new care workers’ (n=9) knowledge and belief median responses at TP1
and TP2 and TP3 were determined. Table 6.3 presents a summary of student/new
care worker responses.

No change in median score or statistically significant difference was seen, in the first
four questions regarding pain in the young vs the older person. Neither was a

104
statistically significant difference seen in the questions regarding the person with
dementia and the experience or assessment of pain.

Changes in median scores and a statistically significant difference, was seen in the
questions regarding workplace pain assessment and treatment procedures and
attention given to people with dementia (indicated by the asterisk). At TP3,
graduated students had progressed to become AINs. Friedman tests indicated that
there was a statistically significant difference regarding knowledge of how pain is
assessed in the workplace (Q7) (X2 (2, N=9) = 10.9, p< 0.005), how pain was
treated (Q8) (X2 (2, N= 9) = 9.6, p <0.01) and how much attention was given to
residents with dementia (Q9) (X2 (2, N= 9) = 12, p<0.005).

Modified Pain Management Student Survey (Savvas et al., 2014b).

The Modified Pain Management Student Survey (Savvas et al., 2014b), was a
questionnaire that had previously been trialled in Australia during the EBPRAC pain
management project in 2009, which included RNs, ENs, AINs and AH practitioners
(Savvas et al., 2014b). Part A had 14 questions with a four-point Likert Scale (absent
option was a” no opinion”). PART B, added to this questionnaire, had eight
questions, to evaluate student knowledge and attitudes to pain in the elderly (Ferrell
& McCaffery, 2012). Both were completed at TP1, TP2 and TP3. Questionnaire
responses were coded and the data entered into SPSS (version 24). Variables with
missing data were not used for comparison in the Wilcoxon Sign Rank Test or
Friedman’s test, and this is reflected in the tests of significance. However, there were
instances when students provided an answer as ‘not applicable’ as both of these
questionnaires did not have a ‘no opinion’ option.

Part A.
TP1 versus TP2.
Twenty-three students (n=23), completed this questionnaire at TP2 (five
questionnaires were removed because of large amounts of missing data). Students
(n=18), were asked to choose a category from the four-point Likert Scale which best
represented their views on the statements. The knowledge and confidence
responses at TP1 and TP2, were calculated as median scores. Table 6.4 presents a
summary of the students’ responses.

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Table 6.4 Responses to the Modified Student Pain Management Survey
between TP1 and TP2.
T1 v T2 (n=18)
QUESTIONS Median
p- value
CORRECT ANSWERS IN GREEN T1 T2 Effect size
(p<0.05)
Z= -3.442, N=17, r =
1.I am confident in my pain management skills?
3 2 0.008* 0.83 large effect
(1. SA, 2. A, 3. D, 4. SD)
Z= - 3.0, N = 7, r=
2. I am able to recognise when a resident is
2 1 0.030* 0.73, large effect
experiencing pain? (1. SA, 2. A, 3. D, 4. SD)
3. I am able to recognise pain in those with
Z = - 3.218, N = 17,
dementia or non-verbal residents?
3 2 0.013* r = 0.78, large effect,
(1. SA, 2. A, 3. D, 4. SD)
4. I know and understand the Australian Pain
Society Guidelines for Pain Management in
Z = - 3.176, N = 16,
RCFs?
4 2 0.019* r = 0.79, large effect,
(1. SA 2. A, 3. D, 4. SD)
Z = -3.244, N= 16,
5. I know and understand the facility procedures
4 2 0.001* r = 0.8, large effect,
for dealing with pain? (1. SA, 2. A, 3. D, 4. SD)
Z = - 2.310, N = 16,
6.I am happy with the current facility procedures
3.5 2 0.021* r= 0.58, large effect
for dealing with pain? (1. SA, 2. A, 3. D, 4. SD)
7. I know who to tell if I notice a resident is in
Z = - 2.640, N= 17,
pain?
2 1 0.098 r = 0.64 large effect,
(1. SA, 2. A, 3. D, 4. SD)
8. If I notice a resident is in pain, I will always
report this to the appropriate?
1 1 0.89 -
(1. SA, 2. A, 3. D, 4. SD)
9. I believe I have had adequate training to
Z = - 3.090, N =16,
enable me to assess if a resident is in pain?
3.5 2 0.019* r= 0.77 large effect,
(1. SA, 2. A, 3. D, 4. SD)
Z = - 2.392, N = 16,
10.I am regularly involved in providing
4 3 0.017* r=0.6, large effect,
treatment for pain? (1. SA, 2. A, 3. D, 4. SD)
11. I am confident in using a wide range of
pharmacological therapies for pain
Z = - 2.111, N= 16,
management?
4 3 0.035* r = 0.53, large effect,
(1. SA, 2. A, 3. D, 4. SD)
12.I am confident in using a wide range of non-
pharmacological therapies for pain
Z = -2.326, N= 16,
management?
3.5 2 0.020* r= 0.58, large effect,
(1. SA, 2. A, 3. D, 4. SD)
13.I believe that the non-pharmacological
Z = -2.138, N = 16,
treatments provided for pain are effective?
3 2 0.033* r=0.54, large effect,
(1. SA, 2. A, 3. D, 4. SD)
14. I believe that the pharmacological
treatments provided for pain are effective?
2 2 0.76 -
(1. SA, 2. A, 3. D, 4. SD)
*statistically significant Abbreviations SA – strongly agree, A – agree, D- disagree, SD- strongly disagree

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Statistically significant differences were seen in Questions 1-7 and 9–13. Calculation
of effect size showed that the training provided during the Certificate course and the
practical experience, significantly improved the students’ knowledge and confidence
in identifying, assessing and managing pain. They also improved their knowledge in
the best practice documentation (PRACMS guidelines) (Goucke et al., 2005) and in
the policies and procedures of the facility. Interestingly, students felt more confident
in using pharmacological therapies during this period. This was despite no
involvement in administering medication during this time.

TP1 versus TP2 versus TP3.

Individuals, who progressed to TP3, completed the survey 3 months post completion
of the certificate. New care workers (n=9), were asked to choose a category from the
Likert Scale which best represented their views on the statements. Responses were
coded and the data entered into SPSS (version.24). However, there were instances
when participants provided an answer that was not applicable, as this tool did not
have a ‘no opinion’ option. The participants (n=9) knowledge and confidence median
responses were recorded at TP1, TP2 and TP3 and statistical significance was
determined by the Friedman Test. Results are presented in Table 6.5.

As in the TP1 vs TP2, statistically significant differences were seen in the Questions
1-7, 9, 10 and 11. During this time, new care workers commenced working in an
RCF or community care position. With the increase in practical experience, their
knowledge, experience and confidence improved significantly in all areas of pain
identification, assessment and management, except for areas related to reporting of
identified pain, confidence in non-pharmacological therapies, and belief about
different management strategies. The participants’ improved confidence and
knowledge in this area, was reflected in their diary and interview responses.

This questionnaire showed greater sensitivity in detecting changes in knowledge and

confidence between the three time points.

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Table 6.5 Responses to the Modified Student Pain Management Survey between TP1, TP2 and TP3
QUESTIONS T1 v T2 v T3 (n=9)
Median
(CORRECT ANSWERS IN GREEN).
T1 T2 T3 p-value Chi-Square
(n=8)
p <0.05
1.I am confident in my pain management skills? X2 (2, N=7) =
3 2 2 0.006*
(1.SA, 2. A, 3. D, 4. SD) 10.2

2.I am able to recognise when a resident is X2 (2, N=7) =

2.5 2 2 0.015*
experiencing pain? (1. SA, 2. A, 3. D, 4. SD) 8.4

3.I am able to recognise pain in those with dementia or X2 (2, N=7) =

3.5 2 2 0.002*
non-verbal residents? (1. SA, 2. A, 3. D, 4. SD) 12.01,

4.I know and understand the Australian Pain Society X2 (2, N=6) =
Guidelines for Pain Management in Residential Care 4 2 2.5 0.008*
9.56
Facilities? (1. SA, 2. A, 3. D, 4. SD)
5. I know and understand the facility procedures for X2 (2, N=6) =
4 2 1 0.006*
dealing with pain? (1. SA, 2. A, 3. D, 4. SD) 10.3

6. I am happy with the current facility procedures for X2 (2, N=6) =

4 2 2 0.023*
dealing with pain? (1. SA, 2. A, 3. D, 4. SD) 7.5

7.I know who to tell if I notice a resident is in pain? X2 (2, N=7) =

2 1 1 0.041*
(1. SA, 2. A, 3. D, 4. SD) 6.4

8.If I notice a resident is in pain, I will always report 1 1 1 0.61

this to the appropriate? (1. SA, 2. A, 3. D, 4. SD)
9.I believe I have had adequate training to enable me X2 (2, N=6) =
to assess if a resident is in pain? 4 2 2 0.009*
9.5
(1. SA, 2. A, 3. D, 4. SD)
10. I am regularly involved in providing treatment for 4 3 3 0.009* X2 (2, N=6) =
pain? (1. SA, 2. A, 3. D, 4. SD). 9.5
11. I am confident in using a wide range of X2 (2, N=6) =
pharmacological therapies for pain management? 4 3 3 0.047*
6.1
(1. SA, 2. A, 3. D, 4. SD)
12.I am confident in using a wide range of non-
pharmacological therapies for pain management? 4 3 2.5 0.074
(1. SA, 2. A, 3. D, 4. SD)
13. I believe that the non-pharmacological treatments
provided for pain are effective? 2 2 2 0.23
(1. SA, 2. A, 3. D, 4. SD)
14. I believe that the pharmacological treatments
provided for pain are effective? 2 2 2 1.0
(1. SA, 2. A, 3. D, 4. SD)
* Statistically significant Abbreviations SA- Strongly Agree, A- Agree, D- Disagree, SD Strongly Disagree

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 109

Knowledge and Attitudes Survey Regarding Pain (Ferrell & McCaffery, 2012).
This questionnaire had eight questions to evaluate student knowledge and attitudes
to pain in the elderly (Ferrell & McCaffery, 2012). It was administered with the other
questionnaires at TP1, TP2 and TP3.

TP1 versus TP2.

Eighteen students (n=18) completed this survey. The percentages were calculated
for TP1 and TP2 and are summarised in Table 6.6. There was little to no change in
percentage scores between TP1 and TP2 and no significant difference seen using
McNemar’s test.

TP1 vs TP2 vs TP3.

Nine care workers completed this step at TP3. The percentages of the results were
calculated for TP1, TP2 and TP3 and are summarised in Table 6.6. There was little
to no change in scores between TP1, TP2 and TP3 and no significant difference
seen using Cochrane’s test.

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 110

Table 6.6 Responses to knowledge and attitudes to pain in the elderly between TP1 vs TP2 and TP1 vs TP2 vs TP3

QUESTIONS T1 v T2 (n=19) McNemar’s test T1 v T2 v T3 (n=8) Cochrane’s

% with p- value % Correct with test
(CORRECT ANSWERS IN GREEN).
correct (n=19) correct p-value
response response
Observations such as pulse, blood pressure are always reliable
63,68 1.0 87,87,87 1.0
indicators of the intensity of a resident’s pain. (True/false)
Pain is an unavoidable part of growing old. (True/false) 68,68 1.0 75,75,87 0.37

Residents who can be distracted from pain usually do not have 95,79 0.62 100,87,75 0.22
severe pain. (True/false)
Residents may sleep despite being in severe pain. (True/false) 58,69 0.69 75,75,62 0.60

94, 100
Elderly residents cannot tolerate opioids (morphine etc) for pain 1.0 87,100,100 0.37
relief. (True/false) (n=17)

Residents should be encouraged to endure as much pain as

74,84 0.62 87,87,100 0.60
possible before using an opioid (morphine). (True/false)
Resident’s spiritual beliefs may lead them to think pain and
94,84 1.0 87, 100,87 0.37
suffering are necessary. (True/false)
Providing a resident who has pain with opioid e.g. morphine 78,78 86,86,86
like medication will contribute to them developing an addiction. 1.0 1.0
(n=18) (n=7)
(True/false)

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6.2.4 Diary entries at TP2 and TP3.
Diary entries TP2.
Students (n=23) were asked to complete a diary during their two weeks of practical
placement (TP2). Some students completed their two weeks of practical time over
five or more weeks because they were working part-time. There were 45 diary
entries to analyse.

The number of diary entries ranged from no entries (four students), because of
inability to complete the diary or ‘did not observe anything’, to eight entries (one
student). The average was two entries. Diaries were either hand written in the blank
paper diary provided or on a notepad, typed on an electronic copy of the diary or in
an email, or photos of their diary entries were taken by the students and sent via
text. The format used was ‘What did you see?’, ‘What did you do?’, ‘What was the
outcome?’ and a reflection question regarding ability to identify pain, and confidence
in identifying pain. One student did not provide a reflection on entries. Diary entries
were very rudimentary and did not provide in depth detail or reflection.

Information collected from the diaries, was analysed using thematic analysis and
manual coding (Bradley et al., 2007). As the purpose of diaries was to identify how
students utilised the knowledge gained during their certificate training, into the
clinical practice areas, and whether they identified any barriers and facilitators to
pain identification, assessment and management practices, diaries were coded with
this purpose in mind. Therefore, pre-set codes (themes) were listed as pain
identification, pain management and barriers or facilitators, to pain practices. Diary
data, was then categorised under these main themes. Subthemes were identified by
the frequency of word occurrence related to the pre-set codes within the diary
entries. The results can be seen in Table 6.7 along with subthemes.

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 Table 6.7 Themes and subthemes from diaries at TP2 and TP3.

TP2 TP3

Theme TP2 Subtheme TP2 Theme TP3 Subtheme TP3

Pain identification Verbal Pain identification Verbal

Non-verbal Non-verbal

Barriers Lack of Knowledge Facilitator Knowledge

Attitude and Beliefs

Facilitators Knowledge Pain management Non-pharmacological

strategies

Pain management Non-pharmacological

Management

6.2.4.1 Themes and subthemes from diary entries.

Diaries completed at Time Point 2.
Theme One - Pain identification.
Subtheme – Verbal and non-verbal pain identification.
The student’s ability to identify pain, varied depending on verbal or non-verbal
expression by the resident. Students found it easy to identify pain when the resident
spontaneously verbalised both its presence and where it was located. Most students
documented, that they found it easy to identify pain, when the resident used the
general behavioural signs of pain (that is facial expressions such as grimacing,
vocalising or moaning, shouting, holding or guarding the painful part, withdrawing the
leg, anxiety, hesitancy, changing position frequently or difficulty walking). These
were mostly detected during movement (i.e. during care, transferring or mobilising)
of the residents. This alerted the students to the possibility of pain and they would
then ask the resident if they were in pain.

Students lacked confidence and found it hard to identify non-verbal behaviours of

pain, if they were not common behaviours, or if they were specifically related to the

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particular resident i.e. changed moaning during care. A student commented that it
was harder to identify the pain ‘if there was no definite cause i.e. like a wound’
(Student 24215, Entry (E) 1: page (p). 1), if the resident presented with multiple
symptoms such as nausea, dizziness and pain at the same time (Student 37216, E1:
p.1), if the resident had dementia and was physically aggressive (Student 78215, E6:
p.1), or due to the fact that they did not know the individual resident well (Student
24215, E1: p.1). One student reported, that it was easy to determine that pain was
present because of the behaviour, but difficult to determine the cause of the pain
(Student 74216, E4: p.1), as the resident was not able to verbalise or communicate
in anyway.

Generally, students commented, that their confidence in their ability to identify pain
behaviours, improved with the length of time they spent interacting with the residents
in general, or with the same residents during their practical training.

Theme Two – Barriers.

Subtheme - Lack of Knowledge.
Students’ comments in the diaries, showed a lack of knowledge and understanding,
about the capabilities of people living with dementia. One student stated, that after
attempting to dress a resident with moderate dementia, that ‘it would be good if they
could help’ (Student 241615, E3: p.1). This student (Student 241615, E2: p.1) also
documented, that you need to make sure you check that the pain is really there (for
people with dementia).

Student reflections around the ability of the person living with dementia to verbally
report details about pain (location or duration), showed a lack of understanding about
the progression of dementia and ability to verbally express needs (Students 78215,
87515, 74715, 42715, 74216). The ability to be able to identify physical pain,
emotional pain and residents’ anticipatory pain, associated with a procedure, also
proved difficult for students to identify and manage (Students: 94215, E2: p.1; 74216,
E1: p.1; 74216, E3: p.1)

Students generally commented, that lack of knowledge of the individual resident,

also impacted upon their ability to identify pain (Student 24215, E1: p.1).

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Subtheme – Attitude.
Students commented on their beliefs and attitudes about the residents and pain
management. One student (Student 7515, E4: p.1), wrote that ‘the behaviour of the
resident may be due to anxiety related to falling, not the resident’s pain’ (resident
had had multiple falls in the preceding two weeks). Student 7515 (E2: p.1) wrote,
they ‘were surprised that someone (a resident) would agree to take morphine, as
they (the student) would not agree to take morphine and instead would look for an
alternative way to treat their pain’. Student 222715 (E4: p.1) wrote, that we need to
be mindful of patterns in pain conversations with patients (alluding to the fact that
your conversation or questioning may lead the resident to believe they have pain).

The attitude of the staff mentors the students were paired with, also impacted on the
students. A student commented that the carers did not seem particularly concerned
about the resident-whether she was in pain or light headed (Student 37216, E1: p.2).
Another student wrote, that staff stated to the student that “the resident is old and
that there was nothing more that could be done to ease her discomfort” (Student
52715, E1: p.2).

Theme – Facilitators.
Subtheme – Knowledge.
Students’ training during the certificate course in the identification and assessment of
pain, helped them to identify instances of pain when residents spontaneously
verbalised, or to identify common behaviours of pain for people with dementia, such
as grimacing. This prompted them to verbally ask the resident if they had pain.

Subtheme - Pain management.

Students observed and utilised a number of non-pharmacological pain management
strategies. These included repositioning, heat therapy, gentle manual handling,
massage, reassurance and soothing words and were aware of the use of a TENS
machine because they had observed it in use.

Diaries completed at Time Point 3.

New care workers who had graduated from their training and now held positions as
AINs (n=9), were asked to complete a diary over a two-week period, approximately
three months after they had finished their certificate. The new care workers at TP3,

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worked in a permanent part time /casual capacity, therefore, diary entries varied in
volume, depending on the number of shifts that they had during the two-week period.
The number of diary entries ranged from one to eight entries. Diary entries written by
new care workers, were documented and returned to the researcher in the same
ways as the student entries. The format used at TP3 was the same as used at TP2.
Again, diary entries were very basic and did not provide in-depth detail or reflection.

Information collected from the diaries, was analysed using thematic analysis and
manual coding (Bradley et al., 2007). The process used for this manual coding was
the same as that described in analysing the diaries for TP2. The pre-set codes for
TP3 included pain identification, assessment and management, barriers and
facilitators. The subthemes were determined based on the frequency of words
associated with the pre-set codes and can be seen in Table 6.7.

Theme - Pain identification.

New care workers found it easy to identify pain in people who could verbalise.
However, in regard to non-verbal behaviours, all participants stated that it was easy
to identify common behaviours such as body positioning, groaning or grimacing,
irritation and changes in mobility or normal personality. They were particularly
observant during activities, and when moving the resident/client. Knowing the
resident/client was significantly beneficial, as it made it easier to identify changes in
behaviours or personality (New care worker 42715, E1: p.1). New care worker 7716
(E1: p.1), reflected in one comment, that they could have asked more about the pain,
its location and intensity after identification, but didn’t.

A new care worker documented, that ‘pain was difficult to identify in cases where the
resident exhibited changes in their normal behaviour, rather than in cases with
common pain behaviour’ (New care worker 722615, E3: p.2), or ‘cases where the
resident was non-communicative and the only difference was change in breathing’
(New care worker 74216, E2:p.1), or cases when the resident was confused and
uncooperative (New care worker 722615, E2:p.2). New care worker 78215 (E4: p.1)
documented, that it was difficult to identify when the resident had pain, as one
resident had experienced an injury with a bleeding knee, but when asked if he had
any pain, he said no.

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New care worker 74216 in this time frame, had a personal pain experience (E1: p.2).
They wrote about this time in a diary reflection and commented how, after this
experience, her behaviour had changed (withdrawn, decreased appetite) and how
vulnerable being in pain made her feel. She wrote, that this experience opened her
eyes to how other people may be feeling (including the older person) and how if
people are unable to express their pain, how bad it is for them to have to live with
pain that is poorly managed.

Theme – Facilitators.
Subtheme - Knowledge.
New care workers wrote, that knowing the resident/client gave them a significant
advantage in identifying changes in behaviour or their usual personality. This
indicated to the new care worker, that something was wrong and led them to ask
questions about the presence of pain or to investigate further if pain was present.

Subtheme - Pain management.

Participants utilised a number of non-pharmacological pain management strategies,
including repositioning, heat therapy, gentle manual handling, massage, reassurance
and soothing words. One new care worker (1615, E2: p.1) reported, that during the
day physiotherapists attended to the non-pharmacological therapies. Some of the
participants reported, that they had little exposure to performing some of the non-
pharmacological pain management tasks, such as applying heat packs or TENS.
Pharmacological management was identified by all participants, as being a key pain
management strategy but they did not participate in this task, or receive information
at handover about medications that the residents/clients were taking.

6.2.5 Interviews at TP2 (student) and TP3 (new care worker).

6.2.5.1 Themes and subthemes from student/new care worker interviews.
Time Point 2 (student).
Student interviews using semi structured questions (Appendix 8), were conducted
post the students practical experience and completion of questionnaires and diaries.
Questions were guided by student response to questionnaires and where possible,
by diary entries. Twenty-three student interviews (n=23) were analysed using
thematic analysis as described previously in Phase One and during the diary
analysis. As the language around pain identification, assessment and management,

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barriers and facilitators to these practices in aged care were of interest, these five
themes were set as pre-set codes. Other themes within the interview data were also
considered if the word surrounding that theme appeared frequently in interview
transcripts (Bradley et al., 2007).

Subthemes emerging from the interview data can be seen in Table 6.8.

Table 6.8 Themes and subthemes of interview at TP2 and TP3.

TP2 TP3
(Students) (New care
workers)
Theme Subtheme Theme

Pain Identification Verbal Pain Identification

Non-verbal

Barriers Resident Facilitators

Staff/Student Pain Management

Facilitators Experience Education

Course

Project

Pain Management Non-Pharmacological

Management

Reporting

Outcomes

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Theme - Pain identification.
Subtheme - Verbal and non-verbal identification.
Students reported, that when residents who could verbally communicate and
spontaneously verbalise about the presence of pain, then it was easy to tell that they
had pain and they could ask more questions about the location, intensity and
duration of it. One student (4715, p.1:5) stated, that it was only her ‘responsibility to
identify it and then report it, not do any further investigations, as she was not able to
diagnose’. However, students also reported, that the residents did not often
spontaneously report pain and so they got into the habit of asking how they were
(the resident) and if they had any pain today. Student 5716 (p.1:33) stated that ‘they
don’t tell you anything’ or ‘some residents are too scared to say anything’ (Student
7416, p.3:28).

Students used known behaviours of pain in both those who could communicate and
those who could not communicate (people with dementia) i.e. grimacing, moaning,
facial expressions, vocalisations, body postures, rubbing area and/or mood, as
triggers for asking residents if they had pain. However, if the resident ‘looked happy
and fine there was no point in asking’ (Student 22715, p.1:22). Students found it
difficult to further identify the location, intensity or duration of the resident’s pain, if
the resident had difficulty communicating. This was particularly difficult in residents
who did not have any generalised pain behaviours or who did not have a specific
cause of their pain, like a wound (Students 42515, p.1:13; 72515, p.2:9-10). One
student (4715, p.1:19) commented that you ‘have to be vigilantly looking for it’.

Theme – Barriers.
Three barriers that became apparent during analysis of the student interviews,
included resident, student/staff and facility barriers.

Subtheme – Resident.
It was identified by two students, that residents do not often spontaneously verbalise
the presence of pain and they identified this fairly early in their practical experience
and therefore commenced asking residents about the presence of pain. Student
74715 (p.1:20) stated that it was ‘the residents’ right not to complain about their pain
if they chose’.

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Caring for residents with dementia, presented a barrier to appropriate pain
assessment. Students reported, that some residents with dementia were able to at
least verbalise that they had pain but were not able to provide any other detail, even
when asked. Students reported that other residents with dementia, clearly displayed
some generalised behaviours of pain as documented above. Others had very
specific behaviours such as a ‘change in the level of grumpiness’ (8215, p.2:14).
This variability in resident responses, made it difficult to assess these residents,
particularly as the students had little familiarity with these residents during their short
time in practical placement.

One student identified, that a resident’s family member potentially contributed to the
distress of a resident, by telling the resident ”to stop whingeing”, as the resident was
complaining of pain during movement. This resident had previously complained of
more pain and shown behaviour indicating the presence of increased pain (Student
8215, p.7:224).

Subtheme - Student/staff barriers.

Student and staff barriers were identified during student interviews and included
attitudes, lack of knowledge and competing priorities.

Attitudes.
Students reported that staff told them things such as;

• “Everyone who gets old has pain” (Student 78215, p.7:17).

• “She is buzzing again” (about her pain) (Student 78215, p.4:4).
• ‘Staff labelled a resident “a complainer” because they were continually
complaining about their pain’ (Student 78215, p.4:3).
• “She is always in pain” (4215, p.1:42).
• “People with dementia feel no pain” (78215, p.2:26-27) (therefore no
analgesia was provided after injury).
• Students were told not to engage with the residents: “Don’t waste your time
with them (the residents…don’t do that because when you’re gone, we will
have to do it” (74216, p.2:35).

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Students stated the following in their interviews.

• ‘That residents could be hypochondriacs exaggerating their pain for attention’

(Student 41615, p.1:21-22).
• ‘Everyone’s pain tolerances are different and will only say “ouch” when they
are in a lot of pain’ (Student 887515, p.2:12).
• ‘It’s just behaviours not pain’ (Student 722715, p.2:21).
• ‘Psychologically that they may think there is a pain but there isn’t, I could see
that if you plant the seed it brings it up for them’ (Student 222715, p.1:9-10).
• ‘She said (referring to education provided by the clinical facilitator during
training) that “morphine isn’t addictive and it doesn’t kill you”. I was not sure
about that. That is my personal opinion’ (Student 222716, p.1:13-15).
• ‘You appreciate carers who are passionate about what they do, compared to
those who it is just a job or are complacent about the job’ (Students 74216
p.2:50, 22716, p.2:8, 78215, p.4:8, 722715, p.1:25).
• ‘The staff brand their patients’ (residents) (Student 78215, p.4:1).

Lack of knowledge.
During the interviews, students demonstrated a lack of knowledge about pain in
people with dementia and pain in the older person, which differed to their
questionnaire responses. They also commented that a lack of knowledge about the
resident/client, also impacted on knowing what was normal or abnormal behaviour
for that individual (Student 37216, p.1:31). No education was provided for the
students about the different resident behaviours that may be expressed indicating
pain, or any other need during their practical experience (Student 24215, p.1:40).

Competing priorities.
Students stated that particularly during the morning (which is when most students did
their practical experience time), they were always rushed, time poor and told by staff
to hurry, as there were so many other tasks and competing priorities that needed to
be completed by a certain time: ‘In the facilities its tasked focused and in the facility,
it is go go go. So, we wake up the residents early to get things done at specific times’
(Student 37216, p.1:38). They found in this time, that some staff became very task
focussed and spent little time conversing with residents. They commented that they

120
could see at times like this, how you could easily overlook observing for pain in
residents, particularly if the resident didn’t spontaneously verbalise or display
significant non-verbal pain behaviours. Understaffing was often a problem in two of
the facilities and this further contributed to the time pressures (Student 64715,
p.2:11).

Theme- Facilitators.
There were three facilitators that students identified, as assisting them to identify
pain in the older person: experience, the course, and being part of this project.

Subtheme - Experience.
Twenty-one out of the 23 students that continued to TP2, were aged over 31 years.
Nine of the students had cared for an older relative, worked as a carer, caring for
older people, had a child with a disability, or were currently working in RCFs in a
different capacity (environmental services). The remaining students had children. All
students commented that these different life experiences, gave them an increased
awareness of how to identify pain in individuals who cannot verbalise.

Subtheme - Certificate III course.

All students commented, that what they learnt during the certificate course helped
them to learn about pain identification, assessment and management strategies.
They also commented that the practical experience further helped to cement their
knowledge in this area.

Subtheme – Project.
Being part of the PhD research project, also assisted students in learning about how
to identify pain. Students stated, that being part of the project made them focus on
identifying residents in pain, while they were out on their practical experience. One
student reported, that being part of the project made her ‘deliberately focus on
finding someone in pain, so she could identify it and she probably wouldn’t have
bothered otherwise, as there were so many other things to learn’ (Student 4215,
p.5:213).

Theme - Pain management.

Students reported, that for the most part, they thought that pain was managed well.
They were able to identify, utilise and observe a multitude of pain management

121
strategies whilst on practical. Medications were used frequently as a pain
management strategy. However, students were also able to utilise repositioning,
massage, reassurance and distraction techniques. They also observed heat packs,
TENS machines and pressure mattresses being used.

Theme – Reporting.
Students felt confident reporting to their team leader or the RN, about pain that was
either reported to them by the resident or that they observed in a resident. Students
observed, that whilst their report to the staff was verbal, they could see the
importance of documenting reports of identified pain. One student said, that they
also needed to follow up the RN about actioning their report, as when the student
followed up with the resident about their pain, they were still in pain (Student 78215.
p.5:162) or the RN had failed to follow up on the report and the student had to
remind them three or four times (Student 78215, p.5:9). Student 78215 (p.5:5)
reported, that due to the time pressures and requirements in the morning, there was
often no time to ask further questions regarding pain and all they could do was report
to the RN. These time pressures and morning task requirements also often resulted
in ‘a delay in the reporting of pain to the RN of up to two hours’ or ‘it sometimes
(pain) gets overlooked’ (Student 26715, p.3:3).

Themes – Outcomes.
The final question students were asked, was regarding the outcomes of poorly
treated pain. Students reported, that poorly treated pain would result in a poor quality
of life, depression, anxiety and that whole aspects of the older person’s life would be
affected if pain was not managed appropriately.

Interview data - new care worker TP3.

New care worker interviews (n=8), were conducted using semi-structured questions,
three months post completion of their Certificate III course, and after completion of
the questionnaires and diaries, as at TP2. One new care worker moved during the
time period and failed to respond to requests for completion of the interview at TP3.
Questions were guided by participant response to questionnaires and where
possible by diary entries. Interviews were analysed using thematic analysis utilising
the techniques previously discussed. As the purpose of the interviews, was to
understand more about the new care workers’ experience, translating their

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knowledge of pain identification, assessment and management into the workplace
(particularly related to the support given to the new care workers during their first
months working in aged care setting), pre-set codes of pain identification,
assessment and management, barriers and facilitators were chosen and then, if
there was enough data supporting these pre-set codes, they became themes. If
other themes emerged during the analysis, these were also included (Bradley et al.,
2007).

Similar themes emerged from the interview data at TP3, as from the diary data and
can be seen in Table 6.8.

Theme - Pain identification.

New care workers reported, that when clients spontaneously verbalised about the
presence of pain, then it was easy to tell that they had pain and they could ask more
questions about pain location, intensity and duration. One participant (New care
worker 78215; p.1:32) also commented that the clients did not often spontaneously
report pain and so they got into the habit of asking how they were and if they had
any pain that day. New care workers used behaviours of pain i.e. grimacing,
moaning, facial expressions, vocalisations, body postures, rubbing the area, mood,
as triggers for asking residents/clients if they had pain. Overall, participants reported
that their confidence in identifying pain had improved since they had completed the
course and commenced working. One participant reported (New care worker 77216,
p.1:5), that they felt that their skills still needed further development, as they were not
exposed to many clients in pain, due to the effective pain management strategies
used in the facility that they were working in. Two New care workers (78215, p.2:31;
22615, p.1:14) felt that, in instances when a person had advanced dementia, where
there were no communication skills, that it was difficult to tell if the behaviour was
related to pain or some other need.

New care workers (n=7) reported, that apart from the information that they gathered
during the identification stage, they had no further involvement in doing pain
assessments, except for one New care worker (22615), who said that they were
involved in doing the assessment of a resident who could verbalise about their pain.
Otherwise, pain assessment was the responsibility of the RN staff. The sole
responsibility of the care worker was to verbally report what they observed and to

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document it. They were not told of follow up treatment (New care worker 222716,
p.1:11).

Theme – Facilitators.
There were three facilitators that new care workers identified that assisted them to
identify pain in the older person: their Certificate III training, improved knowledge of
the resident, and experience.

All new care workers reported, that having more exposure to residents/clients
provided them with a better opportunity to learn different behaviours related to pain.
They also commented, that seeing the same residents/clients on a regular basis and
getting to know what their normal behaviour was, helped them to identify small
changes in behaviour, that indicated that something was not right with the resident
client (New care workers 8215, p.2:36; 1615, p.1:14; 222716, p.1:29; 37216, p.2:45).

New care workers commented, that what they learnt during the certificate course
helped them to learn the basics about the pain identification, assessment and
management process. However, being able to put what they learnt into action and
gain experience by working in the area of aged care, helped them build on this
knowledge, gain more confidence and piece the theory and practical aspects
together.

New care worker 22615, (p.1:27) reported, that the experience of being an overseas
pharmacist, along with an increased exposure to residents, helped them identify
episodes of pain.

Theme - Pain management.

New care workers reported, that medications were used frequently as a pain
management strategy. However, they were also able to utilise repositioning,
massage, reassurance and distraction techniques. One new care worker reported,
that non-pharmacological measures such as heat packs, were often written on lists
of tasks to attend to in a shift (New care worker 22615, p.2:50), not administered
PRN. However, another New care worker identified that in the facility they were
employed in, some therapies were given on an as-needs basis (71615; p.1:25). New
care worker 22716 (p.2:15) reported, that in the facility where they worked, a
physiotherapy aide was employed and their sole job was to administer hot packs to

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those residents who had been assessed as requiring a heat pack, and the resident
would receive these regularly as part of their care plan and not PRN. They were
given these heat packs regardless of whether they wanted them or not. If the
resident refused, then the documentation was completed to say that they had
received the hot pack.

New care workers reported, that they were provided with limited information about
analgesia that residents/clients were being administered. Sometimes, during
handover, medication administered to a resident during the previous shift may be
reported on (New care worker 22615, p.2:34). However, the primary reason for
reporting this at handover was for the benefit of the RN.

New care worker 1615 reported, on an observation they made, that the ‘younger
RNs are quicker to respond to reports of pain or changes in behaviour indicating the
presence of pain, than the older RNs’. They also said, that ‘the younger RNs were
not shy in giving medication, where the older ones tend to hold back’ (1615, p.1:26).

Theme – Education.
New care workers (n=7) reported, that on commencement in their workplace, there
was no discussion about pain management practices during orientation to the
workplace and they did not receive any pain management education. Those who
worked in community care (n=4), stated that they had a buddy system that lasted for
two weeks with a mentor, who showed them the processes around client care.
However, they stated that at no stage during that two weeks did they discuss pain
management processes. One New care worker (74216, p.2:62) based in the
community reported, that they had had an education session in the early part of their
employment regarding pain identification, how to report it, when the doctor’s
appointment might be, what strategies were in place to manage the client’s pain and
who was their point of call, if they needed assistance. They were also taught how to
help the client in the event that they had an urgent situation related to pain. The
participant reported that she couldn’t immediately remember after the education what
she was supposed to remember but was assured by other staff and her team leader,
that this information would come back to her when it was needed (74216, p.2:62).

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New care worker 74216 (p.2:80), who held a position in the community, made the
suggestion that they should be educated in the workplace about how to teach some
of the client’s pain management self-care strategies, so that when staff were
unavailable, the client could implement some of the strategies themselves. The
participant was going to suggest to the trainers in the workplace that they do an
education session in the future on this.

6.3 Clinical Facilitators (CFs).

CFs (n= 6) from two Registered Training Organisations (RTOs - A & B) located in SE
Qld, were recruited at meetings held in February and June 2015 from each individual
RTO. CFs were provided with a copy of the consent form and an information sheet,
which described the aims of the project, the requirements of participating and risks
(Appendix 6). CFs who consented, provided contact details to the researcher, to
enable further communication. Those who consented were contacted within a day,
provided with the researcher’s contact details, baseline questionnaires–
demographic, Modified Pain Management, Clinical Facilitator questionnaire (Savvas
et al., 2014b), with Knowledge and Attitudes questionnaire attached (Ferrell &
McCaffery, 2012) and ‘Knowledge and Belief about Pain in the Elderly’ questionnaire
(Zwakhalen et al., 2007). They were also provided with a copy of their signed
consent form.

6.3.1 Clinical Facilitator Questionnaire Data.

Demographic information.
Demographic information was collected from the CFs at baseline. Demographic
questions included those about gender, age range, nationality, indigenous status,
employment in aged care, work status and position in aged care, further training in
pain assessment and management and knowledge, length of time working in aged
care, length of time working as a CF, and knowledge of facility pain management
policies, for organisations involved in supporting student practical experience. Table
6.9 provides a summary of this information. All facilitators were female and ranged in
age from 41–60. Sixty–seven percent were Australian (none of the facilitators
identified themselves as Aboriginal and Torres Strait Islander), and two were
concurrently working in aged care and as CFs. The qualifications of the group varied
from, trainers holding a Certificate III in Aged Care, through to an RN. The RN was

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also the Director of one of the RTOs. All the trainers acknowledged that they had
received some formal pain education. This included a four-hour education session
on pain identification, assessment and planning, part of their Certificate III in Aged
Care course, as part of their Diploma of Nursing, as an online DVD education
session through the Aged Care Channel (now known as ALTURA) and through a
palliative care course by a palliative care state provider. Sixty-seven percent stated,
that they had received some formal training in pain assessment. There was wide
variance in the experience of the group in aged care and the length of time working
as a CF.

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Table 6.9: Demographic information of Clinical Facilitators.

Characteristic Number
Gender
Female 6
Age Range
41 - 50 5
51 - 60 1
Nationality
Australian 4
Papua New Guinean 1
South African 1
Working in RAC
Yes 2
No 4
Current position
Care worker with Certificate III in aged care 1
Care worker with Certificate IV in aged care 1
Care worker enrolled in nursing degree 1
Enrolled Nurse with medication endorsement-* 1
Registered nurse (undergraduate degree) 1
Manager/Educator in aged care 1
Formal training in pain assessment in the older person 6
Formal training in pain management
Yes
4
No
2
Length of time working in aged care 15 – 240
Months
Length of time working as a clinical facilitator 15 – 120
Months
(n=4)
Aware of the pain management policy of the facilities that you visit?
Yes 4
No 2

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Questionnaires.
No research had previously been conducted examining pain identification,
assessment and management confidence, knowledge and attitudes of Certificate III
aged care trainers. Three questionnaires were therefore used to test CF knowledge,
beliefs and attitudes. They were: ‘Knowledge and Beliefs about Pain in the Elderly
(Zwakhalen et al., 2007), the Modified Pain Management Clinical Facilitator Survey
(Savvas et al., 2014b) and the ‘Knowledge and Attitudes Survey Regarding Pain’
(Ferrell & McCaffery, 2012), and were given to obtain baseline knowledge of the
CFs. It was assumed that trainers teaching at this level, would have the minimum
requirement of having an RN or EN based qualification. As is evident by the data in
Table 6.9, this was not the case (one RN – manager of RTO, one EN – primary role
was training coordinator, 4 AINs).

Knowledge and Belief about Pain in the Elderly (Zwakhalen et al., 2007).
The questionnaire – ‘Knowledge and Beliefs about Pain in the Elderly’ (Zwakhalen et
al., 2007), was the same questionnaire as that given to the students. The
questionnaire was distributed after consent was obtained. Three of the CFs
responding to this questionnaire came from a Certificate III/IV background. This may
have influenced the answers provided for some questions, as some questions were
targeted at an individual’s knowledge and beliefs about medication. Questionnaire
responses were coded and the data entered into SPSS (version 24). The CFs (n=6)
knowledge and belief median responses at baseline, were calculated. Table 6.10
presents a summary of CF responses. Of note is that there are a lot of ‘no opinion’
and ‘mostly agree’ answers, which differ from the correct responses (indicated in red
in the table). These responses also differed from the student responses to the same
question.

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Table 6.10 Clinical Facilitator responses to Knowledge and belief of Pain in the Elderly Questionnaire.
QUESTIONS (CORRECT ANSWERS IN RED) Median

Older people experience pain less intensely than younger people (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 4

Pain medication works better in young people than in the elderly (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

Pain medication works longer in the elderly than in young people (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

Pain medication has more side effects in the elderly than in younger people (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – 2
strongly agree).
Dementia patients experience less pain than non-dementia patients (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly 4
agree).
Assessing pain in a dementia patient is a matter of guessing (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

Where I work, pain is assessed correctly (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

Where I work, pain is treated correctly (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

Where I work, much attention is given to pain in dementia patients (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly 3
agree).
Pain medication should only be administered to patients suffering from severe pain (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 4
5 – strongly agree).
Patients are often prescribed too much pain medication (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 3

It is better to administer pain medication ‘when necessary’, rather than according to a fixed schedule (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 2
4 – mostly agree, 5 – strongly agree).
Administering pain medication should be postponed as long as possible, because dementia patients should receive as little pain medication as possible (1- 4
strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree).

A dementia patient should first report pain before receiving the next dose of pain medication (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – 4
mostly agree, 5 – strongly agree).
Pain is part of the aging process (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly agree). 4

Older people are more likely to be affected by pain than younger people (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – mostly agree, 5 – strongly 2
agree).
Pain medication, if administered in large quantities, easily leads to addiction among the elderly (1- strongly disagree, 2- mostly disagree, 3 – no opinion, 4 – 4
mostly agree, 5 – strongly agree).

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Questionnaire Modified Pain Management Clinical Facilitator Survey (Savvas et al.,
2014b).
The Modified Pain Management Clinical Facilitator survey, was a questionnaire that
had previously been trialled in Australia during the EBPRAC–pain management
project in 2009 (Savvas et al., 2014b). Part A had 12 questions with a four-point
Likert Scale – 1- Strongly Agree, 2 - Agree, 3 - Disagree and 4 - Strongly Disagree
(absent option was – no opinion). This varied from the student survey version, as
questions regarding how a facility manages pain and their level of happiness with
that procedure, were removed. There was also a PART B added to this
questionnaire, which asked questions about CFs’ knowledge, beliefs and attitudes
about pain. This questionnaire had eighteen questions with true and false responses,
to evaluate CFs’ knowledge and attitudes to pain in the elderly (Ferrell & McCaffery,
2012).

Part A.
The questionnaire was distributed at baseline (after CFs had provided consent). CFs
(n=6), were asked to choose a category from the Likert Scale which best
represented their views on the statements. Questionnaire responses were coded
and the data entered into SPSS (version 24). The CFs (n=6) knowledge and
confidence median responses, were calculated. Table 6.11 presents a summary of
the CFs’ responses and shows that the CFs agreed or strongly agreed with these
statements.

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Table 6.11 Clinical Facilitator responses to Modified Pain Management Clinical
facilitator survey.
QUESTIONS (CORRECT RESPONSES IN RED) Median

I am confident in my pain management skills (1- Strongly Agree, 2 - 2

Agree, 3 – Disagree, 4 - Strongly Disagree)
I am able to recognise when a resident is experiencing pain (1- Strongly 2
Agree, 2 - Agree, 3 – Disagree, 4 - Strongly Disagree)
I am able to recognise pain in those with dementia or non-verbal residents 2
(1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly Disagree)
I know and understand the Australian Pain Society Guidelines for Pain
2
Management in Residential Care Facilities (1- Strongly Agree, 2 - Agree,
3 – Disagree, 4 - Strongly Disagree)
I know who to tell if I notice a resident is in pain (1- Strongly Agree, 2 - 1
Agree, 3 – Disagree, 4 - Strongly Disagree)
If I notice a resident is in pain, I will always report this to the appropriate 1
person (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly Disagree)
I believe I have had adequate training to enable me to assess if a resident
2
is in pain (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly
Disagree)
I am regularly involved in providing treatment for pain (1- Strongly Agree, 3.5
2 - Agree, 3 – Disagree, 4 - Strongly Disagree)
I am confident in using a wide range of pharmacological therapies for pain
3
management (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly
Disagree)
I am confident in using a wide range of non-pharmacological therapies for
pain management (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - 2

Strongly Disagree)
I believe that the non-pharmacological treatments provided for pain are
2
effective (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly
Disagree)
I believe that the pharmacological treatments provided for pain are
1.5
effective (1- Strongly Agree, 2 - Agree, 3 – Disagree, 4 - Strongly
Disagree)

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Part B.
Part B of the Modified Pain Management Clinical Facilitator Survey asked eighteen true
and false questions regarding the CFs’ knowledge and attitudes about pain in the older
person (Ferrell & McCaffery, 2012). Percentages were calculated and summarised in
Table 6.12. There was a significant amount of missing data for this questionnaire, as some
of the questions, were targeted at medication knowledge. Three of the CFs only had a
Certificate III/IV qualification.

The lack of knowledge of medication, its administration, actions, doses and side effects, is
demonstrated by the lack of correct responses and missing data (correct expected
responses indicated in red in the table).

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Table 6.12 Clinical Facilitator responses to knowledge and attitudes survey regarding pain.
QUESTIONS (CORRECT ANSWERS IN RED) %Correct Missing

Observations such as pulse, blood pressure are always reliable indicators of the intensity of a resident’s pain. (True/false) 83 17

Pain is an unavoidable part of growing old (True/false) 67 17

Residents who can be distracted from pain usually do not have severe pain. (True/false) 67 17

Residents may sleep despite being in severe pain. True/false) 50 17

Aspirin and other nonsteroidal anti-inflammatory agents are NOT effective analgesics for painful bone metastases. (True/false) 33 33

Respiratory depression rarely occurs in residents who have been receiving stable doses of opioids over a period of months. (True/false) 17 50

Combining analgesics that work by different mechanisms (e.g., combining an NSAID with an opioid) may result in better pain control with
50 50
fewer side effects than using a single analgesic agent (True/false)

The usual duration of analgesia of 1-2 mg morphine IV is 4-5 hours. (True/false) 0 50

Opioids should not be used in residents with a history of substance abuse. (True/false) 50 50

Elderly residents cannot tolerate opioids (morphine etc.) for pain relief (True/false) 50 50
Residents should be encouraged to endure as much pain as possible before using an opioid (morphine). (True/false) 67 33

Residents’ spiritual beliefs may lead them to think pain and suffering are necessary. (True/false) 83 17

After an initial dose of opioid analgesic is given, subsequent doses should be adjusted in accordance with the individual resident’s response. 67 33
(True/false)
If the source of the resident’s pain is unknown, opioids should not be used during the pain evaluation period, as this could mask the ability to
33 50
correctly diagnose the cause of pain. (True/false)
Anticonvulsant drugs such as gabapentin (Neurontin) produce optimal pain relief after a single dose. (True/false) 50 50

Benzodiazepines are not effective pain relievers unless the pain is due to muscle spasm. (True/false) 17 50
Narcotic/opioid addiction is defined as a chronic neurobiological disease, characterized by behaviours that include one or more of the
67 33
following: impaired control over drug use, compulsive use, continued use despite harm, and craving. (True/false)

Providing a resident who has pain with opioid e.g. morphine like medication will contribute to them developing an addiction (True/false) 33 50

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6.3.2 Interviews – Clinical Facilitator.
CF interviews (n=4), were conducted using semi-structured questions. Two CFs did
not make themselves available for the interview, despite numerous attempts to
contact them. Questions were guided by CF responses to questionnaires. Four CF
interviews were analysed using thematic analysis (Bradley et al., 2007). Transcribed
data were analysed looking for themes in the data that related to knowledge of pain
in the elderly and people with dementia, the education of pain management skills in
Certificate III students and potential barriers to their education. RTO A Certificate
was conducted over 7 weeks full time and 10 weeks part time. Of the three CFs
interviewed from RTO A, one was a care worker also studying a Bachelor of Nursing,
one was a recently Endorsed EN (1-year post graduation), with limited experience in
the role, and one was a community AIN. The RTO B Certificate III course was
conducted part time over 19 weeks. The primary CF for this course was previously a
care worker, now identifying herself as a CF at RTO B. The AINs had no experience
with medications. Themes were identified using thematic analysis, as was previously
discussed in previous sections/chapters and can be seen in Table 6.13 below.

Table 6.13 Themes and subthemes from CF interviews.

Theme Subtheme

Pain identification and

assessment

Barriers Resident

Staff/Student

Competing priorities

Facilitators Experience

Education

Empowerment by RN

Pain management Non-pharmacological

management

Outcomes

Teaching strategies Barriers

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6.3.2.1 Themes and subthemes from CF interviews.
Theme – Pain identification and assessment.
CFs from both RTOs, reported that they spent time during the course and whilst the
students were on practical experience, educating them about how to identify pain
verbally and non-verbally (behaviours) and the importance of reporting findings. The
CFs were able to identify non-verbal signs of pain and describe verbal methods of
pain identification. CFs stated, that if they observed pain whilst they were with
students on clinical practice, they questioned the student about what they were
seeing and what they, (the student), would do about it. In RTO A, identifying pain,
both verbally and non-verbally, was part of the assessment for completion of the
certificate. A CF from RTO A (8262, p.4:19) stated that ‘I role model, I would say to
the student, I am going to do this now so come with me and watch what I do. So, I
am going to talk to the RN (about what I observed) and then you can come and
watch and see what I do’.

The CFs from both RTOs stated, that pain identification, assessment and
management forms only a small part of the palliative care approach module,
although CF (7942) from RTO B in 2016 had added a component to the module on
dementia after completing the University of Tasmania online dementia training,
where they discussed dementia as being a terminal illness. A CF from RTO A (5262,
p.4:5) reported, ‘that on the day that the palliative care module is undertaken, they
(the student) need to complete the whole module, so there is not a lot of time
dedicated to discussing pain. If you concentrated too much on pain, then other
sections would get missed’. A CF (7942) from RTO B commented, ‘It is not an
assessment completed during practical, because there are so many other
requirements (such as competency in activities of daily living skills) needed to be
assessed at this time’.

CF (8262) from RTO A (who is concurrently undertaking a Bachelor of Nursing

Degree), could discuss pain identification and assessment, including assessing pain
intensity, location and duration. This same facilitator was aware of the pain
assessment tools to use for both verbal and non-verbal residents, though she was
not able to name them. The other CFs from RTOs A and B would refer any pain

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identified to an RN within the facility they were site visiting and they would instruct
the students to do the same.

Theme – Barriers.
There were three barriers that CFs identified that could inhibit pain identification and
assessment: resident, student/staff barriers, and competing priorities.

Subtheme – Resident.
The CFs from RTO A and B identified, that the resident themselves can often
provide a barrier to pain identification, assessment and management. Reasons
included the fact that residents do not spontaneously verbalise about the presence of
pain and they may have dementia (55262, p.2:24). The language spoken by the
resident and their social/cultural practices may also influence how, or if they
verbalise about the presence of pain (55262, p.2:26).

It was identified by one CF (8262, p.2:11), that a resident may have multiple pain
sites (as can be the case with multiple comorbidities). Consequently, they find it
difficult to accurately identify and localise their pain and then also verbalise it.
Therefore, effective and appropriate management cannot be implemented.

Subtheme - Student/staff barriers.

Student and staff barriers identified by the CFs during the interviews included, staff
attitudes, lack of knowledge and competing priorities.

Staff Attitudes.
CF 5262 (p.2:12) observed, that sometimes the attitude of staff who were mentoring
students whilst they were on practical, may prove to be a barrier to students learning
about pain identification, assessment and management. For example, staff saying to
the students, ‘Oh don’t worry they’re not in pain (in relation to an observed
behaviour)’, may influence the student or less experienced AIN, to dismiss what they
have observed. This is also reflected in the student interview themes. CF 55262 (p
2:12), believed that students were underexposed to clinical skills, because staff can
become quite possessive of the residents, and that older care workers may say, ‘We
need to look after these people, you should just watch because we take care of
them’. So, they are not letting them do stuff as much as they should’ (CF 55262).
This correlated with two student reports, that students were just making beds for the

137
day (42515, p.2:22), or making teas and doing prep work because the facility was
understaffed (222715, p.1:47).

Students.
Students themselves may provide a barrier to pain identification, assessment and
management. CF 7942 (RTO B), expressed that particularly younger individuals,
may never have been exposed to an older person, or an older person who has
multiple comorbidities and frailties. This could be quite confronting for a young
person and result in an internal conflict. Alternatively, if that young person has had
some unpleasant life experiences, they may find it confronting caring for someone
who has chronic pain or illness and therefore avoid encounters by ignoring signs and
symptoms of pain.

Subtheme - Competing priorities.

Time and competing priorities have been identified as key barriers to pain
identification and assessment. CF 5262, felt that the routine of the workplace and
particularly the rush in the morning to complete tasks, meant that students would not
stop to recognise pain behaviours and instead become task focused. In addition,
CF8262 (p.2:16), who also worked as an AIN, thought that this same time factor and
work pattern of being task and routine focused, often resulted in delays in the
assessment of residents with pain for several hours.

Theme – Facilitators.
There were three facilitators that CFs acknowledged, that assisted the students to
identify pain in the older person. experience, education, and empowerment by the
RN.

Subtheme - Experience.
All CFs from RTOs A and B commented that experience, getting to know the
resident/client, is a really important step in being able to identify behavioural changes
in the resident that might relate to the presence of pain.

Subtheme – Education.
CF 8262 (p.2:39) felt that, education of both the resident and staff, was important for
the pain management process. Educating the resident about pain and the
importance of reporting pain as early as possible to the staff, so that a pain

138
assessment and management plan could be completed, would be of great benefit to
the residents. Educating the staff and students about pain, its identification,
assessment and management, was also important. Education strategies could
include, enhanced mentoring at the bedside during practical placement, to help
students identify different behavioural expressions of pain.

Subtheme – Empowerment.
CF 8262 (p.2:35) indicated during their interview, that if the AINs, worked in an
environment where the RN staff encouraged and empowered the AINs and valued
them for their contribution, then this would enhance the AINs’ practice. This would
empower the AIN, to be more proactive with care, and be more person-centred
instead of task-centred. They would also more readily report issues about resident
care.

Theme - Pain management.

All CFs from both RTOs were able to identify a multitude of non-pharmacological
pain management strategies. They acknowledged that analgesia was used
frequently as a pain management strategy. However, the CFs participating in the
interview process had little to no experience in this area, except for CF 8262 who
was undertaking a Bachelor of Nursing and had nursed her mother while she was
dying.

CFs could identify a number of non-pharmacological strategies including, heat

packs, massage, repositioning, diversion, music therapy and activities. However,
again, whilst the CFs were aware of these tools, they had had little exposure to
utilising them in their carer roles.

Theme – Outcomes.
All of the CFs from both RTOs could clearly tell the researcher what the impact of
poorly treated pain is on the older person. They could state that poorly treated pain
would impact on the physical, mental, spiritual and emotional well-being of a person.
It can lead to depression, debilitation, decreased ability to conduct own ADLs,
interruptions to sleep patterns and quality of life.

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Theme - Teaching strategies.
The CFs employed a number of strategies to assist students to be able to identify
and assess pain. These included

• Instruction through workbook content (CF5262).

• Role playing (CF5262).
• Role modelling (CF8262).
• Utilisation of real–life examples (CF8262).
• Questions whilst on practical (CFs5262, 55262).
• Pop quizzes (CF8262).
• Relating to their own personal experiences (CF8262).
• Getting to know their residents/clients, reading their care plans and talking to
them when possible (CF5262).
They suggested that there is also a need to be flexible in teaching approaches, as
the composition of a Certificate group is different from group to group. It is noted that
the majority of these techniques came from one or two CFs.

Subtheme - Barriers to teaching students about pain.

One CF (8262, p4:45) believed that the young students’ ability to be able to identify
behaviours and read body language, had been severely impacted by the increased
use of social media. They felt that social media, decreased the amount of face-to-
face contact younger generations have with other people, thereby decreasing their
ability to be able to read body language.

For those individuals who have English as a second language, there is often a lack
of comprehension and understanding of the process and procedures underlying pain
identification, assessment and management. CF 5262 (p.3:40) stated that often
these individuals need significant one-on-one time to help them complete and
comprehend tasks, information and assessment. However, resources in the RTOs
are not available to provide this one–on–one support.

As mentioned previously in student/staff barriers to conducting a pain assessment,

the attitude of the staff and mentors where students undertake their practical
placement, can also impact on the students’ beliefs, knowledge and attitude.

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6.4 Document analysis.
As part of the triangulation of data, the primary documents used for educating
Certificate III students in the area of pain identification, assessment and
management, were obtained and analysed using document analysis (Bowen, 2009).
The content of these documents was based on the unit CHCPA301B from
training.gov.au Deliver Care Services Using a Palliative Care Approach, and two
were related to Provide Support to meet Personal Care needs (CHCICS301B)
(Department of Education and Training, 2018).

RTO A provided a copy of the Learning Guide and Assessment workbook for the
Deliver care Services Using a Palliative Care Approach (CHCPA301B), which
contained the primary education and training content related to pain identification,
assessment and management. They also provided the learning guide and
assessment workbook for Provide Support to meet Personal Care needs
(CHCICS301B).

The Deliver Care Services Using a Palliative Care Approach Learning Guide
provided basic information in this module about pain and discussed the importance
of managing pain in relation to:

• quality of life and suffering;

• potential for people facing end of life to fear pain;

• it could be a physical symptom experienced, that requires attention;

• the care workers role, is to identify goal of care in care plan, observe for pain
report verbally, document findings, implement planned care and evaluate
care delivered;

• the importance of recognising pain and/or discomfort and reporting it to a

RN/EN;

• assessment tools that can be used to assess pain; numerical, verbal pain
assessment tools, and observation tools such as the PAINAD tool (Warden et
al., 2003) and Abbey Pain Tool (Abbey et al., 2004) and examples;

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 • it discusses observing for behavioural changes in a resident, but does not
cover detail about what regular or specific behaviours may be;

• management strategies including pharmacological and non-pharmacological

and instructs the student to follow what is outlined in the care plan;

• discussing the myths of pain;

• discussion of differences in older people and their under-treatment and

reluctance to take opioids;

• pain as a personal experience.

The accompanying assessment guide provided goals for the student to achieve
whilst on practical experience, which included responding to pain and other
symptoms of discomfort. It provides case studies that allow the student to explore
distress related to poorly managed pain (which may be physical and emotional). It
asks students to locate the organisational policy on pain management, identify the
assessment tools used by the organisation, discover who is responsible to report to,
identify the pain assessment flow chart and complete it with one resident, identify
four verbal and non-verbal signs of pain, discover reporting procedures, identify four
strategies for pain management and discuss myths. The student is provided with a
competency task sheet, which they are required to complete with an assessor during
their two weeks of placement.

In the learning guide and assessment workbook for Provide Support to meet
Personal Care needs (CHCICS301B) from RTO A, pain was mentioned in relation to
age or disease-related changes, pain that may be experienced during procedures
related to activity of daily living or procedures including application of compression
stockings. The only content about pain identification, was for the student to develop
their observational skills of identifying pain related behaviour changes. There was no
mention of pain in the associated workbook.

RTO B provided a copy of the power point presentation (ppt) that they use to present
the lecture on pain identification, assessment and management. This ppt
presentation was discussed during the discussion of the Deliver Care Services Using

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a Palliative Care Approach module. The ppt presentation discussed the fact that pain
is a common problem in palliative care, pain fluctuates and is a personal experience,
pain assessment includes assessing the physical, psychosocial, spiritual and
emotional components, the goal of pain management, is to help the individual to be
pain free and that to do this, the pain process of identification, assessment and
management should be followed. The ppt listed the different types of pain that can
be experienced. Different management strategies were discussed, including
pharmacological and non-pharmacological strategies. How to identify pain was also
discussed, including observational methods of identifying pain, and determining the
level of pain, its location and intensity for those who could verbally report, reporting
to clinical leaders and documentation. Pain tools such as the PAINAD (Warden et
al., 2003), visual analogue scale, graphic rating scale, faces scale, and pain location
chart were introduced. Finally, the ppt asked students to spend five minutes
discussing an instance when they were in pain.

6.5 Summary.
This chapter has presented the results of Phase Two of this research, which
examined the training provided by two RTOs offering the Certificate III in Aged Care.
The content for the Certificate III in Aged Care were based on the guidelines
provided by the Australian Government. This Phase, was aimed at identifying, how
current education strategies, are influencing the care workers’ ability to undertake EB
pain identification, assessment and management practices, once they enter the
workforce. The data collected in this Phase, demonstrated,that the information
provided during the Certificate III course regarding the identification, assessment and
management of pain is very basic, only forming one hour of the training, during the
undertaking of the palliative care module. The primary focus of this material, is to
educate care workers in the practice of identifying pain and reporting it to clinical
leaders, with little instruction regarding pain, its assessment or the use of
management strategies. Whilst the certificate course provides the basic knowledge
regarding EB pain management strategies in aged care, the majority of AINs obtain
knowledge about pain identification and management once they have commenced
work in the field and get to know the residents they care for. However, this
experience is not supported by further education in the workplace, of EB pain
managment practices. A number of barriers were also identified by students and

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their CFs (attitudes, English language comprehension, attitudes and beliefs [of
students and mentors], workplace environment), that impacted on the students/new
care workers ability to learn about pain, identification, assessment and management
processes.

CFs who provided education and support to the students during their certificate,
have some knowledge of pain management processes, but little experience in this
area of practice. This was particularly evident in the AIN trainers. During the
certificate trainig, they CFs did use a number of different teaching strategies.
Primarily strategies included discussing the resource based material (workbooks or
Ppt presentation). CFs from RTO A, also utilised a number of different strategies,
such as role playing or role modelling, to facilitate student learning. RTO A also
included a competency on developing pain identification, assessment and
management skills, during their students practical experience. Finally, the
documents utilised during the training of the students, analysed, provided further
evidence, to support the limitations of the information provided on EB pain
management practices during the certificate III course.

The following chapter (Chapter 7), contains the discussion, limitations and
recommendations of this research.

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 Chapter Seven: Discussion and Conclusion.
7.1 Introduction.
The poor recognition, assessment and management of pain in older people living in
residential care facilities (RCFs), has been acknowledged at both national and
international levels. Inadequate implementation of evidence-based (EB) pain
management practices and a number of individual and organisational factors, have
been identified as a contributing to continuing poor practice (Bruneau, 2014; Colón-
Emeric et al., 2016; Hadjistavropoulos et al., 2016; Savvas, Toye, Beattie, & Gibson,
2014a).

This research identifies, that maintaining EB pain management practices in aged

care is difficult, with a number of individual and organisational barriers at multiple
levels, impacting on practice. EB pain identification, assessment and management,
is therefore an ongoing problem for RCFs and therefore, by default, an issue for
residents. A significant organisational factor impeding the sustainability of EB
practices, is that care workers (AINs), who form the primary care workforce in RCFs,
are generally inadequately prepared to implement and maintain best practice pain
management strategies, in the current aged care environment, where older people
are living with multiple comorbidities (including dementia), geriatric syndrome and
frequently complex persistent pain. Current education strategies used by Registered
Training Organisations (RTOs) offering the Certificate III in aged care course,
provide AINs, with only rudimentary knowledge of how to identify pain (either verbal
or non-verbal identification), and briefly discusses available assessment tools and
management strategies. This lack of knowledge, about pain, its assessment and
management, is further compounded by a lack of education, either on orientation of
new staff members to a facility, or regularly during their time of employment.

Despite recognition of the issues adversely effecting pain management practices in

aged care and the development of resources to address these issues, little
advancement has been made in improving practice in this area. Thirty to eighty
percent of older people living in RCFs are still in pain (Goucke, 2018; Painaustralia,
2017). This creates a serious ethical issue for the aged care industry and providers
of care (Hadjistavropoulos et al., 2009). ‘Access to pain management is a human
right’(International Pain Summit Of The International Association For The Study Of
Pain (IASP), 2011, p. 11), which we are denying to older people living in RCFs
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(particularly those living with dementia), because of inadequate identification and
assessment of pain.

We (as health care providers), are also failing in a number of other key areas, with
continuing inappropriate pain identification, assessment and management. Firstly, in
our duty of care to keep older people living as well as possible in the RCF, and
promoting their psychosocial, emotional or spiritual well-being (Nursing and
Midwifery Board of Australia (NMBA). 2008). Secondly, we are also failing to meet
the Australian Aged Care Quality Agency (AACQA) accreditation standards.
Standard 2.8, which states that ‘All care recipients are as free as possible from pain’
(AACQA, 2014, p. 4).

To address the deficits in this area and assist facilities to implement and sustain EB
pain management practices, attention must be paid, not just to the development and
implementation of best practice guidelines, but all levels of the industry need to work
together, to examine the factors impacting best practice sustainability and develop
strategic plans to address these deficits. This would potentially, improve the quality
of life of older people living in RCFs and reduce unnecessary suffering.

7.2 Aim of the research.

The aim of this research was to examine the factors that are impacting the
implementation and sustainability of best practice in pain management in RCFs.
There is a lack of research that specifically relates to RCFs, in this area of care
(Colón-Emeric et al., 2016; Masso et al., 2014).

Specifically, this research project aimed to answer the following questions:

1. What individual factors impact direct care staffs’ ability to conduct evidence-
based pain identification, assessment and management practices for older
people in RCFs?
2. What organisational factors impact direct care staffs’ ability to conduct
evidence-based pain identification, assessment and management practices for
older people in RCFs?
3. How do current educational training practices for aged care workers, influence
their ability to conduct evidence-based pain identification, assessment and
management practices for older people in RCFs?

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7.3 Individual factors impacting direct care staffs’ ability to conduct EB practice.
Analysis of the data collected in both phases of this research, identified that
individual factors relating to the resident, staff, students/new care workers and CFs,
impacted the direct care staffs’ ability to conduct and sustain best practice. Resident
factors included, the presence of multiple comorbidities (including persistent pain),
dementia and language barriers, especially for residents from culturally and
linguistically diverse (CALD) backgrounds. Staff, student/new care worker and CF
related factors, included lack of knowledge, inappropriate attitudes and beliefs about
pain in the older person and people with dementia, or language and literacy barriers,
specifically related to staff from CALD backgrounds. Many of these factors have
previously been identified in the literature as impacting the pain management
process and the implementation of best practice in RCFs (Achterberg et al., 2013;
Bruneau, 2014; Goucke, 2018; Masso et al., 2014; Veal et al., 2018). However, what
this research adds, is that these factors continue to impact the sustainability of best
practice.

7.3.1 Resident.
Comorbidities/dementia/geriatric syndrome.
The demographic audit in Phase One of this research, established that residents
being cared for in this facility, experienced a significant disease burden, living with
more than three comorbidities, with dementia, cardiovascular and musculoskeletal
diseases being the most prevalent. The residents were also in the last six months of
their life, all had dementia and some had pre-existing comorbidities, associated with
altered mobility, falls, sensory impairment, depression and incontinence. Therefore,
geriatric syndrome was most likely contributing to their functional decline, frailty and
pain (Won et al., 2013).

The presence of multiple comorbidities, geriatric syndrome and dementia in older

people living in RCFs, has been identified and reported previously in this population.
Hillen et al. (2017) found that medical diseases of the circulatory, cerebrovascular,
musculoskeletal (arthritis), endocrine (diabetes) and neurological (Parkinson’s
disease) systems, were the most prevalent in RCFs in Australia. Geriatric syndrome,
which includes ‘incontinence, dementia, delirium, falls, pressure ulcers, visual and
auditory sensory impairment, sarcopenia, malnutrition, frailty, immobility, gait
disturbances and depression’ (Won et al., 2013, p. 336), is not recognised as a

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disease state. Its prevalence therefore in RCFs in Australia is unknown. However, its
existence, contributes to disability, frailty and decline in quality of life of the older
person (Hillen et al., 2017).

Particularly relevant to Australia, is that more than 50% of the RCF population live
with a form of dementia. Admission into care, often means that the dementia has
advanced to the point where the older person requires a higher level of care (Hillen
et al., 2017; National Centre for Social and Economic Modelling [NATSEM], 2017).
Higher levels of care, can also be attributed to (in this population), the coexistence of
other multiple comorbid diseases, as well as dementia, as Bunn et al. (2014) found
in their review.

Delivering best practice in pain management to individuals living in RCFs, requires

direct care staff to have an understanding, not only of the significant disease burden
of this population and its implication for the experience of pain, but also the
psychosocial, emotional and spiritual factors that can impact on the older persons
quality of life and pain experience. It also requires direct care staff to have an
understanding, that more than half of the residents they are caring for in a facility
have cognitive impairment, which will impact the resident’s ability to verbalise the
presence of pain. However, it has been clearly identified in the literature, that these
are the key areas of knowledge deficit in direct care workers (CNs/RNs/ENs & AINs)
in RCFs (Achterberg et al., 2013; Bruneau, 2014).

Pain.
In Phase One of this research, residents either had a known diagnosis of persistent
pain or a disease burden and psychosocial history, that would suggest that
persistent pain was likely. They were also entering the last weeks or months of their
lives, where the experience of pain may have been altered because of the dying
process. Multiple comorbidities, ageing, geriatric syndrome, dementia, psychosocial,
cultural, emotional and spiritual factors, and admission to an RCF, can alter the
experience and expression of pain (Campbell & Edwards, 2012; Charette & Ferrell,
2011; Goucke, 2018). This alteration in expression of pain by people with multiple
chronic diseases and dementia, (because of multifocal sites of pain), was
acknowledge by a CF in Phase Two.

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Spontaneous verbal reporting of pain, remains the gold standard process for
identifying and assessing pain. However, older people in RCFs form three distinct
groups when it comes to reporting pain: those that have the capacity to verbalise and
do self-report; those that have the capacity to self-report and don’t; and those without
the capacity to verbalise because of cognitive or physical impairments (Goucke,
2018). The latter two groups are often the most prevalent (Veal et al., 2018).

Where residents maintain verbal skills, staff rely on them to verbally report the
presence of pain, but many do not (Veal et al., 2018). Personal beliefs and attitudes
about pain, can influence their verbal reporting of pain, or taking of medication, as
was demonstrated in Veal et al.’s (2018) research.

In this situation, it is important that care staff ask the resident if they have pain, or
look for non-verbal pain behavioural cues, such as grimacing and vocalising, to
initiate a conversation (Goucke, 2018). Some of the participants from both Phase
One and Two, identified the importance of asking the resident about pain and
observing residents for pain related behaviour changes, whilst attending to care
needs of the resident/clients.

In addition to these individual factors, the presence of multiple comorbidities (as

identified in this research), can have further impacts on the experience and
expression of pain. The presence of other comorbidities can result in changes in the
significance of the pain being experienced. Older people may play down the pain
because of symptoms associated with other comorbidities, for example
breathlessness associated with chronic pulmonary disease (Molton & Terrill, 2014).
These same chronic diseases, when associated with persistent pain and age-related
physiological changes, can alter the perception of pain, meaning individuals do not
experience pain in the same way as those without disease. Consequently, older
people may report pain less often (Hadjistavropoulos et al, 2009), meaning care staff
need to be vigilant in asking residents about the presence of pain or observing for
behaviours of pain (as identified by the students in Phase 2).

It is well documented, that the presence of dementia significantly impacts the

individual’s perception, interpretation and verbalisation of pain, particularly as the
dementia advances. All of the residents included in Phase one had a diagnosis of

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dementia, but dementia of different types, which will impact the way that the
individual experiences and expresses pain (Achterberg et al., 2013).

It is also well documented, that direct care staff (specifically AINs), have difficulty
with identifying and assessing pain, particularly in people with moderate to severe
dementia (Corbett et al., 2014; Goucke, 2018; Herr, 2011; McAuliffe et al., 2012).
This was confirmed by data from this research. AINs involved in Phase One and the
students/new care workers in Phase Two, clearly acknowledged the difficulties
associated with identifying pain in the person with moderate to severe dementia,
particularly when the behaviours were not clear, were associated with confusion,
agitation and/or aggression.

These findings highlight the fact that, despite it being common knowledge in the
health care industry, about the difficulty of identifying, assessing and managing pain
for older people with advanced dementia, the current strategies to improve practice
in this area (education, development of best practice guidelines and development of
observational assessment tools), are not effective. As suggested by the AINs in
Phase one, more one-on-one individualised training, would assist AINs to identify
pain in people with advanced dementia. However, whilst this would certainly improve
knowledge and skills, it is unlikely to be a viable option for RCFs, because of
resource availability and funding. It may be best addressed in the training that they
receive during their certificate, through an increased focus on competencies.

Culturally and linguistically diverse residents – Language.

Care staff in Phase One, identified that assessing pain in and caring for people from
CALD backgrounds was a challenge, primarily because of language barriers. The
difficulty associated with caring for people with pain from CALD groups, has been
highlighted in the Pain in Residential Aged Care Guidelines (PRACMS) 2nd ed.,
(Goucke, 2018) and in a literature review by Shavers, Bakos and Sheppard (2010).

Twenty percent of older people living in RCFs in Australia are from CALD
backgrounds (Goucke, 2018). Many CALD individuals revert to their first language,
which may even be a dialect of their home country (FECCA, 2015). This makes
communication (an important part of pain assessment), difficult.

Language barriers associated with CALD groups, are easily identified. What is not so
evident, is the variation in beliefs and attitudes about pain and its management, held

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amongst the different cultural and religious groups, in the population. There may also
be large diversity in the attitudes and expectations of the individual and their
significant others, regarding the treatment of pain, particularly use of medication. All
of these factors can also be impacted on by gender, socioeconomic status,
education, religious beliefs and dementia, which further complicates pain
assessment and management in this group (Brady, Veljanova, & Chipchase, 2017;
Shavers et al., 2010). These beliefs, attitudes, psychosocial, cultural factors and
dementia, may determine how pain is experienced and expressed by the person
from a CALD background, subsequently impacting on the direct care staff’s ability to
appropriately and accurately identify and assess pain (Brady et al., 2017; Goucke,
2018).

Poor identification and assessment of pain in the CALD group of residents living in
RCFs, may be further complicated, by a lack of culturally appropriate pain
assessment tools for both verbal and observational assessment of pain (Corbett et
al., 2014; FECCA, 2015). In aged care in Australia (including in the facility involved in
Phase one of this research), the Modified Brief Pain Verbal Inventory (M-BPVI) for
people who can verbalise, the Abbey Pain Scale (Abbey et al., 2004) or the PAINAD
tool (Warden et al., 2003), are the tools discussed and recommended by both the
Department of Health and the APS for assessing pain in RCFs in Australia (Goucke,
2018). The Abbey tool has been translated in to Japanese, and the PAINAD tool has
been translated into German, Chinese, Dutch, Portuguese and Italian (Carezzato,
Valera, Vale, & Hortense, 2014, p. 100). However, these tools are not commonly
used in practice. This may be due to lack of knowledge regarding the presence of
these different tools for different cultural groups, accessibility of these tools to RCFs
and the lack of empirical research into the use of these tools in an Australian context
(Givler & Maani-Fogelman, 2018; Goucke, 2018). In addition, as identified in this
research in Phase one and by Peisah et al., (2014), pain management practices in
RCFs, are often driven by regulatory requirements of the ACFI or accreditation, not
by a person-centred model of care.

There has been no empirical research conducted in Australia examining CALD

groups and pain management in RCFs, only in the community (Brady et al., 2017;
FECCA, 2015).

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What do these findings tells us?
RCFs are unique in that they are not only a place of work for staff, but they are also
a resident’s home. Whilst previous studies on organisational learning and sustaining
best practice in RCFs, have concentrated on the role staff play in sustaining
knowledge (Berta et al., 2005; Virani et al., 2009), in regards to pain identification,
assessment and management, residents and their significant others also form an
important part of the membership group in the active organisational context.

They do this by reporting episodes of pain (where possible), participating in

assessment and management strategies (where possible) and contributing to the
experience gained by staff, whilst they are undertaking pain identification,
assessment and management practices (Argote & Miron-Spektor, 2011; Goucke,
2018; Veal et al., 2018). The presence of multiple morbidities, geriatric syndrome,
dementia, being from a CALD background, language barriers, having persistent pain,
holding different attitudes and beliefs about pain and other psychosocial, emotional
and spiritual issues, can impact on their ability to actively participate in this process
(Colón-Emeric et al., 2016; Veal et al., 2018). Inability to fully participate in the
process, disrupts the network that is usually formed between members, tools and
tasks in organisational learning (Argote, 2013). Ultimately, this impacts on the ability
of direct care staff to gain experience and acquire knowledge of pain management
processes and contribute to ongoing organisational learning.

Accurate EB identification and assessment of pain, is also required, so that a

comprehensive biopsychosocial management plan can be developed and
implemented. Language barriers, lack of knowledge of cultural disparities and use of
the CALD appropriate assessment tools, may not only result in inadequate
assessment of pain for the older person from the CALD background, but also mean,
that knowledge that may be stored in the CALD assessment tools, that may assist
direct care staff to learn and gain experience in the assessment of pain in CALD
groups, is not available, further impacting ongoing organisational learning.

7.3.2 Direct care staff/students/new care workers/CFs.

Individual factors such as the language and literacy, knowledge, experience, beliefs
and attitudes of direct care staff, student/new care workers and CFs, were found to
impact the sustainability of EB pain management practices, during this research.

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These factors have previously been identified as impacting pain management
practices in RCFs (Bruneau, 2014; Goucke, 2018; Hadjistavropoulos et al., 2016;
Kaasalainen et al., 2010; Tse & Ho; Veal et al., 2018). Resources such as best
practice guidelines and training tools, have been developed to address these issues.
However, the results of this research indicate these factors continue to impact on
practice. If the industry is to sustain EB pain management practices, then the
individual factors related to direct care staff identified in this research - language,
literacy, knowledge, experience, beliefs and attitudes, require further consideration.

Knowledge/Application of knowledge.
In this research, both the direct care workers involved in Phase One (ENs and AINs)
and the students/new care workers, workplace mentors and some of the CFs in
Phase Two, demonstrated a lack of knowledge of pain in older people, pain in
people with dementia and the identification, assessment and management process.
In Phase One, AINs stated that, they required more education on how to, correctly
identify behaviour changes in people with dementia, how to apply knowledge and
how to use observational assessment tools. Lack of knowledge was also identified
amongst the different staff members (PT, CN and AINs) in Phase One.

In Phase Two, students/new care workers who participated, both during their training
and post entry into the workforce, demonstrated changes (some of which were
statistically significant), in their knowledge across all three time points in two
questionnaires. However, on further examination of student diaries and data from the
interviews, students/new care workers demonstrated a lack of knowledge around
identifying, assessing and managing pain, particularly in people with moderate to
advanced dementia. Likewise, some of the CFs directly involved in educating
students, showed a lack of knowledge in the same areas (as can be seen in their
questionnaire responses).

Knowledge of pain its identification, assessment and management, has been

examined in previous research involving nursing managers and direct care staff
(RNs, ENs or AINs), working in aged care (Barry, Parsons, Passmore, & Hughes,
2012; Brorson, Plymoth, Ormon, & Bolmsjo, 2014; Ghandehari et al., 2013; Hughes,
Bagley, Reilly, Burns, & Challis, 2008; Jansen et al., 2017). However, there is a lack
of research, examining the change in knowledge in the student undertaking their

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vocational certificate in care work, during their course and immediately post
completion (Mavromaras et al., 2017; Tse & Ho, 2014).

Lack of knowledge regarding pain and its identification, assessment and

management (particularly for older people living with dementia) in this part of the
health sector and the application of this knowledge, has long been identified as a
barrier to appropriate pain management (Achterberg et al., 2013; Ahn & Horgas,
2013; K. Holloway & McConigley, 2009; Kaasalainen et al., 2010). The reasons for
knowledge deficits have been related to, lack of utilisation of best practice resources;
lack of education, mentoring and training of all direct care staff; ineffective leadership
by managers or clinical leaders; and high staff turnover (Barry et al., 2012; Colón-
Emeric et al., 2016; Jansen et al., 2017; McAuliffe et al., 2012). These are similar
factors to those identified as impacting on the sustainability of EB practice (Fleiszer
et al., 2015b; Wiltsey Stirman et al., 2012).

Attempts have been made to address these knowledge deficits, through the
development of guidelines, protocols, education, training modules and materials,
both here in Australia and internationally (Abdulla et al., 2013; American Geriatric
Society Panel on the Pharmacological Management of Persistent Pain in Older
Persons, 2009; Edith Cowan University, 2007; Ghandehari et al., 2013; Goucke,
2018; Hadjistavropoulos et al., 2016; Herr et al., 2011; Kaasalainen et al., 2010).
However, the aged care industry continues to face the same issues regarding
knowledge and application of knowledge in RCFs, as evidenced by the ongoing
need for improve pain management processes, through the development of more
resources, particularly for people with persistent pain and those with dementia
(Goucke, 2018; Hadjistavropoulos et al., 2016; Painaustralia, 2017) and the results
of this research.

Gaps in knowledge can be addressed with education, training and mentoring, by

utilising the various resources that are available. Educational provision is particularly
important for the continued education of care workers, such as AINs, the primary
care givers in the Australian aged care industry. This group of direct care workers,
receive only basic training in pain management practices (1 hour of content), during
their Certificate, as identified in Phase Two. However, of crucial importance, is
understanding why knowledge about pain and best practice pain management

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strategies, gained through education, whilst initially leading to a change in practice is
not sustained, and identify what can be done to improve the long-term sustainability
of the new practice.

Strategies that could improve the sustainability of EB pain management practices

and organisational learning, may include: education, the provision of resources and
time for regular education in RCFs, the availability of a suitably qualified Clinical
Nurse with expert knowledge in pain management practices, pain in older people,
pain in people with dementia and CALD groups, who could help promote the practice
in the facility. The designation of number of pain champion roles, may help the
knowledge and information about the practice, be more widely disseminated
throughout different receptacles and result in more promotion of the practice (Virani
et al., 2009). These individuals could also help mentoring new staff (though the
presence of two pain champions in Phase One, appeared to have limited impact on
the sustainability of EB practices in that facility).

A managerial and leadership team that engage with direct care staff (particularly with
the AINs), and support the new practice, has been known to promote changes in
practice (Colón-Emeric et al., 2016; Goucke, 2018; Maas, Specht, Buckwalter,
Gittler, & Bechen, 2008a, 2008b). The CN in Phase One, particularly demonstrated
this strategy, with their constant engagement with the AIN staff and promotion of
pain management practices through conducting toolbox training, developing a
number of communication strategies, to remind care staff of resident assessment
needs and being easy to approach by the AIN staff. Though clearly the utilisation of
these strategies was not enough to sustain EB practices in this facility.

The implementation of these different strategies (education, clinical experts and pain
champions), would potentially contribute to continuing organisational learning and
sustaining of best practice, by allowing a number of different receptacles to retain the
knowledge of the practice and allow people such as the clinical expert and the pain
champions, to support other direct care workers in the undertaking of the clinical
practice (Argote, 2013).

Findings from this study indicate, that knowledge and experience were also
considered a facilitator to the identification, assessment and management of pain.
Phase One staff noted, that they gained more experience and knowledge about the

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processes involved in pain management, once they had worked with residents and
got to know them. Similarly, students/graduates from Phase Two, reported that the
Certificate course provided them with the basic knowledge of how to identify pain in
verbal and non–verbal residents, which gave them a good grounding for their
practical experience and once they were working. Students/new care workers, also
commented, that working with the residents improved their knowledge and
confidence in this area. Caring for the residents (gaining experience) and getting to
know residents, has been shown to help AINs particularly, to identify changes in the
residents’ behaviour (Ghandehari et al., 2013; K. Holloway & McConigley, 2009) and
contributes to organisational learning through the AINs gaining of experience, by
working with different residents.

Beliefs and attitudes.

Beliefs and attitudes held by direct care staff, about pain in the different groups in
RCFs and about pain management strategies, has previously been identified, as a
factor impacting on EB pain management practices (Achterberg et al., 2013; Douglas
et al., 2016; Veal et al., 2018). Altered beliefs and attitudes, about pain and its
management in older people and people with dementia living in RCFs, was evident
in Phase Two. Not in the student/new care worker questionnaire data on attitudes
and beliefs, but in their diaries and interview data. Students also reported in their
interviews, some of the altered beliefs and attitudes held and expressed by the direct
care worker staff mentors available during their practical experience.

Whilst education has been shown to improve health care workers beliefs and
attitudes in the short term (Ghandehari et al., 2013; Tse, Vong, & Ho, 2012), long
term retention of knowledge and change of beliefs and attitudes about pain in the
older person and management of pain, have not been empirically researched.
However, inappropriate beliefs and attitudes about pain in older people and people
with dementia, can impact on the identification, assessment and subsequent
management of pain (Tse & Ho, 2014). This was evident in Phase Two, where the
students reported on the facility care staff’s attitude and beliefs about pain in older
people and people with dementia.

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Language and literacy of the direct care worker.
Aged care is increasingly reliant on a migrant workforce, largely as a direct
consequence of poor funding to this health sector and workforce shortages (Nichols,
Horner, & Fyfe, 2015). In 2016, 32% of the RCF workforce in Australia were born
overseas. For the majority of these care workers, English was their second language
(Mavromaras et al., 2017).

Thirty-eight percent of the care workforce in Phase One and 23% of students in
Phase Two (at TP1) (similar to the national average), were from a non-English
speaking background. Clinical and managerial leaders in the facility in Phase One
reported, that communication skills and the migrant workers’ ability to comprehend
both written and spoken English, often posed a challenge in day-to-day care. In
Phase Two, CFs in RTO A specifically, reported that if the student was from a CALD
background, there was often a lack of comprehension and understanding of all
learning material. CFs stated that these individuals often needed significant one-on-
one time to help them complete and comprehend tasks, information and
assessments. However, resources in the RTOs were not available to provide this
one–on–one support and assist the students to learn the required material. Students
were left to progress through the learning material on their own. This highlights the
fact that, there is a significant gap here in meeting the needs of the migrant care
worker, who often make up 25% of a student group (as seen in this research). Lack
of understanding and knowledge by migrant workers, in areas of care, may not only
significantly impact the delivery of EB pain management practices, but also quality
safe care for older people living in RCFs.

As the number of CALD residents residing in RCFs increases in Australia (AIHW,

2017; Goucke, 2018), having direct care staff that are linguistically diverse is
important, as they are able to communicate with residents from similar CALD
backgrounds. It also helps to increase the workplace understandings about different
cultures. However, diversity in the workforce also brings its challenges, in
communication, and developing a workforce and workplace culture, that embraces
mutual respect for each other and the multicultural nature of the facility (Mavromaras
et al., 2017; Nichols et al., 2015).

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Communication and comprehension of written documentation by direct care staff,
identified in Phase One of this research, by both the CM and CN, impacted on
practice and care of the residents. Communication, literacy and comprehension of
both spoken and written English is important to many processes in Australian RCFs.
They allow care staff to be able to communicate with the majority of residents and
their families, other staff, follow directions and meet requirements of care, participate
in education and accreditation tasks in the workplace, and accurately document in
resident records (Mavromaras et al., 2017). It has been noted in a report by the
Department of Social Services (2015), that improving communication, language and
numerical literacy across the aged care workforce, is an ongoing issue that needs to
be addressed, but is particularly relevant in the migrant workforce (Mavromaras et
al., 2017).

Mavromaras et al. (2017) reported, that migrant care workers in aged care could
read and speak English well–very well, but found writing English more difficult
(Mavromaras et al., 2017). However, this was not supported by managers of facilities
who in the same research, reported that communication difficulties existed between
the AIN and the leadership group, other staff within the facility, residents and
resident families. Written language however, was good (Mavromaras et al., 2017).

There is a lack of research in aged care regarding the migrant direct care workers
and the delivery of best practice quality care. This includes, how having English as a
second language (ESL), impacts on verbal and nonverbal communication in complex
areas of care, such as that required in the pain management process. There is also
no research relating to how migrant workers’ cultural and or religious beliefs, impact
on these processes.

If there are difficulties in communication between ESL direct care workers, residents
and other staff (as indicated in the 2017 Mavromaras et al. research and as reported
by clinical leaders in Phase one of this research), it would seem impossible for the
pain being experienced or expressed by the resident (either verbally or non-verbally),
to be identified correctly by the migrant care worker and reported. Not only because
of language barriers, but also because, Caucasian Australians and CALD individuals
may experience, express and report pain very differently (Brady et al., 2017).

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In addition, there may be negative reactions from some residents to the migrant care
worker, depending on the resident’s nationality or cultural heritage. This may
influence what the resident verbally expresses to the care worker, or influence how
the resident (particularly those with dementia), may behaviourally respond to the
migrant care worker, particularly if they have had previous negative experiences or
hold certain beliefs about a particular cultural group (Nichols et al., 2015). These
responses by the resident to the migrant worker, may influence how pain is
expressed verbally or non-verbally to the direct care worker, or influence how the
migrant care worker may report the behaviour. Ultimately resulting in, inappropriate
and inadequate identification, assessment and management of pain.

What do these findings tells us?

Knowledge, beliefs and attitudes about pain have been known to improve in the
short term with education, but deficits in more complex areas of care associated with
pain, such as persistent pain, pain in advanced dementia and CALD groups are still
prevalent (Ghandehari et al., 2013; Savvas et al., 2014b). AINs particularly, obtain
knowledge about pain management practices through experience and exposure to
different residents (K. Holloway & McConigley, 2009; Liu, 2013). However, the
factors that have been identified here under staff barriers, may impact on how
knowledge regarding pain management practices is attained, retained and
transferred (Argote, 2013), particularly amongst the AIN group.

There are major factors here impacting on the sustainability of best practice and
organisational learning. Care workers receive only basic training about pain
management practices (1 hour of training in the whole Certificate III course). The
interview of participants in Phase One and Two, demonstrated that there were gaps
in the knowledge of care workers regarding pain in older people, pain in people with
dementia and the identification, assessment and management of pain, which even
the participants identified. Yet AINs are the primary care givers of all residents in
aged care, who mentor and train new graduate AINs, student AINs, undergraduate
registered nurses and new AIN staff. AINs new to a facility (or community service),
are not educated about pain management processes on commencement at a facility
and ongoing formal education provided by organisations, is minimal. Therefore,
maintenance of knowledge about EB pain management practices is poor.

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In addition, if direct care staff hold different attitudes and beliefs about pain in older
people and people with dementia, or staff have inadequate literacy and language
skills, tasks associated with pain management processes, that is the identification,
assessment and management of pain, will not be completed or completed
inadequately. This will further impact knowledge attainment and organisational
learning, that is normally gained through the completion of tasks (Argote & Miron-
Spektor, 2011). Networks that are normally formed in an organisation between the
members, tools and tasks, will also be affected and there will be an inadequate
transfer of knowledge between the organisational context and the active context.
This will further impact knowledge retention and transfer, the sustainability of the
practice and organisational learning (Virani et al., 2009).

7.4 Organisational factors impacting direct care staff’s ability to conduct EB practice.
This research identified that external environmental factors such as the aged care
funding instrument (ACFI), access to GPs, and external specialist clinics, impacted
on the maintenance of EB pain management practices. Internal organisational
contextual factors impacting on the maintenance of EB practice included: the
physical structure of the facility, staffing models, organisational culture, leadership
strategies, policies and procedures, communication strategies, competing priorities,
assessment tools and processes, continuity of care and education.

Argote and Miron-Spektor (2011), discuss how the environmental context (external
to the organisation) and the internal organisational context (though active and
inactive components), can impact organisational learning. This will be explained in
more detail in the following sections. These external and internal organisational
factors, have also been identified by Bond et al., (2014), Colón-Emeric et al., (2016);
Fleiszer, Semenic, Ritchie, Richer, and Denis (2015b), Perry et al., (2011) and
Wiltsey Stirman et al., (2012), as being essential to the sustainability of best practice
in any health care setting.

7.4.1 Environmental context (external to the organisation).

Aged Care Funding Instrument (ACFI).
Care provision in RCFs is supported through the ACFI. Individuals entering aged
care are assessed using the ACFI, which is then used to determine the level of care
required and the amount of funding provided, for delivery of care. The greater the

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dependency of the individual, the higher the level of care needed, the higher the
funding provided (Department of Health: Ageing and Aged Care, 2017).

This research found that assessment and management of pain in the facility in
Phase One, was driven primarily by the funding able to be generated, from
completing the ACFI. The CM used information from the resident’s history regarding
the comorbidities, to request that direct care staff undertake a pain assessment, so
funding could be claimed for pain management under complex health care. It was
unclear, if this practice impacted on the delay in residents receiving an admission
pain assessment, within the first days of admission to the facility.

Initial and ongoing pain assessment and management strategies used in the facility
in Phase One, appear to be primarily driven by the ACFI and accreditation standards
requirements, not person-centred care (AACQA, 2014; Department of Health:
Ageing and Aged Care, 2017). In Phase One, the majority of pain assessments
conducted, were during the admission period (10 – 30 days after admission to the
facility) and during the six-monthly reviews, with a small number of formal
assessments (using recognised tools), undertaken with episodes of pain. This
relates to what Peisah et al. (2014) also noted in their research, pain assessments
and management tasks are completed because of regulation requirements, not
person-centred care.

The ACFI funding, supports a medical model of pain management based on passive
management strategies, such as the use of medication, TENs machines and heat
packs (primary strategies used in Phase one). These are required to be delivered by
a RN, CN or PT (as was the case in Phase One), to achieve maximum funding
(Department of Health: Ageing and Aged Care, 2017). The guidelines also state, that
a baseline assessment, a care plan and ongoing evaluation is required, to meet the
standard.

Passive strategies such as medications, TENs and heat packs however, do not
follow current EB pain management practices for persistent pain in older people,
which centres on a biopsychosocial model of management. A biopsychosocial
approach to pain management involves, physical activity and psychosocial support
(Goucke, 2018; Goucke et al., 2005; Kress et al., 2014; Main, Sullivan, & Watson,
2008; Painaustralia, 2017).

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Use of these passive strategies only, potentially contributes to a greater level of
disability and suffering for the residents. This was a particularly important point
raised by the PT in Phase One, who discussed (with fervour), the barrier that the
ACFI presented, because it discourages the use a model of active care (mobilisation
and physical activity) and promotes physical dependency.

This promotion of dependency and lack of implementation of best practice, using

physically active strategies for the management of pain in RCFs, is something that
industry experts from Painaustralia and the Allied Health Professions Australia
group, are currently petitioning the government about. (Stoyles, 2017). Persistent
pain experienced by older people in aged care, is acknowledged as being best
managed with a biopsychosocial approach (Egan, 2016; Goucke, 2018;
Painaustralia, 2017).

The claiming of funding support for complex health care by using these passive
strategies, was also demonstrated in Phase Two. A new care worker stated that in
the facility they were working in, heat packs were administered by a physio aide on a
schedule, not PRN. The new care worker reported, that residents received the heat
pack whether they wanted it or not. If they refused, then it was still signed off as
having been delivered which meets the criteria for funding.

7.4.2 Organisational context (internal).

The latent and active components of the organisational context, can impact on best
practice sustainability, by inhibiting or promoting knowledge retainment and transfer
(Argote & Miron-Spektor, 2011; Virani, 2012; Virani et al., 2009).

The latent contextual factors identified in this research included, the physical
structure and layout of the building, staffing models and skill mix, resident
demographics (previously discussed), protocols and policies, organisational culture,
leadership, available assessment tools and communication strategies. The identified
active contextual factors included, which direct care staff members were allocated to
use the tools (pain assessment tools and pain management strategies), when and
how were the tools used in undertaking pain management related tasks.

The undertaking of the pain identification, assessment and management tasks, by

the direct care staff and the use of the tools during the process, develops networks
and relationships between residents, staff, the tools and the tasks. This process

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allows staff to gain experience, store, retrieve and transfer knowledge, which should
contribute to ongoing organisational learning about pain management practices
(Argote & Miron-Spektor, 2011).

However, in RCFs, the AINs role, is to identify pain and then report it to the
EN/RN/CN, as described by the participants in both Phase One and Two. Once that
process is over, they are not typically involved in undertaking assessments, or
contributing to the development of the plan of care (though AINs in Phase one did
undertake pain assessment tasks). They are also likely to have, minimal involvement
in implementing any pain management strategies. Therefore, the experience (and
knowledge) that would be gained by the AINs completing or being involved in the
pain assessment and management process, is absent and there is disruption of the
identify pain, assess pain and manage pain cycle.

Staffing models and skill mix.

Staffing models, levels and skill mix, were key elements impacting the delivery of
care in the facility in Phase One of this research and were identified by the students
during their practical experience in Phase Two, as impacting care. Staffing models,
level and skill mix of direct care staff, also impact knowledge attainment, retention
and transference of knowledge, within the organisation and impact the ability to
sustain EB pain management practices (Virani et al., 2009).

Staffing levels, skill mix and models, have been previously identified as impacting the
quality of care, and the implementation of EB pain management practices
(Hadjistavropoulos et al., 2016; Maas et al., 2008b; Perry et al., 2011; Verbeek et al.,
2013; Virani, 2012). The Australian Productivity Commission and previous Senate
Inquiries within Australia, have identified inadequate staffing levels and skill mix, as
impacting on the delivery of quality safe care in RCFs, with no government action
taken to address this problem to date (Willis et al., 2016).

AINs in Phase One discussed, how they often worked short staffed and how this
meant that they had the same workload but with fewer staff. Consequently, their
ability to then undertake tasks such as pain identification and assessment, evaluate
the effectiveness of strategies that had been implemented, or even return to check
on residents, was hindered.

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In addition, the AINs’ ability to provide care and carry out pain assessment or
management tasks in a timely and appropriate manner, was further impacted by the
physical layout of the facility. Residents were either in their own rooms during the
day or in common spaces but had to be returned to their room, for care. Staffing
level and models, meant that many residents were out of visual range for frequent
observation by staff, while other resident cares were being attended too.

The physical structure of the facility in Phase One, with nurses’ stations being away
from the resident rooms, also meant, that there was often delays in reporting
episodes of pain, either verbally or in writing, or documentation was completely
missed. This occurred particularly during the morning routine, as resident acuity,
competing priorities and time pressures, meant that AINs were not able to leave the
floor to document episodes of pain in progress notes, until later in the shift, as
computers required for documentation, were only located in nurses’ stations.

Comments from students/new care workers in Phase Two, also supported this claim,
of a delay in reporting observed incidents of pain. They stated in their interviews, that
observed behaviour changes or complaints of pain, were often not reported until the
completion of the morning routine - washing, toileting, showering, dressing and
placements in dining rooms for meals (a delay of one to two hours), so as not to
interrupt workflow and job requirements.

Lack of human resources and skill mix was particularly evident in the facility in Phase
One regarding RNs. At the time that the research was being conducted, the CN was
covering two roles, that of the CN and that of the RN in all three high care clinical
areas. This was because the facility had been unable to find an RN to fill the vacant
position during the day. The CN reported, that this frequently meant that following up
on reports of pain were delayed because of competing priorities. They also had little
opportunity to monitor AIN practices or their completion of pain assessment or
management tasks.

Henderson et al., (2017) identified in their research, that staffing levels, skill mix and
increasing levels of resident acuity, significantly impacted the ability of direct care
staff to provide timely and appropriate care to residents. This resulted in care being
missed at least part of the time, with unplanned and rehabilitative care missed
predominately (Henderson et al., 2017).

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These factors, staffing levels, skill mix, resident acuity and competing priorities, could
be the reason behind why so many episodes of pain were missed or improperly
assessed in Phase One. Missed care opportunities as discussed by the AINs,
RNs/CNs in Phase One, also impacted on the direct care staff’s ability, to gain
experience in completing the pain identification, assessment and management tasks,
and build on individual and organisational knowledge.

The current trend in aged care services in Australia, is a reduction in the number of
RN/ENs and an increase in the number of care workers (AINs). The reason for this
trend in staffing for aged care, has been related to funding and difficulty in recruiting
suitably trained RN/ENs to the sector (Australian Nursing and Midwifery Federation.,
2016; Bonner, 2017; Hillen et al., 2017; Mavromaras et al., 2017; Productivity
Commission., 2011).There are no mandatory ratios in aged care, meaning that RNs
often care on average, upward of 59 residents on one shift (Willis et al., 2016).
These residents often have high care needs.

Reductions in the level of qualified nursing staff (RNs/ENs), is a significant issue for
the delivery of quality and safe care to the most vulnerable people in the population
(Aiken et al., 2017; Harrington et al., 2012; Maas et al., 2008b; Willis et al., 2016).
AINs, although delivering the majority of care in RCFs, are inadequately prepared
during their training to understand disease processes, assess pain and develop
plans of care, without the instruction of qualified nursing staff (Department of Social
Services., 2015; Willis et al., 2016).

The current level of staffing, skill mix and model of care, does not have the capacity
to sustain EB practice, organisational knowledge or learning. Certificate III/IV care
workers do not learn about EB practice during the current certificate
(https://training.gov.au /Training/Details/CHCPAL001), how to implement or maintain
best practice strategies in the workplace, or how to teach or mentor other AINs.
RNs/CNs, are not only required to manage large numbers of residents with high care
clinical needs, but other duties that are indirectly related to clinical care. For
example, the CN in Phase one, was not only fulfilling the role of RN, by being directly
involved in patient care, but they were also required to lead and monitor the care
provided by the AINs (often missed), attend to documentation related to ACFI,
interact with residents families and other visitors to the facility (including GPs) and

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complete other administrative requirements (Bonner, 2017; Henderson et al., 2017;
Willis et al., 2016). These types of demands, do not leave RNs/CNs a lot of time to:
consistently participate in implementation of new EB strategies, integrate new
strategies into previous practice, monitor the new practice and evaluate care
outcomes related to the new practice (Masso et al., 2014). These are all strategies
which are part of the requirements for implementing and sustaining best practice
(Wiltsey Stirman et al., 2012).

A second trend in aged care facilities, is to admit older people who have higher care
needs, as this attracts more funding. Higher care needs mean, that older people
have more chronic comorbidities (as identified early in Phase One of this research
and in research conducted by Hillen (2017)), that require management. The resident
is more likely, to be living with moderate to advanced dementia, with significant
behavioural and psychological symptoms of dementia (BPSDs), as these types of
residents also attract more funding support through ACFI, and often require in care
in a RCF, because they cannot be managed in the community (Willis et al., 2016).
Additionally, as older people are staying at home longer with community support
services, they are often admitted to RCFs in the last year of their life, when a
palliative approach and end of life care is required. This is proven by the fact that in
2011 approximately 27% of older people died within six months after admission to
aged care, and a further 11% within 12 months (AIHW, 2012). Whilst the acuity and
dependency of the resident has changed, staffing models have not, and they are
inadequate to meet the increasing care needs of the older person now being
admitted to RCFs (Verbeek et al., 2013; Willis et al., 2016).

Leadership.
In Phase One, the CN in the facility, lead the team with a supportive leadership style.
Supportive leadership has been known to promote the sustaining of EB practice and
the delivery of quality care (Colón-Emeric et al., 2016; Havig, Skogstad, Kjekshus, &
Romøren, 2011; Virani et al., 2009). The supportive leadership style, creates a
balance between both a task-orientated type of leadership and a relationship-
orientated type of leadership. This has also been shown, to be the best style to
promote quality care , meet outcomes in the aged care environment and work with
current staffing models in aged care, residents and their families (Havig et al., 2011).

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The CN in Phase One, was present during the EBPRAC project and became a pain
champion for the facility. They understood the importance of maintaining the pain
identification, assessment and management processes, and attempted with their
limited time, to promote the practice. This was done through conducting toolbox
training (though the content and frequency of these training sessions were not
recorded), setting up reminders for the staff about pain assessment tasks through
the iCARE system, placing reminders on the white board in the nurses’ station about
current pain assessments, and giving verbal reminders to the AINs. Their role did not
involve auditing.

The AINs in this facility, reported that they felt supported by the CN and comfortable
to approach them with reports of incidents or changes in residents’ conditions. The
care manager, whilst a leader, had little day-to-day clinical input apart from ACFI
related assessments and overall management of day to day running of the facility.

The biggest barrier for the CN in this research, to promote best practice principles
and organisational learning in pain identification, assessment and management with
the other direct care staff, were the staffing levels and competing priorities (being the
only RN/CN on the floor for 75 residents). Another barrier voiced by the CN, was the
difficulty in gaining access to other health resources (GPs and external pain
specialist providers), which restricted them from delivering prompt EB quality care.

CF’s in Phase Two, commented that the style of leadership and particularly how the
RNs/CNs treated and supported the AINs, had an impact on staff behaviour,
particularly in regards to the reporting of changes in residents’ conditions. Marchionni
& Ritchie (Marchionni & Ritchie, 2008) identified that leaders in aged care who
create a supportive organisational culture, help sustain EB practice, by creating unity
in the team towards a common goal and organisational values. In this type of culture,
every member of staff no matter what their role, is respected as contributing to the
care of the resident. Leaders in this type of organisation, create an atmosphere
where staff feel safe, supported and comfortable in reporting errors, incidents or
changes in care (Ratnapalan & Uleryk, 2014).

In some RCFs this is not the type of leadership that is practiced, as identified by the
CF from RTO A. It has been documented that when AINs often feel undervalued and
ignored, the result is a decrease in communication about incidents or changes to

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RN/ENs (Caspar et al., 2016). Addressing issues related to leadership styles and the
organisational culture, is essential not only for the delivery of quality care, but also to
promote organisational learning and ultimately the sustaining of EB practice (Argote
& Miron-Spektor, 2011; Marchionni & Ritchie, 2008; Perry et al., 2011).

Policies, procedures and processes.

The result of the chart audit at the facility in Phase One, demonstrated that policies,
procedures and processes, whilst present, were not being followed. There were gaps
in what the facility policy and procedure requested to be carried out, in regard to
screening for pain and assessing pain, compared to what was happening in clinical
practice.

Policies and procedures are important quality management tools and form one of the
important elements of organisational learning. They not only act as guidelines for the
clinical practice concerned, but they contribute to maintenance of knowledge of the
task, as they constitute another place where information about the task can be
stored. They can also be used a guide to evaluate the practice and determine if the
facility is meeting current best practice guidelines (Goucke, 2018; Virani, 2012).
Wiltsey Stirman et al. (2012) found that, integrating best practice strategies into
policies and processes was an important part of sustaining practice. However,
Colón-Emeric et al. (2016) in their study, did not find that development of a policy
and procedure, was important for sustaining complex interventions, but rather, they
discussed the importance of other organisational contextual factors impacting on
care. This area clearly needs more examination in RCFs.

Fleiszer et al. (2015a) noted the importance of sustaining EB practice through

embedding the new practice into routines, until it becomes a habitual part of practice.
Similarly, Goucke (2018) highlighted the importance of embedding and promoting EB
pain management practices in routines, and how this can create a pain-vigilant and
therapeutic culture, which results in a universal process for identifying, assessing
and managing pain.

Embedding knowledge in processes and routines and creating a pain vigilant culture,
as suggested by Fleiszer et al. (2015a) and Goucke (2018), means that knowledge
is more easily retained in the organisation, avoids decay because it is part of the
organisational processes and routines. The knowledge then is also not just stored in

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the staff’s memory, but in the routines and processes of the organisation
(organisational memory). It also means that the knowledge about the practice is
easily transferred to new staff, because it is distributed across multiple different
resources and is part of organisational culture (Argote & Miron-Spektor, 2011;
Goucke, 2018).

One factor regarding the policies and procedures, that may be impacting on the
sustainability of EB pain management practices, may be that AINs do not access
these documents regularly, have little influence or input in the development of these
documents or processes, but are the direct care workers that deliver the majority of
care on a daily basis to the residents (Goucke, 2018; Jansen et al., 2017).
Consequently, they are unaware of the contents of these documents and how they
could assist them with knowledge regarding the performance of a procedure, for e.g.
pain assessment.

The RN/EN failure to comply with policies, may be related to the availability of
physical and human resources, staff models and the multiple requirements of their
role in RCFs, impacting on their ability to complete tasks (as was alluded to be the
CN in Phase One). Their current responsibilities mean, that they do not have time to
complete tasks associated with best practice, except for where it is regulated and
associated with funding requirements (Willis et al., 2016).

Caspar et al. (2016) also noted in their research, that AINs, tend to refer to their AIN
colleagues for information on particular care needs of residents, processes or
procedures, rather than the policy or procedure documentation or a RN/CN. This is
often because of the demands of caring for the residents and staffing levels, mean
they have little time to return to the nurses’ stations to check documents. Poor
relationships and access to RN/EN staff, may also contribute to this practice of AINs
referring to colleagues, rather than qualified nursing staff (Caspar et al., 2016).

Verbal sharing of knowledge in this way (between AINs), can alter details of the
procedure or process, particularly if it is not a skill that is used often. Or as is in the
case with pain in older people and people with dementia, where a lack of knowledge
exists and there is a large variability in the experience and expression of pain in the
population. Knowledge stored only in the staff (AINs), can lead to knowledge decay,
particularly if there is a high staff turnover or other factors impacting on

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communication. The ultimate impact however of knowledge decay, is on continuous
organisational learning and sustainability of best practice (Virani et al., 2009).

With current staff levels and models in aged care, integrating best practice into
policies, procedures, processes and routines alone, is not enough to contribute to
the sustaining of best practice or organisational learning. This is supported by the
findings from this research and from the literature, with ongoing poor pain
management practices frequently documented (Achterberg et al., 2013; Veal,
Bereznicki, Thompson, & Peterson, 2014). Review of how policies and procedures
documents can be utilised more effectively in practice in RCFs is urgently required

Communication.
Communication amongst all staff in RCFs is important for the delivery of quality of
care, transferring knowledge, maintaining organisational learning and sustaining
practice (Argote, 2013; Argote & Miron-Spektor, 2011; Virani et al., 2009).
Communication difficulties associated with the residents because of altered
cognition, or language barriers, and/or language barriers associated with migrant
staff because of having ESL, have already been addressed.

Different staff in Phase One, CN, AIN, PT and DT/physiotherapy aide, commented
on the problems associated with both verbal and written communication amongst the
staff in the facility and with staff external to the facility. Particularly relevant to pain
management practices, was that verbally reported incidents of pain by AINs to the
CNs/RNs/ENs, were not always documented in the residents’ progress notes. This
meant that any follow up action required, was sometimes missed because CN/RNs
had no written record of the report. Caspar et al. (2016) also found that RNs/ENs
failed to acknowledge the verbal report from AINs on occasions, particularly when
there were poor relationships between the registered staff and AINs. Documentation
then is clearly important to not only record changes in the resident, but also to give
RNs reminders of AIN verbal reports and maintain that network of communication
between the members and tasks.

AINs in Phase One however, also reported that there were communication strategies
used within the facility, that helped them complete pain management tasks. These
included reminders on the electronic documentation (iCARE) in message of the day,
written reminders on the white board, and the presence of the pain assessment tools

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being on the electronic documentation, which improved the AINs ability to locate
documents for recording information. However, as previously noted, time and
competing priorities often impacted the AINs ability to complete these tasks.

The CN found that communicating and explaining to doctors about increased pain in
residents, often resulted in inaction by the doctor (despite the provision of evidence
through pain assessments). The PT supported this by reporting that GPs were
reluctant to listen to her and take action in regards to referring residents with
persistent pain, on to pain specialists external to the facility. This may indicate a lack
of knowledge of GPs in managing persistent pain in older people and people with
dementia. A factor that has also been previously documented in the literature (Veal
et al., 2018).

Communication difficulties that exist between staff within and external to the facility
(GPs) and residents, have been identified by Caspar et al. (2016), Jansen et al.
(2017), Peisah et al. (2014) and Veal et al. (2018), as being barriers to the delivery of
quality best practice care in pain management. Peisah et al. (2014) reported from
their study, that GPs did not want to listen to reports that the resident was in pain,
particularly those residents with cognitive impairment. Jansen et al. (2017) and
Caspar et al. (2016), both found that communication and the relationship between
registered staff, managers and the AINs, impacted on the reporting of pain and
changes in residents, identified by the AINs. Where these relationships were strained
or poor, there was a decrease in communication between the AINs and RNs/ENs.
Where the relationship was supportive and mutual respect was shown and
communication improved (Caspar et al., 2016; Jansen et al., 2017).This has also
been identified by Argote and Miron- Spektor (2011) as a key factor impacting on
organisational learning.

Peisah et al. (2014) highlighted in their article, the importance of communication in

aged care, during the complex process that is involved in identifying and assessing
pain and developing appropriate pain management strategies for people with
advanced dementia. They identified that there is a long and protracted chain of
communication that begins with the person with dementia finding ways to
communicate about their pain. This communication then relies on the proxy observer
(staff or significant other) identifying these behaviours and then reporting the change

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to an RN/EN either immediately or after some time delay. The AIN worker then also
needs to document the identification of pain in records (which as noted above, may
or may not happen). The RN/EN then needs to action the report, (which may be
delayed because of competing priorities) by undertaking an assessment, set up
monitoring, evaluate the assessments and then communicate the information to the
GP, who may or may not act on the report (Peisah et al., 2014). It can then be a
multistep process to implement any planned strategy. This complicated process of
communication brings with it many opportunities for breakdown in the chain of
communication, pain management strategies may be delayed in being delivered, if
delivered at all and experience obtained from completing the task may be drawn out
and disjointed.

Assessment tools and processes.

Assessing pain requires that pain be first identified. This requires direct care staff
(particularly the AINs) to have knowledge of how to identify pain in older people, who
can and cannot verbalise.

Both the AINs in Phase One and the students/new care workers in Phase Two,
understood this to be clearly part of their role. However, after the identification of
pain and reporting to RNs/CNs and documentation, the AINs have a limited part to
play in the assessment and management process (except for the AINs in Phase
One, who had a limited role to play in ongoing monitoring). This lack of participation
in the wider pain assessment and management process, prevents AINs gaining
experience and knowledge in the assessment and management of pain,
understanding about pain in older people and pain in people with dementia. In other
words, learning about the importance of appropriate pain management.

This issue with AINs and their role in the pain management practices, has been
identified by Jansen et al. (2017). They noted that once care workers reported the
identification of pain, they were not included in further activities associated with the
assessment or management of pain, or included in case management discussions
about the residents. This was despite the fact that they informally assessed the
residents for pain (using the criteria provided on pain assessment tools) and
monitored the outcomes of pain management strategies implemented (Jansen et al.,
2017).

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Once pain has been identified, reported and documented, a structured process of
assessment is required as has previously been noted (Goucke, 2018). Systematic
assessment, using a recognised tool and use of best practice guidelines, has been
shown to be effective in ensuring comprehensive pain assessment is conducted and
an appropriate pain management plan is developed, for all residents in aged care
(Hadjistavropoulos et al., 2016).

At present, this comprehensive assessment is not a standard part of nursing

practice in aged care, but it is important to assess people with persistent pain in this
manner, to assess the different aspects of pain (i.e. quality, radiation) and to develop
an appropriate plan of care. The PRACMS 2nd edition (Goucke, 2018), provides
schematic diagrams for the systematic assessment of pain. The reasons for lack of
completion of the comprehensive assessment is unclear, but may be lack of
knowledge and skill in undertaking such an assessment for older people with
persistent pain, time pressures and availability of staff resources (Henderson et al.,
2017; Willis et al., 2016).

However, undertaking of this process of assessment, would assist RN staff to obtain

knowledge about the multimodal nature of pain and the complexity of pain that can
be experienced by older people living in aged care. This is one way that the external
environmental and the organisational context, (through the provision of the
guidelines and instructions on how to complete a comprehensive assessment), could
contribute to the development of knowledge in pain in the older person and help with
the sustaining of best practice (Argote & Miron-Spektor, 2011; Goucke, 2018).

Given that care workers are the primary care group attending to activities of daily
living and mobilising, moving and transferring residents, they are in the best position
to undertake pain assessments, particularly with residents who have dementia or are
unable to communicate. Recommendations from the best practice guidelines are that
assessments should be conducted on movement and at rest (Goucke, 2018). This
would be particularly beneficial to the residents, as CN/RN resources are poor (as
has been documented in this research and in the literature), therefore their ability to
undertake this task assessment tasks is limited. The facility in Phase One allowed
the AINs to conduct ongoing pain monitoring assessments utilising the Abbey pain
tool after initial assessment by the CN/RN. However, many of them asked for more

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training to be able to undertake these assessments and utilise the assessment tools
more appropriately to more accurately assess pain. New care workers in Phase Two
reported that they were rarely involved in the assessment of pain after the initial
reporting to the RN.

The researcher also utilised this process during their role as a Clinical Nurse in a
facility. AINs would conduct pain assessments, particularly in dementia specific units
and with residents requiring high levels of care. The strategy worked well but
required that the CN work closely with the AINs initially, to ensure their
understanding of the task and how to identify pain behaviours. However, most RCFs
do not have the staffing capacity to conduct this type of mentoring (Willis et al.,
2016).

Continuity of care.
AINs reported in Phase One that they were often allocated to work in different areas
of the facility on a daily basis, which significantly impacted on their ability to get to
know the residents and their different behaviours. AINs in Phases One and Two
reported, that knowing the resident significantly helped them to identify changes in
the resident, and even though they may not have understood what the changes in
the resident’s behaviour meant, it would alert them to report this to the RN/EN (as
noted above).

To improve problems associated with identifying pain in people with advanced

dementia or at the end–of–life, and provide AIN staff the opportunity to learn about
the resident and their “normal” behaviours, consideration must be given to
maintaining stable, regular staffing to areas particularly involved in dementia care on
a day–to–day basis (Goucke, 2018; Roberts, Nolet, & Bowers, 2017). This practice
would also promote ongoing organisational learning, as care staff are more familiar
with the residents and the environment in which they are working, meaning they
have more time to complete tasks and gain experience (Argote & Miron-Spektor,
2011).

Education.
It has been documented, that formal, regular education is one of the key facilitators
for improving attitudes, beliefs, myths and knowledge about pain, pain in people with
dementia, and pain management strategies in aged care (Ghandehari et al., 2013).

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The majority of staff/student/new care workers from Phases One and Two,
requested more education, using specifically, one–on–one training methods,
particularly in the area of identifying pain in people living with advanced dementia
and use of assessment tools. However, it was noted that in Phase One, only one
formal education session on pain was conducted. The CN reported that they
conducted a number of “tool box training” sessions regarding pain its assessment
and management, but the topics and scheduling of these sessions were never
documented and there has been no research conducted, on how effective short
training sessions are on maintaining procedural or organisational knowledge about a
specific task.

Ongoing education and training need to be provided in the workplace and the
methods used to educate staff are of particular importance. Didactic education or
education provided online electronically, as utilised in the training of the Certificate III
care workers in Phase Two, although relaying information and being more
economically viable, has proven to be ineffective. A more interactive style of learning
is required, particularly in an area of care where hands on skills are required
(Ghandehari et al., 2013; Jansen et al., 2017).

As AINs are the primary care workers, hands on and visual training is particularly
important for them. These modes of education also meet the needs of different
learners such as those with low literacy and the staff where English is the second
language (Mavromaras et al., 2017). This type of training can be time and resource
intensive, and can improve quality of care, but rarely occurs in RCFs in Australia
because of funding and resource constraints (Maas et al., 2008b).

Knowledge attained through education is important element of organisational

learning. Also important is targeting all individuals in the organisation to ensure that
the organisation is adequately disseminating the information about best practice,
across a large number of staff to account for staff turnover, avoid knowledge decay
and develop organisational memory (Virani et al., 2009). Education of all staff had
not occurred in the facility in Phase One and only two of the nine participants in
Phase Two received education about pain assessment and management within the
first three months of their employment. This may have contributed to the breakdown
in the use of EB pain management practice strategies, particularly in Phase One.

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Organisational memory, refers to how knowledge regarding a particular skill or
practice (task) is stored within the organisational context (Argote, 2013; Virani et al.,
2009). In aged care, knowledge of a task can be stored in best practice guidelines,
policies and procedures, routines or the staff. However, typically, policies,
procedures and best practice guidelines are often underutilised in day-to-day care as
had been discussed previously.

Most of the knowledge about the residents, their care, routines and the processes of
a facility, are stored in the experiential knowledge of the direct care workers (Caspar
et al., 2016; Jansen et al., 2017). As the primary workers in aged care are the AINs,
this means that knowledge about the resident and how pain is expressed and what
strategies may help the individual in pain, is stored in the care workers’ memories.
This information was found by Caspar et al. (2016), to not often be shared with
registered staff, because of relationship or communication issues, or because AINs
were not included in the development of care plans or resident case meetings.

However, storing knowledge of residents, policies and processes in this manner

relies on the AIN retrieving information about the resident and these processes from
their own knowledge, then transferring their knowledge to other staff during the day
to day routine of work, or when mentoring new staff (Caspar et al., 2016; Jansen et
al., 2017). This verbal communication may make little reference to policies or
procedures, assessment tools or the resident’s care plan and may vary over time (as
previously noted) (Caspar et al., 2016). There may be barriers to effective
communication related to the presence of ESL migrants and relationship breakdown
between different members of staff (Caspar et al., 2016). This was evident in Phase
Two of this study, where the majority of new care workers did not receive education
about pain policies, procedures or processes in each service, on commencement of
their employment.

The primary source of knowledge provided to the AIN about pain identification,
assessment and management, comes through education during their Certificate III
training, which from this research has been shown to be very basic information. This
knowledge is built on by intermittent training within the facility, experience gained in
completing the tasks associated with pain management, and communication
between direct care staff (Caspar et al., 2016). However, as participants from Phase

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One and Two reported, AINs orientate or mentor AINs in the tasks and routines
associated with a new workplace in aged care. If the more senior AIN or mentor
lacks knowledge or hold poor attitudes and beliefs about the older person or people
living with dementia and pain, then this lack of knowledge and attitudes is passed
onto the next AIN, and poor knowledge of pain management practices are
maintained. This impacts on wider organisational learning as knowledge is not being
exchanged with the active or latent context (Argote, 2013).

Investing all of the knowledge of the pain identification, assessment and

management process into training, either formal or informal (as is often the case in
aged care), relies heavily on the memory of the individual. Storing knowledge in this
manner is a problem, if there is a high turnover of staff, such as there is in aged care
facilities in Australia (Mavromaras et al., 2017; Radford, Shacklock, & Bradley, 2015;
Virani et al., 2009). This can contribute to loss of organisational knowledge about
residents, procedures and policies in the facility. Consequently, impacting on the
sustainability of best practice as knowledge reservoirs are depleted over time
(Argote & Miron-Spektor, 2011; Virani et al., 2009).

In addition to the above, if education sessions are infrequently scheduled, poorly

attended (as is often the case, as workers are unable to leave the floor because of
care requirements), or the information poorly presented and understood because of
literacy and language issues, then insufficient transfer of knowledge can also occur.
This means that knowledge can be easily lost and the importance of the practice not
understood, resulting in a return to prior knowledge and previous practice skills
(Colón-Emeric et al., 2016; Virani et al., 2009).

What the findings tell us?

This research has found that there is a complex number of external and internal
contextual factors that contribute to loss of organisational knowledge, ongoing poor
pain management practices that impact the sustainability of EB practice.
Government funding through the ACFI, does not provide for the provision of EB pain
management practices, particularly for the resident with persistent pain (which is
stated as 1 in 3, according to Painaustralia’s website), but drives regulatory pain
assessment and the use of passive management practices. The fact that the ACFI
restricts the use of certain pain management strategies because of lack of funding,

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means that staff do not get to implement or experience the use of the best EB pain
management strategies, for older people with persistent pain.

The internal organisational factors (apart from the organisational structure)

impacting sustainability, relate to the lack of adequate staff numbers, inappropriate
staff models and lack of suitably skilled staff. More staff resources (including
RNs/ENs/AINs), would provide time for more appropriate delivery of quality care,
more thorough and appropriate pain assessment, better monitoring of care provided
by AINs, and facilitation of clinically relevant hands on one-on-one education.
Facilities need to be able to identify organisational factors that impact their particular
context, prior to the implementation of new practice to ensure that implementation is
successful in the long term. Organisational learning theory and the framework
developed by Argote and Miron Spektor (2011), could be used to help managers
identify potential factors impacting practices, and provide them with the opportunity
to develop strategies to moderate these factors.

7.5 Education practices, AINs and their ability to conduct EB pain management
practices.
In the preceding sections of this discussion chapter, some of the education practices
that influence the aged care workers (AINs) ability to conduct EB pain management
practices, have already been discussed. The following section focuses specifically
on the training provided by the RTOs.

Students.
AINs in Phase One could not remember any of the training that they received during
their certificate courses, even though some of them had graduated within the
previous year. The students and subsequent new care workers from Phase Two,
stated that the course work provided them with the basic knowledge of what to do in
the identification, assessment and utilisation of non-pharmacological strategies only.
However, the new care workers from Phase Two stated, that their role in the facility
was only to identify pain and report it. They did not participate in assessment of pain
and engaged very little with non-pharmacological strategies, except for repositioning
of the resident. In these circumstances, there was lack of exposure to pain
management practices.

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There is a distinct difference that exists between knowledge learned (declarative
knowledge – ‘knowing what’) and knowledge of the skills or routines (procedural
knowledge- ‘knowing how’), required to actually complete the tasks (Argote, 2013).
Individuals completing the Certificate III course, learn about the basics of pain in
older people, how to identify it, how to report it and some baseline non-
pharmacological strategies. The results of this research identify, that there is little
instruction provided by either RTO’s or aged care organisations on how to actually
complete the tasks of pain identification, assessment or management during other
routine tasks such as activities of daily living. This then impacts on knowledge
brought into the organisation or facility and means that, new AINs can contribute little
to ongoing organisational learning. In addition, given the lack of education in both
pain and pain management practice strategies (the know-how), AINs lack the
knowledge and experience to identify, assess and contribute to the management of
pain in different facility contexts and with different resident populations. This is
evident by the data gathered in Phases One and Two. Students/new care workers
agreed, that their confidence had improved in the identifying pain in the
questionnaires. However, there was a distinct lack of confidence in the ability of the
AIN staff and students/new care workers, to assess pain in people with moderate or
advanced dementia, or CALD individuals, particularly if they displayed confusion,
were agitated, displayed aggressive behaviour or spoke a language other than
English, as was identified through their diaries and interviews.

With the level of education obtained from training, there is limited opportunity for the
new care worker to contribute to organisational learning. New care workers
commencing work in RCFs in actual fact, are inadequately prepared to enter the
workforce and care for older people with advanced complex needs and complex
pain. In this way the RTOs, as an external organisation, are impacting on the
attainment and maintenance of knowledge of pain management practices (Argote &
Miron-Spektor, 2011).

All direct care staff, RNs, ENs, PT and care workers (AINs), enter the aged care
environment with a qualification. Whilst the Nursing and Midwifery Board of Australia
have regulated RN and EN training, Certificate III care worker training is not yet
regulated. A review by Australian Skills Quality Authority (ASQA) in 2013 found that
training for AINs, was often inadequate and insufficient to provide care workers with

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the required skills to work in the sector and commented that, changes needed to be
made to the national standards for training.

Analysis of the documents associated with the certificate training at both RTO A and
RTO B, showed that pain identification, assessment and management education,
accounted for only one hour of a care worker’s training and was attached primarily to
the palliative care module. This may lead AINs to think that pain occurs only when
residents are deemed palliative. The content provided care workers with basic
knowledge on how to identify pain in people who can verbalise and about the
standard pain behaviours to observe for in people with dementia. There is little
discussion of how behavioural and psychological symptoms of dementia (BPSDs),
may indicate the presence of pain and no discussion on pain in CALD residents, or
of the impact that persistent pain may have on the older person, in the content.
There is also no discussion of EB practice or how to implement and maintain it.

The Australian government, through the training.gov.au website, provides guidelines,

regarding the elements and performance criteria, that is required by graduates of the
Certificate III in aged care (now the Certificate in Individual Support), to know about
pain identification, assessment and management. However, the training content
required to achieve the performance criteria, is open to interpretation by individual
RTOs, as can be seen by the different course lengths and content, each RTO
included in the material to educate trainees about pain management practices. The
ASQA (2013) found that there was significant variation between RTOs in the
conducting of Certificate III and IV aged care courses, particularly in the number of
hours scheduled for practical experience and the assessment of skills. ASQA (2013)
also found, that students were inadequately prepared to deliver quality care in the
work environment. This is concerning, particularly with the increased complex needs
of the individuals entering aged care.

Students/new care workers involved in Phase Two, commented that the training
during the certificate, provided them with baseline knowledge only. Further training
once they reached the workplace, would have helped them to build on that
knowledge and potentially improve their confidence in identifying pain, particularly in
people with dementia and in workplace policies and procedures. Only two new care

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workers received this training in their orientation to the workplace. These were two of
the community care workers.

Clinical Facilitators.
This research found that in Phase Two, CFs, held either a Certificate III/IV in Aged
Care (residential/community), had recently graduated as an EN, with little experience
in this role, or were working as an AIN and undertaking a Bachelor of Nursing
degree. Their level of knowledge and experience in assessing or delivering pain
management strategies, varied from none to extensive, and this was evident by both
the responses to the questionnaires and the data derived from the interviews. These
factors impacted their responses to the questionnaires and what education strategies
they utilised with the students during their training.

ASQA (2013) found during their review, that there were significant discrepancies in
the trainers’ current industry skills, vocational training and assessment skills.
However, the standards relating to the requirements of trainers lacked clarity
(Australian Skills Quality Authority [ASQA], 2013). It has been recommended by
ASQA, that facilitators leading these groups, should have a standard of level of
education, which allows them to provide interactive learning, not just didactic
learning (ASQA, 2013).

RTO’s
As RTO’s form an organisation in their own right, then there are both external and
internal contextual factors that are impacting on the RTO’s ability to provide
information and education to the students on EB pain management practices.

Firstly, the training.gov.au guidelines for the Certificate III course, predominantly
discuss pain management practices in the module ‘Deliver care services using a
palliative approach’ (Commonwealth of Australia, 2018, Retrieved from:
training.gov.au). Discussing pain in this context only, means that students may miss
the link to pain being an everyday occurrence for older people, particularly those with
multiple comorbidities as found in the current population of older people living in
RCFs (Hillen et al., 2017).

Secondly, the primary element or performance criteria regarding pain in this palliative
care module is ‘respond to signs of pain and other symptoms of discomfort’

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(Commonwealth of Australia, 2018, Retrieved from: training.gov.au). Here the
guidelines state, ‘observe for pain, identify and promptly report…implement
strategies to promote comfort, evaluate and document effectiveness of strategies…
report misconceptions surrounding the use of medications’ (Commonwealth of
Australia, 2018, Retrieved from training.gov.au, CHCSS0050, p.1).

The results of this research have shown, that the broad performance criteria
provided here by the government agency, is open for interpretation, meaning that
RTO’s can incorporate minimal and variable content regarding pain its identification,
assessment and management, in their learning material, as long as the criteria are
addressed. This variation in how the performance criteria can be met, was seen in
the differences between RTO A (learning guide, workbook and competency) and
RTO B (ppt presentation).

In addition to these external factors impacting on pain education in RTO’s, internal

factors such as knowledge and experience of the CFs, content of learning material,
tools and strategies utilised to teach students (didactic vs interactive), competing
priorities and time allocated for teaching modules and content during the certificate
course, objectives set for student practical experience, time available for teaching
students how to undertake pain management practices during their practical
experience, English comprehension of the students, mentoring and organisational
culture of the facilities students visit during their practical experience, all impact on
the creation, attainment and retention of knowledge within the RTOs, the CFs and
students regarding pain its identification, assessment and management (Argote &
Miron-Spektor, 2011).

What the results from Phase Two tells us?

Current training practices for the Certificate III/IV care worker are inadequate to meet
the current requirements for delivering EB pain management practices in the current
aged care environment. The baseline knowledge provided in the current curriculum
of the certificate does not provide the new care worker with adequate knowledge or
skill, to care for the older people with complex, persistent pain, who are now being
admitted to RCFs, or to identify pain in people with advanced dementia or in the
CALD resident. There are variations between providers as to the length and content
of their courses, their support for ESL students and the competency assessments

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required. CFs also vary in their qualifications, knowledge and experience in RCFs
and in pain management practices. This can then impact the quality of training
provided during the certificate course, the attainment of knowledge regarding pain
identification, assessment and management policies and processes and the future
contributions of AINs to the workplace.

In addition, RCFs do not appear to provide adequate information to new care

workers on commencement of employment to their facilities, of current pain
management practices in the facility or the role of the new care worker/graduate in
the facility in relation to that practice. They instead rely on the worksite mentors
(usually other AINs), to divulge vital information about pain identification, assessment
and management practices. Given that it has been previously identified by K.
Holloway & McConigley (2009), and in this research, that AINs identify changes in
the behaviour of the resident by how they know the resident, rather than identifying
pain related behaviours, and that more mature AINs carry a number of beliefs and
attitudes about older people with pain (as described in this research), then it is not
surprising that in conjunction with other individual and organisational barriers
identified in this research, that there is persistent, poor knowledge attainment and
retention, of pain management practices (particularly in AINs), inadequate
organisational learning and sustaining of EB pain management practices.

7.6 Limitations.
The use of only one facility that had implemented the PRACMS guidelines (Goucke
et al., 2005), means that the results may not be an accurate reflection of the
sustainability of EB pain management practices in other RCFs. However, there is a
large amount of literature available that suggests, that the factors identified in this
research as impacting on best practice pain management sustainability, have been
identified as impacting on pain management practices in aged care, both nationally
and internationally (Achterberg et al., 2013; Goucke, 2018; Hadjistavropoulos et al.,
2016; Masso & McCarthy, 2009; Veal et al., 2018). Other facilities that had
introduced the best practice guidelines in the EBPRAC project were not used in this
research, as the researcher had worked at three of the other five facilities involved in
the EBPRAC project, as a Clinical Nurse Specialist and bias may have been
introduced into the results (Fain, 2013). Future studies in this area should consider

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involving more facilities that may/may not have implemented best practices
guidelines.

A second limitation in Phase One, was the number of resident charts (only 17 of the
available 29), that were able to be audited during the time the researcher was in
attendance at the facility (three days). Contributing factors to low sample size
included, poor filing of the documents related to resident care, and ability to access
the charts only when the Clinical Nurse was present in the facility (approximately 8
hours a day for three days under supervision by the CN). This means that the
sample of charts chosen may not have adequately represent the conducting of EB
pain management practices in the facility. However, despite the fact that not all 29
charts were audited, it was felt that of those charts that were audited (n=17) (58%),
from different time points, post implementation of EB practice, the data collected
adequately represented the failure to sustain best practice consistently for all
residents. The problem of not achieving greater number of chart audits could be
addressed by permitting a longer time to attend the facility to allow for auditing.

The use of a convenience sample of direct care staff, student/new care workers and
CFs in both Phase One and Two, may not be an adequate representation of each
population and their knowledge and experience in pain management practices. In
addition to sample type, recruitment and retention were difficult in both phases and
sample sizes were small. Therefore, these results are internally valid but may not be
generalisable to wider aged care and the RTO community. Convenience sampling
has been used in research involving direct care workers in regards to pain
management before (Dobbs, Baker, Carrion, Vongxaiburana, & Hyer, 2014; K.
Holloway & McConigley, 2009; Veal et al., 2018) but not students undertaking their
care worker certificate. This problem of sample type and size could be addressed by
including more facilities and RTOs, a broader and larger range of staff/s from
different categories (RN/EN/AIN) and student groups.

The use of a mixed methodology in this research project provided the opportunity to
look at factors impacting practice from both a quantitative and qualitative point of
view. The questionnaires used in this research project in Phase Two, had not been
used for students or new care workers previously, potentially affecting the
generalisability of these results. AINs are less educated about pain, its identification,

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assessment and management than RNs and subsequently they have less
knowledge in this area. This restricted role and other factors related to their working
relationships with RN staff, may impact the AINs ability to provide comprehensive
understanding of all of the factors impacting on EB pain management practices.
These factors may have impacted the quantity and quality of the data that was
collected in interviews and diaries. This could be addressed through recruitment and
sampling of a wider category of staff as noted above.

7.7 Recommendations to improve evidence-based pain identification, assessment

and management practices in RCFs.
The following points discuss strategies that could be implemented to improve the
sustainability of evidence-based pain management practices in aged care.

1. Changes to the ACFI are required that will allow for increased support for
the biopsychosocial management of pain. The pain advocacy groups such
as Painaustralia, Chronic Pain Australia and the Australian Pain
Management Association could be approached through a formal letter or
email, regarding lobbying the federal government, to change the current
ACFI policy and any relevant legislation to change the funding model for
pain management to include the biopsychosocial approach. This would
improve the quality of life for the older person with persistent pain by
utilising current best practice strategies.
2. The Australian Aged Care Quality Agency should include pain on their
National Aged Care Quality Indicator Program (planned) and make it
mandatory for all facilities to participate in this program. This should be in
conjunction with increased monitoring of this area of practice, as part of
accreditation requirements. As discussed, in point one above, letters or
emails of communication could be sent to Australian Health related
unions, pain advocacy groups and older people’s consumer advocacy
groups, to lobby government ministers to change the legislation. This may
improve the delivery of EB pain management practices, maintenance of
standards and provide consumers with information about facility practices,
to allow choice of care.
3. Changes to the legislation, regarding minimum level of staffing for
residential care facilities that mandates a ratio of RN/EN/AIN to residents.

185
 The Australian Nursing and Midwifery Federation are currently (2018), in
the process of campaigning government representatives, to improve ratios
and change legislation in this area. Contributing to this, by promoting
campaign resource material and emailing local ministers, will add support
to this operation. Improved ratios and skill mix will improve the quality of
care and the ability for facilities to implement and sustain best practice.
4. Promote the utilisation of an implementation strategy (such as the
organisational learning theoretical framework) to facility managers. This
framework could be utilised prior to the implementation of new evidence-
based practice strategies, particularly where complex interventions are
required. This could help managers to identify individual or organisational
contextual factors potentially affecting implementation and sustainability of
the practice and help them to develop a strategic plan to moderate these
factors.
5. Commence education of the resident and their significant others during
the admission period, on the importance of reporting any incident or
changes in pain to direct care staff. This allows discussion with the
resident how the facility works in partnership with the individual to
assesses and manage their pain, and the management strategies that are
currently available in the RCF.
6. Education of all managers, clinical leaders and direct care staff, on all
aspects of pain in older people, people with dementia (all stages), people
from CALD backgrounds and the identification, assessment and
management of pain. Education sessions should be planned three-
monthly throughout the year, covering a number of topics and delivered in
a number of different formats, to meet different learning needs of the staff.
This would address knowledge deficits.
7. Promote the increased use of technology in the sector such as mobile
phones and tablets, by discussing with facility managers and clinical
leaders, the benefits of increasing the use of technology in the sector.
Benefits include, that the direct care staff could communicate more
immediately about episodes of identified pain, action these reports more
effectively and automatically create a documentation trail. Creation of
electronic assessment tools, where alerts are built into them, so that the
186
 results of the assessment are actioned and evaluations are conducted if
new treatment is initiated, could also be of benefit. This could limit delays
in reporting and actioning of incidents of pain and improve documentation.
The development of virtual reality technology could also be investigated,
to be used for education of staff (particularly AINs), in the clinical skills
required to undertake EB pain management practices.
8. Development of a pain champion role in the facility, to monitor practice,
promote this area of care, mentor and educate staff and residents.
9. Implementation of the updated version of Pain in Residential Aged Care:
Management Strategies (Goucke, 2018). This document provides current
EB guidelines for the identification, comprehensive assessment and
management of pain for the different groups of older people living in
RCFs. It also provides information on how to develop quality management
systems for this area of care. This would ensure facilities are delivering
current best EB practice to the residents.
10. Development of a cultural awareness package that is tailored to each
facility to improve the quality of care to all residents.
11. Through the promotion of the outcomes of this research, discuss with
aged care industry leaders, to lobby registered training providers, to
improve and standardise the content, delivery and assessments of the
training for Certificate III/IV care workers, particularly in areas such as
pain, where complex care is required. This would include the requirement
of a standard level of knowledge and competency for Clinical facilitators
involved in the training of the aged care certificate. This may address the
issues related to standard of knowledge of new graduate AINs.

7.8 Plans for dissemination of results.

The following are key strategies for disseminating the results of this research:

1. Formal presentation of results in academic peer reviewed journals in the

areas of pain management, older people, nursing, ageing and implementation
science.
2. Articles in magazines such as Australian Ageing Agenda, and Aged Care
Insite. These magazines in Australia provide information to providers on
barriers and facilitators for sustaining EB practice in aged care.

187
 3. Presentations at conferences. These could include AACQA Better Practice
Conferences, Emerging Researchers in Ageing, the Australian Pain Society
Annual Scientific Meeting.
4. Join International Association for the Study of Pain Special Interest Group:
Pain in Older Persons. Participate in meetings and online discussion forums
involved in promoting the awareness and research of pain in older people.
5. Utilise existing networks with pain advocacy groups, Australian Pain Society,
Persistent Pain Management Services, residential care facilities, aged care
direct care workers and RTOs, to disseminate findings and conduct education
sessions on pain in older people groups and strategies to sustain best
practice in RCFs.
6. Utilise electronic communication such as social media, websites, blogs and
discussion forums to promote current research and discussion.

7.9 Future research.

The findings from this research highlights several areas that could be explored, to
improve the quality of care delivered through pain management practices in RCFs.

More research is required to examine the experience and expression of pain in older
people from CALD populations (including those with dementia in this specific group)
in Australia. Such research would have the potential to provide greater
understanding of how to improve the care of this particular group.

In line with researching CALD older people in RCFs, research with CALD migrant
care workers should be considered: specifically, how their cultural beliefs affect their
knowledge, attitudes and skills in identifying and assessing pain in older people and
people with dementia.

In terms of organisational deficits in the research, there is a requirement for more

empirical research into staffing mix and care models and their impact on care
outcomes. This could include research on the different leadership styles utilised
within these different models of care to determine how effective these models and
skills are in affecting quality of care.

7.10 Conclusion.
The findings from this research has highlighted the fact that there are individual,
internal, and external organisational factors. impacting the sustainability of evidence-

188
based pain management practices in aged care. Many of these factors have
previously been identified as barriers and facilitators to pain management practices
and as impacting the implementation of best practice. However, despite considerable
efforts to improve the situation, this is still an area of significant concern.

Organisational learning theory provided the framework for examination of the

different factors impacting the sustaining of evidence-based pain management
practices, knowledge and organisational learning. These factors included, external
factors relating to, legislation governing the industry to internal contextual factors,
which included membership of the organisation (residents, all staff), resource
availability for undertaking and supporting the pain management practices and how
factors such as organisational structure, culture and leadership style, impacted on
the sustainability and delivery of best practice care. Variations in these factors also
impacted ongoing organisational learning and knowledge retention and transference.

Individual factors related to the residents’ comorbidities, cognitive status, culture and
ethnicity. These are difficult to modify and can only be addressed through education
and the implementation of a comprehensive pain assessment process on admission.
Education regarding pain its identification, assessment and management in different
groups residing in RCFs, should include the resident and their significant others and
all direct care staff. Addressing these factors will be a positive step in improving the
identification, assessment and management of pain.

Staff factors relating to knowledge, experience, beliefs, attitudes, language and

literacy, could be enhanced through ongoing planned education, mentoring and the
strategic development of resources to support and educate direct care workers,
particularly those with English as second language. However, RCFs must plan for
and fund ongoing education if this is to be successful.

There were a number of external and internal organisational contextual factors

identified as affecting best practice in this research. External factors specifically
identified, the Aged Care Funding Instrument acting as both a facilitator for the
regular monitoring of pain, but also as a barrier to the implementation of evidence-
based assessment and a biopsychosocial pain management approach.

Internal contextual factors in Phase One, primarily related to the lack of appropriate
levels of skilled direct care staff, which meant that quality of care was compromised.

189
Poor identification, or delays in reporting episodes of pain, resulted in inadequate
assessment. Inadequate or postponed assessment resulted in inappropriate
management. Organisational and staff related factors and the delivery of quality
care, require a more proactive strategic approach, to identify their presence and
manage their impact on organisational knowledge and the sustaining of best
practice.

A significant finding in relation to the education of the care worker during their
Certificate training, were that these workers are inadequately educated and not well
prepared to provide the complex care that is required to identify, assess and manage
pain for the older people currently being admitted to residential care facilities. The
length and standard of education provided to these potential care workers is
significantly variable. Again, this area is poorly resourced and skill levels amongst
Clinical facilitators varies, resulting in poor outcomes.

The reality is that older people living in residential care often have persistent,
multifactorial pain associated with multiple chronic comorbidities, dementia and
geriatric syndrome. There is a long long-drawn-out communication chain for an older
person to have their pain recognised, assessed, and managed, which can at any
point fail. As the primary care deliverer in residential care facilities are the Assistants
in Nursing, making up two-thirds of the workforce in aged care, there is an increased
need for Assistants in Nursing to be better educated and more involved in pain
assessment and management processes. However, better educating Assistants in
Nursing, would require investment in the training for and mentoring of this group, for
which the aged care industry lacks resources to commit too.

Whilst education and the provision of guidelines have been the primary strategies
utilised within the aged care industry to address poor pain management practices, a
more extensive look at the contextual factors has identified their impact on sustaining
practice. This establishes that a strategic approach to maintaining knowledge and
sustaining practice is required for this complex area of care in residential care
facilities. Utilisation of a framework such as organisational learning theory may help
managerial and leadership groups, to proactively assess the organisation prior to the
implementation of future best practice strategies. This would also provide them with
the opportunity to develop strategic plans to overcome any barriers identified.

190
We are failing in our duty to deliver quality, safe care to the most vulnerable of our
population, concerning pain. We are not providing evidence-based pain
management because of inadequate identification and assessment of pain and a
complicated number of contextual factors. There needs to be serious consideration
from the aged care industry, our profession and State and Federal governments, as
to how we can improve care delivery in this area so that older people living in
residential care facilities, are not suffering with poorly managed pain and living with a
reduced quality of life in their last years.

191
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 Appendices.
Appendix 1 Ethics approval– Phases One and Two.

Appendix 2 Letter of support – Phases One and Two.

Appendix 3 Pain Practices Audit Tool.

Appendix 4 Phase One –Participant information and consent.

Appendix 5 Phase One - Demographic questionnaire and interview questions.

Appendix 6 Phase Two - Participant information and consent.

Appendix 7 Phase Two- Student questionnaires.

• Demographic questionnaire.
• Pain knowledge and belief questionnaire.
• Modified Pain Management Student Survey.
• Knowledge and Belief about Pain.

Appendix 8 Phase Two – Student interview questions.

Appendix 9 Phase Two –Clinical Facilitator questionnaires.

• Demographic questionnaire.
• Pain knowledge and belief questionnaire.
• Modified Pain Management Clinical Facilitator Survey.
• Knowledge and Belief about Pain.

Appendix 10 Phase Two – Clinical Facilitator interview questions.

210
Appendix 1: Ethics approvals - Phase One and Two.
Phase One.

211
Phase Two.

212
Appendix 2: Letters of support- Phase One and Two
Phase One. Letter of support.

From: Vanda Schulz [mailto:VSchulz@uchwa.com]

Sent: Friday, 16 March 2012 3:27 PM

To: Helen Holloway

Subject:

Hi Helen

I am pleased to say that St Andrews is happy to assist you with your proposed research
project.

I understand you will now proceed with the ethics application. I look forward to hearing
from you soon.

Kind regards

Vanda

Vanda Schulz

Care Manager

Uniting Church Homes

20 Burwood Road Balcatta WA 6021

Ph (08) 9240 030008) 9240 0350IP Ph 1358EMail vschulz@uchwa.com

213
Phase Two – Letter of support from RTO A.

10th December 2014

Helen Holloway
PhD Candidate
University of Queensland
School of Nursing and Midwifery

Dear Helen,

RE: Letter of Support Helen Holloway Research: Pain Management & Training of
Direct Care Staff

Xxxxxxxxxxxx a Registered Training Organisation in Queensland and we

commenced delivering Certificate III in Aged Care in 2004. Since then we have
added Certificate III in Home and Community Care and Certificate III in Disability.

When Helen approached me, the Director of AMC, regarding her research
proposal I was very interested and supportive. AMC is passionate about the
quality care of our elders and especially those most vulnerable who require more
active intervention in their care to ensure their comfort.

I am excited to work with Helen and two of my student cohorts in Term 1 and
Term 2 in 2015. The opportunity to improve our training in Pain Management
and effect real change in elder care resonates with AMC philosophy.

Regards

Anne Cock
Director

214
Phase Two – Letter of support from RTO B.

Debbie < >

Reply all|
To:
Ms Helen Holloway;

Cc:
White, Sue <Sue.White@tafe.qld.edu.au>;
Tue 15/03/2016 16:38

This document is to confirm

I am providing permission for Helen Holloway to access aged care students within TAFE
Qld. This access is for as long as is required for the project to be completed. The time
frame will be May 2015 - December 2017.

Deb

Debbie Blow
Director of Faculty and Executive Leader, Health and Nursing

P: 07 5581 8391
M: 0437025302
E

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Appendix 3: Phase One- Pain Practices Audit Tool (PPAT).

Pain Practices Audit Tool (Holloway, H., 2012)

This audit tool can be used to evaluate current pain management practices in the Residential Care Facility (RCF). Sections 1 to 3 evaluate clinical outcomes
based on documentation in the clinical files, Section 4 examines systems issues, including current policies, education and presence of an interdisciplinary
team and Section 5 provides an area to identify key findings and develop an action plan. The following is an outline of what is contained in each section.
• demographic and clinical information (Section 1)
• resident history (Section 2A)
• routine assessment - admission and three-monthly reviews (Section 2B)
• episodes of pain (Section 2C). Episodes of pain may be identified either by a complaint of pain, change in behaviour (not linked to other problem i.e.
infection, constipation, hunger or thirst) or a change in the person’s condition, medication, hospitalisation or illness
• pain management (Section 3)
• policy (section 4A), education (section 4B) and the presence and activity of an interdisciplinary team (section 4C)
• key findings and action plan (section 5)
A minimum of 10% of clinical files, taken from a cross section of areas of care should be used. Progress notes, assessments tools and care plans of the last
six months, may be used to obtain the information required to complete the tool (six months allows for the provision of at least one regular review in that time).
The tool can be used to do a complete evaluation of pain assessment and management practices, or sections can be completed in isolation to look at current
practice at each stage e.g. on admission, three monthly, with episodes, management, policy or education. This audit tool was developed from Guidelines of
an Ideal Pain management System, in Pain in Residential Aged Care: management strategies, (Goucke et al., 2005, p. 59) and Post Audit Data for the PMG
Kit for Aged care (Edith Cowan University, 2007, p. 29).

Date of Collection: ______________________________ Completed by: ______________________________ Position:

______________________________

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SECTION 1 – DEMOGRAPHIC AND CLINICAL INFORMATION
Resident Name: ________________________________ DOB:
______________________________________
Gender: ______________________________
Medical/surgical history:

Medications (list/attach):

217
SECTION 2 - PAIN ASSESSMENT

To complete this section please tick Yes, No or Not Applicable (NA) boxes. Shaded areas allow for clarification of answers.

2. A. - RESIDENT HISTORY

Question Yes No NA Comments

2.A.1. Is there a history of persistent pain? (Note a pain assessment should be □ □ □

conducted according to residential care facility (RCF) policy regardless if
condition is identified).
2.A.2. Has the cause been identified? □ □ □ Specify cause:

2.A.3. Is the individual able to verbally communicate about the presence of □ □ □

pain? (This may include answering yes/no to verbal questions by RCF staff)
2.A.4. What word/s are used by the resident able to verbally communicate to Provide details:
describe their pain?
2.A.5. What type of behavioural symptoms have been observed or documented Provide details:
that may indicate the presence of pain for this individual?
2.A.6. What are the tool/s used to assess pain in the RCF? List the tools used Verbal Pain Tool:
for residents able to verbally and non-verbally respond. Non-Verbal Pain Tool:

2.A.7. Is it a tool recommended by the Australian Pain Society? □ □ □ □ Unknown

2.A.8. Is it a tool recommended by the RCF/ Organisation? □ □ □ □ Unknown

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SECTION 2.B. – ROUTINE ASSESSMENTS - ADMISSION and THREE-MONTHLY REVIEW

To complete this section, tick yes, no or NA in the boxes provided. Shaded areas require clarification of answers. This page can be photocopied as required, for
assessing admission and or three-monthly reviews.
GUIDELINE: Routine and timely assessment (Goucke et al., 2005, p.1, 7 & 59).
A pain assessment that includes a pain intensity rating is performed on all patients on admission and is included in the patient’s record (p.59).
Either at rest or movement-based periods should be included in the assessment (p.7).
The possibility of the onset of pain should be considered if there is a significant change in a resident’s condition and, routinely, every three months (p.1).

Question Yes No NA Comments

2.B.1. Was a pain assessment conducted within four weeks of admission to the □ □ □ If No/NA, provide reason/s:
RCF?
2.B.2. Has a pain assessment been conducted every three months? □ □ □ If No/NA, provide reason/s:

2.B.3. Was a pain tool as recommended by the APS used? □ □ □ Specify which tool:

2.B.4. Was the pain assessment tool completed correctly (all sections □ □ □ If No, provide details:
answered)?
2.B.5. Was it completed at rest? □ □ □
2.B.6. Was it completed during movement? □ □ □ If during movement, what activity?

2.B.7. What was the job classification of the person completing the □ □ □
assessment? For example, Care Manager, Clinical Nurse. Registered Nurse,
other?
2.B.8. If pain was identified and assessed on admission or in the three-monthly □ □ □ Provide details of to whom and when:
review, was this communicated to the Doctor, Care Manager, Clinical Nurse,
Registered Nurse, Enrolled Nurse, family and resident?

219
Question Yes No NA Comments

2.B.9. Were management strategies implemented/reviewed? □ □ □ Provide details:

2. B.10. Were new management strategies evaluated post implementation for □ □ □ What period of time the pain was evaluated for?
their effectiveness
2. B.11. If the pain was unresolved were new management strategies □ □ □ Provide details:
implemented and evaluated?

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SECTION 2.C. - PAIN ASSESSMENT for EPISODES OF IDENITIFIED PAIN

To complete this section please tick Yes, No or NA in the boxes provided. Shaded areas require clarification of answers. This page can be photocopied as many
times as required to evaluate episodes of pain during the period being reviewed.
GUIDELINE: If pain is not identified on admission then the issue of pain identification should be raised again (Goucke et al., 2005, p. 4 & 59).
• Whenever significant change in residents’ condition
• Anytime pain is suspected
Note, a change may include a fall, hospitalisation, illness, change in behaviour (once infection, dehydration, constipation or other clinical need has been assessed),
or a change in medication.
Responsibility for action is determined from the pain assessment (p.59).
EPISODE NUMBER:____________________ Starting Date of Episode: ____________________

Question Yes No NA Comments

2.C.1. Was a pain assessment conducted if the resident verbalised the □ □ □ If No, detail the episode identified here:
presence of pain, changes in behavioural symptoms were identified or their
condition changed?
2.C.2. Was a pain tool recommended by the APS used? □ □ □ Specify which tool:

2.C.3. Was the pain assessment tool completed correctly? □ □ □ If No, provide details:

2.C.4. Was the tool completed at rest? □ □ □

2.C.5. Was the tool completed during movement? □ □ □ If during movement, what activity?

2.C.6. What was the job classification of the person completing the
assessment, e.g. Care Manager, Clinical Nurse, Registered Nurse, other?

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 Question Yes No NA Comments

2.C.7. If the pain assessment showed a change in the resident’s pain or new □ □ □ Provide details of to whom and when:
pain episode, was this communicated to and followed up by the Doctor, Care
Manager, Clinical Nurse, Registered Nurse, Enrolled Nurse, family and resident?
2.C.8. Were management strategies implemented/ reviewed? □ □ □ Provide details of strategies:

2.C.9. Were new management strategies evaluated post implementation for □ □ □ Provide details of length of evaluation post:
their effectiveness?

2.C.10. If the pain was unresolved, were new management strategies □ □ □ Provide details of strategies implemented:
implemented and evaluated?

SECTION 3 – PAIN MANAGEMENT

To complete this section, tick yes, no or NA in the boxes provided. Shaded areas require clarification of answers.
GUIDELINE: Pain management is provided by a multidisciplinary team with the primary care provider as the central link in the system (Goucke et al., 2005, p. xii.
7, 18, 59)
Multidisciplinary collaboration between Doctors (Dr’s), registered nursing staff, care workers, physiotherapist (PT) and other care staff is the key to effective pain
management (p.xii)
A resident and his or her representative must be informed about and actively involved in pain assessment and management so that optimum outcomes can be
achieved and procedures can be balanced with the resident’s wishes and overall aims of care (p.7)
Management should involve a combination of pharmacological and non-pharmacological therapies incorporated into the pain management care plan? (p.18)

Question Yes No NA Comments

3.A.1. Were there members of a multidisciplinary team involved in planning □ □ □ Please tick those that apply:
the residents care? Pain Specialist or Persistent Pain Team
Medical Officer (GP)
Care Manager
Clinical Nurse

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Question Yes No NA Comments

Registered Nurse
Enrolled Nurse
Assistant in Nursing (or equivalent)
Physiotherapist
Diversional Therapist
Psychologist
Occupational Therapist
Other (e.g. palliative care, external allied
health professional) Specify:
___________________________________________
3.A.2. Does the residents’ care plan identify if the resident and their □ □ □
representative were involved in the development of the plan of care?
3.A.3. Does the pain management care plan detail the resident’s needs and □ □ □ List pharmacological and non- pharmacological
detail how it will be managed with both pharmacological and non- strategies implemented for this resident:
pharmacological strategies?
3.A.4. Is analgesia ordered around the clock for persistent pain? □ □ □ Provide details of medication:

3.A.5. Has breakthrough analgesia or predictable incident analgesia been □ □ □ Provide details of medication:
ordered? (p.21)
3.A.6 Is there a Multidisciplinary Pain Service available for residents to be □ □ □ Provide details of service:
referred to, when the pain is not able to be managed with current strategies

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SECTION 4 – POLICY AND EDUCATION

GUIDELINE: Pain Management Standards are in place (Goucke et al., 2005, p. 59).
A facility wide policy for pain is established that meets the Aged Care Accreditation and Standards Agency requirements: “That all residents are as a free as possible
from pain” (Department of Health and Ageing., 2009).

SECTION 4.A. - POLICY

GUIDELINE: The development of objective and quantifiable clinical indicators, which reflect the quality of pain management and are available to health services,
care providers, consumers and researchers (Goucke et al., 2005, p. 52 & 59).
A standard nursing policy established for pain that includes pain management definitions and beliefs (p.59).

Question Yes No NA Comments

4.A.1. Does the RCF have a pain management policy? □ □ □ Attach a copy of the policy if available.

4.A.2. Does the pain management policy include pain management definitions
□ □ □
and beliefs of the RCF or organisation?

4.A.3. Does it state when pain assessments should be conducted? □ □ □

4.A.4 Does it state that all residents should have an assessment on
□ □ □
admission?
4.A.5. Does it state that pain should be regularly reviewed (every three months) Provide details if No/NA:

□ □ □
Is this the RACF/ organisations policy:
□ Yes □ No □ Unsure

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Question Yes No NA Comments

4.A.6. Does it state that pain should be reviewed, whenever a complaint of pain
is received, a change in behavioural symptoms is identified, a change in □ □ □
medication, hospitalisation, illness or fall? (p.54).
4.A.7. Does it state who is to conduct the assessment e.g. Care Manager, Provide details:
Clinical Nurse, Registered Nurse, Enrolled Nurse, Assistant in Nursing (or □ □ □
equivalent)?
4.A.8. Are assessment tools that are recommended suitable for use with Provide details of tools in use in the RACF:
cognitively intact and cognitively impaired residents according to the Australian □ □ □
Pain Society (Goucke, Scherer et al. 2005) used?
4.A.9. Is there a standardised pain monitoring sheet? Attach a copy of the monitoring documentation if
A monitoring sheet allows for uni-dimensional monitoring of pain. For available.
example, for those able to verbalise their pain, a verbal rating scale of intensity □ □ □
only is suitable, once a full assessment has been completed using a Residents
Brief Verbal Pain Inventory (RVBPI) tool or equivalent.
4.A.10. Does the policy outline what pain management strategies are available □ □ □ Provide details of the strategies available
at the RCF? (pharmacological and non-pharmacological):

4.A.11. Does the policy describe the role of the RCF staff in administrating □ □ □ Provide details:
medication, including: Analgesics, Schedule 8’s, Adjuvants (antidepressants,
anti- convulsants), nurse initiated and PRN medications? (PMG kit p.29)?
4.A.12. Does the policy state what allied health services are available in the RCF □ □ □ Provide details of allied health services available:
and their role?

4.A.13. Has a copy of the policy been provided? □ □ □ Attach policy.

225
Question Yes No NA Comments

4.A.14. Has a copy of the pain assessment tools and monitoring documentation □ □ □ If Yes, please attach a copy of all tools and monitoring
been provided? documentation.

226
SECTION 4.B. - EDUCATION

GUIDELINE: Programs to educate residential sector health care providers about state-of-the-art principles of pain management are a consistent with their scope
of practice (Goucke et al., 2005, p. 51).

Question Yes No NA Comments

4.B.1. Has the pain management education been provided to all RCF staff □ □ □ If No, provide details or attach training record:
consistent with their scope of practice, including Directors of Nursing, Care
Managers, Clinical Nurses, Registered Nurses, Enrolled nurses, Assistants in
Nursing, Physiotherapists, Diversional Therapists, Managers and Environmental
Staff on an annual basis?
4.B.2. Have all RCF care staff attended an annual pain assessment/ □ □ □ If No, provide details:
management update, including revision of the pain policy?

4.B.3. Have all RCF care staff, received education about the use of □ □ □ If No, provide details:
assessment tools as recommended by the APS?
4.B.4. Has a competency assessment been conducted with the Registered □ □ □ If No, provide details:
nursing staff or assistants in nursing, assessing their ability to identify
behavioural symptoms of pain and their competence in completion of the
assessment tools?
4.B.5. Are residents and their families being involved in and educated about □ □ □
pain assessment and management practices in the facility? (p.51)

227
SECTION 4.C. – INTERDISCIPLINARY TEAM

GUIDELINE: An interdisciplinary pain management team is present in the facility (Goucke et al., 2005, p. 58)

Question Yes No NA Comments

4.C.1. Is there a pain management team? □ □ □

4.C.2. Does the pain management team have key participants? □ □ □ Please tick those that apply:
 Nursing staff
 Care workers
 Physiotherapist
 Diversional Therapist
 General Practitioner
 Pharmacist
Other (specify)
_________________________________
4.C.3. How often are the pain management team meetings scheduled, Provide details:
e.g. weekly, monthly, bimonthly, other?

4.C.4. Are the minutes of this meeting available to all care staff? □ □ □ If No, provide details:

228
SECTION 5 - KEY FINDINGS AND ACTION PLAN
KEY FINDINGS

1.

2.

3.

4.

5.

229
 Key Recommendations Actions Action Person Comments/action status
P
Findings required date responsible (Provide examples of changes in practices,
h (specify “None”, (Name and problems encountered in facilitating change,

ot No. if none required) classification) reasons why recommendation has not been
actioned etc.)
o
c
o
p
y

a
s

r
e
q
ui
r
e
d

(Goucke et al., 2005)

230
Appendix 4: Phase One– Participant information and consent.

PARTICIPANT INFORMATION FOR RESEARCH PROJECT

Research Project Contact

Helen Holloway

Masters , School of Nursing and Midwifery, University of Queensland

0412516195

helenholloway@bigpond.com

Project Title: Facilitators and Barriers to the identification and assessment of pain in
individuals living in a residential aged care facility with moderate to severe
dementia.

1. Introduction.
The management of St Andrew’s Uniting Church Care Homes have agreed to participate
in this research project which examines the Barriers and Facilitators to pain assessment in
individuals with moderate to severe dementia.

2. What is the purpose of the research project?

Previous research has shown that there are barriers that exist to the successful
identification, assessment and management of pain in the individual living with a diagnosis
of dementia in a residential aged care facility. St Andrew’s Uniting Church Care Homes
were part of a project - Establishing Best Practice in Residential Aged Care project in 2008
– 2009. This project involved implementing the Australian Pain Society Guidelines for
people with dementia. This current project aims to evaluate the long-term outcomes of that
project and identify if barriers remain inhibiting the identification and assessment of pain or
are processes still in place so that best practice pain assessment and management
strategies continue to impact care in residential aged care facilities.

3. What does participation in this research involve?

You are invited to participate in a 30-minute interview to discuss your views on what
barriers or facilitators remain in the identification and assessment of pain for individuals
with moderate to severe dementia. The interview will be audio-taped for the purpose of
maintaining an accurate record and reporting of data. None of the recordings will be used
231
in public and all information or names will be deidentified. The interviews will take place at
the residential aged care facility, via phone or via the internet through Skype. If you require
an interpreter another staff member who speaks your preferred language may be able to
assist you. You will not be paid for your participation in the research.

4. What are the possible benefits?

By participating in this part of the project you can be actively involved and have your say
about how pain identification, assessment and management are conducted in the
workplace and make suggestions for improvement. This may lead to enhanced work
satisfaction.

In addition, helping to identify ongoing barriers and facilitators to pain identification and
assessment in the workplace will assist the primary investigator and perhaps the wider
aged care community to address some of the ongoing issues related to pain identification
and assessment in the individual with dementia. This will ensure that best practice pain
assessment and management strategies can continue in our residential aged care
facilities.

5. What are the possible risks?

There are no known aspects of this study that are essentially harmful to you. Sometimes
questions in the interview may raise matter that trigger an emotional response. For
example, questions about what barriers you believe exist in the workplace that prevent you
from undertaking a pain assessment, may bring up feelings of frustration and anger.
However, being able to share your frustrations with a person who is sensitive to the
barriers in the workplace may help you. If you find the questions upsetting, you will be
reminded by the primary investigator that you need not continue with that question and the
opportunity to discuss this question at a later date or not at all.

6. Do I have to take part in this research project?

Participation in this research is voluntary. If you do not wish to take part you do not have
to. If you decide to take part and later change your mind, you are free to withdraw from the
project at a later stage.

7. How will you be informed of the final results

Outcomes of the research in a de-identified format will be available to the participants, the
Care Manager and Clinical Nurse of the facility.

232
8. What will happen to the collected information?
Any information obtained in connection with this research project that can identify you will
remain completely confidential and will only be used for the purpose of the research
project. The outcomes may be discussed in peer reviewed publications but all information
will be de-identified. All information collected will be stored in digital format with secure
password protected files. Seven years after completion of the study all materials will be
disposed of as confidential waste.

9. Is this research project approved?

This study adheres to the Guidelines of the ethical review process of The University of
Queensland Behavioural & Social Sciences Ethical Review Committee (BSSERC). Whilst
you are free to discuss your participation in this study with me, if you would like to speak to
an officer of the University not involved in the study, you may contact the Ethics Officer on
(07) 3365 3924 or email: humanethics@research.uq.edu.au

10. Consent
If you decide to take part in the research project you will be asked to sign the consent form
attached to the back of this introductory form. By signing this form, you are agreeing that
you have:

• Read the document and understood what has been read

• Consent to take part in the research project
• Consented to the use of the information that you provided to be used in any reports
written.

233
 Consent Form – Staff.

Primary Investigator Contact.

Helen Holloway.

Masters Student, School of Nursing and Midwifery, University of Queensland.

Ph 0412516195

helenholloway@bigpond.com

Project Title: Barriers and Facilitators to the identification and assessment of pain in
individuals living in a residential aged care facility with moderate to severe
dementia.

I have read or have had read to me this document, in a language that I understand. I
understand the purpose, procedures and risks of this research project as described in the
information.

I have asked any questions to clarify any concerns and are happy with the answers I
received.

I agree to participate in the research project as described.

I understand that I will be given a copy of this consent form to keep for my personal
records.

Participants
Name:_____________________________________________________(printed)

Participant’s Signature: _______________________________________________

Date :___________

Declaration by the Primary Investigator:

I have given a verbal explanation of the research project, the procedures, purposes and
risks associated with the research project. I believe that the participant has understood
that explanation.

234
Primary Investigator
Name:___________________________________________________(printed)

Primary Investigator
Signature:______________________________________Date:________

Witness Name:___________________________________________________(printed)

Witness Signature:______________________________________________Date:

Complaints

If you have any concerns regarding the conduct of this project please contact the Primary
Investigator (details are above) or the Ethics Officer of the University of Queensland on
(07) 3365 3924 or email: humanethics@research.uq.edu.au

235
Appendix 5: Phase One- Demographic questionnaire and interview questions.
QUESTIONS for Staff Interviews

PART 1 – Demographic information

1. Are you: Male Female

2. What age group do you fall into?
16 – 20
21 – 30
31 – 40
41 – 50
51- 60
61 – 70
Over 70
3. Place a tick in the column next to the description that best describes your position?
Paid Personal Carer without Registered Nurse
certification

Multiskilled Care Worker: • Hospital trained

• With Certificate IV in Aged • Undergraduate degree

Care
• Without certification • Postgraduate training
• Enrolled in nursing degree • Enrolled in further studies
Enrolled Nurse: Other (Please specify)
• Enrolled Nurse
• Medication Endorsed EN …………………………………………….

• Enrolled in nursing degree

4a). Have you ever received any formal training (outside of the facility or provided by an
external provider) regarding pain assessment in the older person with dementia?

Yes No
b) Have you ever received any formal training (outside of the facility or provided by an
external
provider) regarding pain management in the older person with dementia?

236
 Yes No
5. If yes, please provide details of name of course, institution providing the training,
duration of the course and the year completed.

Name of Course Institution Duration Year

Completed

6. How long have you been caring for the older person with dementia?

years and months

7. How many times in the past two years would you have attended an education/toolbox
session on pain assessment in the older person with dementia?

Never Once or twice Three to five times

More than 6 times Don’t know

8. Are you aware of the facilities pain management policy?

Yes No

237
PART 2

1. Were you present during the implementation of the EBPRAC pain management
project?

YES NO

For staff present during EBPRAC project

1. What barriers or challenges have you encountered since the implementation of the
EBPRAC project in 2008/9? Prompts: challenges assessing resident’s pain,
commitment from other health care providers – doctors etc. or colleagues, system
issues – time constraints, staff ratio, competing demands or priorities, the education
package itself?

2. What facilitators (things that have helped) have you encountered?

3. If your facility was involved in another project that was similar in the future, what
strategies do you think would be most effective in changing practice in the short
term and long term?

4. What advice would you give to other staff working in LTC with respect to the
implementation of pain identification and assessment best practice guidelines for
people with dementia?

238
All staff

1. Can you describe the role you play in identifying and assessing pain in the facility?
Prompts: identify pain, assess pain using tools, documentation, communication to
EN/RN/GP, motivate staff, engage residents and family members, reminded and
supported staff about Pain related practices

2. What barriers or challenges do you encounter during the daily work routine that might
prevent you or stop you from identifying pain or undertaking a pain assessment in the
person with dementia?
⎯ Prompts: challenges assessing residents’ pain- residents unable to report pain,
system issues such as time constraints and lack of staff, inadequate knowledge,
inadequate communication, competing demands/priorities, etc.

3. What Facilitators do you encounter or could be used, to help you to identify pain or
undertaking a pain assessment for the person with dementia?
Prompts: more education and training, prompts, whiteboard with resident’s names,
communication at handover etc.

4. Do you have any recommendations for improving pain assessment and management
in the facility?

5. Is there anything else you would like to share with respect to this topic that I have not
asked about?

239
Appendix 6: Phase Two- Participant information and consent.

STUDENT PARTICIPANT INFORMATION FOR RESEARCH PROJECT

Research Project Contact: Helen Holloway Mob: 0412516195, E: helen.holloway@uq.net.au

Project Title (shortened): Knowledge versus experience in pain identification,

assessment and management.

Identifying and managing a resident’s pain is important role for carers working in aged
care. Untreated pain can affect a resident’s quality of life. Previous research has shown
that pain identification, assessment and management is poorly attended to in residential
aged care. There are a number of reasons that have been identified as contributing to poor
practice. Improving knowledge through education of all staff has been identified as a key
factor in improving practice. This aim of this study is to explore how knowledge on pain
identification, assessment and management is taught, learnt and then applied in practice,
when a Certificate III Aged Care student becomes a residential aged care worker.

What does participation in this research involve?

Your participation in this project means that you will be asked to complete questionnaires
which will take you 5 – 10 mins to complete. They will ask you different questions about
your knowledge and beliefs of pain in the elderly. During clinical experience and for a
period of two weeks after you have graduated you will be asked to complete a journal of
your experiences identifying, assessing and managing pain. These daily entries will take
you 5 – 10 mins to complete. There will also be the opportunity for a 10 – 15 min
conversation with the principal investigator (Helen Holloway) at completion of your
certificate and 3 months after you graduate.

Voluntary participation- Participation in this research is voluntary. If you do not wish to

take part you do not have to. If you decide to take part and later change your mind, you
are free to withdraw from the project at a later stage and all data previously collected from
you will be destroyed. You will be offered a $20 gift voucher.

Consent: A consent form is attached for you to sign

240
Confidentiality: Any information provided will have any identifying information removed
and be held in the strictest confidence. Any data used in public reports or publications will
not contain any identifying information.
Storage of information: Any information collected will be stored in password protected
files for electronic documents. De-identified data will be kept for 7 years.

What are the possible benefits: By participating in this part of the project you can be
actively involved and have your say about how students learn and then utilise that
knowledge when moving from the training room to the clinical workforce.

What are the possible risks: There are minimal risks to you for participating in this
research project.

Feedback: Reports and publications that are produced as a result of this study will be
available to the AMX training group and wider publications. All information included will
have any material able to be identified removed.

Is this research project approved: This study adheres to the Guidelines of the ethical
review process of The University of Queensland Behavioural & Social Sciences Ethical
Review Committee (BSSERC). Whilst you are free to discuss your participation in this
study with me, if you would like to speak to an officer of the University not involved in the
study, you may contact the Ethics Officer on (07) 3365 3924 or email:
humanethics@research.uq.edu.au

241
Consent Form – Student

Primary Investigator Contact

Helen Holloway

PhD Candidate, School of Nursing and Midwifery, University of Queensland

Ph 0412516195

helenholloway@uq.net.au

Project Title (shortened): Knowledge versus experience in pain identification,

assessment and management

I have read or have had read to me this document, in a language that I understand. I
understand the purpose, procedures and risks of this research project as described in the
information.

I have asked any questions to clarify any concerns and are happy with the answers I
received.

I agree to participate in the research project as described.

I understand that I will be given a copy of this consent form to keep for my personal
records.

Participants
Name:_____________________________________________________(printed)

Participant’s Signature:_______________________________________________Date
:___________

Declaration by the Primary Investigator:

I have given a verbal explanation of the research project, the procedures, purposes and
risks associated with the research project. I believe that the participant has understood
that explanation.

Primary Investigator
Name:___________________________________________________(printed)

242
Primary Investigator
Signature:______________________________________Date:________

Witness Name:___________________________________________________(printed)

Witness Signature:______________________________________________Date:

Complaints

If you have any concerns regarding the conduct of this project please contact the Primary
Investigator (details are above) or the Ethics Officer of the University of Queensland on
(07) 3365 3924 or email: humanethics@research.uq.edu.au

243
CLINICAL FACILITATORS PARTICIPANT INFORMATION FOR RESEARCH PROJECT

Research Project Contact

Helen Holloway

Doctor of Philosophy Student, School of Nursing and Midwifery, University of

Queensland

0412516195

helenholloway@uqconnect.edu.au

Project Title: Transition of knowledge from Certificate III Aged Care student to care
worker: examining the role of knowledge versus experience in pain identification,
assessment and management.

11. Introduction
The Director of xxxxxxxxxxxxxxx has agreed to participate in this research project, which
examines the transition of knowledge from student to aged care worker, specifically
examining the clinical realm of pain identification, assessment and management in
residential aged care.

12. What is the purpose of the research project?

Previous research has shown that pain identification, assessment and management is
poorly attended to in residential aged care. There are a number of barriers that have been
identified as contributing to poor practice and can be classified as resident, staff, facility or
systems orientated. There have been a small number of facilitators identified, the primary
one being, education of all staff. This project seeks to explore how knowledge on pain
identification, assessment and management is taught and applied in practice, with
Certificate III Aged Care students transitioning to residential aged care worker.

13. What does participation in this research involve?

You are invited to participate in this research. Participation means you will be asked to
complete questionnaires and undertake interviews. The questionnaires will ask you
questions about yourself and your experience including your age, sex, previous training or
244
experience in aged care, clinical experiences, length of time as a clinical facilitator and
attitudes to pain, knowledge and confidence in identifying, assessing and managing pain.
These should take about 5 mins to complete. This will be followed within one to two
weeks, in a 30-minute interview. The initial interview will centre on discussing further your
knowledge in pain identification, assessment and management, barriers and facilitators
that you may be able to identify in the identification and assessment of pain for the older
person, non – pharmacological and pharmacological management strategies. The
interview will be electronically recorded for the purpose of maintaining an accurate record
and reporting of data. None of the recordings will be used in public and all information or
names will be deidentified. The interviews will take place at the training facility or another
suitable location, via phone or via the internet through Skype. If you require an interpreter
another staff member who speaks your preferred language may be able to assist you. You
will not be paid for your participation in the research however a small gift may be
presented to you to thank you for your participation.

14. What are the possible benefits?

By participating in this part of the project you can be actively involved and have your say
about how students learn and then utilise that knowledge when moving from the training
room to the clinical workforce, particularly in the area of pain identification, assessment
and management. Understanding how the knowledge is taken from the training room to
the clinical area will help to improve training delivery methods, ensuring that we continue
to meet best practice pain identification, assessment and management strategies in the
residential aged care facilities. It will also help us to examine identify teaching methods to
ensure that implemented best practice is sustained.

15. What are the possible risks?

There are no known aspects of this study that are essentially harmful to you. Sometimes
questions in the interview may raise matter that trigger an emotional response. However,
being able to share your frustrations with a person who is sensitive to the issues in the
workplace may help you. If you find the questions upsetting, you will be reminded by the
primary investigator that you need not continue with that question and the opportunity to
discuss this question at a later date or not at all.

245
16. Do I have to take part in this research project?
Participation in this research is voluntary. If you do not wish to take part you do not have
to. If you decide to take part and later change your mind, you are free to withdraw from the
project at a later stage. All data collected on you at that time will be destroyed.

17. How will you be informed of the final results

Outcomes of the research in a de-identified format will be available to the participants, the
Directors and the Clinical Facilitators.

What will happen to the collected information?

Any information obtained in connection with this research project that can identify you will
remain completely confidential and will only be used for the purpose of the research
project. During the project you will be provided with a unique code. The outcomes may be
discussed in peer reviewed publications but all information will be de-identified. All
information collected will be stored in digital format with secure password protected files.
Seven years after completion of the study all materials will be disposed of as confidential
waste.

18. Is this research project approved?

This study adheres to the Guidelines of the ethical review process of The University of
Queensland Behavioural & Social Sciences Ethical Review Committee (BSSERC). Whilst
you are free to discuss your participation in this study with me, if you would like to speak to
an officer of the University not involved in the study, you may contact the Ethics Officer on
(07) 3365 3924 or email: humanethics@research.uq.edu.au

19. Consent
If you decide to take part in the research project you will be asked to sign the consent form
attached to the back of this introductory form. By signing this form, you are agreeing that
you have:

• Read the document and understood what has been read

• Consent to take part in the research project
• Consented to the use of the information that you provided to be used in any reports
written.

246
Consent Form – Clinical Facilitator

Primary Investigator Contact

Helen Holloway

PhD Candidate, School of Nursing and Midwifery, University of Queensland

Ph 0412516195

helenholloway@uqconnect.edu.au

Project Title: Project Title: Transition of knowledge from Certificate III Aged Care
student to care worker: examining the role of knowledge versus experience in pain
identification, assessment and management.

I have read or have had read to me this document, in a language that I understand. I
understand the purpose, procedures and risks of this research project as described in the
information.

I have asked any questions to clarify any concerns and are happy with the answers I
received.

I agree to participate in the research project as described.

I understand that I will be given a copy of this consent form to keep for my personal
records.

Participants
Name:_____________________________________________________(printed)

Participant’s Signature:_______________________________________________Date
:___________

Declaration by the Primary Investigator:

247
I have given a verbal explanation of the research project, the procedures, purposes and
risks associated with the research project. I believe that the participant has understood
that explanation.

Primary Investigators
Name:___________________________________________________(printed)

Primary Investigators
Signature:______________________________________Date:________

Witness Name:___________________________________________________(printed)

Witness Signature:______________________________________________Date:

Complaints

If you have any concerns regarding the conduct of this project please contact the Primary
Investigator (details are above) or the Ethics Officer of the University of Queensland on
(07) 3365 3924 or email: humanethics@research.uq.edu.au

248
Appendix 7: Phase Two- Student quesionnaires.
Student Demographic information.
1. Are you: Male Female
2. What age group do you fall into?
16 – 20
21 – 30
31 – 40
41 – 50
51- 60
61 – 70
Over 70

3a. What nationality are you?___________________________________

b. Are you of Aboriginal or Torres Strait Islander decent? Yes/No

4. What did you do (student/job) prior to enrolling in the Certificate III course?_
_______________________________________________________________________
5. Why did you decide to become a care worker in aged care?
__________________________________________________________________
__________________________________________________________________
_______________________________________________________________
6. Are you currently working in an Aged Care Facility?
Yes No
7. Place a tick in the column next to the description that best describes your position ?
Paid Personal Carer without Registered Nurse
certification
Multiskilled Care Worker : • Hospital trained
• With Certificate IV in Aged • Undergraduate degree
Care
• Without certification • Postgraduate training
• Enrolled in nursing degree • Enrolled in further studies
Enrolled Nurse: Other (Please specify)
• Enrolled Nurse (e.g. Overseas trained professional (if
so what profession?)
• Medication Endorsed EN …………………………………………….
• Enrolled in nursing degree

249
8 a). Have you ever received any training regarding pain assessment in the older person?
Yes No
Details
b) Have you ever received any formal training regarding pain management in the older
person? Yes No
Details
.
9. Are you aware of the facilities pain management policy?
Yes No NA

250
 Questionnaire – Knowledge and Beliefs about Pain in the elderly(Zwakhalen et al.,
2007)

Instructions: This survey will ask you for your views about current pain management. Your
answers will help us to gather information about how you gain knowledge in identifying,
assessing and managing pain and what is the best method of learning. It will also help us
identify your beliefs about pain in the older person. Answers given will be completely
confidential and anonymous and will not be known by anyone other than the survey staff
and this questionnaire has no bearing on your studies.

251
1 Older people
Strongly Mostly Mostly Strongly No
experience pain less
Agree Agree Disagree Disagree opinion
intensely than
younger people
2 Pain medication
Strongly Mostly Mostly Strongly No
works better in young
Agree Agree Disagree Disagree opinion
people than in the
elderly
3 Pain medication Strongly Mostly Mostly Strongly No
works longer in the Agree Agree Disagree Disagree opinion
elderly than in young
people
4 Pain medication has
Strongly Mostly Mostly Strongly No
more side effects in
Agree Agree Disagree Disagree opinion
the elderly than in
younger people
5 Dementia patients
Strongly Mostly Mostly Strongly No
experience less pain
Agree Agree Disagree Disagree opinion
than non-dementia
patients
6 Assessing pain in a Strongly Mostly Mostly Strongly No
dementia patient is a Agree Agree Disagree Disagree opinion
matter of guessing
7 Where I work, pain is Strongly Mostly Mostly Strongly No
assessed correctly Agree Agree Disagree Disagree opinion

8 Where I work, pain is Strongly Mostly Mostly Strongly No

treated correctly Agree Agree Disagree Disagree opinion

252
9 Where I work, much
Strongly Mostly Mostly Strongly No
attention is given to
Agree Agree Disagree Disagree opinion
pain in dementia
patients
10 Pain medication
should only be Strongly Mostly Mostly Strongly No
administered to Agree Agree Disagree Disagree opinion
patients suffering
from severe pain
11 Patients are often Strongly Mostly Mostly Strongly No
prescribed too much Agree Agree Disagree Disagree opinion
pain medication
12 It is better to
administer pain
Strongly Mostly Mostly Strongly No
medication ‘when
Agree Agree Disagree Disagree opinion
necessary’, rather
than according to a
fixed schedule.
13 Administering pain
medication should be
postponed as long as
Strongly Mostly Mostly Strongly No
possible, because
Agree Agree Disagree Disagree opinion
dementia patients
should receive as
little pain medication
as possible
14 A dementia patient
should first report
Strongly Mostly Mostly Strongly No
pain before receiving
Agree Agree Disagree Disagree opinion
the next dose of pain
medication
15 Pain is part of the Strongly Mostly Mostly Strongly No
aging process Agree Agree Disagree Disagree opinion

253
 16 Older people are Strongly Mostly Mostly Strongly No
more likely to be Agree Agree Disagree Disagree opinion
affected by pain than
younger people
17 Pain medication, if Strongly Mostly Mostly Strongly No
administered in large Agree Agree Disagree Disagree opinion
quantities, easily
leads to addiction
among the elderly
Zwakhalen, S., Hamers, J., Peijnenburg, R., Berger, M. (2007). Nursing staff knowledge
and beliefs about pain in elderly nursing home residents with dementia. Pain Research
and Management. Vol 12. No. 3, PP. 177-184

254
 Modified Pain Management Student Survey (Savvas et al., 2014b)
Instructions: This survey will ask you for your views about current pain management. Your answers will
help us to gather information about how you gain knowledge and confidence in identifying, assessing and
managing pain and what is the best method of learning. Answers given will be completely confidential and
anonymous and will not be known by anyone other than the survey staff and this questionnaire has no
bearing on your studies.

Please answer every question by circling one of the boxes, if you are unsure about how to answer a
question, please give the best answer you can.

Participant Code: ………………….…....

Part A

1. I am confident in my pain management Strongly Mostly Mostly Strongly

skills Agree Agree Disagree Disagree

2. I am able to recognise when a resident is Strongly Mostly Mostly Strongly

experiencing pain Agree Agree Disagree Disagree

3. I am able to recognise pain in those with Strongly Mostly Mostly Strongly

dementia or non-verbal residents Agree Agree Disagree Disagree

4. I know and understand the Australian

Strongly Mostly Mostly Strongly
Pain Society Guidelines for Pain
Agree Agree Disagree Disagree
Management in Residential Care Facilities

5. I know and understand the facility Strongly Mostly Mostly Strongly

procedures for dealing with pain Agree Agree Disagree Disagree

6. I am happy with the current facility Strongly Mostly Mostly Strongly

procedures for dealing with pain Agree Agree Disagree Disagree

7. I know who to tell if I notice a resident is in Strongly Mostly Mostly Strongly

pain Agree Agree Disagree Disagree

8. If I notice a resident is in pain, I will Strongly Mostly Mostly Strongly

always report this to the appropriate person Agree Agree Disagree Disagree

9. I believe I have had adequate training to Strongly Mostly Mostly Strongly

enable me to assess if a resident is in pain Agree Agree Disagree Disagree

10. I am regularly involved in providing Strongly Mostly Mostly Strongly

treatment for pain Agree Agree Disagree Disagree

255
11. I am confident in using a wide range of
Strongly Mostly Mostly Strongly
pharmacological therapies for pain
Agree Agree Disagree Disagree
management.

12. I am confident in using a wide range of

Strongly Mostly Mostly Strongly
non-pharmacological therapies for pain
Agree Agree Disagree Disagree
management

13. I believe that the non-pharmacological Strongly Mostly Mostly Strongly

treatments provided for pain are effective Agree Agree Disagree Disagree

14. I believe that the pharmacological Strongly Mostly Mostly Strongly

treatments provided for pain are effective Agree Agree Disagree Disagree

(Savvas et al., 2014b)

Please turn over

256
PART B
This next section will ask you true and false question regarding your knowledge and
attitude about pain in the elderly.

15. Observations such as pulse, blood pressure are always reliable indicators of
T F
the intensity of a resident’s pain.
T F 16. Pain is an unavoidable part of growing old

T F 17. Residents who can be distracted from pain usually do not have severe pain.
T F 18. Residents may sleep despite being in severe pain.
T F 19. Elderly residents cannot tolerate opioids (morphine etc.) for pain relief.
20. Residents should be encouraged to endure as much pain as possible before
T F
using an opioid (morphine).
T F 21. Resident’s spiritual beliefs may lead them to think pain and suffering are
necessary
22. Providing a resident who has pain with opioid e.g. morphine like medication
T F
will contribute to them developing an addiction
(Ferrell & McCaffery, 2012)

257
Appendix 8: Phase Two- Student interview questions.

QUESTIONS for Student Interviews

1. Can you tell me what verbal cues may indicate that an older person is in pain?

2. Can you tell me what non-verbal cues or behaviours you may observe in a person who
is not able to communicate i.e. like someone with dementia?

3 If pain in the older person is not managed or treated appropriately what could be the
outcome?

4. What are some of the barriers to pain identification, assessment and management in the
individual living in residential aged care?

5 What are some of the facilitators to pain identification assessment and management?

Post Certificate Course Questions and Care Worker Question

1. Did you find that you learnt more about identifying pain in the course or in the
workplace?
2. Did you find that you learnt more about assessing pain in the course or in the
workplace?
3. Did you find that you learnt more about medication strategies for pain management
during the course or in the workplace?
4. Did you find that you learnt more about non-pharmacological strategies i.e.
massage, heat therapy etc.?
5. Do you feel more confident to identifying pain in the older person? Explain
6. Do you feel that you are able to complete a pain assessment tool, either a verbal
tool or non-verbal tool?

258
Appendix 9: Phase Two- Clinical facilitator questionnaires.

Clinical Facilitator - Demographic information

1. Are you: Male Female

1. What age group do you fall into?

16 – 20
21 – 30
31 – 40
41 – 50
51- 60
61 – 70
Over 70

3a. What nationality are you?__________________

b. Are you of Aboriginal or Torres Strait Islander decent? YES/NO

_________________

4. Are you currently working in an Aged Care Facility?

Yes No
5. Place a tick in the column next to the description that best describes your position?
Paid Personal Carer without Registered Nurse
certification

Care Worker: • Hospital trained

• With Certificate III in Aged • Undergraduate degree

Care
• Without certification • Postgraduate training
• Enrolled in nursing degree • Enrolled in further studies
Enrolled Nurse: Other (Please specify) e.g.
Clinical Nurse
• Enrolled Nurse
• Medication Endorsed EN …………………………………………….

259
 • Enrolled in nursing degree

6a). Have you ever received any training regarding pain assessment in the older person?
Yes No
Details

b) Have you ever received any formal training regarding pain management in the older
person? Yes No
Details
.
7. How long have you been working in aged care for?

years and months

8. How long have you been working as a clinical facilitator for?

years and months

9. Of the facilities that you visit are you aware of the facilities pain management policy?

Yes No NA

260
Questionnaire – Knowledge and Beliefs about Pain in the elderly (Zwakhalen et al.,
2007)

Instructions: This survey will ask you for your views about current pain management. Your
answers will help us to gather information about how you gain knowledge in identifying,
assessing and managing pain and what is the best method of learning. It will also help us
identify your beliefs about pain in the older person. Answers given will be completely
confidential and anonymous and will not be known by anyone other than the survey staff
and this questionnaire has no bearing on your studies.

1 Older people
experience pain Strongly Mostly Mostly Strongly No
less intensely Agree Agree Disagree Disagree opinion
than younger
people
2 Pain medication
Strongly Mostly Mostly Strongly No
works better in
Agree Agree Disagree Disagree opinion
young people
than in the elderly
3 Pain medication
Strongly Mostly Mostly Strongly No
works longer in
Agree Agree Disagree Disagree opinion
the elderly than in
young people
4 Pain medication
has more side Strongly Mostly Mostly Strongly No
effects in the Agree Agree Disagree Disagree opinion
elderly than in
younger people
5 Dementia patients
Strongly Mostly Mostly Strongly No
experience less
Agree Agree Disagree Disagree opinion
pain than non-
dementia patients

261
6 Assessing pain in
Strongly Mostly Mostly Strongly No
a dementia
Agree Agree Disagree Disagree opinion
patient is a matter
of guessing
7 Where I work, Strongly Mostly Mostly Strongly No
pain is assessed Agree Agree Disagree Disagree opinion
correctly
8 Where I work, Strongly Mostly Mostly Strongly No
pain is treated Agree Agree Disagree Disagree opinion
correctly
9 Where I work,
Strongly Mostly Mostly Strongly No
much attention is
Agree Agree Disagree Disagree opinion
given to pain in
dementia patients
10 Pain medication
should only be Strongly Mostly Mostly Strongly No
administered to Agree Agree Disagree Disagree opinion
patients suffering
from severe pain
11 Patients are often
Strongly Mostly Mostly Strongly No
prescribed too
Agree Agree Disagree Disagree opinion
much pain
medication?
12 It is better to
administer pain
Strongly Mostly Mostly Strongly No
medication ‘when
Agree Agree Disagree Disagree opinion
necessary’, rather
than according to
a fixed schedule?

262
 13 Administering
pain medication
should be
postponed as
long as possible, Strongly Mostly Mostly Strongly No
because Agree Agree Disagree Disagree opinion
dementia patients
should receive as
little pain
medication as
possible
14 A dementia
patient should
Strongly Mostly Mostly Strongly No
first report pain
Agree Agree Disagree Disagree opinion
before receiving
the next dose of
pain medication
15 Pain is part of the Strongly Mostly Mostly Strongly No
aging process Agree Agree Disagree Disagree opinion

16 Older people are

more likely to be Strongly Mostly Mostly Strongly No
affected by pain Agree Agree Disagree Disagree opinion
than younger
people
17 Pain medication,
if administered in
Strongly Mostly Mostly Strongly No
large quantities,
Agree Agree Disagree Disagree opinion
easily leads to
addiction among
the elderly

(Zwakhalen et al., 2007)

263
 Modified Pain Management Clinical Facilitator Survey.

Instructions: This survey asks for your views about pain management. Your answers will help me to gather
information about your current level of knowledge and confidence in identifying, assessing and managing
pain in the elderly. Answers given will be completely confidential and anonymous.
Answer every question by marking one of the boxes. If you are unsure about how to answer a question,
please give the best answer you can.
Participant Code: ….………………....
Strongly Mostly Mostly Strongly
1. I am confident in my pain management skills.
Agree Agree Disagree Disagree

2. I am able to recognise when a resident is Strongly Mostly Mostly Strongly

experiencing pain. Agree Agree Disagree Disagree

3. I am able to recognise pain in those with Strongly Mostly Mostly Strongly

dementia or non-verbal residents. Agree Agree Disagree Disagree

4. I know and understand the Australian Pain

Strongly Mostly Mostly Strongly
Society Guidelines for Pain Management in
Agree Agree Disagree Disagree
Residential Care Facilities.

Strongly Mostly Mostly Strongly

5. I know who to tell if I notice a resident is in pain.
Agree Agree Disagree Disagree

6. If I notice a resident is in pain, I will always report Strongly Mostly Mostly Strongly
this to the appropriate person. Agree Agree Disagree Disagree

7. I believe I have had adequate training to enable Strongly Mostly Mostly Strongly
me to assess if a resident is in pain. Agree Agree Disagree Disagree

8. I am regularly involved in providing treatment for Strongly Mostly Mostly Strongly

pain. Agree Agree Disagree Disagree

9. I am confident in using a wide range of Strongly Mostly Mostly Strongly

pharmacological therapies for pain management. Agree Agree Disagree Disagree

10. I am confident in using a wide range of non- Strongly Mostly Mostly Strongly
pharmacological therapies for pain management. Agree Agree Disagree Disagree

11. I believe that the non-pharmacological Strongly Mostly Mostly Strongly

treatments provided for pain are effective. Agree Agree Disagree Disagree

12. I believe that the pharmacological treatments Strongly Mostly Mostly Strongly
provided for pain are effective. Agree Agree Disagree Disagree

(Savvas et al., 2014b)

264
This next section will ask you true and false question regarding your knowledge and
attitude about pain in the elderly. (Ferrell & McCaffery, 2012)

1. Observations such as pulse, blood pressure are always reliable indicators of

T F
the intensity of a resident’s pain.

T F 2. Pain is an unavoidable part of growing old.

T F 3. Residents who can be distracted from pain usually do not have severe pain.
T F 4. Residents may sleep in spite of severe pain.
T F 5. Aspirin and other nonsteroidal anti-inflammatory agents are NOT effective
T F analgesics
6. for painful
Respiratory bonerarely
depression occurs in resident’s who have been receiving
metastases.
stable doses of
7. Combining opioids over
analgesics thatawork
period
byof months.mechanisms (e.g., combining
different
T F
an NSAID with an opioid) may result in better pain control with fewer side
T F 8. The usual
effects duration
than using of analgesia
a single of agent.
analgesic 1-2 mg morphine IV is 4-5 hours.
T F 9. Opioids should not be used in residents with a history of substance abuse.
T F 10. Elderly residents cannot tolerate opioids (morphine etc.) for pain relief.
11. Residents should be encouraged to endure as much pain as possible
T F
before using an opioid (morphine).
12. Resident’s spiritual beliefs may lead them to think pain and suffering are
T F
necessary.
13. After an initial dose of opioid analgesic is given, subsequent doses should
T F
be adjusted in accordance with the individual resident’s response.
14. If the source of the resident’s pain is unknown, opioids should not be used
T F
during the pain evaluation period, as this could mask the ability to correctly
15. Anticonvulsant
diagnose the causedrugs such as gabapentin (Neurontin) produce optimal pain
of pain.
T F
relief after a single dose.
16. Benzodiazepines are not effective pain relievers unless the pain is due to
T F
muscle spasm.
17. Narcotic/opioid addiction is defined as a chronic neurobiological disease,
characterized by behaviours that include one or more of the following:
T F
impaired control over drug use, compulsive use, continued use despite harm,
and craving.
18. Providing a resident who has pain with opioid e.g. morphine like
T F
medication will contribute to them developing an addiction.

265
Appendix 10: Phase Two- Clinical facilitator interview questions.
Questions for Clinical facilitator Interviews

1. If you are a registered nurse working in a residential aged care facility and a care worker
came to you to report that they had a resident complain to them about the presence of
pain, what would you do, i.e. how would you manage the situation, assess the resident?
What tools would you use?

2. If a care worker came to you too report that they had observed a resident grimacing in
pain when they were mobilizing the resident (who has dementia), can you tell me what you
would do, what tool would you use, how would you go about assessing pain in this
resident?

3. If pain in the elderly is not managed or treated appropriately what could be the
outcome?

4. What are some of the barriers to pain identification, assessment and management in the
individual living in residential aged care?

5 What are some of the facilitators to pain identification assessment and management?

6, Can you tell me some of the medications used in RAC and the principles of medication
management for pain in the elderly?

I.e. Start low go slow etc.?

7. What are some of the key non-pharmacological treatments available?]

8. Can you tell me how you support students to learn about pain identification, assessment
and management during their clinical placement?

9. What are the barriers, if any, to teaching students about pain identification, assessment
and management?
266