Multi-disciplinary interpretations of pain in older patients on medical units

Nurse Education in Practice (2008) 8, 249–257

Nurse

www.elsevier.com/nepr

Educationin Practice

Multi-disciplinary interpretations of pain in olderpatients on medical units

Julie Gregory a, Carol Haigh b,*

a Royal Bolton Hospital, Minvera Road, Farnworth, Bolton BL4 OJR, UKb Salford Centre for Nursing Midwifery and Collaborative Research, University of Salford, AllertonBuilding, Fredrick Road, Salford M6 6PU, UK

Accepted 13 September 2007

Summary The aim of this study was to assess the knowledge and attitudes of thehealth care team caring for older patients on acute medical wards. Pain is probablythe most distressing symptom experienced by hospital patients. Pain managementhas traditionally been seen as part of the anaesthetist’s role, within the UK, estab-lishment of acute pain teams was a response to the report ‘pain after surgery’ whichcemented the link between pain and surgery. However, in 2004–2005, 63% of admis-sions to general medicine in the UK were individuals in the 60+ age group suggestingthat older people are significant users of general medicine services. Treatment ofpain is multi-disciplinary and effective pain management should be a universalresponse by health care professionals and non-professionals. A questionnaire wasdistributed to all nurses; registered and non-registered, junior doctors who workedon the acute medical wards, all physiotherapists and all pharmacists in the hospital.There were varying levels of pain management education identified across the pro-fessional groups and, whilst there is a reasonable level of pain knowledge both gen-eral and specific to the older person, there is still a need to improve the knowledgeand attitudes of all health care professional groups caring for older patients in painon acute medical wards.

�c 2007 Elsevier Ltd. All rights reserved.

KEYWORDSEducation;Pain management;Older people;Medical units

1d

Introduction

Pain is a universal phenomenon and is probably themost distressing symptom experienced by hospital

471-5953/$ - see front matter �c 2007 Elsevier Ltd. All rights reseoi:10.1016/j.nepr.2007.09.004

* Corresponding author. Tel.: +44 7850120235.E-mail address: [email protected] (C. Haigh).

patients (Gloth, 2001). Treatment of pain is mul-ti-disciplinary and effective pain managementshould be a universal response by health care pro-fessionals (Brown et al., 1999). The public assumesthat nurses and physicians posses a comprehensiveknowledge of pain management that is readily usedin practice. However pain management deficits oc-cur in clinical practice and shortfalls in knowledge

rved.

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250 J. Gregory, C. Haigh

of pain and its management is often cited as thereason for this (Coyne et al., 1999). It has been ar-gued that the single most important tool forimproving the management of pain is education(Lander, 1990). Historically a minimum amount oftime has been spent on education around pain man-agement, both at the training and post qualifyingstage across all health care professions. Theseinadequacies contribute to fears and misconcep-tions of pain therapies (Ferrell et al., 1993). Lackof training, inadequate pain assessment and areluctance to prescribe opioids are consistently of-fered as reasons for poor pain management (Gloth,2001). In an era of multi-disciplinary approaches tohealth care these deficiencies must be seen as acause for concern and one that requires greaterexploration.

Therefore this study was carried out with theintention of assessing the knowledge and attitudesof the health care team caring for older patients onacute medical wards at a District General Hospital(DGH) in the United Kingdom. A questionnaire wasdesigned and used to provide an overview of funda-mental pain knowledge, beliefs and practices of anumber of health care staff. The sample includedmedical staff, physiotherapists, pharmacists, regis-tered nurses and non-registered nurses with theaim of examining any differences in knowledgeand attitudes between the health care groups. Itwas anticipated that this information would helpto establish the educational requirements of themulti-disciplinary team thereby improving themanagement of pain for older patients cared forwithin acute medical wards.

Background

The cornerstone of pain management is a strongclinical knowledge base composed of three generalareas; pain assessment, pharmacological therapyand non-pharmacological therapy (Coyne et al.,1999). Unrelieved acute pain increases the risk ofcomplications; these are life threatening in olderpatients with pre-existing medical conditions. Themanagement of pain is essential for humanitarianreasons, ethical accountability, and cost effective-ness and as an indicator of quality care (Briggs,2002).

Previous studies have concentrated on the man-agement of pain within surgical and oncology areasof hospitals. The extent of poor pain managementis unknown in non-surgical areas (Maxwell et al.,1999). There is an assumption that many patientswith non-surgical pain are ineffectively managed,although there is little published information on

the subject (Vickers, 2000). Globally, pain manage-ment has traditionally been seen as part of theanaesthetist’s role. Within the UK, the primaryimpetus for the establishment of acute pain teamscame from the report ‘pain after surgery’ (RoyalCollege of Surgeons and College of Anaesthetists,1990), cementing the link between pain and sur-gery to the detriment of other areas of health care.Nonetheless, Dix et al. (2003) found 43% of medicalpatients in hospital had experienced pain with 12%reporting unbearable pain. Strategies such as, painassessment, education and specific prescribing/management guidance would reduce the numberof patients experiencing unbearable pain in themedical setting.

Pain assessment is the first step in the pain man-agement decision-making process; inadequateassessment is thought to be a source of errors inclinical decision-making for managing pain (Dolset al., 1998). Pain management decisions are inex-plicably linked with accurate assessment of patientspain and is fundamental to pain management andthe care of patients in pain (Lawler, 1997). The lackof consistency in pain assessment is due to lack ofknowledge of assessment infrastructure across dis-ciplines and a reliance on attitudes, judgmentsand beliefs about pain (Haigh, 2001).

The greatest hurdle to overcome remains theeducation of health care professionals (HCP’s) tomake what’s known about pain management acces-sible and used by HCP’s (Simmons, 2002). Educa-tion is the first step to good pain management aswell as offering an empathetic approach (Hiscock,1993). Pain exists across all specialties; pain teamsmust educate and develop skills among direct caregivers (Schofield and Dunham, 2003). There hasbeen a lack of pain assessment education in doctorand nurses training (Sjostrom et al., 1997). Lander(1990) recommended education as the most impor-tant tool to improve pain management. It seemsnecessary that nurses’ should be taught more aboutpain assessment whilst in training and followingregistration to improve the treatment of pain(Thorn, 1997). Education on technique and respon-sibility can reduce misconceptions about painassessment (Young et al., 2006). Ongoing, plannededucation is necessary to improve and support painmanagement practice and documentation (MacDonald and Hilton, 2001).

Pain management cannot be planned withoutknowledge of the nature and severity of the pain.Communication and interpretation of behaviourare skills identified as prerequisites of pain assess-ment (Lawler, 1997). The greatest impact on theclinical process of pain management is nurses’knowledge (Barnaston et al., 1998). Following par-

Multi-disciplinary interpretations of pain in older patients on medical units 251

ticipation in continuing education nurses will usethe knowledge and develop skills to improve healthcare (Camp-Sorrell and O’ Sullivan, 1991).

Educating nurses is necessary as research showsthat they have inadequate knowledge about painevaluation techniques and pain treatments (DeRond et al., 1999). Discrepancies often exist be-tween the nurses’ perception of a patients’ painand the patients’ experience, nurses attitudes sug-gested that they frequently do not belief patients(Thorn, 1997).

Real improvements in pain management is onlylikely when a range of professionals are brought to-gether to share their knowledge and expertise(Carr et al., 2003). Irajpour et al. (2006) recom-mend a more holistic approach to inter professionaleducation and pain management.

Scott (1992) found that 52% (n = 53) of the regis-tered nurses surveyed were reluctant to believe pa-tient’s description of their own pain even whilstacknowledging that good pain assessment is relianton the individual description of nature and intensityof pain. Fourty-one percent (n = 21) of the nursesfelt the patient should suffer pain although 69%(n = 36) found the use of pain scales helpful. Themost common scale used was a numerical (0–10)scale. Lloyd (1994) also used a questionnaire surveyof surgical nurses finding 7% expected patients tosuffer pain and 83% had used a pain scale to assesspatients’ pain. These attitudes are replicated andenhanced when dealing with older people.

Older people are more likely to have painfulconditions, for example arthritis is twice as preva-lent in people over 65 years. Expectation of painwith age inhibits patients reporting their pain.Talking about pain is seen as complaining and gen-erally older patients prefer to remain stoic (Amer-ican Geriatric Society, 2002). There is strongevidence that older people receive different treat-ment to that of younger people and do not get ade-quate pain management (Bruce and Kopp, 2001).The tendency to stereotype the older person leadsto poor pain management, despite the importanceof effective pain management in achieving satis-factory patient outcomes (Ardery et al., 2003).Factors leading to inadequate management of painby health professionals in older people include: dif-ficulty in assessment, lack of knowledge of pharma-cology, misconceptions and attitudes towards theelderly (Gagliese and Melzac, 1997). Furthermore,attitudes and beliefs about ageing and death andhow these influence delivery of care to older peo-ple also impact upon pain management in this pa-tient group (Ferrell, 1996).

There are many misconceptions and exagger-ated fears of opioid use in the older person, with

doses of analgesia often started too low and admin-istered on an as required basis although pain shouldbe prevented rather than chased (Gloth, 2001).Sloman et al. (2001) surveyed nurses as they pro-vide direct interventions for pain relief and foundsignificant deficits. There has been a lack of sensi-tivity to the problem of pain and its sequalae inolder people contribution to the under recognitionand under treatment of pain (American GeriatricSociety, 2002).

There has been extensive assessment of knowl-edge and attitudes to pain management, almostexclusively in the nursing profession (see, for exam-ple Coyne et al., 1999). The knowledge and skills tomanage pain are seen as key skills for nurses.Recommendations for educational programmes toincrease nurse’s knowledge of pain assessment,pharmacology of analgesia and the managementof pain have long been mooted. The majority ofstudies have concentrated on the effectiveness ofeducation on increasing nurses’ theoretical knowl-edge of pain management measured by a self-report survey (for example, Coyne et al., 1999;Mc Caffery and Ferrell, 1997).

Although, in hospitals, the central role for painrelief lies with the ward based nurses, nurses donot work in isolation when caring for patients inpain. If the patient’s pain is unacceptable, a reviewby medical staff is required, with pharmacists toprovide advice and information on the differentanalgesia available. Physiotherapists can provideassistance with non-pharmacological pain relief.Pain management therefore involves the multi-dis-ciplinary team responsible for the individual pa-tient (Brown et al., 1999). In short, collaborationimproves pain relief.

Methods

Aim

The aim of this study was to asses the knowledgeand attitudes of health care professionals andnon-professionals caring for older patients on acutemedical wards at a District General Hospital (DGH)in the United Kingdom. The method utilised was asurvey approach to 407 individuals across fivedisciplines.

Tools

The questionnaire used was composed of four sec-tions: section A focused upon demographic andpain management education information. Section


B comprised of general pain management knowl-edge and attitudes adapted from the validated toolof Mc Caffery and Ferrell (1997). Since this adapta-tion focused solely upon the differences in languagebetween the US and the UK permission was notsought from the originators of the tool. Questionsincluded knowledge of pain assessment, analgesiaand attitudes to patients in pain. Section C con-tained questions on the pain management and olderpeople based on a validated questionnaire used bySloman et al. (2001). Section D consisted of a listof pain assessment scales requesting the respon-dents to indicate their experience of their use.

A total of 407 questionnaire were distributed viainternal mail to all disciplines, with a deadline oftwo weeks for return. At the end of the two weeksa further global reminder was sent to all potentialparticipants. A total of 89 questionnaires were re-turned giving a response rate of 21.8%. Templetonet al. (1997) note that, as long as potential respon-der bias is acknowledged a low response rate neednot affect the validity of data.

Ethics

The study was submitted to the Local Research Eth-ics Committee (LREC) for approval and was alsoscrutinised by the ethical review body of the Uni-versity of Salford. Data collection did not start un-til the approval of both bodies had been obtained.

Sample

The questionnaire was distributed to all the nurses;registered (192) and non-registered (101), the ju-nior doctors (36) who work on the acute medicalwards, all the physiotherapists (58) and pharma-cists (20) in the hospital (total sent was 407).

The professions; registered nurse, doctor, phys-iotherapist and pharmacists were included as theyare the group who take responsibility for the man-agement of pain in the clinical setting. However,the reliance upon non-registered health care assis-tants in providing bedside care (Mckenna et al.,2004) meant that the ability of this group to recog-

Table 1 Response rates

Professional group No. of respon

Registered nurses 42 (22%)Non-registered nurses 10 (9.9%)Doctors 6 (16.6%)Pharmacists 8 (40%)Physiotherapists 23 (39.6%)

nise and understand the pain that their patientsmay be reported was also seen as important. Thus,although not ‘professionals’ in the strictest inter-pretation of the term their input was seen as a use-ful contribution.

Analysis

Given the small sample size, analysis was restrictedto simple descriptive statistics. A reliability testwas carried out on the questionnaire, providing aCronbach’s alpha coefficient on standardised itemsof .831, within the acceptable range of values, .7–.8 (Field, 2005). However, as different elements ofthe questionnaire related to different attitudes andknowledge these sets were also subjected to reli-ability checking which Field (2005) suggests is goodpractice.

Results

Table 1 shows the response rates for each of thedisciplines surveyed in this study (Section A of thequestionnaire). It can be seen that the best re-sponse rates were those of the pharmacists andphysiotherapists (40% n = 8 and 39.6% n = 23),respectively. The lowest rate of response was fromthe non-registered nursing staff and this may re-flect the amount of input that this group has inthe management of pain or may be due to a lackof interest in the topic or a poor knowledge ofthe topic. Openhiem (1992) warns of the potentialfor bias when using a questionnaire on disparateoccupational groups. The respondents who havean interest and potentially better knowledge ofpain management may be more likely to respondto the questionnaire (Oppenheim, 1992).

Table 2 outlines the years of experience whichrespondents from each discipline had in clinicalpractice. The group which had the most years’experience (over 16 years) was the registerednurses.

We also asked respondents about the amountand type of pain management education they had

ses (%) Gender

2 male and 40 female2 male and 8 female3 male and 3 female1 male and 7 female2 male and 21 female

Table 2 Years qualified

Years qualified 0–2 3–5 6–10 11–15 16 +

Registered nurses 6 (14%) 6 (14%) 5 (12%) 8 (19%) 17 (40.5%)Doctors 2 (33%) 2 (33%) 1 (16.5%) 0 1 (16.5%)Pharmacists 2 (25%) 2 (25%) 0 1 (12.5%) 2 (25%)Physiotherapists 6 (26%) 4 (17%) 7 (30%) 5 (22%) –


received. The group that had had the most atten-dance at educational sessions were the Physiother-apists with 48% (11) of respondents having had‘extra’ pain management training. Fifteen regis-tered nurses (36%) had also attended additionalpain management training. The majority of the ses-sions were short in-house training events and noneof the respondents indicated that they had any for-mal qualification in pain management.

Table 3 shows the response to the section of thequestionnaire which was concerned with generalpain management knowledge. A reliability test wasrun upon this set of questions providing a Cronbach’salpha coefficient of .588. with an inter-item of .788.The medical staff showed the best general painknowledge with an overall mean score of 82.5% cor-rect responses. Given that the non-registered nursesprobably spent the most time with patients it was ofsome concern that 80% of this group relied upon vitalsigns to corroborate patient reports of pain.

Table 4 shows the responses to the questionsthat were concerned particularly with pain man-agement in older people. A reliability test on thisdata set provided a Cronbach’s alpha coefficient

Table 3 General pain management knowledge

RN N

Patients must be encouraged toendure as much pain as possible

0% 0

Rely on vital signs and behaviour toverify patients statement of severe pain

26% n = 11 8

Pain intensity should be ratedby a clinician

2.5% n = 1 1

Patients can sleep despite pain 38% n = 16 0‘Round the clock’ analgesia is more

effective than ‘as required’ medication86% n = 36 2

Opioids act on the central nervoussystem

71% n = 30 3

Ibuprofen acts on the peripheralnervous system

38% n = 16 3

Increasing the dose of morphine canincrease the pain relief

47% n = 20 1

of .981 and internal item correlation of .886 ren-dering the subsequent data highly reliable. Onlythe physiotherapists felt that pain was a naturaladjunct to the ageing process and only 35% ofresponding physiotherapists felt that to be painfree was an achievable goal in older people, com-pared to 100% of doctors and pharmacists, Doctorswere the only professional group who did not haveconcerns about respiratory depression when usingopioids in older people.

All the physiotherapists, doctors, pharmacists,registered nurses feel that assessing pain is impor-tant; 90% non-registered nurses felt it was impor-tant. Fourty percent of non-registered nurseshave never used a pain scale. As shown in Table 5the assessment tools of choice seemed to be a ver-bal descriptor scale (76% of the respondents), anumerical score (0–10) (72% of all respondents)and a numerical verbal scale (55% of all respon-dents). Ninety-six percent of the physiotherapistshad used a visual analogue scale or VAS, 4 althoughonly 9.5% (n = 4) of the nurses had. The Cronbach’salpha coefficient for this set of data was .531 andthe inter-item correlation was .513.

on-RN Doctors Pharmacists Physiotherapists

% 0% 0% 0%

0% n = 8 0% 50% n = 4 30% n = 7

0% n = 1 0% 0% 100% n = 23

% 33% n = 2 25% n = 2 43% n = 100% n = 2 83% n = 5 62% n = 5 61% n = 14

0% n = 3 83% n = 5 87.5% n = 7 48% n = 11

0% n = 3 33% n = 2 37% n = 3 26% n = 6

0% n = 1 66% n = 4 50% n = 4 13% n = 3

Table 4 Pain in older people

RN Non-RN Doctors Pharmacists Physiotherapists

Pain is a natural accompaniment ofthe aging process

7% n = 3 0% 0% 0% 25% n = 6

Older people experience pain lessintensely

13% n = 5 0% 17% n = 1 12.5% n = 1 4% n = 1

Older people report pain more often 15% n = 6 20% n = 2 17% n = 1 37.5% n = 3 22% n = 5Literature suggests pain is undertreated in the elderly

98% n = 41 80% n = 8 100% n = 6 75% n = 6 78% n = 18

Pain free goal 90% n = 38 80% n = 8 100% n = 6 100% n = 8 35% n = 8Avoid opioids due to risk ofrespiratory depression

36% n = 15 60% n = 6 0% 25% n = 2 56% n = 13

Analgesia more effective inyounger people

15% n = 6 10% n = 1 50% n = 3 0% 52% n = 12

Table 5 Experience of pain assessment scales

RN Non-RN Doctors Pharmacy Physiotherapists

Descriptive or verbal rating scale, askedwhich word best described the pain,for example, no pain, mild pain moderatepain or severe pain

79% n = 33 60% n = 6 83% n = 5 62.5% n = 5 78% n = 18

Descriptive numerical scale, asked to ratethe pain as above but this is then givena numerical ranking for example, nopain = 0, mild pain = 1 moderate pain = 2and severe pain =3

71% n = 30 50% n = 5 66% n = 4 37.5% n = 3 56.5% n = 13

Numerical rating scale, asked to rate thepain between 0 and 10: 0 being no painand 10 the worse pain imaginable

71% n = 30 30% n = 3 100% n = 6 25% n = 2 100% n = 23

Visual analogue scale, asked to mark on a10 cm along line the pain with 0 at oneend 10 at the other end, the line canbe vertical or horizontal

9.5% n = 4 10% n = 1 100% n = 6 12.5% n = 1 91% n = 21

Body outlines, asked to mark on the bodythe location and type of pain

26% n = 11 10% n = 1 33% n = 2 25% n = 2 96% n = 22

Mc gill Questionnaire, asked to describetheir pain from lists of descriptive wordssuch as agonizing, burning annoying etc.

26% n = 11 20% n = 2 17% n = 1 12.5% n = 1 17% n = 4

Other: please describe 2% n = 1 0% 0% 0% 4% n = 1


Discussion

This discussion section is organised as three subcategories: assessment, pharmacological, pain inolder people and pain assessment to reflect withmulti-focus nature of the questionnaire.

Assessment

Pain assessment severity must be assessed throughthe patients report rather than external factors(Bucknall et al., 2001) such as vital signs andbehaviour. A wide range of responses was obtained

between the professionals from no reliance on vitalsigns and behaviour among the doctors, to 80% ofnon-registered nurses stating that they relied uponthese indicators to assess pain. Hundred percent ofthe physiotherapists feel the clinician should ratethe patient’s intensity of pain. This inconsistencyin assessment of pain and diversity of attitudes toassessment could be the reason for poor standardsof pain assessment and suggests a lack of painassessment knowledge between the professionalgroups reflecting the findings of Haigh (2001).

The pain assessment tool of choice in the site ofthis study is the verbal descriptor tool. The doc-


tors, RN’s and Physiotherapists had experience ofboth verbal descriptor scores and numerical scores.Few RN’s pharmacists and non-registered nurseshad experience of visual analogue scale, but allthe doctors and 91% of the physiotherapists had.Body outlines had been used by physiotherapists,but few of the other professional groups. Althoughthe respondents are aware that assessment of painis important, the clinical area does not currentlyreflect this, documentation of pain score is poor.None of the respondents chose to comment onthe appropriateness or otherwise of the pain scalesin dealing with older people and pain despite theprevious section of the questionnaire dealing spe-cifically with older people in pain.

Pharmacological

Pharmacological pain control knowledge is animportant aspect of RN’s, doctors and pharmacistsrole in the management of pain. The results fromthis questionnaire demonstrate a varied knowledgeof analgesia. Over 70% of the doctors pharmacistsand RN’s aware of the CNS action of opioids, how-ever fewer indicated that they would increase thedose of morphine to improve pain relief. All ofthe respondents had a low awareness, 38% and be-low, that Ibuprofen acted peripherally.

In previous studies using a similar questionnaireby Mc Caffery and Ferrell (1997) a score of 75–80% has been considered acceptable. The RN’s onthe acute medical wards in this study produced amean score of 72.6% (range 20–100%) putting themjust below the accepted score. We can speculatethat, if the respondents (22% of the RN surveyed)have an interest and potentially better knowledge,the non-respondents could have a lower knowledgesuggesting a need for more or better education toimprove knowledge and attitudes within this pro-fessional group (Templeton et al., 1997). In ourstudy, the doctors had an acceptable mean score(82.5%), physiotherapists and pharmacists had amean score below the accepted 75–80% as set byprevious authors. This again suggests a need formulti-disciplinary education to improve knowledgeand attitudes in managing pain as recommended byBrown et al. (1999).

Pain in older people

Twenty-five percent of the physiotherapists agreethat pain is a natural accompaniment of the ageingprocess. Closs (1996) found 33% of the nursesresponding to the survey did feel pain was a naturalpart of ageing. This attitude could lead to neglect

in the management of this group of patients pain.The goal of a pain free state was indicated by allthe doctors and pharmacists responding to thequestionnaire, 90% of RN’s and 80% of non-regis-tered nurses compared to 35% of the physiothera-pists, again this may reflect the different focus ofeach of the participating disciplines.

Elderly patients do not experience less pain thanyounger patients (Fine, 2001) although 17% of thedoctors and 13% of the RN’s feel they do. Older pa-tients are less likely to report pain although in oursample up to 37.5% pharmacists, 22% physiothera-pists, 15% of nurses and 16.6% of the doctors feltthat they actually report more pain than youngeradults.

When opioids are used to control pain in olderpeople there is a low risk of respiratory depressioncompared to other drug reactions and side effects.Lower doses are prescribed to this age group. Noneof the doctors indicated concern with respiratorydepression, but 36% of RN’s and 56% of the physio-therapists agree that opioids should be avoided inthe frail elderly. If the doctor has prescribed anopioid over a third of the RN’s would be reluctantto administer it and non-registered nurses woulddiscourage its use also as 80% indicated that opioidsshould be avoided. Opioids provide a powerful toolto make a huge difference to the lives of those withsevere pain (Fine, 2001). Fifty percent of the doc-tors and 15% of RN’s feel that analgesia is moreeffective in younger people, leading to lower dosesbeing prescribed for the older client with an evenlower dose administered by the RN.

Conclusion

It is acknowledged that the poor response ratemeans that any insights provided by this study mustbe treated with caution. However, it must also beemphasised that this work provides new knowledgewhich will contribute to a previously under re-searched area of education. Chalmers (2006) notedthat ‘study findings should be communicated,regardless of outcome for the benefit of the com-munity at large’. The results from this survey doindicate a range of knowledge and attitudes to painand its management, within and across the profes-sional and non-professional groups surveyed. Liter-ature suggests that an increased knowledge of painassessment and management will lead to improvedpatient comfort. The respondents to the survey doindicated that they had minimal educational input.The continued lack of training, inadequate assess-ment of pain and reluctance to prescribe and


administer opioids appears to continue to be fac-tors in pain management inadequacies. Specificknowledge of commonly used analgesia was lowerthan expected from RN’s and pharmacists, the doc-tors appeared better informed generally. The phys-iotherapy group do appear to have differentattitudes to pain than the other groups. They indi-cate they use a wide range of assessment scalescompared to other professionals and have a rela-tively negative attitude to older people in pain.The results of the survey suggest a need to improvethe knowledge and attitudes of all health care pro-fessional groups caring for older patients in pain onacute medical wards and suggest fruitful directionsfor the development of training programmes andprofessional education events.

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Multi-disciplinary interpretations of pain in older patients on medical units

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