The COVID-19 pandemic, caused by the spread of SARS-CoV-2 infection, exposed significant health-related disparities among high-risk populations, including older adults. People 65 years of age and older were at increased risk for severe illness, complications, and death, and were disproportionately affected by the virus.1 For example, although people in this age group represented about 16.9% of the U.S. population in 2020,2 to date they account for more than 81% of COVID-related deaths.1 In addition to increased mortality rates, older adults reported increased financial hardships, decreased access to health care, and feelings of isolation as a result of the pandemic.3, 4 This population also experienced decreased physical function, greater infection-related symptom burden, and reduced quality of life.5, 6

Nurses possess a unique set of skills and insights into providing care to vulnerable populations such as older adults. In particular, pain management nurses—RNs who specialize in pain assessment and management—practice therapeutic communication and counseling, and provide patient and family education across a variety of clinical settings and in the community.7 More than 120 million Americans are living with pain, including more than 30% of older adults, who have a higher prevalence of chronic pain than the general population.8, 9 During the pandemic, pain management nurses continued to manage pain and other COVID-19 symptoms while supporting the critical needs of their health systems.10 Several studies have reported the experiences and perceptions of nurses caring for patients in long-term care and acute care settings11-13; however, no studies have explored the experiences and perceptions of pain management nurses caring for older adults during the COVID-19 pandemic. There is also limited empirical research on these nurses caring for older adults during a pandemic, and a qualitative approach based on firsthand accounts by pain management nurses can offer important insights.

Study purpose. In this study, we sought to understand the professional experiences and perceptions of pain management nurses who cared for older adults during the COVID-19 pandemic. This study is the second part of a larger, three-part qualitative study. The first part explored role changes among pain management nurses caring for patients during the pandemic and has been published elsewhere10; the third part will describe the lived personal and professional experiences of pain management nurses during the height of the pandemic and is forthcoming.

BACKGROUND

Older adults are vulnerable to complications and death from COVID-19.1 Among adults ages 65 years and older, the number of COVID-19 deaths is 97 times higher than it is among those ages 18 to 29 years.1 The aging immune system and presence of comorbidities, such as cancer or cardiovascular or lung diseases, contribute to older adults' increased risk for severe infection.14, 15 Additionally, older adults with COVID-19 have reported persisting symptoms of fatigue, dyspnea, joint pain, and cough following hospitalization.16 Therefore, care of infected older adults has focused on mitigating the spread of the virus and symptom management.

The pandemic has also had negative effects on the emotional well-being of older Americans. The National Poll on Healthy Aging surveyed 2,023 adults between the ages of 50 and 80 years and found that 44% felt stressed, 28% were more anxious and worried, and 19% had worse depression or sadness compared with how they felt before the pandemic.17Older adults in the United Kingdom reported that the pandemic contributed to feelings of uncertainty and nervousness, and raised concerns about its impact on their end-of-life experience.18 Additionally, the implementation of social distancing guidelines exacerbated feelings of loneliness and social isolation among older adults.19, 20 Recent research involving individuals living with chronic pain indicated that their pain experiences, including pain severity, were negatively affected by the pandemic.21

Nurses have played an essential role in caring and advocating for patients during COVID-19 by providing direct patient care, educating patients and families, and developing protocols to limit the spread of the virus.22 However, even before the pandemic, nurses faced challenges in caring for aging individuals both globally and in the United States. For example, nurses caring for older adults in a long-term care facility in Taiwan perceived that they were not sufficiently prepared to meet the complex psychological needs of patients.12 They also noted a lack of support from administrators and colleagues, who often showed a limited understanding of the importance of family members' involvement to older patients' emotional well-being.12 Similarly, U.S. studies conducted prior to the pandemic noted shortcomings in nursing home care, such as inadequate staffing levels, deficient infection control, and failures in oversight and regulation.23 The pandemic drew attention to these long-existing problems while revealing new ones. For example, nurses caring for patients in U.S. nursing homes during the pandemic faced the continued challenges of a lack of support and inadequate staffing, while grappling with new challenges such as supply chain disruptions.24 A study conducted in Iran highlighted the ethical concerns described by nurses during the pandemic: a risk of declining quality of patient care, stigmatization of nurses caring for infected patients, poor spiritual and compassionate care due to time constraints, and a lack of family-centered care.25 In the United States, some health systems were reorganized to deal with the dramatic increase in infected patients and some pain management nurses temporarily practiced in critical care areas, joining interdisciplinary teams to care for seriously ill patients such as older adults with COVID-19.10 As a result, these nurses can provide a unique perspective on the care of older adults during the pandemic.

METHODS

Design. A qualitative descriptive approach was employed to address the study aim of understanding the experiences of pain management nurses caring for older adults during the pandemic. According to Sandelowski, qualitative description provides a fundamental yet comprehensive summary and close interpretation of contextualized data.26 Qualitative description has many advantages, among them to enable an understanding of the perspectives of individuals experiencing or directly affected by the phenomenon of interest and to generate practical knowledge.27-29 Additionally, qualitative description is especially useful when resources and time are limited or when more immediate information is needed from those experiencing a phenomenon, such as a pandemic, or to address an urgent challenge.27 Given the rapidly changing nature of COVID-19, we applied a focused qualitative analytic approach in order to examine and quickly disseminate our findings to support real-world practice issues. See Figure 1 for details regarding study design, implementation, and enrollment.

Figure 1.:

Study Design, Implementation, and Enrollment

The study was approved by the institutional review boards (IRBs) of each investigator's affiliated university. The study was deemed to have no more than minimal risk to human subjects, and a waiver of consent was obtained from the primary IRB (the University of Iowa). Because of the political polarization surrounding COVID-19 and the potential exposure of institutional health practices, great care was taken to maintain participants' and institutions' confidentiality by removing any indicators that might identify people, places, and practices.

Sample. Pain management nurses (currently licensed RNs and advanced practice registered nurses [APRNs] who had provided direct patient care since January 2020) were recruited using convenience and snowball sampling. Participants were recruited from the American Society for Pain Management Nursing's weekly e-newsletter advertisements and membership listserv. All participants agreed to be interviewed and audio recorded.

Data collection. Audio-recorded interviews were conducted by telephone between July 2020 and July 2021 by three of us (BSM, JB, TJS). A semistructured interview guide was used to gather information about participants' demographic and career characteristics. Participants were also asked about the effect of the global pandemic on the role of pain management nurses, and about their perceptions and experiences of COVID-19's impact on older adults. Examples of such questions include: “Tell me how the pandemic has affected older people who have pain,” “Talk with me about how you perceived pain management for older people with pain during the pandemic,” and “Tell me about any ethical concerns related to pain management for older people with pain during the pandemic (for example, resource allocation [rationing], advance directives, and altered cognition).” Audio recordings were professionally transcribed by a vetted transcription service (Rev.com). One investigator (BSM) verified a subset of transcripts against audio recordings for accuracy. All data were stored on a secure network that required two-factor authentication and was accessed through a virtual private network.

Data analysis. We used a systematic approach to analyze textual data from the transcripts based on the authors' experiences of conducting content analysis.

Step 1: Determine units of analysis. One investigator (BSM) created a Word document containing segments of data specifically about older adults. Step 2: Read the segmented data about older adults to ensure that the data are pertinent to the research aim. Step 3: Develop an analysis plan (SQB, TJS), including procedures for coding the data. Step 4: Read the segmented data and assign an initial set of codes to clusters of data related to nurses' experiences with or perceptions of older adults. Each of the two analysts (SQB, TJS) created their own sets of initial codes, which they stored in an Excel spreadsheet. The analysts then met biweekly to compare their codes for similarities and differences. Each analyst developed a similar number of individual codes (75 versus 85). After determining that the two sets of codes were similar, the analysts further interpreted and consolidated their individual codes. Step 5: Consolidate open codes into subcategories and summaries. After organizing similar codes into subcategories, the analysts met to review their results. All the subcategories were scrutinized until a consensus was reached. Once a final list of subcategories was agreed upon, they were further reviewed and combined into categories. For each category, the characteristics (who, what, when, where, why, and how) were described, a summary statement was written, final naming was suggested, and illustrative quotes were identified. Lastly, we identified one theme that unified and linked each category.

Rigor. Strategies to establish reliability and internal validity were used to demonstrate rigor. The two data analysts (SQB, TJS) created a coding system (coding schemes to map codes to original data and codebooks to define individual codes) and debriefed the research team during scheduled meetings, strategies that enhance reliability and internal validity.30 Validity was further enhanced by identifying and discussing the analysts' reactions to and biases about the data, including questioning whether pain management nurses' perceptions fully captured the state of the environment or the extent of what occurred during the pandemic. When biases were identified, both analysts revisited the data to base their interpretations on the evidence—namely, the participants' words and experiences.

RESULTS

Sample. A majority of the 18 participants were non-Hispanic White (n = 17) and female (n = 17). These nurses held positions on pain management teams; inpatient service lines; and in specialties such as oncology, hospice, and wound care, in which pain management is a central function. Although most (n = 11) identified as APRNs (clinical nurse specialists and NPs) prior to the pandemic, during surges in the number of infected and hospitalized patients with COVID-19, some experienced changes in their primary roles and responsibilities to meet the needs of both their patients and their employers.10 For more details on participant characteristics, see Table 1 and the study by Sowicz and colleagues.10

Table 1. - Participant Characteristics (N = 18) Characteristic n (%) Gender    Female 17 (94)    Male 1 (6) Race    Non-Hispanic White 17 (94)    Asian/Pacific Islander 1 (6) Work setting    Inpatient 13 (72)    Outpatient/Ambulatory 5 (28) Nursing role    APRN 11 (61)    RN 7 (39) Level of education    Bachelor's degree 4 (22)    Master's degree 8 (44)    Doctorate (DNP or PhD) 6 (33)

Overarching theme and four categories. Based on the experiences and perceptions of the pain management nurses in our study, pain management for older adults during the pandemic was affected by both challenges to health care delivery and unpredictable biopsychosocial consequences for patients, but also benefited from the novel strategies nurses adopted to effectively address the needs of older patients. The overarching theme was from the pain management nurses' perspective: “Pain management for older adults remained unchanged during the pandemic despite unpredictable survival, restrictions on human interactions, and communication challenges.” This theme encompasses four categories: unpredictable survival, restriction-induced isolation, perceived continuity and equality of pain management, and communication challenges (see Table 2).

Table 2. - Main Theme and Four Supporting Categories Main Theme Category Category Description Abbreviated Description Illustrative Quotes Pain management for older adults remained unchanged during the pandemic despite unpredictable survival, restrictions on human interactions, and communication challenges. Unpredictable survival Surviving COVID-19 infection or dying as a result was not always predictable, and impacted attitudes, personal and clinical behaviors, and feelings. Unpredictable survival impacted nurses' attitudes, behaviors, and feelings.

“I went by the ICU one day and saw him . . . trached with ECMO on the dialysis device, and I said to someone—he was an older gentleman, he was in his mid-70s—‘What are we doing? What in the name of God are we doing? He's been like this for weeks now.’ . . . He ended up being discharged from the ICU onto a floor bed, and he ended up being discharged from the hospital to rehab.”

“And you could almost tell which ones just weren't going to make it once they coded. And one did. He shocked us to all get-out. He was in his 80s. He already had dementia, but he had a lot of decrease in his brain activity. But even after 15 minutes of CPR, he came back and he actually was discharged to a nursing home and we're like, I don't know how.”

Restriction-induced isolation Restricting human beings and their normal behaviors led to negative reactions and consequences with fewer solutions. Restrictive practices led to isolation in older adults and the need to counteract it.

“Social isolation has been a huge challenge and the older people, and the younger people who love the older people, are really struggling to figure out how to balance that.”

“So, you had people that should be more active, should not be isolated, and being with other people, family, support groups, that kind of thing, a year of isolation. So, I think but specifically, the lack not moving and not being as active has really, I think, amplified patient's pain to the point that, where, they've gotten sedentary, and then, when they do start to move, I think, then their pain is exacerbated.”

Perceived continuity and equality of pain management Pain management was unchanged and equitable before and during the pandemic through the lens of the nurse. Equality of pain management remained seemingly unchanged despite known complexities. “No, our treatment remained the same for whatever pain it was, trying to stay with multimodal regimen[s] and then having to make those same adjustments to any of those medicines based upon age and comorbidities.” Communication challenges Varied communication difficulties arose and necessitated sudden change in practices to deliver critical information and communicate with patients and families. Strategies were used to resolve communication challenges and their consequences. “It's [high-flow oxygen] really loud and it's really noisy and sometimes we have masks on patients, and they might not be able to hear as well anyway, and you try to get the phone in there and it wasn't ideal. We'll just say that. So, we probably did not do justice for our patients that we had language barriers with.”

CPR = cardiopulmonary resuscitation; ECMO = extracorporeal membrane oxygenation.

Underlying the four categories were general perceptions of older adults that were shared by study participants. For example, nurses assumed that older adults (1) were more likely to recognize the severity of COVID-19 and strictly follow national COVID-19 infection control standards, (2) had more pain because pain was a part of aging and consequently had a higher tolerance for pain than younger people, (3) wanted reassurance and needed human connection, and (4) were less proficient at using technology. These perceptions and observations affected pain management nurses' interactions with older adults across work settings.

Category 1: Unpredictable survival. This category emerged from data about surviving or not surviving COVID-19. Nurses talked about who became infected and died. They also described their attitudes about aging and survivorship, and their feelings about patients, and questioned their own practice behaviors. The unpredictable nature of COVID-19 created challenges for surveillance, and for predicting who would be infected and who would survive or die. Pain management nurses noted that multiple chronic diseases, obesity, and frailty, as well as type of health care coverage, placed older adults at higher risk for infection, hospitalization, and sudden mortality. According to one nurse,

“Our managed Medicaid population, over the [normal, prepandemic] year, 2% die . . . I was told that in four months [during the pandemic], we lost 8%. We totally wiped out a large population of our geriatric patients.”

Ageist stereotypes and biases regarding older adults were amplified during the pandemic, such that pain management nurses recognized older adults might believe, as one nurse noted, “that their lives were considered less valuable than other members of society.” Nonetheless, concerted efforts were made to ensure that all patients were provided fair and quality care. In managing older patients' acute needs, it was difficult to determine when life-sustaining treatment rather than end-of-life care should be provided. Using the dire hypothetical situation of having to decide between saving a 40-year-old and a 95-year-old patient, one nurse speculated that the health care team would likely save the younger patient:

“There might be a difference in the attitude. If you have a 95-year-old and a 40-year-old and you can only save one, now that didn't happen, but I'm just trying to explain . . . because there is a sense that the 95-year-old had their life, and you just want to make them as peaceful as possible. So, in that sense, I think that the attitude was different, but we actually didn't provide any different care.”

The uncertainty surrounding survival and the speed with which patients deteriorated and died left many nurses and families with a sense of tragedy, as well as shock when some recovered. One nurse recalled a woman with several comorbidities who required limb restraints to prevent her from removing the bilevel positive airway pressure she needed. The woman declined over the course of a week, which left the nurse and family both surprised and perplexed as they tried to arrive at some understanding of her rapid deterioration. The nurse recalled a family member saying, “This is a woman who was just cooking dinner for us at home the other night. How could it be that you're telling me that she's dying?”

Pain management nurses felt a tremendous sense of loss, especially when mortality rates surged. In response, they invested great energy in caring for their patients and in effectively promoting survival, recovery, and symptomatic relief. Additionally, nurses had to navigate ethical end-of-life issues, determine when to initiate conversations about advance directives, understand legalities associated with the death of dependent adults, and seek equity in providing life-sustaining care. Some nurses even initially questioned the intensive care of an older adult who was eventually discharged alive. These incorrect first impressions, assumptions, and assessments caused one nurse to note: “It does make you stop and say, ‘Wait a minute, who am I?’” Despite this, stories of hope, survival, and “miracles” were common among the participants.

Category 2: Restriction-induced isolation. Isolation and its many facets were frequently described by participants as they shared their perceptions of and experiences with older adults. Institutional restrictions and self-isolation were the main drivers of social isolation. The restrictions on human interactions and movements in the community led to negative reactions and consequences with few solutions. At the onset of the pandemic and during surges, many health care institutions implemented strict infection control practices, with policies of no or limited visitors, which restricted families', friends', and caregivers' access to and social interactions with patients. Exceptions were made for older adults with cognitive impairment, developmental challenges, and disabilities, and for situations in which the caregiver lived with the patient. One nurse shared,

“And I think the worst thing for people, not just the older people, everybody, was not being able to see their families. We only started letting visitors come back in the last two weeks. Prior to that they could not have visitors and it was just heartbreaking for them. You know, I can't imagine being in a hospital and not having my family be allowed to come see me.”

The possibility of a life-threatening illness prompted older adults to take seriously COVID-19 precautions such as masking; physical and social distancing; and the avoidance of public venues such as stores, clinics or hospitals, and pharmacies. As a result, older adults established a self-imposed isolation to minimize exposure to COVID-19. This compounded the limitations on social and physical mobility that were already in place for some patients due to existing chronic illness, including pain. Regardless of older adults' reasons for isolation, pain management nurses recognized that it had caused negative reactions and consequences, including angst, anxiety, loneliness, depression, and fear. One nurse commented, “Well, loneliness, you can tell that they [older adults] seem more depressed, more agitated in general, not being able to get out.” Negative reactions were exacerbated if the older adult was unable to use technology or social media to reach out for support.

Physical pain and psychosocial well-being were negatively affected by restriction-induced isolation. As one nurse noted, there was a general fear and hesitancy among some older patients to seek outpatient pain care despite the presence of significant levels of pain: “The others who are in a lot of pain prefer to get their injection, doesn't matter whether they get exposed. So, a majority of my own [patients] really, they prefer to wait because of the fear of being exposed.” As a result, some older adults delayed care to prevent exposure to COVID-19, which led to delayed diagnoses and treatment, limited access to treatments such as opioids, the exacerbation of existing pain or the development of new pain, and relapse of substance use disorder.

Other important sequelae were the absence of support at the end of life (resulting in dying alone), less physical activity and social interaction, restricted autonomy, and worsening cognitive impairment and debility. It was clear that solutions were needed to move beyond isolation and ensure consolation for older adults. Solutions for reducing the impact of isolation and loneliness centered on establishing support systems and advocating for patients and families, making house calls, and allowing at least one individual to accompany patients within health care facilities.

Category 3: Perceived continuity and equality of pain management. Acute and chronic pain were common issues among hospitalized older adults with COVID-19, as well as among uninfected older adults living at home. Importantly, pain management nurses perceived that pain management was unchanged and remained equitable before and during the pandemic regardless of patients' ages or probability of survival. Yet, because of distancing recommendations, there were challenges to in-person encounters for diagnosis and treatment. For example, ventilation or perfusion scans could not be done for the evaluation of chest pain due to aerosolization. Nurses relied on physical assessment to identify the cause of pain, and one voiced the following concern: “We might've missed different things and we're treating one pain and it was a different pain. We tried our best to . . . because we had limited diagnostic[s].”

Although the health of hospitalized patients' respiratory systems was prioritized during COVID-19, most pain management nurses believed that pain care remained largely unchanged regardless of age or prognosis. Interestingly, some nurses assumed older adults could tolerate pain better than younger individuals and that pain was a normal part of the aging process. However, pain interventions were maintained despite the implementation of new strategies to reduce the spread of infection and alterations in how pain management is typically delivered. For example, the types of pain medications used, including nonsteroidal antiinflammatory drugs and opioids, were carefully chosen to prevent adverse effects on respiratory and renal systems. And while one nurse appreciated that IV and oral steroids may temporarily replace invasive steroid injections, they questioned whether this was an ethical and safe strategy for older adults with comorbidities who were already at higher risk for becoming infected:

“Some of my other colleagues it was like, “Well, if they can't have interventional injections, then we're going to be starting on IV steroids for a day or so and then we'll transition to oral prednisone taper and send them out of here.” And my concern was, “Well, wait a minute, we're in a pandemic, they're older adults, they have comorbidities, prednisone and steroids, steroids lower your susceptibility to [effectively fight] infection and we're going to send these people back out into the community where there's COVID after you load them up with steroids?” That was an ethical [issue] and that was a concern for me because I think no one really thought about it and no one does think about it.”

Areas for improvement in resource allocation and assessment were also identified. All patients needed additional pain education and access to pain control resources (for example, to pharmacies and/or opioid medications, to lists of pain resources in the community). About pain assessment, one participant acknowledged that some nurses are often reluctant to evaluate pain because it “opens up a can of worms.” This participant countered nurses' reluctance to assess pain by saying that pain assessment can validate the patient's pain experience and may even decrease its impact. The pain management nurses further acknowledged that identifying and navigating patients to community resources may help them live better with their pain.

Category 4: Communication challenges. According to the nurses, communication challenges were significant for older adults. One of the major difficulties concerned end-of-life conversations with families. Because of the uncertainty and confusion about who would survive, nurses and other clinicians were not always able to gauge when to initiate these crucial conversations about advance directives and comfort care. End-of-life conversations were sometimes initiated either too late or needlessly when patients unexpectedly recovered.

Some technology (for example, iPads) to assist in communication with providers created barriers to timely and prioritized communication with older adults. Institutional restrictions forced families and nurses to communicate using video or voice calls. Some older patients were unable to access or use technology for telehealth visits and needed reassurance, help from family members, and technical assistance. Language barriers among patients, their families, and nurses intensified communication barriers. Isolation limited physical contact and personal protective equipment such as masks impeded verbal communication, particularly when older patients had impaired hearing and were unable to visualize the mouth for lipreading. There were also challenges in caring for patients with cognitive impairment and helping them understand COVID-19 precautions. The presence of cognitive conditions often resulted in longer interactions between nurses and patients and in perceptions of ineffective communication. As one nurse noted:

“When we serve a lot of lower income [people] and [people who speak] different languages and especially elderly people that speak a different language, it's bad enough when you're not wearing a mask. Like wearing a mask, it's almost like you feel deflated when they leave, because you don't feel you really communicated what you needed to communicate.”

These challenges likely increased feelings of isolation, left families feeling uninformed, and made care more time consuming. Several solutions were implemented to address these communication difficulties. For example, nurses made additional efforts to listen to and be “present” with patients, used interpreters (professional or family) or translation services, and helped patients and families troubleshoot technological problems.

As the nurses observed, the COVID-19 pandemic was extremely challenging for older adults, their families, and their caregivers. Pain management nurses were charged with advocacy, education, and finding innovative solutions to the care of older adults afflicted with pain, infected with COVID-19, and living with comorbid conditions.

DISCUSSION

Pain management is a critical responsibility of all nurses, especially those working with older adults who are more susceptible to the detrimental effects of pain. Pain management nurses' perceptions and experiences of providing pain care to older adults during the COVID-19 pandemic indicate that pain management remained a priority during an international health crisis that created high-risk situations in health care facilities. Interviews with these nurses highlighted the complexities of caring for older patients with COVID-19. Still, despite implicit beliefs about pain tolerance and changes in health among older adults, nurses described that pain management remained stable for these patients despite the immense personal and professional toll of the pandemic. Unpredictability, survivorship, dying, human interaction, and communication are concepts many nurses contended with in practice and developed knowledge about before the pandemic. Their persistence during the pandemic may indicate that these are universal, relevant concepts associated with people living with pain and the nurses who engage with them, even if they were amplified in more uncertain and chaotic times. These concepts are particularly noteworthy because they were identified by practitioners. The recognition of new concepts (or those observed in a new context) is an important step toward building empirical and theoretical knowledge to inform nursing practice.

Nurses' experiences with older adults were often associated with uncertainty and unpredictability during the pandemic. In our study, nurses explained that it was difficult to predict which patients would become infected, hospitalized, survive, or die. This inability to predict a patient's outcome was sometimes the result of an incorrect first assessment—for example, when someone who was expected to succumb in fact survived. Patients' characteristics such as age and comorbidities were included in risk assessments for death or survival, yet they weren't consistently predictive of the anticipated outcome. The unpredictability generated strong feelings and reactions among nurses and family members, especially when decisions had to be made about life-sustaining versus hospice care.

Uncertainty has emerged as a theme in other studies among nurses during the pandemic. Canadian nurses working in various specialties and practice settings also experienced uncertainty during the pandemic; however, its causes differed somewhat from those identified by our participants.31 In the Canadian study, uncertainty resulted from issues involving communication, leadership, and the struggle to balance new requirements imposed by the pandemic with patient needs and nursing best practices.31 It is clear that the antecedents to uncertainty are numerous. A worthwhile area for knowledge synthesis or development would be to explore how unpredictability and uncertainty permeate nurses' professional lives and job functions, affect care and decision-making, and impact patient outcomes.

The concept of social isolation among older adults has been defined as “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts and they are deficient in fulfilling and quality relationships.”32 Nicholson identified the following categories of antecedents to social isolation: “lack of relationships, psychological barriers, physical barriers, low financial and resource exchange, and prohibitive environment.”32 Our findings add to this literature; for example, hospital policies limiting the number of visitors is a prohibitive environmental factor. While similar policies may have existed prior to the pandemic, such as in ICUs, they were more prohibitive during this time. We also found that nurses were aware of the negative consequences associated with restrictions placed on older adults with pain, including worse pain and substance use relapse.

Several screening tools for assessing loneliness and isolation are available and should be more widely used.33 Comparative research on loneliness and pain before and after the pandemic may lead to a new understanding of how these are experienced during public health crises. New research shows that video calls, voice calls and texts, and social media may be protective against depressive symptoms particularly in older adults who have vision or hearing impairment.34 As technology, including telehealth, becomes better integrated into health care, now is the time to assist older adults with sensory impairments to develop proficiency and feel more comfortable with communication technologies.

Limitations. This study had several limitations. First, we did not link the timing of the interviews or participants' geographic locations to periods of surges in infections or to declines in hospitalizations, which might have affected nurses' views and experiences. Three of us (BSM, JB, TJS) conducted the interviews, and the varying experiences with interviewing likely led to variable probing about nurses' attitudes toward older adults. Advertising for study participants through a specialty organization could introduce sampling bias; that is, pain management nurses who were not members of the organization may have been less likely to participate. Finally, based on the generally negative nature of the categories that emerged from the data, one could reasonably assume that the pain management of older adults would be adversely impacted by the emergence and persistence of this pandemic; however, the nurses conveyed that it remained unchanged. The perceptions of the nurses were not compared with those of the patients they cared for and whose experiences they reflected on or with facility-level outcome data. It may be that there were quantifiable differences in the implementation of pain management standards and subsequent patient outcomes during the pandemic.

Theoretical implications. We discovered a need for a theoretical model in the area of pain management of older adults during COVID-19 in order to reduce possible knowledge gaps as suggested by nurses' perceptions and beliefs, understand equitable care, prioritize needs during an unpredictable and widespread health crisis, and enhance awareness of the importance of individualized communication strategies. This model is proposed to mitigate the challenges of pain management and to make improvements in the future.

Based on the findings of this study, we introduce a new descriptive theoretical model that suggests that nurses' experiences with and perceptions of older adults influence pain management of this population (see Figure 2). Our theory is in its infancy, and we acknowledge that it can be further developed (for example, as a middle-range or situation-specific theory) by 1) synthesizing the empirical and theoretical literature about nurses' influences on pain management, 2) articulating propositions that are nonrelational (such as pandemic restriction-induced isolation) or relational (such as that older adults who experience isolation are less likely to receive nurse-provided pain management), and 3) investigating the relationship of our theory to existing theories of aging. This theoretical model could be used and expanded to guide nurses' clinical practice and research during the current pandemic (or during future catastrophic events); it could also be expanded to explain or predict how nurses working with older adults may influence, either positively or negatively, their pain management.

Figure 2.:

Theoretical Model: Nurses' Perceptions of Older Adults' Pain Experiences During the Pandemic

Clinical implications. The COVID-19 pandemic has revealed countless health care design modifications that are critically needed to address the well-being, care, and recovery of older adults. First, in addition to routinely screening for geriatric syndromes, such as functional decline, delirium or agitation, and falls, pain management nurses should assess for depression and isolation that may result from chronic pain. Depression, loneliness, and isolation are strong psychosocial consequences of both chronic pain and COVID-19,35, 36 and the importance of evaluation and treatment cannot be overstated. Addressing these issues is paramount for enhancing the quality and meaningfulness of life. In addition, assessing caregiver stress should accompany health care encounters involving dependent older adults. Because many older adults have great concern about exposure to infectious diseases, there may be a greater need to move care away from formal clinics and hospitals and toward communities or the home, and to expand the use of telehealth, in order to reduce infection exposure. The pandemic also exposed the unpredictability of survival. This should renew focus on the importance of discussions about and documentation of advanced care planning to help clarify end-of-life wishes and expectations regarding provision of care. Early communication with patients, providers, and family when patients are at their healthiest—for example, during well visits with primary care providers or early in the course of a chronic or life-limiting illness—can enhance patient-centered care.

CONCLUSIONS

Older adults have been significantly and negatively affected by the COVID-19 pandemic. This includes the exacerbation of existing pain and the development of new COVID-related pain among older adults. Hence, understanding the experiences of pain management nurses within the larger nursing profession is critical to ensuring that patients receive quality pain care and symptom management. Moreover, during difficult and unexpected crises, we are better able to support pain management nurses and enhance patient care when their voices are heard, their firsthand experiences are shared, and solutions are developed and customized to fit their needs.