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Laures E, Williams J, McCarthy AM. Pain assessment & management decision-making in pediatric critical care. J Pediatr Nurs 2023; 73:e494-e502. [PMID: 37884405 DOI: 10.1016/j.pedn.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE The aim of this study was to explore how nurses in the Pediatric Intensive Care Unit (PICU) reach their pain management decisions in children who are mechanically ventilated and chemically paralyzed. DESIGN AND METHODS A qualitative descriptive design was used following a quantitative phase of a multi-method study. Eighteen PICU nurses participated in semi-structured interviews aiming at understanding how they assess pain and make management decisions. Content analysis was used to guide coding and generate themes. RESULTS Three major themes were identified: 1) Assessment or cues that nurses use to trigger a pain assessment; 2) Mental models or patterns that nurses create to interpret cues to guide decision-making; 3) External factors that inhibit or facilitate decision-making. Overall, nurses rely on physiological cues to assess pain. From there, a large amount of variation exists on how nurses interpret those cues to make their pain management decision. External factors such as unit culture, perceived barriers and facilitators, and the nurse's experiences impacted how decisions are made. CONCLUSIONS Variation exists in the mental models' nurses create to make their pain management decision in this population. Nurses reported confusion on pain and sedation scale selection and various documentation practices for pain assessment. "Assume pain present" was identified as a concept and documentation practice that may guide decisions; further research is needed. PRACTICE IMPLICATIONS Development of clinician decision support tools that not only aid their understanding of reliable pain cues but also help create clear documentation practices may help nurses make pain management decisions.
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Affiliation(s)
- Elyse Laures
- University of Iowa College of Nursing, 50 Newton Drive, Iowa City, IA 52242, United States of America; University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA 52242, United States of America.
| | - Janet Williams
- University of Iowa College of Nursing, 50 Newton Drive, Iowa City, IA 52242, United States of America
| | - Ann Marie McCarthy
- University of Iowa College of Nursing, 50 Newton Drive, Iowa City, IA 52242, United States of America
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2
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Djordjevic CM. Finding a meaning for pain: Definitions, sense-making, and philosophical health. J Eval Clin Pract 2023; 29:1196-1202. [PMID: 37309094 DOI: 10.1111/jep.13873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
Pain has proven to be a refractory problem in US healthcare. This paper argues that starting to address this requires viewing pain-assessment as a form of sense-making that occurs between patients and providers. Section I argues that two standard definitions of 'pain' that are thought to subtend pain assessment are not viable. Section II proffers a very different way to think about the meaning of 'pain'. Section III develops this novel account by pairing Rorty's account of hermeneutics with recent developments in the pain-assessment literature. Finally, section four moves beyond Rorty by linking sense-making to philosophical health. Should this prove persuasive, I will have shown an area in biomedicine where philosophy is not an 'optional add on', but a vitally important part of what should be clinical practice.
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Affiliation(s)
- Charles M Djordjevic
- Lorain County Community College, Elyria, Ohio, USA
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Neville EK, Stolic S, Wagstaff RA, Neville CC. Pain Management in the Postoperative Period for People With Dementia: An Integrative Review. ANNALS OF SURGERY OPEN 2023; 4:e301. [PMID: 37746623 PMCID: PMC10513124 DOI: 10.1097/as9.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/31/2023] [Indexed: 09/26/2023] Open
Abstract
Objective With the increased global prevalence of older people with dementia, more will present for surgery over the coming decades. Therefore, the objective of this study was to synthesize the existing research about how pain in managed for people with dementia in the postoperative period and discuss the implications for clinical practice. Methods For this integrative review, the Cumulative Index to Nursing and Allied Health literature, Medline/Pubmed, ProQuest, ERIC, and Health Source Nursing were searched to identify original empirical research published between 2000 and 2021. Tasks were divided between reviewers to ensure independent study selection, data extraction, and risk of bias assessment. Results Eleven articles were eligible. The evidence is incompletely developed therefore the review focused on pain assessment, the types and amount of pain relief, that people with dementia receive less analgesia than people without dementia and the challenges for effective pain management. Most studies were surgery for hip fracture so there is scope to look at outcomes for other types of surgery. Analgesia was administered but it was noted that even over a 20-year period, people with dementia received less than cognitively intact people. Pain management could have a stronger evidence-base with more psychometric development of pain assessment tools. Challenges are due to the impaired ability of the person with dementia to communicate pain and that clinicians have difficulty understanding pain behavior in people with dementia. Conclusion Adequate pain management for people with dementia in the postoperative period is important for a faster and better recovery.
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Affiliation(s)
- Emily K Neville
- From the Department of General Surgery, St Vincent's Hospital, Melbourne, VIC, Australia
- University of Notre Dame Australia, School of Medicine, Wagga Wagga Rural Clinical School, Wagga Wagga, NSW, Australia
| | - Snezana Stolic
- School of Nursing and Midwifery, University of Southern Queensland, Ipswich, QLD, Australia
| | - Ruth A Wagstaff
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
| | - Christine C Neville
- School of Nursing and Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia
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4
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Laures EL, LaFond CM, Marie BS, McCarthy AM. Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation. Am J Crit Care 2023; 32:346-354. [PMID: 37652886 DOI: 10.4037/ajcc2023403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice. OBJECTIVES To describe how PICU nurses are assessing and managing pain for children who require NMB. METHODS A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither. RESULTS A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent. CONCLUSIONS These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.
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Affiliation(s)
- Elyse L Laures
- Elyse L. Laures is a nurse scientist, University of Iowa Hospitals and Clinics, and instructional track faculty, University of Iowa College of Nursing, Iowa City
| | - Cynthia M LaFond
- Cynthia M. LaFond is a senior nurse scientist, University of Iowa College of Nursing, Iowa City, and Ascension Illinois, Chicago
| | - Barbara St Marie
- Barbara St. Marie is an associate professor, University of Iowa College of Nursing, Iowa City
| | - Ann Marie McCarthy
- Ann Marie McCarthy is a professor, University of Iowa College of Nursing, Iowa City
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Duah-Owusu White M, Kelly F. A narrative review of staff views about dementia care in hospital through the lens of a systems framework. J Res Nurs 2023; 28:120-140. [PMID: 37152201 PMCID: PMC10160577 DOI: 10.1177/17449871221142104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment). Aim The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach. Methods We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines. Results Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools). Conclusion The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.
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Affiliation(s)
| | - Fiona Kelly
- Lecturer, Division of Nursing, Queen Margaret University, Musselburgh, UK
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Jensen AM, Wilson RL, Pedersen BD, Hounsgaard L, Tingleff EB. Nursing care of people with dementia in an orthopaedic acute care setting: An integrative literature review. J Clin Nurs 2022; 32:2298-2318. [PMID: 36229899 DOI: 10.1111/jocn.16557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 04/26/2022] [Accepted: 09/20/2022] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES This integrative literature review is to collect what is known about the care of people with dementia when they require a hospital admission for an orthopaedic surgical procedure and to contribute to developing an evidence-base to support nursing practice when caring for people with dementia in an orthopaedic setting. BACKGROUND People with a dementia diagnosis are increasingly common in acute orthopaedic care settings and the admission exposes people with dementia to risks during their hospital stay. In addition, nurses find people with dementia challenging to care for due to the complexity of dual conditions. Little is known specifically about the care requirements for people with dementia in orthopaedic settings. DESIGN Integrative literature review. METHODS An integrative literature review and qualitative deductive content analysis using McCormack and McCance's theoretical nursing framework (Person-Centred Nursing Framework) of nine studies were undertaken. The process of the review was guided by PRISMA checklist. RESULTS The care environment and resistance either in passive form, or through physical intervention, is common in orthopaedic nursing. Planning and delivering care for physical, cognitive and emotional needs is identified as being difficult, resulting in a lack of inclusion for patients, partly due to communication challenges. Finding ways to implement tailored care plans within standard ward routines proves difficult, and the consequence is a less than optimal care experience with adverse effects on patients characterised by an increase in dementia symptoms. CONCLUSIONS Care for people with dementia in an orthopaedic setting is complex. It needs to be further studied so that more evidence and supporting literature can contribute to improved care for this group of patients. RELEVANCE TO CLINICAL PRACTICE This study describes the complexity of providing fundamental care for people with dual conditions of dementia and orthopaedic injury and suggests opportunities for improvement.
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Affiliation(s)
- Anders M Jensen
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Research Centre for Health and Welfare Technology, VIA University College, Holstebro, Denmark
| | - Rhonda L Wilson
- School of Nursing and Midwifery, University of Newcastle, Ourimbah, New South Wales, Australia.,School of Nursing, Massey University, Auckland, New Zealand
| | - Birthe D Pedersen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lise Hounsgaard
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ellen B Tingleff
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Research Unit Forensic Mental Health Psychiatric Department Middelfart (RFM) and CPS, Mental Health Services in the Region of Southern Denmark & Institute of Regional Health Research, Faculty of Health Science, University of Southern Denmark, Odense, Denmark.,Nursing Education, Vejle, and Health Sciences Research Center, UCL University College, Svendborg, Denmark
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Overen CK, Larsson M, Hillestad AH, Eriksen S. Process of pain assessment in people with dementia living in nursing homes: a scoping review protocol. BMJ Open 2022; 12:e063230. [PMID: 36171025 PMCID: PMC9528625 DOI: 10.1136/bmjopen-2022-063230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pain is a common symptom in people with dementia; untreated, it reduces quality of life and causes suffering. People with dementia living in nursing homes most often have dementia in moderate to severe stages. The cognitive impairment, including language and communication difficulties, challenges pain assessment. Since pain is a subjective experience, self-reporting is the gold standard of assessment methods. Healthcare professionals are advised to help people with dementia communicate about their pain. The proposed scoping review is the first step in the development of a systematic pain assessment model for people with dementia living in nursing homes. The scoping review aims to identify, categorise and summarise knowledge on how pain assessment processes in this population are described in the literature, with a special focus on self-reporting. METHODS AND ANALYSIS The scoping review will be conducted following the six-stage framework developed by Arksey and O'Malley, in addition to recent methodological developments. Systematic searches in CINAHL, Embase, Medline and PsycInfo will be conducted. The protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklists, and the scoping review will adhere to the PRISMA-ScR checklist. The review will include research that concerns assessment of pain in people with dementia living in nursing homes. Studies will be evaluated for quality and ethical standards. The analysis process will follow Bradbury-Jones et al's PAGER framework. Patterns will be formed using thematic analysis. An overview of advances, gaps, evidence for practice and research recommendations associated with each pattern will be prepared. The research questions and results will be presented to and discussed in a reference group comprising nursing home residents, relatives, healthcare professionals and nursing home managers. ETHICS AND DISSEMINATION The scoping review aims to collect and summarise data from available publications and does not require ethical approval. The final manuscript will be submitted to a peer-reviewed, open-access journal. REGISTRATION IN OPEN SCIENCE FRAMEWORK: https://osf.io/8kaf5/.
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Affiliation(s)
- Caroline Kreppen Overen
- Institute of Health Sciences, Department of Nursing, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden
- Bachelor Education in Nursing, Lovisenberg Diaconal University College, Oslo, Norway
| | - Maria Larsson
- Institute of Health Sciences, Department of Nursing, Karlstad University, Faculty of Health, Science and Technology, Karlstad, Sweden
| | | | - Siren Eriksen
- Bachelor Education in Nursing, Lovisenberg Diaconal University College, Oslo, Norway
- Norwegian National Centre for Ageing and Health, Tønsberg, Norway
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Abbott RA, Rogers M, Lourida I, Green C, Ball S, Hemsley A, Cheeseman D, Clare L, Moore D, Hussey C, Coxon G, Llewellyn DJ, Naldrett T, Thompson Coon J. New horizons for caring for people with dementia in hospital: the DEMENTIA CARE pointers for service change. Age Ageing 2022; 51:6691373. [PMID: 36057987 PMCID: PMC9441201 DOI: 10.1093/ageing/afac190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Indexed: 01/27/2023] Open
Abstract
Approximately two-thirds of hospital admissions are older adults and almost half of these are likely to have some form of dementia. People with dementia are not only at an increased risk of adverse outcomes once admitted, but the unfamiliar environment and routinised practices of the wards and acute care can be particularly challenging for them, heightening their confusion, agitation and distress further impacting the ability to optimise their care. It is well established that a person-centred care approach helps alleviate some of the unfamiliar stress but how to embed this in the acute-care setting remains a challenge. In this article, we highlight the challenges that have been recognised in this area and put forward a set of evidence-based 'pointers for service change' to help organisations in the delivery of person-centred care. The DEMENTIA CARE pointers cover areas of: dementia awareness and understanding, education and training, modelling of person-centred care by clinical leaders, adapting the environment, teamwork (not being alone), taking the time to 'get to know', information sharing, access to necessary resources, communication, involving family (ask family), raising the profile of dementia care, and engaging volunteers. The pointers extend previous guidance, by recognising the importance of ward cultures that prioritise dementia care and institutional support that actively seeks to raise the profile of dementia care. The pointers provide a range of simple to more complex actions or areas for hospitals to help implement person-centred care approaches; however, embedding them within the organisational cultures of hospitals is the next challenge.
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Affiliation(s)
- Rebecca A Abbott
- Address correspondence to: Dr Rebecca Abbott, Evidence Synthesis Team, NIHR ARC South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK.
| | - Morwenna Rogers
- Evidence Synthesis Team, NIHR ARC South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | - Ilianna Lourida
- Evidence Synthesis Team, NIHR ARC South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK,Mental Health Research Group, University of Exeter Medical School, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | - Colin Green
- Health Economics Group, University of Exeter Medical School, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | - Susan Ball
- Health Statistics Group, PenARC, University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | - Anthony Hemsley
- Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | | | - Linda Clare
- Centre for Research in Aging and Cognitive Health, PenARC, University of Exeter Medical School, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | - Darren Moore
- Graduate School of Education, College of Social Sciences and International Studies, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
| | | | - George Coxon
- Pottles Court Care Home, Days-Pottles Lane, Exminster, Summercourt Care Home, Teignmouth, Exeter EX6 8DG, UK
| | - David J Llewellyn
- Mental Health Research Group, University of Exeter Medical School, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK,The Alan Turing Institute, London, UK
| | | | - Jo Thompson Coon
- Evidence Synthesis Team, NIHR ARC South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, St Luke’s Campus, University of Exeter, Exeter EX1 2LU, UK
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Nurses' Perceptions of the Management of Acute Pain in Emergency Departments: Cross-sectional Study. CLIN NURSE SPEC 2022; 36:254-263. [PMID: 35984978 DOI: 10.1097/nur.0000000000000694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIM This study aimed to describe registered nurses' perceptions of acute pain management in emergency departments. DESIGN The study design was a cross-sectional survey carried out in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. One hundred one nurses from 5 different emergency departments participated in the survey. METHODS Data were analyzed using descriptive methods, nonparametric tests, and principal component analysis. RESULTS Continuing education was significantly related to pain management. Nurses who had received continuing pain management education thought more often that challenges in pain management impact patients' acute pain management than those who had not received education. Nurses reported that patients received inadequate pain medication. The most used nonpharmacological methods were ice therapy and postural care. The nurses reported that music and conversation with the patient ameliorated the patients' acute pain. Nurses stated that their lack of knowledge concerning pain management and workload affected their acute pain management. CONCLUSION Study results emphasize the need to develop ongoing pain management education for registered nurses and in addition to further research of nonpharmacological alleviation method in emergency departments.
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Vitou V, Gély-Nargeot MC, Jeandel C, Bayard S. The influence of Alzheimer's disease stigma on pain assessment in older persons. DEMENTIA 2022; 21:2418-2441. [PMID: 35976758 DOI: 10.1177/14713012221117907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Pain of nursing homes residents with Alzheimer's disease remains under detected compared to their cognitively intact counterparts. Communication difficulties may partly explain this poor quality of care but the influence of stigmatization on pain assessment has never been explored. RESEARCH QUESTION The objective of this research was to analyze whether a diagnosis label of Alzheimer's disease or the stage of the disease may bias pain assessment scores and empathic reactions of health care staff in nursing homes. METHODS Two studies were conducted based on a similar experimental between-subjects design with a video showing an older adult woman experiencing undefined pain. Different labels and vignettes were manipulated to characterize the subject of the video. In the first study, 84 certified nursing assistants were asked to watch the video and then to assess the pain intensity and their empathic reaction. Participants were randomized in two conditions that varied the disease label (Alzheimer's disease vs no diagnosis). In the second study, 67 certified nursing assistants were enrolled who did not participate in the first study. They watched the same video as in the first study and assessed the pain intensity and their empathic reaction. They were randomized in two conditions that varied the stage of the Alzheimer's disease (mild stage vs severe stage). RESULTS Alzheimer's disease label had no influence on assessment scores. In contrast, the stage of the disease had a significant effect on the health care staff assessments with severe stage associated with lower pain intensity scores and empathic reactions. CONCLUSION These results confirm that the Alzheimer's disease stigma is a real phenomenon that tends to be mainly elicited by the symptoms of the acute phase of the disease. These findings are crucial to better understand the stigma related to Alzheimer's disease and to enhance the pain management of this frail population.
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Affiliation(s)
- Valérie Vitou
- 27038EPSYLON, EA4556, Univ Paul Valéry Montpellier 3, F34000, Montpellier, France.,Fondation Partage et Vie, Montrouge, France
| | | | - Claude Jeandel
- Fondation Partage et Vie, Montrouge, France.,Département de Gériatrie, Université De Montpellier, 26905CHU de Montpellier, Montpellier, France
| | - Sophie Bayard
- 27038EPSYLON, EA4556, Univ Paul Valéry Montpellier 3, F34000, Montpellier, France
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11
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Graham F, Beattie E, Fielding E. Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation? Age Ageing 2022; 51:6632478. [PMID: 35796135 DOI: 10.1093/ageing/afac140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched. OBJECTIVE the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain. DESIGN this was a descriptive correlational study using virtual simulation. SETTING AND PARTICIPANTS a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study. METHODS nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants. RESULTS thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5). CONCLUSIONS hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.
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Affiliation(s)
- Frederick Graham
- Division of Medicine, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Elizabeth Beattie
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
| | - Elaine Fielding
- School of Nursing, Queensland University of Technology, Brisbane City, QLD, Australia
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12
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Shaw CA, Ward C, Gordon J, Williams KN, Herr K. Elderspeak communication and pain severity as modifiable factors to rejection of care in hospital dementia care. J Am Geriatr Soc 2022; 70:2258-2268. [PMID: 35642656 PMCID: PMC9378618 DOI: 10.1111/jgs.17910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Background Rejection of care (RoC) occurs when persons living with dementia (PLWD) withstand or oppose the efforts of their caregiver. Improvements in hospital dementia care are needed, and one way to address this need is by identifying factors that lead to RoC, particularly those that are modifiable. Elderspeak communication is an established antecedent to RoC among PLWD in nursing homes. The purpose of this study was to extend these results to acute care settings by determining the impact of elderspeak communication by nursing staff on RoC by hospitalized PLWD. Methods Care encounters between nursing staff and PLWD were audio‐recorded, transcribed verbatim, and coded for semantic, pragmatic, and prosodic features of elderspeak. RoC behaviors was scored in real‐time using the Resistiveness to Care Scale. A Bayesian repeated‐measures hurdle model was used to evaluate the association between elderspeak and both the presence and severity of RoC. Results Eighty‐eight care encounters between 16 PLWD and 53 nursing staff were audio‐recorded for elderspeak and scored for RoC. Nearly all (96.6%) of the encounters included some form of elderspeak. Almost half of the care encounters (48.9%) included RoC behaviors. A 10% decrease in elderspeak was associated with a 77% decrease in odds of RoC (OR = 0.23, 95% CI = 0.03, 0.68) and a 16% decrease (eβ= 0.84, CI = 0.73, 0.96) in the severity of RoC. A one‐unit decrease in pain severity was associated with 73% reduced odds of RoC (OR = 0.27, CI = 0.12, 0.45) and a 28% decrease (eβ= 0.72, CI = 0.64, 0.80) in the severity of RoC. Conclusions Both elderspeak by nursing staff and RoC by PLWD are present and pervasive in acute care. Pain and elderspeak are two modifiable factors of RoC in hospitalized PLWD. Person‐centered interventions are needed that address communication practices and pain management for hospitalized PLWD.
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Affiliation(s)
- Clarissa A Shaw
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Caitlin Ward
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa, USA.,Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Calgary, Alberta, Canada
| | - Jean Gordon
- Department of Communication Sciences and Disorders, University of Iowa, Iowa City, Iowa, USA
| | - Kristine N Williams
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Keela Herr
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
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13
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Hämäläinen J, Kvist T, Kankkunen P. Acute Pain Assessment Inadequacy in the Emergency Department: Patients' Perspective. J Patient Exp 2022; 9:23743735211049677. [PMID: 35005219 PMCID: PMC8733361 DOI: 10.1177/23743735211049677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
For many patients, acute pain is a common cause to seek treatment in an Emergency Department (ED). An inadequate assessment could cause inappropriate pain management. The aim of this study was to describe and explain patients’ perceptions of acute pain assessment in the Emergency Department. The data were collected from ED patients (n = 114). Patients reported that nurses were asking about intensity of pain at rest, but only 52% during movement. According to the patients, the most common tools to assess acute pain were the verbal rating scale (VRS; 54% of patients), numerical rating scale (NRS; 28% of patients), and visual analogue scale (VAS; 9.7% of patients). Over twenty per cent of patients stated that ED nurses did not ask about the intensity of pain after analgesic administration. Twenty-four per cent of the patients were not pleased with nursing pain assessment in the ED. The assessment of acute pain is still inadequate in the ED. Therefore, ED nurses need to be more attentive to systematic acute pain management of patients in the ED.
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Affiliation(s)
- Jenni Hämäläinen
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
| | - Tarja Kvist
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
| | - Päivi Kankkunen
- Department of Nursing Science, Finland University of Eastern Finland, Kuopio, Finland
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14
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The role of experiential knowledge in hospital nurses’ management of pain-related agitation in people with dementia: an expert performance simulation study. Int J Nurs Stud 2021; 127:104160. [DOI: 10.1016/j.ijnurstu.2021.104160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/19/2022]
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15
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Wang J, Cato K, Conwell Y, Yu F, Heffner K, Caprio TV, Nathan K, Monroe TB, Muench U, Li Y. Pain treatment and functional improvement in home health care: Relationship with dementia. J Am Geriatr Soc 2021; 69:3545-3556. [PMID: 34418061 DOI: 10.1111/jgs.17420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pain management is important to post-acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD. METHODS We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60-day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non-opioid analgesic, and opioid. ADRD was identified from ICD-10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode. RESULTS ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non-opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = -0.43, 95% CI: -0.73, -0.13, p = 0.004) and non-opioid analgesic use (β = -0.31, 95% CI: -0.56, -0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status. CONCLUSIONS HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.
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Affiliation(s)
- Jinjiao Wang
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Kenrick Cato
- Columbia University School of Nursing, New York, New York, USA.,Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, New York, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Kathi Heffner
- Elaine Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA.,Department of Psychiatry, University of Rochester Medical Center, New York, New York, USA.,Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas V Caprio
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA.,UR Medicine Home Care, University of Rochester Medical Center, New York, New York, USA.,Finger Lakes Geriatric Education Center, University of Rochester Medical Center, New York, New York, USA
| | - Kobi Nathan
- Division of Geriatrics & Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA.,Wegmans School of Pharmacy, St. John Fisher College, Rochester, New York, USA
| | - Todd B Monroe
- College of Nursing, The Ohio State University, Columbus, Ohio, USA
| | - Ulrike Muench
- School of Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, New York, New York, USA
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16
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Parkman S, Mastel-Smith B, McGuire A, Duke G. Insights to Identifying and Managing Pain in Persons With Dementia in Long-Term Care: A Mixed Methods Study Comparing the Abbey Pain Scale and Pain Assessment in Advanced Dementia Scale. J Gerontol Nurs 2021; 47:21-30. [PMID: 33497447 DOI: 10.3928/00989134-20210113-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/19/2020] [Indexed: 11/20/2022]
Abstract
Pain is usually identified by specific behaviors driven by the need for relief; however, persons with dementia present a unique challenge for nurses in assessing and managing pain. The aim of this mixed methods study was to explore the relationship between two observational pain scales, expressed need-driven behaviors, and likelihood of medication administration for persons with dementia. The qualitative strand examined nurses' perceptions regarding facilitators and barriers to pain scale use. Quantitative data analysis indicated the Abbey Pain Scale was significantly correlated with behaviors (r[26] = 0.41, p < 0.05) and approached significance with medication administration (r[26] = 0.35, p = 0.067). Qualitative analysis identified three core themes: (a) Challenges in Assessing Persons With Dementia for Pain; (b) Facilitators and Barriers to Pain Management; and (c) Difficulty Caring for Persons With Dementia. Clinical implications suggest the need for a systematic, consistent method of observing pain-related behaviors in persons with dementia. [Journal of Gerontological Nursing, 47(2), 21-30.].
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17
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Harmon J, Summons P, Higgins I. Disjunction, tension and dissonance within nursing pain care provision for the older hospitalized person: A focused ethnographic insight. J Adv Nurs 2021; 77:3458-3471. [PMID: 33942354 DOI: 10.1111/jan.14878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/14/2021] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
AIMS This study presents an ethnographic insight into the older hospitalized persons' experiences on how nurses provide pain care provision. The older persons' perceptions of culturally mediated barriers and facilitators are presented. DESIGN Focused ethnography. METHODS Multi-site across eight acute care units within two tertiary referral hospitals on the east coast of Australia collected over a one-year period from 2014 to 2015. Semi-structured interviews (n = 12) of older persons (11 hr). Twenty-three (23) semi-structured interviews with nine (9) registered nurses (12 hr 38 min). Participant observation (1,041 hr) during day, night and evening shifts. RESULTS The older person experienced disjunction within pain assessment by the reliance of nurses on objective measurement gained during functional task completion. Tension emerged during pain management when the older person was not included and/or options provided were not deemed effective. For some older persons this meant they undertook a decision to exclude their nurse from involvement in pain management. A thread woven throughout was a lack of communication, continuity of care and input from the older person. CONCLUSION This study has implications for the provision of nursing care of the older hospitalized person. Dissonance within pain care provision for the older person occurs during episodes of missed pain care. Understanding and insight is gained into aspects of missed communication opportunities between nurses and the experiences of missed pain care of the older person.
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Affiliation(s)
- Joanne Harmon
- UniSA Clinical and Health Sciences, Rosemary Bryant AO Research Centre, University of South Australia, Adelaide, Australia
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18
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Minaya-Freire A, Subirana-Casacuberta M, Puigoriol-Juvanteny E, Ramon-Aribau A. Pain management nursing practice assessment in older adults with dementia. Nurs Open 2021; 8:3349-3357. [PMID: 33826237 PMCID: PMC8510716 DOI: 10.1002/nop2.880] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/29/2021] [Accepted: 03/21/2021] [Indexed: 01/13/2023] Open
Abstract
Aim To assess pain management nursing practice in older adults with dementia through electronic health records (EHR). Design Retrospective study. Methods Data were collected from EHR related to pain management in older adults with dementia treated at the Acute Geriatrics Unit (AGU) of a university hospital in early 2018. Results EHR related to the pain of 111 patients were reviewed. Pain intensity was assessed at admission in 88% of patients and a median of 1.9 times per day of stay. A disproportionate number of the assessments (39%) occurred during the late shift. A median of 1 drug per day was administered. Pain was recorded in 28% of patients’ care plans, and non‐pharmacological interventions were recorded in 12%. In conclusion, exist variability in pain management nursing practice in older adults with dementia. Admission diagnosis correlated with the analgesic administration schedule, the number of drugs administered and the number of pain nursing annotations.
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Affiliation(s)
- Alícia Minaya-Freire
- University Hospital Of Vic-Vic Hospital Consortium (HUV-CHV). C. Francesc Plà "El Vigatà", Vic, Barcelona, Spain.,Research Group on Methodology, Methods, Models and Health and social Outcomes (M3O), Faculty of Health Science and Welfare, Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC). C. Sagrada Família, Vic, Barcelona, Spain
| | - Mireia Subirana-Casacuberta
- Research Group on Methodology, Methods, Models and Health and social Outcomes (M3O), Faculty of Health Science and Welfare, Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC). C. Sagrada Família, Vic, Barcelona, Spain.,Nursing Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Emma Puigoriol-Juvanteny
- University Hospital Of Vic-Vic Hospital Consortium (HUV-CHV). C. Francesc Plà "El Vigatà", Vic, Barcelona, Spain.,Tissue Repair and Regeneration Laboratory (TR2Lab), Faculty of Sciences and Technology, University of Vic - Central University of Catalonia, Faculty of Medicine, University of Vic - Central University of Catalonia. C. Sagrada Família, Vic, Barcelona, Spain
| | - Anna Ramon-Aribau
- Research Group on Methodology, Methods, Models and Health and social Outcomes (M3O), Faculty of Health Science and Welfare, Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC). C. Sagrada Família, Vic, Barcelona, Spain
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19
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Koufidis C, Manninen K, Nieminen J, Wohlin M, Silén C. Unravelling the polyphony in clinical reasoning research in medical education. J Eval Clin Pract 2021; 27:438-450. [PMID: 32573080 DOI: 10.1111/jep.13432] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 11/27/2022]
Abstract
RATIONALE Clinical reasoning lies at the heart of medical practice and has a long research tradition. Nevertheless, research is scattered across diverse academic disciplines with different research traditions in a wide range of scientific journals. This polyphony is a source of conceptual confusion. AIMS AND OBJECTIVES We sought to explore the underlying theoretical assumptions of clinical reasoning aiming to promote a comprehensive conceptual and theoretical understanding of the subject area. In particular, we asked how clinical reasoning is defined and researched and what conceptualizations are relevant to such uses. METHODS A scoping review of the clinical reasoning literature was undertaken. Using a "snowball" search strategy, the wider scientific literature on clinical reasoning was reviewed in order to clarify the different underlying conceptual assumptions underlying research in clinical reasoning, particularly to the field of medical education. This literature included both medical education, as well as reasoning research in other academic disciplines outside medical education, that is relevant to clinical reasoning. A total of 124 publications were included in the review. RESULTS A detailed account of the research traditions in clinical reasoning research is presented. In reviewing this research, we identified three main conceptualisations of clinical reasoning: "reasoning as cognitive activity," "reasoning as contextually situated activity," and "reasoning as socially mediated activity." These conceptualisations reflected different theoretical understandings of clinical reasoning. Each conceptualisation was defined by its own set of epistemological assumptions, which we have identified and described. CONCLUSIONS Our work seeks to bring into awareness implicit assumptions of the ongoing clinical reasoning research and to hopefully open much needed channels of communication between the different research communities involved in clinical reasoning research in the field.
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Affiliation(s)
- Charilaos Koufidis
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Katri Manninen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Huddinge, Sweden
| | - Juha Nieminen
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Wohlin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Charlotte Silén
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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20
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Gregory J. Holistic pain assessment in older people and older people living with dementia. Nurs Older People 2020; 33:e1293. [PMID: 33403836 DOI: 10.7748/nop.2021.e1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 11/09/2022]
Abstract
Pain occurs in a wide range of diseases and long-term conditions associated with ageing and can affect every aspect of an individual's life, reducing their ability to recover, their independence and their quality of life. The assessment of pain is an important aspect of nurses' role and requires them to obtain detailed information on how the older person experiences pain and how pain is affecting their life. However, there are many challenges to effective pain assessment in older people, including challenges concerning communication and cognition. This article provides an overview of pain assessment in older people, particularly those living with dementia, based on the author's expertise and on relevant literature, notably the recently revised UK national guidelines on the assessment of pain in older people.
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Affiliation(s)
- Julie Gregory
- East Lancashire Hospitals NHS Trust, Blackburn, England
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21
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Gullick J, Wu J, Reid C, Tembo AC, Shishehgar S, Conlon L. Heideggerian structures of Being-with in the nurse-patient relationship: modelling phenomenological analysis through qualitative meta-synthesis. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2020; 23:645-664. [PMID: 32894396 DOI: 10.1007/s11019-020-09975-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/27/2020] [Indexed: 06/11/2023]
Abstract
Heideggerian philosophy is frequently chosen as a philosophical framing, and/or a hermeneutic analytical structure in qualitative nursing research. As Heideggerian philosophy is dense, there is merit in the development of scholarly resources that help to explain discrete Heideggerian concepts and to uncover their relevance to contemporary human experience. This paper uses a meta-synthesis methodology to pool and synthesise findings from 29 phenomenological research reports on Being-with in the nurse-patient relationship. We firstly considered and secured the most relevant Heideggerian elements to nurse-patient Being-with (Dasein-with, circumspection, solicitude, and discourse). Under these deductive codes, we then inductively developed sub-themes that seemed to explain the multifaceted nature of Being-with, through a secondary analysis and synthesis of published data from 417 patient, carer and nurse participants. Dasein-with was enhanced when nurses had first-hand experience with a phenomenon. Nurses moved between the inauthentic they-mode (task-orientated busyness, existential abandonment, rough handling and deficient modes of concern in potentially violent encounters), and the authentic self-mode (seeking connection [knowing], and openness [unknowing], which exposed their emotional vulnerability). Through circumspection (making room for, deseverance and directionality), technology and people were encountered environmentally feeding into nursing attention, assessment and communication. Nursing as a social arrangement (solicitude) was expressed through either leaping-in care (also perceived as 'power over') or leaping-ahead care (moving the patient towards independence). There was a place for both inauthentic (idle talk) and authentic discourse (including non-verbal and spiritual discourse) that nurses wove through the ontic everydayness of nursing tasks.
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Affiliation(s)
- Janice Gullick
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia.
| | - John Wu
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia
- University of Sydney (Sydney Conservatorium of Music and University Library), Sydney, NSW, Australia
| | - Cindy Reid
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia
| | - Agness Chisanga Tembo
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia
- Maitland Hospital (Intensive Care Unit), Maitland, NSW, Australia
| | - Sara Shishehgar
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia
- Faculty of Health, University of Technology, Sydney, NSW, Australia
| | - Lisa Conlon
- University of Sydney (Susan Wakil School of Nursing & Midwifery, Faculty of Medicine & Health), Sydney, NSW, Australia
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22
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Gwernan-Jones R, Lourida I, Abbott RA, Rogers M, Green C, Ball S, Hemsley A, Cheeseman D, Clare L, Moore D, Burton J, Lawrence S, Rogers M, Hussey C, Coxon G, Llewellyn DJ, Naldrett T, Thompson Coon J. Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Being in hospital can be particularly confusing and challenging not only for people living with dementia, but also for their carers and the staff who care for them. Improving the experience of care for people living with dementia in hospital has been recognised as a priority.
Objectives
To understand the experience of care in hospital for people living with dementia, their carers and the staff who care for them and to assess what we know about improving the experience of care.
Review methods
We undertook three systematic reviews: (1) the experience of care in hospital, (2) the experience of interventions to improve care in hospital and (3) the effectiveness and cost-effectiveness of interventions to improve the experience of care. Reviews 1 and 2 sought primary qualitative studies and were analysed using meta-ethnography. Review 3 sought comparative studies and economic evaluations of interventions to improve experience of care. An interweaving approach to overarching synthesis was used to integrate the findings across the reviews.
Data sources
Sixteen electronic databases were searched. Forwards and backwards citation chasing, author contact and grey literature searches were undertaken. Screening of title and abstracts and full texts was performed by two reviewers independently. A quality appraisal of all included studies was undertaken.
Results
Sixty-three studies (reported in 82 papers) were included in review 1, 14 studies (reported in 16 papers) were included in review 2, and 25 studies (reported in 26 papers) were included in review 3. A synthesis of review 1 studies found that when staff were delivering more person-centred care, people living with dementia, carers and staff all experienced this as better care. The line of argument, which represents the conceptual findings as a whole, was that ‘a change of hospital culture is needed before person-centred care can become routine’. From reviews 2 and 3, there was some evidence of improvements in experience of care from activities, staff training, added capacity and inclusion of carers. In consultation with internal and external stakeholders, the findings from the three reviews and overarching synthesis were developed into 12 DEMENTIA CARE pointers for service change: key institutional and environmental practices and processes that could help improve experience of care for people living with dementia in hospital.
Limitations
Few of the studies explored experience from the perspectives of people living with dementia. The measurement of experience of care across the studies was not consistent. Methodological variability and the small number of intervention studies limited the ability to draw conclusions on effectiveness.
Conclusions
The evidence suggests that, to improve the experience of care in hospital for people living with dementia, a transformation of organisational and ward cultures is needed that supports person-centred care and values the status of dementia care. Changes need to cut across hierarchies and training systems to facilitate working patterns and interactions that enable both physical and emotional care of people living with dementia in hospital. Future research needs to identify how such changes can be implemented, and how they can be maintained in the long term. To do this, well-designed controlled studies with improved reporting of methods and intervention details to elevate the quality of available evidence and facilitate comparisons across different interventions are required.
Study registration
This study is registered as PROSPERO CRD42018086013.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 43. See the NIHR Journals Library website for further project information. Additional funding was provided by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Affiliation(s)
- Ruth Gwernan-Jones
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Ilianna Lourida
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Rebecca A Abbott
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Morwenna Rogers
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Colin Green
- Health Economics Group, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Susan Ball
- Health Statistics Group, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | | | - Linda Clare
- Centre for Research in Ageing and Cognitive Health, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Darren Moore
- Graduate School of Education, College of Social Sciences and International Studies, University of Exeter, Exeter, UK
| | - Julia Burton
- Alzheimer’s Society Research Network Volunteers, c/o University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sue Lawrence
- Alzheimer’s Society Research Network Volunteers, c/o University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | | | | | - David J Llewellyn
- Mental Health Research Group, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
- The Alan Turing Institute, London, UK
| | | | - Jo Thompson Coon
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
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23
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Gamborg ML, Mehlsen M, Paltved C, Tramm G, Musaeus P. Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine. BMC Emerg Med 2020; 20:73. [PMID: 32928158 PMCID: PMC7489001 DOI: 10.1186/s12873-020-00367-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/31/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Clinical decision-making (CDM) is an important competency for young doctors especially under complex and uncertain conditions in geriatric emergency medicine (GEM). However, research in this field is characterized by vague conceptualizations of CDM. To evolve and evaluate evidence-based knowledge of CDM, it is important to identify different definitions and their operationalizations in studies on GEM. OBJECTIVE A scoping review of empirical articles was conducted to provide an overview of the documented evidence of findings and conceptualizations of CDM in GEM. METHODS A detailed search for empirical studies focusing on CDM in a GEM setting was conducted in PubMed, ProQuest, Scopus, EMBASE and Web of Science. In total, 52 publications were included in the analysis, utilizing a data extraction sheet, following the PRISMA guidelines. Reported outcomes were summarized. RESULTS Four themes of operationalization of CDM emerged: CDM as dispositional decisions, CDM as cognition, CDM as a model, and CDM as clinical judgement. Study results and conclusions naturally differed according to how CDM was conceptualized. Thus, frailty-heuristics lead to biases in treatment of geriatric patients and the complexity of this patient group was seen as a challenge for young physicians engaging in CDM. CONCLUSIONS This scoping review summarizes how different studies in GEM use the term CDM. It provides an analysis of findings in GEM and call for more stringent definitions of CDM in future research, so that it might lead to better clinical practice.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark.
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Charlotte Paltved
- Corporate HR MidtSim, Central Region of Denmark & Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Gitte Tramm
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Peter Musaeus
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark
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24
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Walsh B, Dahlke S, O'Rourke H, Hunter KF. Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia. J Clin Nurs 2020; 31:2024-2035. [PMID: 32860272 DOI: 10.1111/jocn.15477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). BACKGROUND Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. DESIGN A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD. METHODS Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. RESULTS Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making. CONCLUSIONS These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.
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Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Bullock L, Chew-Graham CA, Bedson J, Bartlam B, Campbell P. The challenge of pain identification, assessment, and management in people with dementia: a qualitative study. BJGP Open 2020; 4:bjgpopen20X101040. [PMID: 32457099 PMCID: PMC7330220 DOI: 10.3399/bjgpopen20x101040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Painful conditions are common in older adults, including people with dementia. The symptoms associated with dementia (for example, diminished language capacity, memory impairment, and behavioural changes), however, may lead to the suboptimal identification, assessment, and management of pain. Research has yet to qualitatively explore pain management for community-dwelling people with dementia. AIM To explore pain identification, assessment, and management for community-dwelling people with dementia. DESIGN & SETTING A qualitative study was undertaken, set in England. METHOD Semi-structured interviews took place with people with dementia, family caregivers, GPs, and old-age psychiatrists. Data were analysed thematically. RESULTS Interviews were conducted with eight people with dementia, nine family caregivers, nine GPs, and five old-age psychiatrists. Three themes were identified that related to pain identification and assessment: gathering information to identify pain; the importance of knowing the person; and the use of pain assessment tools. A further three themes were identified that related to pain management: non-drug strategies; concerns related to analgesic medications; and responsibility of the caregiver to manage pain. CONCLUSION Identifying and assessing the pain experienced by people with dementia was challenging. Most people with dementia, family caregivers, and healthcare professionals supported non-drug strategies to manage pain. The minimal concerns associated with non-drug strategies contrasted the multifactorial concerns associated with analgesic treatment for people with dementia. Given the complexity of pain identification, assessment, and management, primary care should work together with family caregivers and community services, with case finding for pain being considered in all assessment and management plans.
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Affiliation(s)
- Laurna Bullock
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Carolyn A Chew-Graham
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
| | - John Bedson
- School of Primary Community and Social Care, Keele University, Keele, UK
| | - Bernadette Bartlam
- School of Primary Community and Social Care, Keele University, Keele, UK
- Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University Singapore, Singapore, UK
| | - Paul Campbell
- School of Primary Community and Social Care, Keele University, Keele, UK
- Midlands Partnership NHS Foundation Trust, St Georges' Hospital, Stafford, UK
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Minaya-Freire A, Ramon-Aribau A, Pou-Pujol G, Fajula-Bonet M, Subirana-Casacuberta M. Facilitators, Barriers, and Solutions in Pain Management for Older Adults with Dementia. Pain Manag Nurs 2020; 21:495-501. [PMID: 32482567 DOI: 10.1016/j.pmn.2020.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/10/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although qualitative studies have been conducted to identify barriers and facilitators that influence the pain management of older adults with dementia, as far as we know, only a very recent study (Andrews et al., 2019) has used participatory action research (PAR) as a methodology for studying pain management. It allows nurses to examine and improve their practice based on their realities and within their context. AIM To reflect on nursing practice and identify facilitators and barriers in the management of pain in older adults with dementia and to propose actions for improvement. DESIGN We used qualitative participatory action research. PARTICIPANTS/SETTINGS Ten nurses from the geriatric acute care unit of a university hospital in Spain were recruited through convenience sampling. METHODS Data were generated through a written questionnaire and three focus groups. RESULTS One of the main facilitators the participants identified was professional experience. The main barriers they identified were lack of knowledge and skills and lack of time. The participants proposed two main improvements: (1) a training program consisting of three courses (pain evaluation and management, dementia and pain, and pharmacology) and (2) the creation of a specific register for nurses to record patients' pain. CONCLUSIONS Involving nurses directly in research on their practices can result in precise proposals for improvements based on their needs and oriented toward improving the quality of care. Moreover, our results confirm previous findings in other countries.
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Affiliation(s)
- Alícia Minaya-Freire
- University Hospital of Vic, Vic Hospital Consortium (HUV-CHV), Barcelona, Spain; Research Group on Methodology, Methods, Models and Health and Social Outcomes (M(3)O), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Barcelona, Spain
| | - Anna Ramon-Aribau
- Research Group on Methodology, Methods, Models and Health and Social Outcomes (M(3)O), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Barcelona, Spain.
| | - Gemma Pou-Pujol
- University Hospital of Vic, Vic Hospital Consortium (HUV-CHV), Barcelona, Spain
| | | | - Mireia Subirana-Casacuberta
- University Hospital of Vic, Vic Hospital Consortium (HUV-CHV), Barcelona, Spain; Research Group on Methodology, Methods, Models and Health and Social Outcomes (M(3)O), Centre for Health and Social Care Research (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), Barcelona, Spain
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Horler C, Hebron C, Martyn K. Personalizing education: The clinical reasoning processes of physiotherapists using education for the treatment of people with chronic low back pain. Physiother Theory Pract 2020; 38:412-421. [DOI: 10.1080/09593985.2020.1765437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Christopher Horler
- School of Health Sciences, University of Brighton, Eastbourne, UK
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Clair Hebron
- School of Health Sciences, University of Brighton, Eastbourne, UK
| | - Kathy Martyn
- School of Health Sciences, University of Brighton, Eastbourne, UK
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Gwernan-Jones R, Abbott R, Lourida I, Rogers M, Green C, Ball S, Hemsley A, Cheeseman D, Clare L, Moore DA, Hussey C, Coxon G, Llewellyn DJ, Naldrett T, Thompson Coon J. The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies. Int J Older People Nurs 2020; 15:e12325. [PMID: 32412167 DOI: 10.1111/opn.12325] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/30/2020] [Accepted: 04/14/2020] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To systematically review and synthesise qualitative data from studies exploring the experiences of hospital staff who care for people living with dementia (Plwd). BACKGROUND In hospital, the number of Plwd continues to rise; however, their experiences of care remain problematic. Negative experiences of care are likely to contribute to poorer mental and physical health outcomes for Plwd while in hospital and after discharge. Experiences of the hospital staff who care for Plwd can also be poor or unrewarding. It is important to understand the experiences of staff in order to improve staff well-being and ultimately the experience of care for Plwd while in hospital. DESIGN Systematic review and evidence synthesis of qualitative research. DATA SOURCES We searched 16 electronic databases in March 2018 and completed forward and backward citation chasing. METHODS Eligible studies explored the experiences of paid and unpaid staff providing care in hospital for Plwd. Study selection was undertaken independently by two reviewers, and quality appraisal was conducted. We prioritised included studies according to richness of text, methodological rigour and conceptual contribution. We adopted approaches of meta-ethnography to analyse study findings, creating a conceptual model to represent the line of argument. FINDINGS Forty-five studies reported in 58 papers met the inclusion criteria, and of these, we prioritised 19 studies reported in 24 papers. The line of argument was that Institutions can improve staff experiences of care for Plwd by fostering person-centred care (PCC). PCC aligned with staff perceptions of 'good care'; however, staff often felt prevented from providing PCC because of care cultures that prioritised tasks, routines and physical health. Staff experienced conflict over the care they wanted to give versus the care they were able to give, and this caused moral distress. When staff were able to provide PCC, this increased experiences of job satisfaction and emotional well-being. CONCLUSIONS Person-centred care not only has the potential to improve the experience of care for Plwd and their carers, but can also improve the experiences of hospital staff caring for Plwd. However, without institutional-level changes, hospital staff are often unable to provide PCC even when they have the experience and knowledge to do so. IMPLICATIONS FOR PRACTICE Institutional-level areas for change include the following: training; performance indicators and ward cultures that prioritise psychological needs alongside physical needs; adequate staffing levels; inclusive approaches to carers; physical environments that promote familiarisation, social interaction and occupation; systems of documentation about individual needs of Plwd; and cultures of sharing knowledge across hierarchies.
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Affiliation(s)
- Ruth Gwernan-Jones
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Rebecca Abbott
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Ilianna Lourida
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Morwenna Rogers
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Colin Green
- Health Economics Group, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Susan Ball
- Health Statistics Group, PenCLAHRC, College of Medicine and Health, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | | | | | - Linda Clare
- Centre for Research in Aging and Cognitive Health, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
| | - Darren A Moore
- Graduate School of Education, College of Social Sciences and International Studies, St Luke's Campus, University of Exeter, Exeter, UK
| | | | | | - David J Llewellyn
- Mental Health Research Group, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK.,The Alan Turing Institute, London, UK
| | | | - Jo Thompson Coon
- Evidence Synthesis Team, PenCLAHRC, University of Exeter Medical School, St Luke's Campus, University of Exeter, Exeter, UK
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Voss S, Brandling J, Pollard K, Taylor H, Black S, Buswell M, Cheston R, Cullum S, Foster T, Kirby K, Prothero L, Purdy S, Solway C, Benger J. A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project. BMC Emerg Med 2020; 20:6. [PMID: 31996145 PMCID: PMC6988190 DOI: 10.1186/s12873-020-0306-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022] Open
Abstract
Background Paramedics are increasingly required to make complex decisions as to whether they should convey a patient to hospital or manage their condition at the scene. Dementia can be a significant barrier to the assessment process. However, to our knowledge no research has specifically examined the process of decision-making by paramedics in relation to people with dementia. This qualitative study was designed to investigate the factors influencing the decision-making process during Emergency Medical Services (EMS) calls to older people with dementia who did not require immediate clinical treatment. Methods This qualitative study used a combination of observation, interview and document analysis to investigate the factors influencing the decision-making process during EMS calls to older people with dementia. A researcher worked alongside paramedics in the capacity of observer and recruited eligible patients to participate in case studies. Data were collected from observation notes of decision-making during the incident, patient care records and post incident interviews with participants, and analysed thematically. Findings Four main themes emerged from the data concerning the way that paramedics make conveyance decisions when called to people with dementia: 1) Physical condition; the key factor influencing paramedics’ decision-making was the physical condition of the patient. 2) Cognitive capacity; most of the participants preferred not to remove patients with a diagnosis of dementia from surroundings familiar to them, unless they deemed it absolutely essential. 3) Patient circumstances; this included the patient’s medical history and the support available to them. 4) Professional influences; participants also drew on other perspectives, such as advice from colleagues or information from the patient’s General Practitioner, to inform their decision-making. Conclusion The preference for avoiding unnecessary conveyance for patients with dementia, combined with difficulties in obtaining an accurate patient medical history and assessment, mean that decision-making can be particularly problematic for paramedics. Further research is needed to find reliable ways of assessing patients and accessing information to support conveyance decisions for EMS calls to people with dementia.
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Affiliation(s)
- Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
| | - Janet Brandling
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Katherine Pollard
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Hazel Taylor
- Research Design Service, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sarah Black
- Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Taunton, UK
| | - Marina Buswell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Richard Cheston
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Sarah Cullum
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Theresa Foster
- Research Support Services, East of England Ambulance Service NHS Trust, Bury St. Edmunds, UK
| | - Kim Kirby
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.,Research and Audit Department, South Western Ambulance Service NHS Foundation Trust, Taunton, UK
| | - Larissa Prothero
- Research Support Services, East of England Ambulance Service NHS Trust, Bury St. Edmunds, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Solway
- Research Network, Alzheimer's Society, London, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
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Fatania V, De Boos D, Tickle A, Connelly D. How do inpatient psychiatric nurses make sense of and respond to behaviours in dementia? An Interpretative Phenomenological Analysis. Aging Ment Health 2019; 23:1156-1163. [PMID: 30406667 DOI: 10.1080/13607863.2018.1479835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Existing literature demonstrates that nurses' understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia. Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA. Results: Four interrelated themes were identified: 'Effort to sense make', 'Pressures of the organisation', 'Balancing personal and professional selves: The underlying emotional connection'; and '"Looking back on it…"'. Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.
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Affiliation(s)
- Vidya Fatania
- a Trent Doctorate in Clinical Psychology , University of Nottingham , Nottingham , UK
| | - Danielle De Boos
- a Trent Doctorate in Clinical Psychology , University of Nottingham , Nottingham , UK.,b Nottinghamshire Healthcare NHS Foundation Trust
| | - Anna Tickle
- a Trent Doctorate in Clinical Psychology , University of Nottingham , Nottingham , UK.,b Nottinghamshire Healthcare NHS Foundation Trust
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Gregory J. Use of pain scales and observational pain assessment tools in hospital settings. Nurs Stand 2019; 34:e11308. [PMID: 31468952 DOI: 10.7748/ns.2019.e11308] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 11/09/2022]
Abstract
Pain is a personal, individual and subjective experience. The complex and dynamic nature of pain makes its assessment and management challenging for healthcare professionals. Various pain scales are available that can assist in identifying the patient's experience of pain; however, these tend to reduce this experience to a measure of pain intensity. The use of pain scales also requires patients to communicate and describe their pain; when this is not possible, it is necessary for healthcare professionals to observe patient behaviours that may indicate pain. Various observational pain assessment tools have been developed to assist in recognising and assessing pain. This article discusses the various pain scales and observational pain assessment tools that are available, and the evidence to support their use.
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Affiliation(s)
- Julie Gregory
- East Lancashire Hospitals NHS Trust, Blackburn, England
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32
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Kim M, Jeong SYS. Appraisal of International Guidelines for Cancer Pain Management. JOURNAL OF PROBLEM-BASED LEARNING 2019. [DOI: 10.24313/jpbl.2018.00129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Dillane I, Doody O. Nursing people with intellectual disability and dementia experiencing pain: An integrative review. J Clin Nurs 2019; 28:2472-2485. [PMID: 30786087 DOI: 10.1111/jocn.14834] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/09/2019] [Accepted: 02/09/2019] [Indexed: 12/31/2022]
Abstract
AIMS AND OBJECTIVES To explore the current evidence of nurses caring for people with intellectual disability and dementia who experience pain. BACKGROUND People with intellectual disability are ageing and are experiencing age-related health conditions including dementia and conditions associated with pain, but at an earlier age. Addressing the needs of people with intellectual disability who develop dementia is a new challenge for nurses. DESIGN An integrative literature review. METHODS A systematic search of databases: CINAHL, MEDLINE, PsycINFO, Cochrane, EMBASE, Academic Search Complete, Scopus and Web of Science between 27 October 2017-7 November 2017. Hand searching and review of secondary references were also undertaken. Quality appraisal (Crowe Critical Appraisal Tool), thematic data analysis (Braun and Clarke, Qualitative Research in Psychology, 3, 2006, 77) and reporting using the PRISMA guidelines. RESULTS Seven papers met the inclusion criteria, and three themes emerged from this review: nurses knowledge of ageing, dementia and pain; recognising pain in people with intellectual disability and dementia; and the role of nurse education. People with intellectual disability and dementia have difficulty communicating their pain experience compounded by pre-existing communication difficulties. CONCLUSIONS A pain experience can present similar to behavioural and psychological symptoms of dementia, and diagnostic overshadowing often occurs whereby a pain need is misinterpreted as behavioural and psychological symptoms resulting in inappropriate treatment. Nurses need greater knowledge about the presence of pain and potential causes in people with intellectual disability and dementia, and education can be effective in addressing this knowledge deficit. RELEVANCE TO CLINICAL PRACTICE Pain assessment tools for people with intellectual disability and dementia need to include behavioural elements, and baseline assessments are required to identify changes in presentation. Nurses need to recognise and respond to pain based on the evidence in order to deliver quality care.
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Affiliation(s)
| | - Owen Doody
- Health Research Institute, Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
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Geddis-Regan AR, Stewart M, Wassall RR. Orofacial pain assessment and management for patients with dementia: A meta-ethnography. J Oral Rehabil 2018; 46:189-199. [PMID: 30307635 DOI: 10.1111/joor.12732] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/08/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Abstract
Delivering dental treatment for patients with dementia can be challenging, and the complexity of treatment provision can increase as dementia progresses. Treatment at the later stages of dementia can be associated with ethical challenges and procedural risk meaning that a comprehensive patient assessment is crucial; the presence of orofacial pain is a key indication for active intervention from dental teams. To explore the process of oro-facial pain assessment and management, a comprehensive review of qualitative literature was undertaken by searching six electronic databases. No literature specific to orofacial pain assessment was identified. The inclusion criteria were widened to explore assessment and management of pain in general for patients with dementia. Meta-ethnography with reciprocal translation was used to identify key concepts and themes and synthesise information applicable to the dental setting. Three major themes arose as follows: challenges with pain assessment, challenges with pain management and logistics and education. Healthcare teams struggle with pain identification in patients with dementia though many signs were identified which may suggest a patient is experiencing pain. The long-term knowledge of individual patients held by family members and care teams can allow identification of deviation from patients' normal states; this knowledge can assist healthcare professionals in determining whether to provide specific treatments or interventions. Pain assessment tools were found to be problematic and are unlikely to be a practical solution to use for complex patients in dental settings. Education for dental and wider care teams on orofacial pain would be highly valuable; yet, this needs to be based on suitable evidence.
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Affiliation(s)
| | - Margaret Stewart
- Patient and Public Involvement Researcher, Newcastle upon Tyne, UK
| | - Rebecca R Wassall
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
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McWilliams L, Farrell C, Grande G, Keady J, Swarbrick C, Yorke J. A systematic review of the prevalence of comorbid cancer and dementia and its implications for cancer-related care. Aging Ment Health 2018; 22:1254-1271. [PMID: 28718298 DOI: 10.1080/13607863.2017.1348476] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A comorbid diagnosis of cancer and dementia (cancer-dementia) may have unique implications for patient cancer-related experience. The objectives were to estimate prevalence of cancer-dementia and related experiences of people with dementia, their carers and cancer clinicians including cancer screening, diagnosis, treatment and palliative care. METHOD Databases were searched (CINAHL, Psychinfo, Medline, Embase, BNI) using key terms such as dementia, cancer and experience. Inclusion criteria were as follows: (a) English language, (b) published any time until early 2016, (c) diagnosis of cancer-dementia and (d) original articles that assessed prevalence and/or cancer-related experiences including screening, cancer treatment and survival. Due to variations in study design and outcomes, study data were synthesised narratively. RESULTS Forty-seven studies were included in the review with a mix of quantitative (n = 44) and qualitative (n = 3) methodologies. Thirty-four studies reported varied cancer-dementia prevalence rates (range 0.2%-45.6%); the others reported reduced likelihood of receiving: cancer screening, cancer staging information, cancer treatment with curative intent and pain management, compared to those with cancer only. The findings indicate poorer cancer-related clinical outcomes including late diagnosis and higher mortality rates in those with cancer-dementia despite greater health service use. CONCLUSIONS There is a dearth of good-quality evidence investigating the cancer-dementia prevalence and its implications for successful cancer treatment. Findings suggest that dementia is associated with poorer cancer outcomes although the reasons for this are not yet clear. Further research is needed to better understand the impact of cancer-dementia and enable patients, carers and clinicians to make informed cancer-related decisions.
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Affiliation(s)
- L McWilliams
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK
| | - C Farrell
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK.,b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - G Grande
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - J Keady
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - C Swarbrick
- b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
| | - J Yorke
- a Christie Patient Centred Research (CPCR), School of Oncology , The Christie NHS Foundation Trust , Manchester , UK.,b Division of Nursing, Midwifery and Social Work, Faculty of Biology, Medicine and Health , University of Manchester , Manchester , UK
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Lautenbacher S, Sampson EL, Pähl S, Kunz M. Which Facial Descriptors Do Care Home Nurses Use to Infer Whether a Person with Dementia Is in Pain? PAIN MEDICINE 2018; 18:2105-2115. [PMID: 28034977 DOI: 10.1093/pm/pnw281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objectives Pain assessment in people with advanced dementia relies strongly on observable pain behaviors, such as facial expressions, body movement, and vocalizations. However, the process of inferring pain in others based on such observations is not well understood. We aimed to investigate which features of facial expressions caregivers rely on when inferring the presence and intensity of pain in people with dementia. Methods A questionnaire, including items on 13 facial descriptors, which were extracted from established observational scales for pain in dementia, was sent to 366 nursing homes in Germany. We asked the nurses to observe patients with dementia and then rate their observations using the facial descriptors, as well as to provide an overall pain estimate of the residents' pain. We used regression analyses to identify which facial descriptors nurses use most commonly to infer whether a person with dementia is in pain and to grade the pain's intensity. Results Seventy-nine nursing homes participated (22% response rate), and a total of 284 completed observer ratings were returned. The observed individuals suffered from moderate to severe dementia and were observed in everyday care situations. The average pain estimated by the caregivers was slight to moderate. Mainly anatomically based descriptors ("frowning," "narrowed eyes") and indicators of emotional arousal ("looking tense," looking frightened") significantly predicted the overall pain ratings by nurses, explaining approximately 45% of the variance. Conclusions Although all presented facial descriptors were used by the nurses, some descriptors were used clearly more frequently than others to infer whether a resident with dementia was in pain. Development of observational pain tools and training in their use should consider the preexisting assumptions that nurses use to infer pain as well as their potential bias.
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Affiliation(s)
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Sonja Pähl
- Physiological Psychology, Otto-Friedrich University, Bamberg, Germany
| | - Miriam Kunz
- Physiological Psychology, Otto-Friedrich University, Bamberg, Germany.,Gerontology Section, Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Naef R, Ernst J, Bürgi C, Petry H. Quality of acute care for persons with cognitive impairment and their families: A scoping review. Int J Nurs Stud 2018; 85:80-89. [PMID: 29859348 DOI: 10.1016/j.ijnurstu.2018.05.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND An increasing number of older persons with cognitive impairment use inpatient services for co-occurring acute illness. Research has demonstrated that persons with cognitive impairment face more adverse health outcomes during hospitalization than their age counterparts without cognitive impairment. As hospitals tend to be ill equipped to meet the complex care needs of this population, various initiatives underscore the need to better utilize existing evidence to improve quality of care. OBJECTIVES To map the extent of knowledge about quality of acute care in inpatient settings, and to synthesize knowledge on strategies to improve quality care for persons with cognitive impairment and their families. DESIGN A scoping review using Arksey and O'Malley's methodological framework. DATA SOURCES CINAHL and Medline were searched and reference lists of pertinent articles screened to identify publications regarding acute care for persons with cognitive impairment. REVIEW METHODS Two reviewers independently screened and identified publications based on eligibility criteria. Publications were included if they targeted acute care issues relating to persons with cognitive impairment 65 years or older, their family members, or health professionals caring for them, and were published after 2000 in English or German. Publications were read and data were extracted using a predefined template. Thematic analysis was conducted by two reviewers. RESULTS Of the 1445 identified publications, 66 were included. Quality of acute inpatient services pertained to structural (such as staff capacity and knowledge) and process dimensions (such as forming a caring relationship, assessing and intervening). Strategies identified to improve care quality included interventions at the point of care, such as specific tools and specialist roles to improve patient outcomes, as well as educational and training interventions to enable staff to care for this patient group. CONCLUSIONS There is a discrepancy between clearly defined best practice for persons with cognitive impairment utilising inpatient services, and the quality of care actually experienced by patients, family members, and staff. Research reveals a sobering picture of inadequate care and manifold challenges encountered by this patient group, family members and staff alike. Promising strategies to improve care quality target health professionals' knowledge and capacity to work with this group and include specific tools and models of care, such as specialist roles and units. Organisation-wide efforts to ensure quality care for this patient group are needed, as is further research to determine which implementation and intervention strategies achieve the most beneficial outcomes for all involved.
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Affiliation(s)
- Rahel Naef
- Centre of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland.
| | - Jutta Ernst
- Centre of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland
| | - Catherine Bürgi
- Division of Abdomen-Metabolism, University Hospital Zurich, Zurich, Switzerland
| | - Heidi Petry
- Centre of Clinical Nursing Science, University Hospital Zurich, Zurich, Switzerland
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Abstract
UNLABELLED ABSTRACTBackground:The ability of nursing staff to assess and evaluate behavioral and psychological symptoms of dementia (BPSD) to determine when intervention is needed is essential. In order to assist with the assessment process, the current use of the Neuropsychiatric Inventory Nursing Home version (NPI-NH) is internationally accepted. Even though the NPI-NH is thoroughly validated and has several advantages, there are also various challenges when implementing this system in practice. Thus, the aim of this study was to explore clinical reasoning employed by assistant nurses when utilizing the NPI-NH as a tool to assess frequency and severity of BPSD in individuals with advanced dementia. METHOD Twenty structured assessment sessions in which assistant nurses used the NPI-NH were audio recorded and analyzed with a discourse analysis focusing on the activities in the communication. RESULTS Four categories were identified to convey assistant nurses' clinical reasoning when assessing and evaluating BPSD using the NPI-NH: considering deteriorations in ability and awareness, incorporating individual and contextual factors, overcoming variations in behaviors and ambiguous formulations in the instrument, and sense-making interactions with colleagues. CONCLUSION The NPI-NH served as a supportive frame and structure for the clinical reasoning performed during the assessment. The clinical reasoning employed by assistant nurses became a way to reach a consensual and broader understanding of the individual with dementia, with the support of NPI-NH as an important framework.
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Tsai IP, Jeong SYS, Hunter S. Pain Assessment and Management for Older Patients with Dementia in Hospitals: An Integrative Literature Review. Pain Manag Nurs 2018; 19:54-71. [DOI: 10.1016/j.pmn.2017.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 08/18/2017] [Accepted: 10/02/2017] [Indexed: 01/01/2023]
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Handley M, Bunn F, Goodman C. Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review. BMJ Open 2017; 7:e015257. [PMID: 28713073 PMCID: PMC5541590 DOI: 10.1136/bmjopen-2016-015257] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia. DESIGN A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature. ELIGIBILITY CRITERIA Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded. RESULTS Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context-mechanism-outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress. CONCLUSIONS This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes. TRIAL REGISTRATION NUMBER CRD42015017562.
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Affiliation(s)
- Melanie Handley
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
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Closs SJ, Dowding D, Allcock N, Hulme C, Keady J, Sampson EL, Briggs M, Corbett A, Esterhuizen P, Holmes J, James K, Lasrado R, Long A, McGinnis E, O’Dwyer J, Swarbrick C, Lichtner V. Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- S José Closs
- School of Healthcare, University of Leeds, Leeds, UK
| | - Dawn Dowding
- School of Nursing, Columbia University, New York, NY, USA
- Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA
| | - Nick Allcock
- Clinical Specialist, Pain Management Solutions, Nottingham, UK
| | - Claire Hulme
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - John Keady
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Michelle Briggs
- School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
| | | | - John Holmes
- Leeds Institute of Medical Education, University of Leeds, Leeds, UK
| | - Kirstin James
- School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Reena Lasrado
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Andrew Long
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - John O’Dwyer
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Caroline Swarbrick
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
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Gregory J. Initial testing of a behavioural pain assessment tool within trauma units. Int J Orthop Trauma Nurs 2016; 24:3-11. [PMID: 27919714 DOI: 10.1016/j.ijotn.2016.08.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/18/2016] [Accepted: 08/31/2016] [Indexed: 10/21/2022]
Abstract
Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.
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Affiliation(s)
- Julie Gregory
- School of Nursing, Midwifery and Social Work, University of Manchester, Jean MacFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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Lichtner V, Dowding D, Allcock N, Keady J, Sampson EL, Briggs M, Corbett A, James K, Lasrado R, Swarbrick C, Closs SJ. The assessment and management of pain in patients with dementia in hospital settings: a multi-case exploratory study from a decision making perspective. BMC Health Serv Res 2016; 16:427. [PMID: 27553364 PMCID: PMC4995653 DOI: 10.1186/s12913-016-1690-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 08/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is often poorly managed in people who have a dementia. Little is known about how this patient population is managed in hospital, with research to date focused mainly on care homes. This study aimed to investigate how pain is recognised, assessed and managed in patients with dementia in a range of acute hospital wards, to inform the development of a decision support tool to improve pain management for this group. METHODS A qualitative, multi-site exploratory case study. Data were collected in four hospitals in England and Scotland. Methods included non-participant observations, audits of patient records, semi-structured interviews with staff and carers, and analysis of hospital ward documents. Thematic analysis was performed through the lens of decision making theory. RESULTS Staff generally relied on patients' self-report of pain. For patients with dementia, however, communication difficulties experienced because of their condition, the organisational context, and time frames of staff interactions, hindered patients' ability to provide staff with information about their pain experience. This potentially undermined the trials of medications used to provide pain relief to each patient and assessments of their responses to these treatments. Furthermore, given the multidisciplinary environment, a patient's communication about their pain involved several members of staff, each having to make sense of the patient's pain as in an 'overall picture'. Information about patients' pain, elicited in different ways, at different times and by different health care staff, was fragmented in paper-based documentation. Re-assembling the pieces to form a 'patient specific picture of the pain' required collective staff memory, 'mental computation' and time. CONCLUSIONS There is a need for an efficient method of eliciting and centralizing all pain-related information for patients with dementia, which is distributed in time and between personnel. Such a method should give an overall picture of a patient's pain which is rapidly accessible to all involved in their care. This would provide a much-needed basis for making decisions to support the effective management of the pain of older people with dementia in hospital.
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Affiliation(s)
| | - Dawn Dowding
- Columbia University School of Nursing, New York, NY 10032 USA
- Center for Home Care Policy and Research, Visiting Nursing Service of New York, New York, NY USA
| | - Nick Allcock
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - John Keady
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michelle Briggs
- Centre for Pain Research, Leeds Beckett University, Leeds, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King’s College London, London, UK
| | - Kirstin James
- School of Health, Nursing and Midwifery, University of the West of Scotland, Paisley, UK
| | - Reena Lasrado
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Caroline Swarbrick
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - S. José Closs
- School of Healthcare, University of Leeds, Leeds, UK
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Hanson E, Hellström A, Sandvide Å, Jackson GA, MacRae R, Waugh A, Abreu W, Tolson D. The extended palliative phase of dementia – An integrative literature review. DEMENTIA 2016; 18:108-134. [PMID: 27460046 DOI: 10.1177/1471301216659797] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.
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Affiliation(s)
- Elizabeth Hanson
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Amanda Hellström
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
| | - Åsa Sandvide
- The Swedish Family Care Competence Centre, Linnaeus University, Sweden
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Lichtner V, Dowding D, Closs SJ. The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia. BMC Med Inform Decis Mak 2015; 15:111. [PMID: 26703244 PMCID: PMC4690343 DOI: 10.1186/s12911-015-0233-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/15/2015] [Indexed: 11/16/2022] Open
Abstract
Background Assessment and management of pain in patients with dementia is known to be challenging, due to patients’ cognitive and/or communication difficulties. In the UK, pain in hospital is managed through regular assessments, with the use of pain intensity scores as triggers for action. The aim of this study was to understand current pain assessment practices, in order to later inform the development of a decision support tool designed to improve the management of pain for people with dementia in hospital. Methods An exploratory study was conducted in four hospitals in the UK (11 wards), with observations of patients with dementia (n = 31), interviews of staff (n = 52) and patients’ family members (n = 4) and documentary analysis. A thematic analysis was carried out, structured along dimensions of decision making. This paper focuses on the emergent themes related to the use of assessment tools and pain intensity scores. Results A variety of tools were used to record pain intensity, usually with numerical scales. None of the tools in actual use had been specifically designed for patients with cognitive impairment. With patients with more severe dementia, the patient’s body language and other cues were studied to infer pain intensity and then a score entered on behalf of the patient. Information regarding the temporality of pain and changes in pain experience (rather than a score at a single point in time) seemed to be most useful to the assessment of pain. Conclusions Given the inherent uncertainty of the meaning of pain scores for patients with dementia, numerical scales were used with caution. Numerical scores triggered action but their meaning was relative - to the patient, to the clinician, to the time of recording and to the purpose of documenting. There are implications for use of data and computerized decision support systems design. Decision support interventions should include personalized alerting cut-off scores for individual patients, display pain scores over time and integrate professional narratives, mitigating uncertainties around single pain scores for patients with dementia. Electronic supplementary material The online version of this article (doi:10.1186/s12911-015-0233-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Dawn Dowding
- Columbia University School of Nursing, New York, NY, USA. .,Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York, NY, USA.
| | - S José Closs
- School of Healthcare, University of Leeds, Leeds, UK.
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