Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

Registered nurses' knowledge, attitudes and practices of pain management for aged care residents with dementia: an integrative review

AIM

To assess the knowledge, attitudes and practices of Registered Nurses working in residential aged care facilities pertaining to pain management for residents living with dementia.

BACKGROUND

Sub-optimal pain management continues for people living with dementia in residential aged care. Registered Nurses are the pivotal staff responsible for complex assessment and management of people residing in residential aged care facilities.

DESIGN AND METHODS

:This integrative literature review was informed by Whittemore (2005). Searching and screening followed the PRISMA guidelines.

RESULTS

Thirteen papers were identified, the major themes identified were gaps in knowledge and skills, uncertainty of assessment, and delays in treatment.

CONCLUSION

Registered Nurses require education on pain management for people living with dementia in residential aged care. Broader issues in residential aged care contribute to the problem and require examination. Research pertaining to Registered Nurses' roles pain management for residents living with dementia is required.

Hospital nurses perceived challenges and opportunities in the care of people with dementia: A mixed-methods systematic review

AIM

To synthesise evidence from the literature on hospital nurses' perceived challenges and opportunities in the care of people with dementia.

BACKGROUND

People with dementia often have longer lengths of hospital stay and poorer health outcomes compared to those without dementia. Nurses play a pivotal role in the care of people with dementia. However, there is a scarcity of systematic reviews that synthesise the challenges and opportunities they perceive.

METHODS

A mixed-methods systematic review was conducted with a database search covering Ageline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Emcare, Embase, Medline, PsycINFO, ProQuest, Scopus and Web of Science in April 2022. In total, 27 articles that met the selection criteria were critically reviewed and included in this systematic review. Data from the selected articles were extracted and synthesised using a convergent segregated approach.

RESULTS

Three main themes and eight subthemes were identified. Theme 1 described nurse-related factors consisting of the lack of capability in dementia care, experiencing multiple sources of stress and opportunities for nurses to improve dementia care. Theme 2 revealed people living with dementia-related factors including complex care needs and the need to engage family carers in care. Theme 3 explained organisation-related factors comprising the lack of organisational support for nurses and people with dementia and opportunities for quality dementia care.

CONCLUSION

Hospital nurses experience multidimensional challenges in the care of people with dementia. Opportunities to overcome those challenges include organisational support for nurses to develop dementia care capability, reduce their stress and partner with the family caregivers.

RELEVANCE TO CLINICAL PRACTICE

Hospitals will need to build an enabling environment for nurses to develop their capabilities in the care of people with dementia. Further research in empowering nurses and facilitating quality dementia care in acute care hospitals is needed.

REPORTING METHOD

The review followed the PRISMA 2020 checklist.

PATIENT OR PUBLIC CONTRIBUTION

No.

Aspiration pneumonia in nursing literature-a mapping review

Introduction

Aspiration pneumonia (AP) is an infection of the lungs caused by inhalation of material. The reported incidences vary across literature and clinical populations and is associated with high morbidity and mortality. Management of AP is best carried out by a multidisciplinary team.

Methods

This aim of this review was to collate and describe the available evidence on AP to develop a greater understanding of the concept of AP as it is represented in the nursing literature. As a collaborative team, we undertook the six stages of a systematic mapping review. We searched for the term aspiration pneumonia in 200 peer reviewed nursing journals across 10 databases, over a ten-year period (2013-2023).

Results

In this review, 293 papers were coded. Dysphagia, oral health and tube feeding emerged as the most frequent risk factors for AP, and the most reported factors for preventing this condition. Mortality was the most commonly described consequence of AP, followed by hospitalisations and morbidity. Multiple management approaches were reported including dysphagia assessment, risk evaluation, oral care and texture modification of food and fluids. The role of nurses and interprofessional collaborations were described.

Discussion

Despite limited evidence related to the topic of AP in the nursing literature, the complexity of the causes, prevention, management and consequences of AP emerged. Certain factors, such as dysphagia, oral health, and tube feeding, were described under prevention, cause and management of AP. The importance of multidisciplinary approach in the management and prevention of AP was presented.

Challenges in recognizing and discussing changes in a resident's condition in the palliative phase: focus group discussions with nursing staff working in nursing homes about their experiences

BACKGROUND

Most nursing home residents have complex care needs, require palliative care and eventually die in these facilities. Timely recognition of changes in a resident's condition is crucial for providing appropriate care. Observations by nursing staff play a significant role in identifying and interpreting these changes.

METHODS

Focus group discussions were conducted with nursing staff from ten nursing homes in the Netherlands to explore their experiences and challenges in recognizing and discussing changes in a resident's condition. These discussions were analysed following the principles of thematic analysis.

RESULTS

The analysis of the challenges nursing staff face in identifying and interpreting changes in a resident's condition, resulted in three themes. First, that recognizing changes is considered complex, because it requires specialized knowledge and skills that is generally not part of their education and must partly be learned in practice. This also depends on how familiar the nursing staff is with the resident. Furthermore, different people observe residents through different lenses, depending on their relation and experiences with residents. This could lead to disagreements about the resident's condition. Lastly, organizational structures such as the resources available to document and discuss a resident's condition and the hierarchy between nursing home professionals often hindered discussions and sharing observations.

CONCLUSION

Nursing staff's experiences highlight the complexity of recognizing and discussing changes in nursing home residents' conditions. While supporting the observational skills of nursing staff is important, it is not enough to improve the quality of care for nursing home residents with palliative care needs. As nursing staff experiences challenges at different, interrelated levels, improving the process of recognizing and discussing changes in nursing home residents requires an integrated approach in which the organization strengthens the position of nursing staff. It is important that their observations become a valued and integrated and part of nursing home care.

Advanced practice nurses' evidence-based healthcare competence and associated factors: A systematic review

BACKGROUND

Evidence-based healthcare (EBHC) enables consistent and effective healthcare that prioritises patient safety. The competencies of advanced practice nurses (APNs) are essential for implementing EBHC because their professional duties include promoting EBHC.

AIM

To identify, critically appraise, and synthesise the best available evidence concerning the EBHC competence of APNs and associated factors.

DESIGN

A systematic review.

DATA SOURCES

CINAHL, PubMed, Scopus, Medic, ProQuest, and MedNar.

METHODS

Databases were searched for studies (until 19 September 2023) that examined the EBHC competence and associated factors of APNs were included. Quantitative studies published in English, Swedish and Finnish were included. We followed the JBI methodology for systematic review and performed a narrative synthesis.

RESULTS

The review included 12 quantitative studies, using 15 different instruments, and involved 3163 participants. The quality of the studies was fair. The APNs' EBHC competence areas were categorised into five segments according to the JBI EBHC model. The strongest areas of competencies were in global health as a goal, transferring and implementing evidence, while the weakest were generating and synthesising evidence. Evidence on factors influencing APNs' EBHC competencies was contradictory, but higher levels of education and the presence of an organisational research council may be positively associated with APNs' EBHC competencies.

CONCLUSION

The development of EBHC competencies for APNs should prioritise evidence generation and synthesis. Elevating the education level of APNs and establishing a Research Council within the organisation can potentially enhance the EBHC competence of APNs.

IMPLICATIONS FOR THE PROFESSION

We should consider weaknesses in EBHC competence when developing education and practical exercises for APNs. This approach will promote the development of APNs' EBHC competence and EBHC implementation in nursing practice.

REGISTRATION, AND REPORTING CHECKLIST

The review was registered in PROSPERO (CRD42021226578), and reporting followed the PRISMA checklist.

PATIENT/PUBLIC CONTRIBUTION

None.

End-of-Life Care of Persons with Alzheimer's Disease and Other Dementias

End-of-life (EOL) care has been a common option for patients with terminal medical conditions such as cancers. However, the utilization of EOL care in Alzheimer disease and other dementing conditions have become available relatively recently. As the end-stage dementia approaches, the clinicians and caregivers become faced with numerous clinical challenges-delirium, neuropbehavioral symptoms, the patient's inability to communicate pain and associated discomfort, food refusal, and so on. In addition to providing quality clinical care to the EOL patients, clinicians should pay special attention to their families, assuring that their loved ones will receive supportive measures to improve quality of life (QOL).

Assessment of pain management among nurses using the knowledge and attitude survey regarding pain tool

BACKGROUND

The prevalence of pain among cancer patients vary in the cancer trajectory and nurses will encounter patients with cancers who may experience pain. Nurses routinely need to assess and manage pain to deliver quality care.

AIM AND METHOD

The study aims to understand the knowledge and attitudes of nurses towards pain management using the self-administered questionnaire-the Knowledge and Attitude Survey Regarding Pain (KASRP).

FINDINGS

Some 80 nurses participated in the study with an average overall KASRP score of 56%. Areas that were poorly answered are related to the knowledge about opioids, assessment of pain and management of pain in different scenarios. Factors like nurse-patient relationships and being unfamiliar with opioids may affect the knowledge and attitude of nurses towards pain management.

CONCLUSION

Curriculum on pain management needs to consider strategies to help nurses translate knowledge to bedside clinical teaching. It needs to include facts of pain management, and topics regarding self-awareness and clarifying misconceptions.

Effects of specialized nursing intervention based on quantitative assessment strategy on psychological state and quality of life of patients with senile dementia

OBJECTIVES

To explore the effects of specialized nursing intervention based on quantitative evaluation strategy on the psychological state and quality of life of senile dementia patients.

METHODS

92 senile dementia patients were divided into the control and intervention groups (n = 46 each). Control group was given routine nursing intervention, while intervention group was given specialized nursing intervention based on the quantitative evaluation strategy. Patients' self-care ability, cognitive function, nursing compliance, psychological state, quality of life, and patient satisfaction indexes were measured.

RESULTS

After nursing interventions, the self-care ability (71.73 ± 4.31 vs 63.82 ± 3.97 points) and cognitive functions such as orientation (7.96 ± 1.02 vs 6.53 ± 1.15), memory (2.16 ± 0.39 vs 1.69 ± 0.31), visual-spatial copying (3.78 ± 0.53 vs 3.02 ± 0.65), language skills (7.49 ± 1.26 vs 6.05 ± 1.28), and recall ability (2.13 ± 0.26 vs 1.75 ± 0.28) were significantly improved in the intervention group compared to the control group (P ˂ 0.05). The patient's compliance in the intervention group (95.65%) was prominently higher than the control group (80.43%) (P < 0.05). Notably, patient's psychological state (anxiety and depression) in the intervention group (47.42 ± 3.12 vs 51.39 ± 3.16, 48.52 ± 2.51 vs 52.83 ± 2.49) was better than the control group (P < 0.05). Furthermore, the quality of life was significantly improved in the intervention group (88.11 ± 1.11 vs 71.52 ± 1.24) compared to the control group (P < 0.05). Also, patients' satisfaction with nursing services in the intervention group (97.83%) was higher than the control group (78.26%) (P < 0.05).

CONCLUSIONS

Specialized nursing intervention based on quantitative evaluation strategy can effectively improve patients' self-care ability, and cognitive function, reduce anxiety and depression and enhance the quality of life, which is worthy of clinical promotion and application.

Nursing Practice Variations in Pain Management in Older Adults With Dementia Admitted to an Acute Geriatrics Unit During the COVID-19 Pandemic

The current retrospective descriptive study evaluated nursing practice variations on pain management in older adults with dementia admitted to an acute geriatrics unit (AGU) before (2018) and during (2021) the coronavirus disease 2019 (COVID-19) pandemic. Data were gathered from electronic health records. Pain intensity was evaluated a median of 1.9 times per day of stay in the pre-COVID-19 sample, whereas in the COVID-19 sample, the median was 0.7 times per day of stay. Median number of analgesic administrations per day of stay and mean percentage of clinical care records that mentioned pain were higher in patients admitted during the pandemic. Variations in nursing care organization in the AGU due to the COVID-19 pandemic had an impact on the patterns of pain management nursing practice in older adults with dementia. [Research in Gerontological Nursing, 16(4), 173-182.].

The Good Life: From Birth to Death

Nurses are almost always present at birth and at death. The aim was to describe the similarities in nursing care between birthing and end-of-life patients under a humanistic and holistic caring perspective, focusing on pain management, anxiety and stress reduction, self-care and empowerment, and emotional and family support.

A Systematic Review of Barriers and Facilitators of Pain Management in Persons with Dementia

Approximately 50% of persons living with dementia experience pain, yet it is frequently undetected and inadequately managed resulting in adverse consequences. This review aims to synthesize evidence on the barriers and facilitators of pain management in persons living with dementia. PubMed, CINAHL, PsycINFO, and Web of Science datasets were used for article searching. Inclusion criteria were peer-reviewed original articles written in English that examined the barriers and facilitators of pain management for persons living with dementia. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies. A total of 26 studies were selected, including 18 qualitative and 3 quantitative (all high quality), as well as 5 mixed methods studies (low-to-high quality). Results were categorized into intrapersonal, interpersonal, environmental, and policy categories. Factors that impact pain management in dementia include cognitive and functional impairment, healthcare workers' knowledge, collaboration and communication, healthcare workers' understanding of patients' baseline behaviors, observation of behaviors, pain assessment tool use, pain management consistency, staffing level, pain guideline/policy, and training. Overall, pain management is challenging in persons living with dementia. The results indicate that there is a need for multi-component interventions that involves multidisciplinary teams to improve pain management in persons living with dementia at the intrapersonal, interpersonal, environmental, and policy levels. PERSPECTIVES: This review systematically synthesized barriers and facilitators of providing pain management in persons living with dementia. Results were presented in intrapersonal, interpersonal, environmental, and policy categories and suggests that multicomponent interventions involving multidisciplinary teams are needed to systematically improve pain management in persons living with dementia.

Process of pain assessment in people with dementia living in nursing homes: a scoping review protocol

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/.

Quality of dying among elderly people diagnosed with dementia in nursing homes: A mixed methods study

WHAT IS KNOWN ON THE SUBJECT

Nurses working at nursing homes can play a pivotal role in mental health as a high proportion of residents diagnosed with dementia are in these facilities. Many institutionalized residents diagnosed with dementia develop clinical complications and symptoms that reduce the quality of dying. A mixed-methods approach can help nurses with the difficult task of assessing the quality of dying among these residents and identify inconsistencies that cannot be found using scales alone, but no studies were found in this topic.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Through the Quality of dying in Long-Term Care Scale (QoD-LTC), nurses described symptom management, quality of care, and end-of-life appearance as adequate and end-of-life communication as lacking. Generally speaking, the scores on the scale were consistent with the data from semi-structured interviews conducted with nurses. In the semi-structured interviews, some of the concepts on the scale, including 'dignity', 'holistic' care, 'good relationships with healthcare professionals', and 'a peaceful death', are complex and not fully incorporated into nurses' practice in nursing homes when assessing residents diagnosed with dementia. This could be improved by using the SENSES Model or person-centred care frameworks. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is evidence of shortcomings among professionals in the correct use of concepts linked to psychological wellbeing, communication, therapeutic relationship, safety and participation, preservation of dignity, decision-making, and resident autonomy, which can be addressed using specific theoretical approaches developed in the field of mental health nursing.

ABSTRACT

Introduction The complex nature of end-of-life assessment of individuals diagnosed with dementia would benefit from a mixed-methods approach that simultaneously assess the perception and response of nurses to standardized tools. Aim/Question To examine nursing professionals' perceptions of the quality of dying among residents diagnosed with dementia using the Quality of Dying in Long-Term Care settings (QoD-LTC) questionnaire and to identify consistencies and inconsistencies in their narratives. Method Mixed-methods study using concurrent triangulation with data integration for results and interpretation. Nurses from eight nursing homes assessed 117 residents diagnosed with dementia who died in the previous 3 months using the QoD-LTC scale. After informed consent was obtained (nurses/caregivers), 17 semi-structured scale-based interviews were conducted. Results Symptom management, quality of care, and end-of-life appearance were found to be adequate, while end-of-life communication was deemed insufficient. The qualitative and quantitative data were consistent for most of the items on the QoD-LTC. Discussion Concepts such as dignity, holistic care, good relationships, and peaceful death are complex and not fully incorporated into professional practice. Implications for Practice The results highlight the need for greater involvement of mental health nurses as well as improved communication, training, and specific tools tailored to residents diagnosed with dementia.

Algorithm-based pain management for people with dementia in nursing homes

BACKGROUND

People with dementia in nursing homes often experience pain, but often do not receive adequate pain therapy. The experience of pain has a significant impact on quality of life in people with dementia, and is associated with negative health outcomes. Untreated pain is also considered to be one of the causes of challenging behaviour, such as agitation or aggression, in this population. One approach to reducing pain in people with dementia in nursing homes is an algorithm-based pain management strategy, i.e. the use of a structured protocol that involves pain assessment and a series of predefined treatment steps consisting of various non-pharmacological and pharmacological pain management interventions.

OBJECTIVES

To assess the effects of algorithm-based pain management interventions to reduce pain and challenging behaviour in people with dementia living in nursing homes. To describe the components of the interventions and the content of the algorithms.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science Core Collection (ISI Web of Science), LILACS (Latin American and Caribbean Health Science Information database), ClinicalTrials.gov and the World Health Organization's meta-register the International Clinical Trials Registry Portal on 30 June 2021.

SELECTION CRITERIA

We included randomised controlled trials investigating the effects of algorithm-based pain management interventions for people with dementia living in nursing homes. All interventions had to include an initial pain assessment, a treatment algorithm (a treatment plan consisting of at least two different non-pharmacological or pharmacological treatment steps to reduce pain), and criteria to assess the success of each treatment step. The control groups could receive usual care or an active control intervention. Primary outcomes for this review were pain-related outcomes, e.g. the number of participants with pain (self- or proxy-rated), challenging behaviour (we used a broad definition that could also include agitation or behavioural and psychological symptoms assessed with any validated instrument), and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the articles for inclusion, extracted data and assessed the risk of bias of all included studies. We reported results narratively as there were too few studies for a meta-analysis. We used GRADE methods to rate the certainty of the results.

MAIN RESULTS

We included three cluster-randomised controlled trials with a total of 808 participants (mean age 82 to 89 years). In two studies, participants had severe cognitive impairment and in one study mild to moderate impairment. The algorithms used in the studies varied in the number of treatment steps. The comparator was pain education for nursing staff in two studies and usual care in one study. We judged the risk of detection bias to be high in one study. The risk of selection bias and performance bias was unclear in all studies. Self-rated pain (i.e. pain rated by participants themselves) was reported in two studies. In one study, all residents in the nursing homes were included, but fewer than half of the participants experienced pain at baseline, and the mean values of self-rated and proxy-rated pain at baseline and follow-up in both study groups were below the threshold of pain that may require treatment. We considered the evidence from this study to be very low-certainty and therefore are uncertain whether the algorithm-based pain management intervention had an effect on self-rated pain intensity compared with pain education (MD -0.27, 95% CI -0.49 to -0.05, 170 participants; Verbal Descriptor Scale, range 0 to 3). In the other study, all participants had mild to moderate pain at baseline. Here, we found low-certainty evidence that an algorithm-based pain management intervention may have little to no effect on self-rated pain intensity compared with pain education (MD 0.4, 95% CI -0.58 to 1.38, 246 participants; Iowa Pain Thermometer, range 0 to 12). Pain was rated by proxy in all three studies. Again, we considered the evidence from the study in which mean pain scores indicated no pain, or almost no pain, at baseline to be very low-certainty and were uncertain whether the algorithm-based pain management intervention had an effect on proxy-rated pain intensity compared with pain education. For participants with mild to moderate pain at baseline, we found low-certainty evidence that an algorithm-based pain management intervention may reduce proxy-rated pain intensity in comparison with usual care (MD -1.49, 95% CI -2.11 to -0.87, 1 study, 128 participants; Pain Assessment in Advanced Dementia Scale-Chinese version, range 0 to 10), but may not be more effective than pain education (MD -0.2, 95% CI -0.79 to 0.39, 1 study, 383 participants; Iowa Pain Thermometer, range 0 to 12). For challenging behaviour, we found very low-certainty evidence from one study in which mean pain scores indicated no pain, or almost no pain, at baseline. We were uncertain whether the algorithm-based pain management intervention had any more effect than education for nursing staff on challenging behaviour of participants (MD -0.21, 95% CI -1.88 to 1.46, 1 study, 170 participants; Cohen-Mansfield Agitation Inventory-Chinese version, range 7 to 203). None of the studies systematically assessed adverse effects or serious adverse effects and no study reported information about the occurrence of any adverse effect. None of the studies assessed any of the other outcomes of this review.

AUTHORS' CONCLUSIONS

There is no clear evidence for a benefit of an algorithm-based pain management intervention in comparison with pain education for reducing pain intensity or challenging behaviour in people with dementia in nursing homes. We found that the intervention may reduce proxy-rated pain compared with usual care. However, the certainty of evidence is low because of the small number of studies, small sample sizes, methodological limitations, and the clinical heterogeneity of the study populations (e.g. pain level and cognitive status). The results should be interpreted with caution. Future studies should also focus on the implementation of algorithms and their impact in clinical practice.

What Intern Nursing Students in Turkey Think About Death and End-of-Life Care? A Qualitative Exploration

This descriptive qualitative study was planned to determine the views of intern nursing students about death and end-of-life care. The study was completed with 12 intern students based on the criterion of data saturation. As a result of the study, the categories of 'end,' 'uncertainty,' 'fear,' 'beginning,' 'helplessness' under the theme of death, 'ensuring peace,' 'continuing communication' 'providing psychosocial/spiritual support,' 'acting in conformity with principles of ethics/morality,' 'continuing to provide physical care,' 'supporting the family,' 'making the best use of the limited remaining time or helping the patient's last wishes come true' under the theme of end-of-life care emerged.

Impact of settings and culture on nurses' knowledge of and attitudes and perceptions towards people with dementia: An integrative literature review

BACKGROUND

Well-trained nurses are required to support dementia patients; however, the quality of the provided dementia nursing care can be impacted by nurses' knowledge, attitudes and perceptions towards people with dementia.

AIM

To obtain an overview of the current nursing practice towards people with dementia around the world.

DESIGN

An integrated literature review was conducted based on Whittemore and Knafl's method.

RESULTS

A total of 72 articles met the inclusion criteria. Three main themes were identified: (1) nurses' knowledge, attitudes and perceptions towards dementia; (2) nursing experience of caring for people with dementia in acute and community care settings; and (3) dementia nursing care across health regions.

CONCLUSION

Nurses play the role of facilitators in the efficient delivery of quality care for dementia patients. A variety of attitudes and perceptions towards people with dementia were found to be triggered by the severity of dementia, religion, ethnicity and gender.

IMPLICATIONS FOR PRACTICE

Healthcare organisations and educational settings need to coordinate and function together to improve nurses' knowledge and encourage positive attitudes towards people with dementia.

The Human Rights of Older People With Mental Health Conditions and Psychosocial Disability to a Good Death and Dying Well

The human right to a good death and dying well is as important as the right to life. At stake at the end of life are human rights to dignity, autonomy, self-determination and respect for will and preferences, equitable access to quality health care that is needs-based, and respect for family and relationships. Older people with dementia, those with serious mental illness, and those with intellectual disability are vulnerable to "bad deaths" due to violations of these rights. In this paper we explore why this is so and examine existing and potential solutions. A human rights-approach to end-of-life care and policy for older persons with mental health conditions and psychosocial disability is one that is needs-based, encompassing physical and mental health, palliative care, social, and spiritual support services provided in the context of inclusive living. Most importantly, end of life care must be self-determined, and not "one size fits all." An important remedy to existing violations is to strengthen human rights frameworks to cater specifically to older persons' needs with a UN convention on the rights of older persons. Finally, as health professionals we have important contributions to make at the coalface by accepting our responsibilities in the area of death and dying. With the concept of the palliative psychiatrist gaining traction and recognition that death is our business, we add that human rights is also our business.

Optimising Medication Use along Dementia Progression: Recommendations from a Qualitative Study

Medicines management is known to be an integral part of the role of family caregivers; it also contributes to the burden and stress of caregivers’ experience. As dementia progresses, new challenges arise as a consequence, which negatively affects the ability of people living with dementia (PLWD) regarding practical decision making and may lead to a change of setting. The aim of this study is to identify and explore changes in medicines management and associated caregiver burden as dementia progresses. To examine medicines management and related issues across severities, a qualitative approach utilising face-to-face and telephone interviews with PLWD and their family caregivers in both the community and care-home setting in London was used. Follow-up interviews with family caregivers were also conducted to gain additional insight into change over time. Eleven family caregivers, ten PLWD, and eight care-home staff were interviewed in 2016. Findings identified how key changes along dementia progression affect medication use. These include changes to caregiver burden, respecting the PLWD’s autonomy and decline in capacity, scheduling and administration, choice of formulation, interactions with and between providers, and information needs. The findings assist in informing recommendations to optimise medication use and alleviate caregiver burden.

"A good death but there was all this tension around"- perspectives of residential managers on the experience of delivering end of life care for people living with dementia

BACKGROUND

End of life care for residents with advanced dementia in the aged care setting is complex. There is prolonged and progressive cognitive decline, uncertain disease trajectory, significant symptom burden and infrequent access to specialist palliative care. Residential aged care managers offer a unique perspective in understanding the experience of providing end of life care for residents with advanced dementia. They bring insight from the coalface to the broader policy context. The aim of this study was to describe the experience and perspectives of residential aged care managers on providing end of life care for residents living with dementia.

METHODS

Focus groups and semi-structured interviews were conducted with residential or care managers from various care homes from one dementia specific aged care organisation in Australia. A comprehensive sampling strategy was used in participating care homes. Transcripts were analysed using thematic analysis.

RESULTS

20 residential or care managers from 11 aged care homes in two states of Australia participated in two focus groups (total 16 participants) or individual interviews (4 participants). Six themes were identified: laying the ground work to establish what families understand about dementia, playing the peacemaker in the face of unrealistic family demands and expectations, chipping away at denial and cultivating a path towards acceptance of death, recruiting general practitioners as allies, supporting and strengthening the front line, and dedication to optimal care is relentless but rewarding.

CONCLUSION

Aged care manager participants described provision of end of life dementia care as a rewarding but sometimes fraught experience requiring persistent personalisation of care and communication to enable family acceptance of the resident's terminal condition. The findings suggest that continuous front line aged care staff skill development, iterative family discussions, and partnership building between aged care staff and general practitioners, are all required to promote optimal end of life dementia care in residential aged care settings.

Pain management nursing practice assessment in older adults with dementia

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.

Nursing care toward older adults with dementia: An integrative review

BACKGROUND

Dementia among older adults is receiving increase attention due to its neurodegenerative pathologies and poses a significant challenge for healthcare services systems. Caring for older adults with dementia is frequently challenging. This integrative review appraised and synthesised the existing literature describing the nursing care given to older adults with dementia.

METHODS

An integrative review was used using six electronic databases (CINAHL, Medline, Science direct-Elsevier, Proquest, Pubmed and Web of Science). The search terms that were included in various combinations using mesh terms were as follows: nurse* OR nursing staff* AND caring OR care OR caring behavior OR affectionate OR compassionate AND older person* OR aging* OR elder* OR geriatric patient* OR older adult* OR gerontology* OR aged* OR old age. A standardised review by Kmet et al. instrument was utilised for appraising the quality of selected 13 articles.

RESULTS

The results were presented based on the two major themes: challenges in providing care and identifying and managing older adults' difficult behaviours.

CONCLUSION

The findings of an integrative review can be used as a foundation for formulating recommendations for how dementia care by nurses can be improved and highlighting where policy development and further research are needed.

Understanding Nurses' Knowledge and Attitudes Toward Pain Assessment in Dementia: A Literature Review

BACKGROUND

Pain is underrecognized and undertreated in patients with dementia. It has been suggested that nurses' attitudinal barriers may contribute to the challenges surrounding pain assessment and management in dementia.

AIMS

This integrative literature review aims to identify and explore nurses' knowledge and attitudes towards pain assessment in older people with dementia and how it may affect pain management in this patient group.

METHOD

Electronic searches were conducted in Web of Science, MEDLINE, Scopus, ProQuest, PubMed, and EBSCOhost from January 2008 to December 2018 for articles specifically focusing on nurses' knowledge and attitudes towards pain assessment in older patients with dementia.

RESULTS

Ten studies were included in the review after meeting the inclusion criteria. Data extracted from each study included study design, aims and objectives, setting/sample, findings, and limitations. Patients with dementia are at greater risk of experiencing underassessment, undertreatment, and delayed treatment of pain due to nurses' knowledge deficits and uncertainty in the decision-making process. Nurses see providing comfort and reducing pain as ethical obligation. However, they find pain assessment a challenge due to the complexity of recognizing painful behaviors, and difficulty differentiating between pain and behavioral disturbances in dementia. Poor multidisciplinary communication, time constraints, and workload pressure, as well as uncertainty about opioid use, are important barriers to effective pain assessment and management among patients with dementia.

CONCLUSION

It is essential that nurses gain confidence in distinguishing signs and symptoms of pain from behavioral changes in dementia. It is important to improve interdisciplinary communication and to get physicians to listen and prioritize pain assessment and management.

Sex-specific Differences in Multisite Pain Presentation among Adults with Lower-Limb Loss

OBJECTIVES

Multisite pain remains significantly understudied following lower-limb loss (LLL), especially among females. This study aimed to explore sex-specific differences in the presentation of multisite pain post LLL. Hypotheses were multisite pain would be more prevalent among females post LLL as compared with males, and female sex would be significantly associated with multisite pain prevalence.

METHODS

In this cross-sectional study, participants answered standardized questions regarding the presence of amputation-specific (ie, phantom-limb, residual-limb) and secondary (ie, contralateral-limb, low-back) pain. Multisite pain was defined as pain in ≥ 2 locations. Sex-specific differences in pain prevalence were evaluated using chi-square tests (P ≤ 0.050). Using logistic regression, the association between sex and multisite pain was examined after controlling for covariates (age, body mass index, time since amputation, amputation etiology and level).

RESULTS

The sample included 303 adults (33% females) ≥ 1 year post unilateral LLL. More females than males reported pain in the residual limb (53.0% vs. 38.4%), low back (56.0% vs. 39.9%), contralateral knee (37.0% vs. 24.1%), and contralateral hip (25.0% vs. 12.3%; P < 0.050). More females than males were classified as having multisite pain (72.0% vs. 54.7%; P = 0.004). While patterns of multisite pain were similar (ie, pain affected both amputation-specific and secondary sites) between sexes, being female was independently associated with higher odds of having multisite pain (odds ratio: 2.40, 95% confidence interval: 1.40 to 4.12).

DISCUSSION

Female sex appears to be associated with multisite pain ≥ 1 year after LLL. Future work is needed to identify mechanisms underlying sex-specific differences in pain presentation and evaluate the impact of sex on pain-related outcomes post amputation.

The effectiveness of interventions to improve pain assessment and management in people living with dementia: A systematic review and meta-analyses

AIMS

To synthesize and evaluate the effectiveness of interventions for nurses to improve the assessment and management of pain in people living with dementia.

DESIGN

Systematic review and meta-analyses of randomized controlled trials.

DATA SOURCES

CINAHL, Joanna Briggs Institute (JBI) EBP, Cochrane Library, PubMed, and Scopus databases were searched for all journal articles published between 2009 -2019.

REVIEW METHODS

Papers were included under population intervention comparator outcome (PICO) framework for: (a) people living with dementia aged 65 years and over; (b) interventions developed for nurses or other health professionals; (c) comparison group of standard care or control; and (d) outcome that measures the intervention effects on nurses and people living with dementia. Independent reviewers undertook critical appraisal, data abstraction, and synthesis. Meta-analyses were performed to determine the effectiveness of interventions.

RESULTS

Of 2099 titles and abstracts screened, six interventions with low-to-moderate risk of bias met inclusion criteria. Studies that implemented a routine pain assessment tool showed no effect on nurses' analgesic management. Studies that developed a comprehensive pain model involving multidisciplinary health professionals showed overall effects on pain assessment and management in dementia care. Physician involvement had an impact on analgesic management.

CONCLUSION

Comprehensive pain models improve nurses' pain assessment and management. A lack of balance between analgesia use and non-pharmacological pain management in dementia care is evident. Multidisciplinary health professionals' involvement is essential for effective intervention design for pain management in dementia.

IMPACT

Various pain assessment tools have been considered to assist identification and management of pain in people living with dementia. Nevertheless, challenges exist when caring for people living with dementia in pain. These findings support the development of a comprehensive pain model, which may be a more effective strategy than routine use of a pain tool alone for nurses to improve pain management in dementia care.

Nurses' needs when collaborating with other healthcare professionals in palliative dementia care

Adequate interprofessional collaboration is essential to provide high quality palliative dementia care across different settings. Within interprofessional collaboration, nurses are the frontline healthcare professionals (HCPs), who interact closely with people with dementia, their loved ones, and other HCPs. A survey was conducted to explore the needs of nurses regarding interprofessional collaboration in home care (HC) organisations, nursing homes (NHs) and during NH admissions. The survey identified the perceived quality of and preferred needs regarding interprofessional collaboration. In total, 384 participants (53.9% home care nurses) completed the survey. The most frequently reported collaboration needs in HC organisations and NH were optimal communication content e.g. information transfer and short communication lines (being able to easily contact other disciplines), and coordination e.g. one contact person, and clear task division and responsibilities). During NH admissions, it was important to create transparency about agreements concerning end-of-life wishes, optimize nurse-to-nurse handover during NH admissions (through performing visits prior to admissions, and receiving practical information on how to guide relatives), and improve coordination (e.g. one contact person). In conclusion, the key collaboration needs were organising central coordination, establishing optimal communication, and creating transparency on end-of-life care agreements.

Facilitators, Barriers, and Solutions in Pain Management for Older Adults with Dementia

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.

Nurses' experiences of pain management in end-of-life dementia care: a literature review

BACKGROUND

Nurses play an important role in assessing and managing pain. However, this is often poorly managed for people living with dementia.

AIM

To explore nurses' experiences of pain management in end-of-life dementia care.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic narrative review of research papers published in English between 2008 and 2018 was conducted. Data sources were CINAHL, Medline, PsycINFO, ScienceDirect and SocIndex. Articles focused on nursing at the end of life and pain management in people with dementia.

FINDINGS

Eight articles were retrieved that met the search criteria. Four studies used qualitative methodology, two quantitative and two mixed methods. Studies from the UK dominated (n=5), the remainder were from Sweden, Norway and the US. Following thematic analysis, three themes were identified: training and education in pain management at the end of life for people with dementia, challenges in identifying pain and pain assessment tool use.

CONCLUSION

The review revealed inadequate education for nurses concerning end-of-life care for people living with dementia, notably concerning pain recognition and use of assessment tools. It is recommended that specialist education is mandated for all nurses working with this client group to improve care delivery.

The Overlap Between Geriatric Medicine and Palliative Care: A Scoping Literature Review

With an increasing aging population worldwide, there is a growing need for both palliative care and geriatric medicine. It is presumed in medical literature that both specialties share similar goals about patient care and could collaborate. To inform future service development, the objective of this review was to identify what is currently empirically known about overlapping working practices. This article provides a scoping literature review on the relationship between geriatric medicine and palliative care within the United Kingdom. The review encompassed literature written between 1997 and 2019 accessed via Scopus, Web of Science, PubMed, and Google Scholar. Three themes were identified: (a) unclear boundaries between specialties, (b) communication within and between specialisms, and (c) ambiguity of how older people fit in the current health care system. We suggest that more empirical research is conducted about the overlap between palliative care and geriatric medicine to understand how interprofessional working and patient care can be improved.

Experience of Intensive Care Nurses in Assessment of Postoperative Pain in Patients with Hip Fracture and Dementia

Introduction:

Patients with hip fracture are one of the most demanding groups in the health-care system. One of the most important tasks for nurses is to assess pain and ensure the patients are pain free. Pain assessment in patients with dementia is a well-known challenge for health-care professionals due to the patients’ difficulties in verbalising pain problems.

Aim:

The aim of this study was to explore the experience of intensive care nurses in assessment of pain in patients with hip fracture and dementia in the postoperative setting.

Methods:

Data were collected through five focus group discussions using open-ended questions and qualitative content analysis. Twenty-one intensive care nurses (6 men and 15 women) participated in the focus group interviews.

Results:

Analysis of the data resulted in three main categories: “Communication”, “Visual assessment of pain”, and “Practical issues” including a number of subcategories. Some of the factors which influence assessment of pain in patients with dementia are the lack of information and knowledge about the patients, which causes loss of time and increased stress. The different forms of communication and ways of assessing pain in these patients were other factors mentioned by nurses as hindrances regarding assessment of the pain.

Conclusion:

In order to improve assessment of pain, more knowledge and information about the patients are needed and better coordination between the pre- and postoperative departments regarding these patients. In this context, different intervention studies on patient’s hip fracture and dementia are needed to increase knowledge and awareness regarding this group of patients.

Barriers and Solutions for Improving Pain Management Practices in Acute Hospital Settings: Perspectives of Healthcare Practitioners for a Pain-Free Hospital Initiative

Background

Effective pain management is a fundamental human right. However, global disparities in pain management practices exist across health settings. This study explored healthcare practitioners’ views on pain management in the acute care hospital setting.

Methods

The focus groups included clinical specialties most likely to encounter patients with ‘difficult to manage pain’, namely those in the Geriatrics and Palliative Care Unit (2 doctors and 3 nurses), Critical Care Unit (7 doctors), and the Pain Management Team (3 doctors and 2 nurses). The transcripts were analyzed using a qualitative thematic analysis.

Results

The data analysis revealed four themes. Theme 1, ‘Being too safe’ described the presence of apprehensive attitudes among patients and healthcare practitioners that limits the appropriate use of diverse and tailored pain medications in acute care hospital settings. Theme 2, ‘Working as a team’ described the need for collaborative approaches to achieve hospital-wide evidence-based pain management. Theme 3, ‘Adaptation for local and cultural preferences’ explored how pain was perceived through cultural lenses and suggested strategies to tailor pain management to local and cultural preferences. Finally, Theme 4, ‘Driving acute pain management forward’ listed clinician solutions for improving pain management in acute care hospital settings toward a pain-free hospital initiative.

Conclusion

Despite advances in pain medicine and pain teaching strategies, effective pain management is proportionate to both clinical and cultural preferences. Future studies should investigate the standardization of global pain management tools and guidelines to fit the local culture and context.

Responding to Varying Levels of Certainty about Pain in People with Dementia after Initial Pain Assessment

Introduction

Pain is still inadequately treated in people with dementia (PWD) due to the complexity of assessing it. Pain assessment in PWD is still challenging because of patient-related or nurse-related factors. The patient-related factors have been studied extensively. However, the nurse-related factors, e.g., nurses' certainty regarding suspected pain in PWD, have been given little attention by researchers.

Purpose

This study aims to investigate how the degree of nurses' certainty is compromised after pain assessment and how this affects levels of pain and agitation in PWD.

Method

A descriptive, correlational design was used, and a convenience sample of 104 nursing home residents with dementia were recruited.

Results

This study found that nurses' certainty after the pain assessment mediates the relationship between the type of pain assessment and patient outcomes when the nurses had a high initial certainty. When nurses had a low initial certainty, their certainty after the assessment and the type of assessment predicted the levels of pain and agitation in PWD.

Conclusion

Understanding how nurses' certainty can be compromising after pain assessment and how this relates to pain management in PWD is crucial.

Nursing staff needs in providing palliative care for people with dementia at home or in long-term care facilities: A scoping review

BACKGROUND

Nursing staff caring for people with dementia have a crucial role in addressing palliative care needs and identifying changes in health status. Palliative care for people with dementia is complex and requires specific competences. A lack thereof may lead to unnecessary hospitalizations, poor symptom control and undesirable burdensome treatments. Understanding what nursing staff need to provide palliative care specifically for people with dementia facilitates the development of tailored and feasible interventions.

OBJECTIVE

To investigate what is known from the literature regarding the needs in providing palliative dementia care as perceived by nursing staff working in home care or in long-term care facilities and to establish an integrated conceptualization of these needs.

DESIGN

A scoping review method combined with thematic analysis methods.

DATA SOURCES

Bibliographic databases of PubMed, CINAHL and PsycINFO were searched for primary research studies.

REVIEW METHODS

Guidelines from the Joanna Briggs Institute were utilized as a framework for setting up and conducting the scoping review. Eligible articles considered nursing staff's perceived needs in providing palliative dementia care at home or in long-term care facilities. Two authors assessed eligibility based on title and abstract, assessed full texts for selected records and assessed the quality of included articles. Thematic analysis methods were used to identify themes from relevant study findings, which were integrated to form a conceptualization.

RESULTS

Of the 15 articles that were included, most used qualitative methods (N = 13) and were conducted in long-term care facilities (N = 14). Themes reflecting nursing staff needs on a direct care-level concern recognizing and addressing palliative care needs (such as comfort), verbal and non-verbal communication, challenging behaviour and familiarity: knowing and understanding the person with dementia. On more distant levels, themes involve a need for interdisciplinary collaboration, training and education and organizational support.

CONCLUSION

A comprehensive overview of nursing staff perspectives on providing palliative care for people with dementia demonstrates interdependent needs related to recognizing and addressing palliative care needs, communicating, handling challenging behaviour and building close care relationships. These care-related needs occur within workplace and organizational contexts. Organizational support is considered insufficient. Yet, healthcare organizations have the authority to fulfil a facilitating role in implementing nursing interventions tailored to nursing staff needs. Areas for further research include home care settings, the psychosocial and spiritual domains of palliative dementia care, advance care planning and family involvement.

Orofacial pain assessment and management for patients with dementia: A meta-ethnography

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.

Evaluation of the impact of telementoring using ECHO© technology on healthcare professionals' knowledge and self-efficacy in assessing and managing pain for people with advanced dementia nearing the end of life

Background

Pain assessment and management in advanced and end-stage dementia are challenging; patients are at risk of under-diagnosis, under-assessment and under-treatment. Previous research has highlighted the importance of needs-driven training and development in this area for physicians, nurses and healthcare assistants (HCAs) across specialties, disciplines and care settings. This study used teleconferencing technology to connect healthcare professionals across multiple settings and disciplines in real-time clinics, based on the Project ECHO© model. This paper reports the evaluation of the clinics by physicians, nurses and HCAs, including their knowledge and self-efficacy in pain assessment and management for patients with advanced and end-stage dementia.

Methods

A mixed method evaluation comprising quantitative survey of self-reported knowledge and self-efficacy pre- and post-ECHO clinic participation, and qualitative exploration of experiences of the clinics using focus group interviews. A census approach to sampling was undertaken. Pre- and post-ECHO evaluations were administered electronically using Survey Monkey software. Mann-Whitney U tests were used to explore differences in knowledge and self-efficacy scores pre- and post-ECHO clinic participation. Statistical significance was set a-priori at p = 0.05. Focus groups were video- and audio-recorded, transcribed verbatim and analysed using Braun & Clarke’s model of thematic analysis.

Results

Eighteen healthcare professionals [HCPs] (physicians [n = 7], nurses [n = 10], HCA [n = 1]) and twenty HCPs (physicians [n = 10], nurses [n = 10]) completed pre- and post-ECHO evaluations respectively, reporting improvements in knowledge and self-efficacy on participation in ECHO clinics and perceived utility of the clinics. Seven HCPs (physicians [n = 2], nurses [n = 5]) participated in two focus groups. Four themes emerged: knowledge and skills development and dissemination; protected time; areas for improvement; and the future of ECHO.

Conclusions

Telementoring clinics for HCP education and training in pain assessment and management in advanced and end-stage dementia demonstrate a positive impact on knowledge and self-efficacy of HCPs and highlight the value of a cross-specialty network of practice which spans across disciplines/HCP types, care settings and geographical areas. Further development of ECHO services in this and in other clinical areas, shows significant potential to support delivery of high-quality care to complex patient populations.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3032-y) contains supplementary material, which is available to authorized users.

A painful experience of limited understanding: healthcare professionals' experiences with palliative care of people with severe dementia in Norwegian nursing homes

BACKGROUND

People dying with dementia have significant healthcare needs, and palliative care, with its focus on comfort and quality of life, should be made available to these patients. The aim of this study was to explore and increase knowledge of healthcare professionals' experiences with palliative care to people with severe dementia in nursing homes.

METHODS

To describe the phenomenon under investigation, we used a phenomenological research approach grounded in the philosophy of Husserl. Data were collected using in-depth interviews with 20 healthcare professionals from four Norwegian nursing homes.

RESULTS

The general meaning structure of the healthcare professionals' experiences with providing palliative care to people with severe dementia is painfulness, due to their limited understanding of patients' individual modes of expression. The painfulness is illustrated by the following themes: challenges related to "reading" the patients' suffering, coming up short despite occasional success, handing the patients over to strangers, and disagreeing on the patients' best interests. The healthcare professionals struggled to understand patients by "reading" their suffering. Occasionally, they succeeded and were able to calm the patients, but they often had the feeling of coming up short in situations related to pain relief and coping with behavioural symptoms, such as aggression and rejection of care. They also found it painful when the weakest patients were moved from the sheltered unit to a somatic long-term unit and were handed over to strangers who did not know the patients' ways of expression. Although the healthcare professionals emphasized the importance of good collaboration with the patients' relatives to ensure the best possible palliative care, they frequently found themselves in difficult situations when they disagreed with the family on the patients' best interests.

CONCLUSIONS

We found healthcare professionals' experiences of providing palliative care to people with severe dementia to be painful. To be able to understand the patients better, long-term familiarity and knowledge of how to "read" and observe patients with severe dementia are necessary. Openness in cooperation with the patients' relatives and with the professional team may increase healthcare professionals' understanding of the patients' situations and hence improve the quality of care.

Exploring healthcare assistants' role and experience in pain assessment and management for people with advanced dementia towards the end of life: a qualitative study

BACKGROUND

Pain assessment and management are key aspects in the care of people with dementia approaching the end of life but become challenging when patient self-report is impaired or unavailable. Best practice recommends the use of observational pain assessments for these patients; however, difficulties have been documented with health professionals' use of these tools in the absence of additional collateral patient knowledge. No studies have explored the role, perspectives and experiences of healthcare assistants in pain assessment and management in dementia; this study provides insight into this important area.

METHODS

A qualitative approach was adopted, using key informant interviews with healthcare assistants caring for people with advanced dementia approaching the end of life in hospice, nursing home and acute care settings. Thematic analysis was the analytic approach taken to interpretation of interview data. Data were collected between June 2014 and September 2015.

RESULTS

Fourteen participants took part in the study. Participants' average length of caring experience was 15.4 years and most were female. Three key themes emerged: recognising pain, reporting pain, and upskilling. Participants were often the first to notice obvious causes of pain and to detect changes in patient norms which signified hidden causes of pain. Comprehensive knowledge of resident norms enabled participants to observe for behavioural and nonverbal indicators of pain and distinguish these from non-pain related behaviours. Pain reporting was heavily impacted by relationships with professional staff and the extent to which participants felt valued in their role. Positive relationships resulted in comprehensive pain reports; negative relationships led to perfunctory or ambiguous reporting. Participants emphasised a desire for further training and upskilling, including in the use and reporting of basic pain tools.

CONCLUSIONS

Healthcare assistants are frontline staff who have a key role in direct patient care, spending a considerable amount of time with patients in comparison to other health professionals. These staff are often first to notice changes in patients that may signify pain and to alert professional staff. However, to ensure the quality of these reports, further efforts must be made in reversing stigma attached to this role and in upskilling these members of the healthcare team.