Nurses' knowledge and beliefs on pain management practices with hospitalised persons living with dementia: A qualitative descriptive study

AIM

To understand nurses' knowledge, beliefs and experiences affect pain management practices in hospitalised persons living with dementia (PLWD).

DESIGN

Naturalistic inquiry using qualitative descriptive design.

METHODS

Semi-structured interviews were conducted with 12 registered nurses who worked in one acute care hospital in Southern California from October to November 2022. Data were analysed using content analysis to identify themes.

RESULTS

Two themes were developed: improvising pain assessment, which included how pain was documented, and administration hesitancy referring to nurse's concerns about PLWD's confusion. Nurses described the challenges of assessing pain in hospitalised PLWD particularly if they were non-verbal and/or demonstrating responsive behaviours. Nurse's years of experience, dementia stigma, and their unconscious biases affected nurses' pain management practices.

CONCLUSIONS

The study findings highlight the complex challenges of pain management in hospitalised PLWD that are exacerbated by nurses' knowledge deficits, negative stereotypical beliefs, dementia stigma and unconscious biases towards older people that contributes to undermanaged pain in hospitalised PLWD.

IMPLICATIONS

A comprehensive strategy using an implementation framework is needed to address nurse's knowledge gaps, unconscious bias, dementia stigma and techniques that enhance communication skills is suggested. Building a foundation in these areas would improve pain management in hospitalised PLWD.

IMPACT

Improving pain management in hospitalised PLWD would improve the quality of life, decrease hospital length of stay, prevent readmissions, and improve nurse satisfaction.

REPORTING METHOD

The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT CONTRIBUTIONS

Improving pain management in hospitalised PLWD would prevent long term confusion, episodes of delirium and improve quality of life as they recover from their acute illness for which they required hospital care.

A Scoping Review on Nurse's Pain Management of Older Patients with Dementia in a Hospital Environment

OBJECTIVES

Hospitalized persons living with dementia often experience unrelieved pain. Unmanaged pain during hospitalization has a significant negative effect on quality of life for persons living with dementia. Despite the central role of nurses in pain management, little is known about how nurses manage pain in this patient population in the hospital environment.

DESIGN

A scoping review explored the nurses' pain management practices when caring for persons living with dementia in a hospital setting.

DATA SOURCES AND REVIEW/ANALYSIS METHODS

After an extensive search for all available evidence on how nurses manage pain in hospitalized persons living with dementia, data were extracted on pain management methods that included assessment, intervention, effectiveness of pain management, and the barriers nurses encountered when managing pain. A descriptive content analysis was used to extract data from qualitative studies.

RESULTS

Six articles published between 2016 and 2021 met the inclusion criteria; four utilized qualitative methods, and the others used mixed-methods and quantitative study designs. A narrative description of the findings was summarized after data were categorized into pain management data elements and barriers nurses encountered when managing pain. Barriers were grouped into the subcategories of communication challenges (nurse to patient), information sharing (nurse to nurse), lack of knowledge, time constraints, and nursing stressors.

CONCLUSION

We identified six articles that met our inclusion criteria, highlighting a noticeable gap in the literature. Managing pain in this population is complex and lacks organizational support. Review findings indicate that pain management methods lack consistency and standardization, making it difficult to assess their effectiveness. Nurses also described knowledge deficits resulting in practice gaps that, when combined with barriers and challenges, result in underrecognized and undermanaged pain.

Membrane protein extraction and purification using partially-esterified SMA polymers

Styrene maleic acid (SMA) polymers have proven to be very successful for the extraction of membrane proteins, forming SMA lipid particles (SMALPs), which maintain a lipid bilayer around the membrane protein. SMALP-encapsulated membrane proteins can be used for functional and structural studies. The SMALP approach allows retention of important protein-annular lipid interactions, exerts lateral pressure, and offers greater stability than traditional detergent solubilisation. However, SMA polymer does have some limitations, including a sensitivity to divalent cations and low pH, an absorbance spectrum that overlaps with many proteins, and possible restrictions on protein conformational change. Various modified polymers have been developed to try to overcome these challenges, but no clear solution has been found. A series of partially-esterified variants of SMA (SMA 2625, SMA 1440 and SMA 17352) has previously been shown to be highly effective for solubilisation of plant and cyanobacterial thylakoid membranes. It was hypothesised that the partial esterification of maleic acid groups would increase tolerance to divalent cations. Therefore, these partially-esterified polymers were tested for the solubilisation of lipids and membrane proteins, and their tolerance to magnesium ions. It was found that all partially esterified polymers were capable of solubilising and purifying a range of membrane proteins, but the yield of protein was lower with SMA 1440, and the degree of purity was lower for both SMA 1440 and SMA 17352. SMA 2625 performed comparably to SMA 2000. SMA 1440 also showed an increased sensitivity to divalent cations. Thus, it appears the interactions between SMA and divalent cations are more complex than proposed and require further investigation.

Nurses' decision-making related to administering as needed psychotropic medication to persons with dementia: an empty systematic review

Behavioural and psychological symptoms of dementia occur in approximately 75% of people with dementia admitted to acute care. Acute care nurses' decision-making regarding administering 'as needed' (pro re nata or PRN) psychotropic medications to persons with dementia are not well understood. This is an important clinical concern because 'as needed' medications are given at the discretion of the nurse. A comprehensive, systematic search and screen for studies that explored nurses' decision-making related to administering as needed psychotropic medication to persons with dementia in acute care settings was conducted. No studies that reported nurses' decision-making related to administration of as needed psychotropic medications to hospitalized persons with dementia were identified. In light of this, we present a discussion based on a narrative review of what is known on this topic from other settings, based on papers found in our original review. We will briefly explore what is needed in future research to address the gap in knowledge about nurse' decision-making related to administering as needed psychotropic medications. IMPLICATIONS FOR PRACTICE: Research is needed to understand and inform the decision-making process in the administration of as needed psychotropic medications to hospitalized persons with dementia.

Quantitative and Qualitative Strategies to Strengthen Internal Validity in Randomized Trials

Although the randomized controlled trial (RCT) is the most reliable design to infer causality, evidence suggests that it is vulnerable to biases that weaken internal validity. In this paper, we review factors that introduce biases in RCTs and we propose quantitative and qualitative strategies for colleting relevant data to strengthen internal validity. The factors are related to participants' reactions to randomization, attrition, treatment perceptions, and implementation of the intervention. The way in which these factors operate is explained and pertinent empirical evidence is synthesized. Quantitative and qualitative strategies are described. Researchers can plan to assess these factors and examine their influence, providing evidence of what actually contributed to the interventions' causal impact.

Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia

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.

Study protocol: pragmatic randomized control trial of my tools 4 care- in care (MT4C-in care) a web-based tool for family Carers of persons with dementia residing in long term care

Background

When a family member resides in long term care facility (LTC), family carers continue caregiving and have been found to have decreases in mental health. The aim of My Tools 4 Care – In Care (an online intervention) is to support carers of persons living with dementia residing in LTC through transitions and increase their self-efficacy, hope, social support and mental health. This article comprises the protocol for a study to evaluate My Tools 4 Care-In Care (MT4C-In Care) by asking the following research questions:

Is there a 2 month (immediately post-intervention) and 4 month (2 months post-intervention) increase in mental health, general self-efficacy, social support and hope, and decrease in grief and loneliness, in carers of a person living with dementia residing in LTC using MT4C-In CARE compared to an educational control group?

Do carers of persons living with dementia residing in LTC perceive My Tools 4 Care- In Care helps them with the transitions they experience?

Methods

This study is a single blinded pragmatic mixed methods randomized controlled trial. Approximately 280 family carers of older persons (65 years of age and older) with dementia residing in LTC will be recruited for this study. Data will be collected at three time points: baseline, 2 month, and 4 months. Based on the feasibility study, we hypothesize that participants using MT4C-In Care will report significant increases in hope, general self-efficacy, social support and mental health quality of life, and significant decreases in grief and loneliness from baseline, as compared to an educational control group. To determine differences between groups and over time, generalized estimating equations analysis will be used. Qualitative descriptive analysis will be used to further evaluate MT4C-In Care and if it supports carers through transitions.

Discussion

Data collection will begin in four Canadian provinces (Alberta, Manitoba, Ontario and Saskatchewan) in February 2020 and is expected to be completed in June 2021. The results will inform policy and practice as MT4C-In Care can be revised for local contexts and posted on websites such as those hosted by the Alzheimer Society of Canada.

Trial registration

NCT04226872 ClinicalTrials.gov Registered 09 January 2020

Protocol Version #2 Feb 19, 2020.

Comparing the Experience of and Factors Perpetuating Chronic Insomnia Severity Among Young, Middle-Aged, and Older Adults

The prevalence of chronic insomnia is on the rise among young, middle-aged, and older adults. This secondary data analysis examined age-group differences in the experience of and factors perpetuating insomnia severity. Pretest data, obtained from a trial of behavioral interventions, were collected from 742 participants, using psychometrically sound measures of perpetuating factors (sleep habits, unhelpful beliefs, presleep arousal), insomnia experience (symptoms, perceived severity), and consequences or impact on daytime functioning. The age groups reported different insomnia symptoms (difficulty maintaining sleep in older adults) and impact on daytime functioning (poorer in older adults), but the same level of perceived insomnia severity. Unhelpful beliefs about sleep predicted insomnia severity in all age groups, and presleep arousal contributed to insomnia in young adults. The results highlight the importance of adequately managing chronic insomnia to minimize its impact on daytime functioning in all age groups, and of tailoring therapy to their experiences.