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Detection and assessment of pain in dementia care practice: Registered nurses’ and certified nursing assistants’ experiences
Jönköping University, School of Health and Welfare. Högskolan i Skövde, Institutionen för hälsa och lärande.ORCID iD: 0000-0001-6357-232X
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aim: The overall aim of the thesis was to explore and describe registered nurses’ (RNs) and certified nursing assistants’ (CNAs) experiences of detection and assessment of pain in older people with cognitive impairment and dementia. A further aim was to evaluate the Abbey Pain Scale-SWE (APS-SWE) in dementia care practice.

Methods: An exploratory and descriptive design was used in Study I. An exploratory and interpreting design was used in Study II and Study III. A prospective, descriptive, observational and instrumental design was used in Study IV. Focus group interviews (I) and individual interviews (II, III) were applied to explore and describe RNs’ and CNAs’ experiences of pain assessment in people living with dementia. Qualitative content analysis (I) and philosophical hermeneutics (II) were used to analyse qualitative data. Observation, instrument, and questionnaire were applied to evaluate reliability and face validity of the APS-SWE for pain assessment. Descriptive statistics and reliability analyses were used to analyse quantitative data (IV).

Results: RNs in special housing accommodation settings experiences that pain assessment in people with dementia is challenging primarily due to their changed RN consultant role, which to a great extent is directed into administrative and consultative tasks rather than bedside care. This has led to decreased time in daily nursing care, preventing recognising symptoms of pain. This have also led to that RNs are dependent on information from CNAs who are the front-line staff providing daily care (I). CNAs’ perception of signs of pain in people with dementia emerges from being present in the care situation and alertness on physical and behavioural changes that could be due to pain, and from providing the care in a preventive, protective and supportive way to prevent painful situations occurring (II). RNs and CNAs working in home healthcare team use a variety of strategies to detect and assess pain. A trustful work relationship based on staff continuity and a good relation to the person in need of care facilitates pain assessment situations (III). Systematic observation of older people living in special housing accommodation during rest and mobility using the APS-SWE demonstrates that the scale has adequate internal consistency, reliability, and face validity for pain assessment (IV).

Conclusions: This thesis found that the RNs’ and CNAs’ detections and assessments of pain rely on solid cooperation, staff continuity, and good knowledge of the person cared for. It was also revealed that there is a lack of using appropriate and assisting pain tools. The APS-SWE show adequate reliability and face validity and can serve as a useful pain tool to assist in detection and assessment of pain in older people who are limited in verbalising pain recognisable. Further evaluation of how the person-centred perspective is applied in pain assessment situations is needed in order to evaluate positive outcomes in people with dementia. Further psychometric evaluation of the APS-SWE in clinical dementia care practice is needed to strengthen validity and reliability.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2015. , 116 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 62
Keyword [en]
Abbey Pain Scale-SWE, cognitive impairment, dementia, municipal elderly care, observational behavioural pain assessment scales, pain assessment, person-centred care
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-28113ISBN: 978-91-85835-61-4 (print)OAI: oai:DiVA.org:hj-28113DiVA: diva2:859422
Public defence
2015-10-23, Forum Humanum, Hälsohögskolan i Jönköping, Jönköping, 10:38 (Swedish)
Opponent
Supervisors
Available from: 2015-10-07 Created: 2015-10-07 Last updated: 2015-10-07Bibliographically approved
List of papers
1. Registered nurses' view of pain assessment among persons with dementia as consultant advisors
Open this publication in new window or tab >>Registered nurses' view of pain assessment among persons with dementia as consultant advisors
2012 (English)In: Open Nursing Journal, ISSN 1874-4346, E-ISSN 1874-4346, no 6, 62-70 p.Article in journal (Refereed) Published
Abstract [en]

Background: Pain assessment in persons with dementia is well known as a challenging issue to professionalcaregivers, because of these patients´ difficulties in verbalising pain problems. Within municipal dementia care inSweden, pain assessment has become problematic for registered nurses, as they have entered a new role in their nursingprofession, from being clinical practitioners to becoming consultant advisers to other health care staff.

Aim: To present municipal registered nurses´ view of pain assessment in personswith dementia in relation to their nursingprofession as consultant advisers.

Methods: Purposive sampling was undertaken with 11 nurses invited to participate. Data were collected by focus groups.Qualitative content analysis was used to analyse the data.

Findings: Four categories were identified to describe registered nurses´ view of pain assessment: estrangement frompractical nursing care, time consuming and unsafe pain documentation, unfulfilled needs of reflection possibilities, andcollaboration and coordination.

Conclusions: The performance of pain assessment through a consultant advising function is experienced as frustrating andas an uncomfortable nursing situation. The nurses feel resistance to providing nursing in this way. They view nursing as aclinical task demanding daily presence among patients to enable them to make accurate and safe assessments. However,due to the consultative model, setting aside enough time for the presence seems difficult to accomplish. It is necessary topromote the quality of systematic routines in pain assessment and reflection, as well as developing professionalknowledge of how pain can be expressed by dementia patients, especially those with communication difficulties.

Keyword
dementia care, pain assessment, registered nurses
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-20445 (URN)10.2174/1874434601206010062 (DOI)
Available from: 2013-01-24 Created: 2013-01-24 Last updated: 2017-12-06Bibliographically approved
2. Certified nursing assistants' perception of pain in people with dementia: a hermeneutic enquiry in dementia care practice
Open this publication in new window or tab >>Certified nursing assistants' perception of pain in people with dementia: a hermeneutic enquiry in dementia care practice
2013 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 22, no 13/14, 1880-1889 p.Article in journal (Refereed) Published
Abstract [en]

Aim.To interpret certified nursing assistants’ perception of pain in people with dementia in nursing care practice.

Background. Detection and understanding of pain in people with dementia remains a challenge due to their difficulty in verbalising their pain. Nursing assistants provide daily nursing care and therefore play a vital role in pain detection. Nevertheless, pain research from the nursing assistants’ perspective is sparse.

Design. A qualitative approach within the interpretive tradition was adopted.

Method. Individual interviews with twelve certified nursing assistants, all working in dementia care, were conducted and interpreted using philosophical hermeneutics.

Results. Nursing assistants’ perception of pain is on three levels. Each level consists of a theme. The first theme ‘Being in the facing phase’ refers to the initial perception of the person’s expressions. The second theme ‘Being in the reflecting phase’ means ability to reflect more deeply on one’s perception, together with other colleagues and next-of-kins. The third theme ‘Being in the acting phase’ means perception arising from preventive and protective care focusing on contributing to well-being.The themes served as a basis for comprehensive understanding, where perception of pain arise from closeness, compassion and dialogue based on personhood, accompanied by professional knowledge of pain and dementia.

Conclusion. Nursing assistants’ perception of pain is based on ethical concerns and on their own subjective pain experiences rather than on medical skills.Their perception derives from fundamental values which are important aspects of nursing care. Interdisciplinary solidarity may strengthen co-operation amongst CNAs and RNs in order to achieve best pain management practice.

Relevance to clinical practice. Attention to nursing assistants’ perception of pain needs to be highlighted when they are front line staff and have developed important pain detection skills. Their skills are essential complements and must be utilised in the development of pain management in dementia care practice.

 

Place, publisher, year, edition, pages
Uk: , 2013
Keyword
certified nursing assistants, dementia, interviews, nursing care, pain, philosophical hermeneutics
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hj:diva-21429 (URN)10.1111/jocn.12197 (DOI)
Available from: 2013-06-11 Created: 2013-06-11 Last updated: 2017-12-06Bibliographically approved
3. Home healthcare teams’ assessments of pain in care recipients living with dementia: a Swedish exploratory study
Open this publication in new window or tab >>Home healthcare teams’ assessments of pain in care recipients living with dementia: a Swedish exploratory study
2015 (English)In: International Journal of Older People Nursing, ISSN 1748-3735, E-ISSN 1748-3743, Vol. 10, no 3, 190-200 p.Article in journal (Refereed) Published
Abstract [en]

Background

Pain assessment in people living with dementia is a challenge due to the complexity of pain and dementia and the difficulties in self-reporting. In home healthcare, nurses are frequently involved in pain assessment situations and there is a need to explore how home healthcare teams’ manage pain assessment in this setting.

Aim

The study aimed to explore home healthcare teams’ experiences of pain assessment among care recipients with dementia.

Design

An exploratory qualitative design was used.

Methods

Open-ended individual interviews were conducted with thirteen registered nurses and ten nursing assistants, working in three different home healthcare teams in one municipality in western Sweden. Philosophical hermeneutics was utilised to interpret the home healthcare teams’ experiences.

Results

Four interpretations emerged: the need for trusting collaboration, the use of multiple assessment strategies, maintenance of staff continuity in care and assessment situations, and the need for extended time to assess pain.

Conclusions

The home healthcare teams recognise pain assessment in people with dementia as involving a complex interaction of sensory, cognitive, emotional and behavioural components in which efforts to acquire understanding of behavioural changes mainly guides their assessments. The solid team coherence between registered nurses and nursing assistants aided the assessment procedure. To assess pain, the teams used multiple methods that complemented one another. However, no systematic routines or appropriate evidence-based pain tools were used.

Implications for Practice

The team members'concern for care recipients when assessing pain is evident and needs to be acknowledged by the organisation which is responsible for the quality of care. Future studies should focus on further exploration of nurses’ experiences with pain and dementia in home healthcare settings and address what nurses identify and how they deal with their findings. It is imperative to investigate how organisations and nurses can ensure best practices and how the implementation of evidence-based routines for assessing pain may aid in pain assessment situations.

Keyword
dementia, home healthcare, pain assessment
National Category
Health Sciences
Identifiers
urn:nbn:se:hj:diva-25153 (URN)10.1111/opn.12072 (DOI)25399656 (PubMedID)2-s2.0-84911072485 (Scopus ID)
Available from: 2014-11-15 Created: 2014-11-15 Last updated: 2017-12-05Bibliographically approved
4. Reliability and face validity of the Abbey Pain Scale-SWE in Swedish dementia care practice
Open this publication in new window or tab >>Reliability and face validity of the Abbey Pain Scale-SWE in Swedish dementia care practice
Show others...
2015 (English)Article in journal (Other academic) Submitted
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-28117 (URN)
Available from: 2015-10-07 Created: 2015-10-07 Last updated: 2016-09-07

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