Decision Factors Nurses Use to Assess Pain in Nursing Home Residents With Dementia

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Abstract

Nurses caring for older people with various psychiatric illnesses face many obstacles when treating pain. One setting with a high percentage of psychiatric conditions is long-term care where more than half of residents have some form of dementia, and behavioral symptoms of dementia (BSDs) may mimic behavioral displays of pain. Furthermore, two-thirds of nursing home residents have pain. Thus, many nursing home residents with dementia have pain that may be confounded by BSDs. Since many people with dementia are at risk for poor pain management, determining current methods in which nurses assess and manage pain in nursing home residents will aid in recognizing potential barriers to using current pain management guidelines and help develop strategies to enhance nurses' assessment and management of pain in this vulnerable population. The aim of this study was to explore nursing home nurses' cues and practices to identify and alleviate pain in nursing home residents with dementia. Nurses use the constructs of 'comfort' and 'quality of life' as key components in their overall pain assessment strategy in people with dementia. Indeed, the extensive process they use involving frequent reassessment and application of interventions is geared towards "appearance of comfort." Nurses reported difficulty in ascertaining whether a person with dementia was in pain, and they expressed further difficulty determining the intensity associated with resident pain. Nurses further reported that residents with dementia who are not well know by the staff were are greater risk of poor pain management. It was not unusual for nurses to discuss the importance of conflict resolution among family members as well as allowing for open expression of family's concerns. Nurses had to focus not only on the resident's comfort, but also the families' level of comfort with pain management, especially at the end-of-life. Findings support further use and development of discomfort behavior scales to help manage pain.

Section snippets

Sample and Setting

An exploratory study using focus group methodology was conducted at two long-term care facilities in the greater Nashville, Tennessee area. Facility A had 250 beds and was located in an urban area; facility B had 160 beds and was located in a suburban setting. Criteria for participation were: registered (RN) or licensed practical (LPN) nurses with direct care responsibilities. Nurses were excluded if their responsibilities did not include the assessment and management of pain.

Procedure

The study was

Results

An overarching theme was identified that recurred and underpinned the nurses' reflections about pain management in people with dementia, “Putting together a complex jigsaw puzzle.” Five additional subthemes were noted throughout the transcripts of the nurses' responses: uncertainty about the pain experience of residents with dementia; ‘being a detective’ to determine pain extent and site; clarifying factors; conflict resolution; and the role of the nurse.

Discussion

The focus group forum provided a picture of the long-term care nurses' roles and necessary skills in determining and treating pain among residents with dementia. A wide spectrum of issues exists that nurses must juggle in addressing this issue. We found that nurses use the constructs of ‘comfort’ and ‘quality of life’ as key components in their overall pain assessment strategy in people with dementia. Indeed, the extensive process they use involving frequent reassessment and application of

Acknowledgment

Funding sources for this project include: The John A. Hartford Foundation, The Mayday Fund, Vanderbilt Office of Clinical and Translational Scientist Development, Vanderbilt Clinical and Translational Research Scholars Program, and the NIH National Institutes of Health (5KL2TR000446-08 from NCATS). The contents are solely the responsibility of the authors and do not necessarily represent the official views of these institutions. Study data were collected and managed using REDCap electronic data

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