Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

BackgroundPain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.Aims and objectivesTwo studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.MethodsFor the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.ResultsData from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.LimitationsGrey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.ConclusionsNo single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts

Milestones of critical thinking: a developmental model for medicine and nursing

Critical thinking is essential to a health professional\u27s competence to assess, diagnose, and care for patients. Defined as the ability to apply higher-order cognitive skills (conceptualization, analysis, evaluation) and the disposition to be deliberate about thinking (being open-minded or intellectually honest) that lead to action that is logical and appropriate, critical thinking represents a meta-competency that transcends other knowledge, skills, abilities, and behaviors required in health care professions. Despite its importance, the developmental stages of critical thinking have not been delineated for nurses and physicians. As part of a task force of educators who considered different developmental stage theories, the authors have iteratively refined and proposed milestones in critical thinking. The attributes associated with unreflective, beginning, practicing, advanced, accomplished, and challenged critical thinkers are conceived as independent of an individual\u27s level of training. Depending on circumstances and environmental factors, even the most experienced clinician may demonstrate attributes associated with a challenged thinker. The authors use the illustrative case of a patient with abdominal pain to demonstrate how critical thinking may manifest in learners at different stages of development, analyzing how the learner at each stage applies information obtained in the patient interaction to arrive at a differential diagnosis and plan for evaluation. The authors share important considerations and provide this work as a foundation for the development of effective approaches to teaching and promoting critical thinking and to establishing expectations for learners in this essential meta-competency

Children's and parents' perceptions of postoperative pain management: a mixed methods study

AIMS AND OBJECTIVES: To explore children's and parents' perceptions about the quality of postoperative pain management. BACKGROUND: Children continue to experience moderate to severe pain postoperatively. Unrelieved pain has short- and long-term undesirable consequences. Thus, it is important to ensure pain is managed effectively. Little research has explored children's and parents' perceptions of pain management. DESIGN: Exploratory study. METHODS: Children (n = 8) were interviewed about their perceptions of pain care using the draw-and-write technique or a semi-structured format and asked to rate the worst pain experienced postoperatively on a numerical scale. Parents (n = 10) were asked to complete the Information About Pain questionnaire. Data were collected in 2011. RESULTS: Most children experienced moderate to severe pain postoperatively. Children reported being asked about their pain, receiving pain medication and using non-pharmacological methods of pain relief. A lack of preoperative preparation was evident for some children. Most parents indicated they had received information on their child's pain management. Generally, participants were satisfied with care. CONCLUSION: Participants appeared satisfied with the care provided despite experiencing moderate to severe pain. This may be attributable to beliefs that nurses would do everything they could to relieve pain and that some pain is to be expected postsurgery. RELEVANCE TO CLINICAL PRACTICE: Children are still experiencing moderate to severe pain postoperatively. Given the possible short- and long-term consequences of unrelieved pain, this is of concern. Knowledge translation models may support the use of evidence in practice, and setting a pain goal with parents and children may help improve care

Managing pain in children: where to from here?

Aims and objectives. The aims of this study are to review research published in the past 15 years to provide insight into the factors impacting on the management of pain in children and identify strategies that can be used to improve pain management practices. Background. The evidence to guide nurses' pain management practices is readily available, in the form of clinical guidelines. However, children's nurses' pain management practices continue to fall short of the ideal with children experiencing moderate to severe unrelieved pain. Several factors have been suggested as providing an explanation for this. There is a need to explore the impact each of these factors have on pain management practices further. With this in mind, a literature review was undertaken. Design. Literature review. Methods. A computerised literature search was carried out using CINAHL, Medline and the British Nursing Index. The search terms used were as follows: pain, pain assessment, pain management, education, quality and nurses. Articles published in the last 15 years were included in the review. Results. Several themes emerged from this review of the literature as possible explanations for why children's pain is still not managed effectively. These include knowledge deficits; incorrect or outdated beliefs about pain and pain management; the decision-making strategies used and organisational culture. Conclusions. Improving pain management requires a multifactorial approach encompassing: education, institutional support, attitude shifts and change leaders. Issues that need addressing include education, decision-making strategies and organisational practices. Further research needs to be carried out to determine other factors that impact on pain management practices. Relevance to clinical practice. Despite the evidence to guide practice being readily available children continue to experience unrelieved pain. The strategies identified in this article may help to ensure that pain is relieved effectively