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shammy smt

on 19 December 2013

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Transcript of RESEARCH

"An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

- International Association for the Study of Pain, 2012
million people with
2030: two-fold (
2050: three-fold (

Nurses' perception of
identification & assessment of pain
in elderly patients with Dementia.
“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does...”
(McCaffery, 1979)
Unfortunately, a person with severe dementia may not be able to verbalize pain, much less present with the classic signs of pain.
(Marzinski, 1991;
Kaasalainen, 2007;
While & Jocelyn, 2009)
Research title
Literature review
Data Analysis
Nursing implications
literature search
sources of information
EBSCO host
nurse’s perception, nurses’ opinions
identification of pain, assessment of pain
pain in elderly, older adult, patients
dementia, Alzheimer’s Disease
Majority of research to date has focused on the
measurement of pain

rather than nurses’ perception on the actual process of pain assessment.
Growing body of literature that highlights that
pain assessment is a significant challenge

for the nurses who look after dementia patients
(Kovach, Logan & Noonan, 2006).
Assessment of pain
Nurses play a crucial role in the identification and assessment of pain in the elderly

Nurses must be sensitive and alert in assessment

Nurses must assess patients for incidence of pain regularly

sufficient and comprehensive assessment of pain

indicators of pain
Vast range of behaviours and responses to pain
Education & Experience of Nurses
Nurses show satisfaction with the way pain is assessed and treated, in spite of knowledge deficits about several aspects of pain

Educational level seems to influence their beliefs and knowledge about pain in older residents with dementia

Pain assessment tools
Under-recognition of pain
Caused by lack of pain assessment and attention to pain behaviours
Lack of pain assessment tools for measuring pain in dementia patient
Nurses' opinions of pain
In a study of 55 nurses in Sweden:

Smiling patient:
14 nurses rate 8/10
nurses rate
less than 8/10

Grimacing patient:
36 nurses rate 8/10
nurses rate
less than 8/10
(World Health Organization, 2012)
(Brown et al., 2011; Kenefick & Schulman-Green, 2004)
(Chang et al., 2011)
(Lin et al., 2010)
(Zwakhalen et al., 2007)
Resisting care
Rapid blinking
Withdrawing from activities
Noisy breathing
Appetite change
(Kaasalainen, 2007;
While & Jocelyn, 2009;
Zwakhalen et al., 2007)
(Zwakhalen et al., 2007)
Self-reporting instruments
Moderate dementia
7-point Verbal Descriptor Scale (VDS)
(Herr, Spratt, Mobily & Richardson, 2004)
A multifaceted approach to combine self-report, observational assessment and proxy report has been recommended for improving the accuracy of pain assessment.
(Cohen-Mansfield, 2008)
Not able to self-report pain
Advanced stages of dementia

6-item Abbey Pain Scale
(Abbey et al., 2004)
(Closs et al., 2004)
Observational Tools
5-item Pain Assessment in Advanced Dementia scale (PAINAD)

60-items Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
(Fuchs-Lacelle & Hadjistavropoulos, 2004)
(Zwakhalen et al., 2007)
(McAuliffe et al., 2009)
(Kjallman Alm & Norbergh, 2013)
Study design

Interpretive phenomenology

will be chosen to analyse the lived experience of the nurses in assessment of pain in elderly patients with dementia.

is the study about ‘being’ and understanding the lived experiences.

(Fossey et al., 2002)
Interpretive Phenomenology
involved interpreting and understanding human experience not just describing it, which is commonly used by nurse researchers.

(Polit & Beck, 2010)
semi-structured interviews
guided by open-ended questions and
photo elicitation
with participants will be conducted

Collected data will be interpreted by researchers

1. What does “pain” mean to you?

2. How do you identify and assess pain in communicative elderly patients with dementia?

3. How do you identify and assess pain in non-communicative elderly patients with dementia?

4. What are the different pain assessment tools available in your ward?

5. How often do you assess pain of your dementia patients in your ward?

6. What are the difficulties and challenges in identifying and assessing pain in elderly patients with dementia?

7. Why is it so important to identify pain in elderly patients with dementia?

The semi-structured interview will be used for data collection due to:

Flexibility and ability to clarify questions during the data collection process
Provides opportunity to explore the intricacy of an issue from the perspective of individual participant

(Dearnley, 2005)
Both verbal and non-verbal cues will be recorded in the
field notes

The interview will also be

The role of the interviewer is to guide the interview by probing, encouraging and understanding.

Mr Ali, 75 years old, complains of
abdominal pain
Upon examination, his vital signs are as follows:
BP – 135/60 mmHg
HR – 80 bpm
RR – 16/min
VNP score – 8/10.
Scenario A
Pain score - 8/10
Scenario B
Pain score - 8/10
On the scale below,
what is the personal and private opinion of the patient’s pain in scenario A?

On the scale below,
what is the personal and private opinion of the patient’s pain in scenario B?
Target Population
Nurses from 2 acute geriatric wards in a local re-structured hospital.

Sampling Methods
Convenience Sampling
Subjects are included in the study merely because they happen to be in the right place at the right time.

The researcher simply choose any available participants into the study until desired sample size is reached.

Basically, convenience sampling is a process that is dependent on the convenience of the researcher.

(Burns & Grove, 2007)

Simple to use
Saves time and cost
Checks bias in subsequent selections of samples
Variances are most often smaller than other alternative sampling
Sample is not an accurate representation of the population
Findings from this sample are less definitive
Completely unstructured approach
Possibility of losing vital information from the population
(Burns & Grove, 2007)

Sample Size
Ward A:
10 participants
Ward B:
10 participants
Total Sample Size :
20 participants
or until saturation of info occurs.
Advertisement on Research
Inclusion Criteria
All nurses who are in direct care of patients:
At least 21 years old
Registered Nurses
Enrolled Nurses
Clinical Instructors
From Ward A & Ward B
Exclusion Criteria
Those who do not perform direct care of patients:
Nurse Managers
Nurse Clinicians
Discharge Coordinators
Not physically in the wards: ML, HL, AL,
Long-term training
Patient Care Assistants
Health Care Attendants
Ward Assistants
Data Collection
Data Collection:

Briefing to participants
Poster to recruit participants
Distribution information to participants
Arrange for date and time of interview session
Book room for interview
Semi-structured interview
Transcribe participant’s response
Record and take note during the interview session
Data saturation achieved
Data storage procedure
(Bertrand, 2012)

Data Analysis
1. The researchers will collect and analyze the data concurrently.
2. The researcher will manually transcribe the interview responses and analyze the transcripts.
3. If there are any issues at the time of interviewing, the researcher will seek clarification with the participants.
4. Develop a category scheme.
5. Code the data according to the categories.
Refers to the reliability of data over time.

eg. Would the study findings be repeated if the enquiry were replicated with the similar participants in a similar context?
Refers to confidence in the truth of the data and interpretations of them.

Refers to objectivity, the potential for congruence between 2 or more independent people about the data's accuracy, relevance or meaning.
(Polit & Beck, 2010)
Refers to the extent to which qualitative finding can be transferred to other settings or group.
Data storage!
The instruments and materials used in this study (tape recorder, interview question paper, USB flash drives, images and consent forms) will be kept in the principle investigator’s office under and
These instruments will be kept for two years, after which paper documentations will be shredded and, all information and data in the USB flash drives will be erased.
The destruction of all the data will be witnessed by all members of the research team.

ethical considerations
1. Obtain approval from the Centralised Institutional Review Board (CIRB) of SingHealth.
2. Obtain permission from the hospital’s ethics committee and the Nurse Managers of the involved wards.
3. Obtain Written consent from the participants after detailed information about the study is explained by the researcher.
Protect participants' privacy at all times.

Ensure participants' confidentiality.

Maintain anonymity.

Ensure that any data collected from the participants will not be identified by their Nurse Managers.

Participants are free to drop out of the study at any point of time during the interview.

The analysed data may be used as part of publications related to this study.
Nursing implications
This study would then prove if nurses need any additional training on identification and assessment of pain in elderly patients with dementia.

It would also illustrate their perceptions of pain itself.

Encourage nurses to improve nursing assessment.
Small group of participants
Cannot be generalised
Does not represent the perception of nurses in other areas of care
Budget Resources
...and we're
Abbey, J., Piller, N., De Bellis, A., Esterman, A., Parker, D., Giles, L., & Lowcay, B. (2004). The Abbey Pain Scale: A 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing, 10(1), 6-13.

Bertrand, S. (2012). Registered nurses integrate traditional Chinese medicine into the triage process. Qualitative Health Research, 22, 263-273.

Brown, S.T., Kirkpatrick, M.K., Swanson, M.S, & McKenzie, I.L. (2011). Pain experience of the elderly. The American Society for Pain Management Nursing, 12(4), 190-196.

Burns, N., & Grove, S. K. (2011). Understanding nursing research: Building an evidence based practice. (5th ed.). Missouri: Elsevier Saunders.

Chang, S. O., Oh, Y., Park, E. Y., Kim, G. M., & Kil, S. Y. (2011). Concept analysis of nurses’ identification of pain in demented patients in a nursing home: Development of a hybrid model. Pain Management Nursing, 12(2), 61-69.

Closs, S. J., Barr, B., Briggs, M., Cash, K., & Seers, K. (2004). A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. Pain Symptom Manage, 27(3), 196-205.

Cohen-Mansfield, J. (2008). The relationship between different pain assessments in dementia. Alzheimer Disease & Associated Disorders 22, 86–93.

Dearney, C. (2005). A reflection on the use of semi-structured interviews, Nurse Research, 13(1), 19-28.

Fuchs-Lacelle, S., & Hadjistavropoulos, T. (2004). Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Management Nursing, 5(1), 37-49.

Fossey, E., Harvey, C., McDermott, F., & Davidson, L. (2002). Understanding and evaluating qualitative research. Australian and New Zealand Journal of Psychiatry, 36, 717-732.

Herr, K. A., Spratt, K., Mobily, P. R., & Richardson, G. (2004). Pain intensity assessment in older adults: Use of experimental pain to compare psychometric properties and usability of selected pain scales with younger adults. The Clinical Journal of Pain, 20(4), 207-219.

International Association for the Study of Pain. (2012). IASP Pain Terminology. Seattle: IASP Press.

Kaasalainen, S. (2007). Pain assessment in older adults with dementia. Journal of Gerontological Nursing, 33(6), 6-10.

Kenefick, A. L., & Schulman-Green, D. (2004). Caring for cognitively impaired nursing home residents with pain. International Journal for Human Caring, 8(2), 32-40.

Kjallman Alm, A. K., & Norbergh, K. G. (2013). Nurses’ opinions of pain and the assessed need for pain medication for the elderly. Pain Management Nursing, 14(2), e31-e38

Lin, P. C., Lin, L. C., Shyu, Y. I., & Hua, M. S. (2010). Predictors of pain in nursing home residents with dementia: A cross-sectional study. Journal of Clinical Nursing, 20, 1849-1857.

Marzinski, L. R. (1991). The tragedy of dementia: Clinically assessing pain in the confused nonverbal elderly. Journal of Gerontological Nursing, 17(6), 25-28.

McAuliffe, L., Nay, R., O’Donnell, M., & Fetherstonhaugh, D. (2009). Pain assessment in older people with dementia: literature review. Journal of Advanced Nursing 65(1), 2-10.

McCaffery, M. (1979) Nursing management of patient with pain (2nd ed.). Philadelphia: Lippincott.

Polit, D. F., & Beck, C. T. (2010). Essentials of nursing research: appraising evidence for nursing practice. (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Warden, V., Hurley, A. C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale. Journal of the American Medical Directors Association, 4, 9-15.

While, C., & Jocelyn, A. (2009). Observational pain assessment scales for people with dementia: A review. British Journal of Community Nursing, 14(10), 438-442.

World Health Organization (WHO). (2012). Dementia: A public health priority. United Kingdom: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream /10665/75263/1/9789241564458_eng.pdf.

The researchers propose to carry out this study with hopes of raising awareness of the challenges associated to the identification and assessment of pain.
Through this awareness, the current pain assessment techniques should be reassessed and in turn, new practice may be developed to promote best practice in the clinical settings.
It is visioned that the findings of this study will encourage the delivery of new and improved nursing practice in the geriatric unit.
Research Aim
to raise awareness of under-recognition of pain in elderly with dementia.
to assess nurses’ knowledge of pain in elderly
to investigate nurses’ perceptions and opinions about pain in elderly
our ultimate goal is to change nurses’ perception under-recognition and under-treatment of pain in elderly.
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