Achieving dignity for older people with dementia in hospital

The quality of care for people with dementia in general hospital settings has attracted widespread concern. While organisation-wide strategies are needed to address many of the issues, the nursing role is critical to articulating and promoting good practice. This article focuses on promoting dignity for older people with dementia and offers a number of strategies to help individual nurses and nursing teams reflect on and promote good practice.     

Understanding Nurses’ Knowledge and Attitudes Toward Pain Assessment in Dementia: A Literature Review

BackgroundPain is underrecognized and undertreated in patients with dementia. It has been suggested that nurses’ attitudinal barriers may contribute to the challenges surrounding pain assessment and management in dementia.AimsThis integrative literature review aims to identify and explore nurses’ knowledge and attitudes towards pain assessment in older people with dementia and how it may affect pain management in this patient group.MethodElectronic searches were conducted in Web of Science, MEDLINE, Scopus, ProQuest, PubMed, and EBSCOhost from January 2008 to December 2018 for articles specifically focusing on nurses’ knowledge and attitudes towards pain assessment in older patients with dementia.ResultsTen studies were included in the review after meeting the inclusion criteria. Data extracted from each study included study design, aims and objectives, setting/sample, findings, and limitations. Patients with dementia are at greater risk of experiencing underassessment, undertreatment, and delayed treatment of pain due to nurses’ knowledge deficits and uncertainty in the decision-making process. Nurses see providing comfort and reducing pain as ethical obligation. However, they find pain assessment a challenge due to the complexity of recognizing painful behaviors, and difficulty differentiating between pain and behavioral disturbances in dementia. Poor multidisciplinary communication, time constraints, and workload pressure, as well as uncertainty about opioid use, are important barriers to effective pain assessment and management among patients with dementia.ConclusionIt is essential that nurses gain confidence in distinguishing signs and symptoms of pain from behavioral changes in dementia. It is important to improve interdisciplinary communication and to get physicians to listen and prioritize pain assessment and management.     

Addressing incontinence for people with dementia living at home: a documentary analysis of local English community nursing service continence policies and clinical guidance

Aim and objectives. To establish whether the problems and issues experienced by people with dementia living at home and their carers were addressed in the clinical guidance for continence management for community nursing services in England. Background. Internationally, the numbers of people with dementia are rising. Managing incontinence is a significant issue as the presence of incontinence is one of the triggers for people with dementia to move their residence to a care home. People with dementia living at home and their family carers report difficulties in accessing knowledgeable professionals and acceptable continence products. Design. A review by documentary analysis of clinical policies and guidance from a sample of community nursing services in all Strategic Health Authority regions of England. Methods. A sample of clinical policy and guidance documents for continence assessment and management from up to four community nursing services in each of the ten Strategic Health Authority regions in England was sought. Documentary analysis was undertaken on the relevance of the documents identified for people with dementia living at home. Findings. Ninety‐eight documents from 38 local community nursing services spread across ten Strategic Health Authority areas were obtained and analysed. Only in the documents of three services were nurses offered detailed guidance about the management of incontinence for people with dementia at home. In the documentation of only one service were people with dementia identified as a special case which warranted the provision of additional continence products. Conclusion. Clinical guidance on continence assessment and management for community nurses in many parts of England does not address the specific needs of people with dementia living at home or their carers. Relevance for clinical practice. Nurses working in community settings and those providing clinical leadership in continence care should review their clinical guidance and policies to ensure relevance for people with dementia living at home and their family carers.     

Peer review in nursing and midwifery: a literature review

Aims and objectives. The Clinical Education Project investigated clinical education in nursing and midwifery settings. The aim of this phase was to investigate and evaluate the processes and outcomes of clinical assessment of preregistration nurses and midwives, focusing on the assessment interview, and to evaluate the feasibility of introducing peer review of the clinical assessment interview in acute clinical settings. Background. Peer review is common in many professional areas. The literature describes various applications of peer review and makes recommendations for its use. However, there is a shortage of studies investigating the use of peer review in nursing and midwifery education and practice. Design. The project involved a systematic literature review and a qualitative exploratory study. This article describes the first part of the study: a systematic literature review of peer review. The second part of the study is reported elsewhere. Methods. The systematic literature review investigated international articles written since 1994 that contained information on peer review in pre/post registration nursing and midwifery within higher education or practice. Results. From the available literature, 52 specific initiatives were analysed. The majority of articles originated in America and involved nursing staff working in secondary care settings. Fifty‐one articles had missing information varying from not stating the sample size to not including information about evaluations. Conclusions. The literature review found that whilst peer review is commonplace in nursing and midwifery practice, there is a lack of robust literature about its use. Relevance to clinical practice. Peer review in clinical settings such as nursing and midwifery can facilitate the sharing of good practice and personal and professional growth. It allows participants to learn from each other and gain insight into their development.     

A literature review exploring how healthcare professionals contribute to the assessment and control of postoperative pain in older people

Little research has examined the care older people receive in the acute surgical setting. Although pain assessment and management are judged to be a priority in nursing, often pain, in older people, is undermanaged for a variety of reasons. Factors such as stoicism, communication and ageism can shape both the patients’ and nurses’ attitude towards the perception of pain which subsequently affects pain management. Through a review of the literature, this paper aims to: (i) identify how healthcare professionals contribute to the assessment and control of postoperative pain in older people and (ii) explore potential barriers to achieving more advantageous pain control in this group. It is suggested that to improve pain management there is a need to individualize pain assessment for older people and to assist clinicians with enhancing their education and decision‐making abilities in this field. This may best be achieved by supporting a programme of change to develop the skills of staff and encouraging learning through reflective practice. There is however a need for further research in this area.     

Cancer care in nursing homes

OBJECTIVES: To review the available scientific literature on cancer care in nursing homes and recommendations for clinical practice and further research are offered. DATA SOURCES: Research studies and review articles. CONCLUSION: Overlooked issues for older adults with cancer in nursing homes include screening, treatment, and symptom management. Cancer care and survivorship in nursing homes receives little direct attention. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses can improve cancer care and survivorship in nursing homes by considering nursing homes as a practice venue.     

Nurses’ pressure ulcer related judgements and decisions in clinical practice: A systematic review

BackgroundPressure ulcers are considered to be an adverse outcome of care that should never occur in clinical practice. The formation of a pressure ulcer is also perceived to be an indicator of poor quality nursing care. Therefore, pressure ulcer prevention is a priority for nurses, healthcare professionals and healthcare organisations throughout the world. A key factor in pressure ulcer prevention and management is individual nurse decision making.ObjectivesTo synthesise the literature on the judgement and decision making of nurses in relation to the assessment, prevention, grading and management of pressure ulcers in all care settings (hospital and community).DesignA systematic search of published literature relating to judgement and decision making in nurses, with a focus on the prevention and management of pressure ulcers.MethodsA search of electronic databases from 1992 to present, together with hand searching of the reference lists of retrieved publications, to identify published papers that reported results of studies evaluating the decision making of nurses in relation to the prevention and management of pressure ulcers. Abstracts were independently reviewed by two authors and full text of potentially relevant articles retrieved. Each paper included in this systematic review was evaluated using recognised appraisal criteria relevant to the specific study design. Included papers provided empirical data on key aspects of nurses’ pressure ulcer related judgements and decision making. Data were synthesised into themes using narrative analysis.ResultsSixteen studies and one systematic review were included in the review, focusing on pressure ulcer risk assessment, pressure ulcer prevention, grading of pressure ulcers and treatment decisions. The results indicated that assessment tools were not routinely used to identify pressure ulcer risk, and that nurses rely on their own knowledge and experience rather than research evidence to decide what skin care to deliver.ConclusionsEmphasising pressure ulcer risk assessment and pressure ulcer grading in clinical practice is unlikely to deliver improved outcomes. Further research into nurses’ pressure ulcer related judgements and decision making is needed and clinicians must focus on the consistent delivery of high quality care to prevent and mange pressure ulcers to all patients in clinical practice.     

某三级甲等医院护士疼痛评估循证护理实践现状调查及影响因素分析

目的探讨护士疼痛评估循证护理实践现状及影响因素。方法采用护士疼痛评估循证护理实践问卷对某市三甲综合医院242名护士进行调查。结果护士疼痛评估循证总分为(95.21±23.12)分,其中疼痛筛查维度得分最高(14.69±2.77)分,疼痛评估中的交流维度得分最低(19.42±6.40)分。多元回归分析显示,护士角色、科室存在开展疼痛评估循证护理的障碍、科室建立制度或规范是影响护士疼痛评估循证护理实践的主要因素(P<0.05)。结论护士疼痛评估循证护理实践水平较高;护理管理者应制订疼痛评估循证护理制度,加强护士疼痛管理相关培训,保障疼痛评估循证护理工作的开展。     

Nursing assessment and management of nutrition in older people with cancer: An integrative review

BackgroundThere is a risk of malnutrition when older people are diagnosed with cancer, highlighting the need for nutritional assessments and appropriate management to be undertaken by healthcare professionals including nurses. The absence of a standardised assessment method and management of nutrition in older people creates a gap in clinical practice and warrants further research.AimThe aim of this review was to explore the current nutritional assessment methods and evidence-based interventions for improving nutritional outcomes in older people with cancer.MethodsAn integrative literature review was conducted using electronic databases. Papers were limited to those published in English between 2009 and 2021. Search terms included older adult, elder, geriatric, senior, cancer, nutrition, malnutrition, hospital, and inpatient across four databases: Embase, CINAHL, MEDLINE, and Scopus. Using the inclusion and exclusion criteria, 303 articles were screened. A Mixed Methods Appraisal Tool (MMAT) (2018) was used for quality appraisal. Concept analysis explored themes across the included articles.FindingsThe themes from the analysis of 10 primary research articles, which included 5,327 participants, were (i) types of nutritional assessment and (ii) management of older people with cancer. The main nutritional assessment scales used were the Mini Nutrition Assessment and Patient-Generated Subjective Global Assessment.ConclusionThe completion of a comprehensive nutritional assessment by health professionals, including nurses, could facilitate early dietary intervention in older persons with cancer. This would enable supportive dietary advice and supplementation to improve health outcomes.     

Postoperative pain in older people: a review of the literature

Aims and objectives. The literature review was conducted to explore those factors which complicate pain management in older people to inform future research, education and nursing practice in this area. Background. Acute pain management in hospitalized older people is complex because of the physiological changes of ageing, pharmacological factors and under‐representation of this patient group in reported research about assessing acute pain. Methods. A review of the literature was undertaken using electronic databases and specified search terms, some hand searching was also used and included the grey literature, textbooks and conference proceedings. A computerized literature search was carried out using CINAHL, Bandolier, Cochrane, Medline, the British Nursing Index and the International Association for the Study of Pain website for the period 1992–2004. The search terms were acute pain, older people, elder care, pain assessment and acute pain services. Thirty‐seven research‐based reviews and published studies and 17 policy documents were included. Conclusions. Managing acute pain well in older adults involves understanding the influence of a series of integrated factors: attitudes and beliefs, physiological ageing processes, pharmacological factors and the social construction of the older person in healthcare contexts. Relevance to clinical practice. This review offers new insight into those factors which, taken together, add complexity to managing acute pain in older people well. Moreover, nurses are the professional group mainly responsible for assessing pain, administering and now prescribing analgesia and evaluating the quality of pain relief in older people. On this basis, they are also the group most likely to effect improved patient outcomes.     

Effect of Pain Education Interventions on Registered Nurses’ Pain Management: A Systematic Review and Meta-Analysis

ObjectivesThis review and meta-analysis aims to reveal how pain education interventions affect registered nurses’ pain management.DesignA systematic review and meta-analysisData sourcesPubMed, Scopus, CINAHL (EBSCOhost), and ERICReview methodsA systematic search of four electronic databases was conducted to identify relevant peer-reviewed English or Finnish-language articles published between 2008 and 2021. The review included a quality appraisal and a meta-analysis of articles providing group-level data before and after the intervention (n = 12). The methods followed the PRISMA guidelines.ResultsOverall, 23 articles met the inclusion criteria for the review, of which 15 were evaluated as good quality. Based on the articles on document audits (n = 10), pain education interventions reduced the risk of not receiving the best pain management by 40%, whereas based on the articles on patients’ experiences (n = 4), they reduced the risk by 25%. The study quality and design of these articles were considerably heterogenous.ConclusionsPain education study strategies varied widely among the included articles. These articles used multivariate interventions without systematization or sufficient opportunity to transfer the study protocols. It can be concluded that versatile pain nursing education interventions, as well as auditing of pain nursing and its documentation combined with feedback, can be effective to nurses in adapting pain management and assessment practices and increasing patient satisfaction. However, further research is required in this regard. In addition, well-designed, implemented, and reproducible evidence-based pain education intervention is required in the future.     

Optimising nutrition for older people with dementia

This article explores interventions that can be undertaken to establish and maintain adequate nutritional intake in older people with dementia. This is often a problem, particularly in the later stages of the disease. A literature review was conducted, which identified 12 articles for inclusion. Most of these articles described interventions to maintain adequate nutritional intake in older adults with dementia. Although no standardised intervention was reported, some approaches did appear to be more successful than others. Further research is required on how nurses and nursing assistants can help older people with dementia to maintain adequate nutrition. Staff need more time and training to improve nutritional intake in this group of patients. In addition, enhanced vigilance with respect to eating difficulties and food consumption is necessary.     

Observation: the original sin of mental health nursing?

The assessment and management of 'risk' has become a focal aspect of contemporary mental health practice. Given their proximal relationship with service users, nurses most often represent the 'front line' of risk management, typically expressed in hospital settings through the bureaucratic process of 'observation'. Much of the available 'evidence' is highly critical of this practice and service user researchers, in particular, have repeatedly called for alternatives. This paper reviews the historical and inter-professional dimensions of the practice of observation, contrasting this with mental health nursing's search over the past two decades, at least within the UK, for professional autonomy. Contemporary mental health nursing is trapped in an anachronistic relationship with psychiatric medicine. If nursing is to prosper, nurses must address the complex issues underlying this inter-professional relationship. The authors describe the development of 'bridging'--a radical alternative to observation practice, which represents a means of managing 'risk' and a way that nurses might develop their interpersonal relationships with people deemed to be at risk, thereby asserting the power of 'caring'.     

Assessment and management of pain in older patients receiving palliative care

This article aims to outline the principles that underpin good practice in the assessment and management of pain syndromes in older patients with advanced, life-limiting illnesses. Older patients receiving palliative care can be nursed in a variety of settings, including acute hospitals and in the community either at home, in nursing homes or hospices. An understanding of pain and approaches to treating it will help ensure that nurses in different clinical settings are able to support patients receiving palliative care and their families.     

Facilitators and barriers in implementing clinical nursing assessment in mental health care for older people: A multimethod approach

With the aging of the population and the growing prevalence of dementia, specialized and collaborative nursing care is paramount in this area. To ensure better quality care, it is necessary to use effective and context‐specific processes to implement evidence‐based practices and more specifically clinical nursing assessment. This study aimed to identify and describe factors that may influence the implementation of clinical nursing assessment in mental health care for older people. The Consolidated Framework for Implementation Research was employed to guide evaluation in the pre‐implementation phase in the specific context of mental health care for older people. Using a multimethod approach, interviews, focus groups, and a quantitative survey were conducted with a non‐probability convenience sample. A total of 39 hospital nurses (registered nurses and head nurses) were interviewed. Analysis yielded five main factors, notably three barriers and two facilitators. Barriers include a lack of general nursing culture, deficiencies in leadership, and difficulties in communication and collaboration. Facilitators comprise team cohesion and the perceived benefits of the study.     

A pain monitoring program for nurses: effects on communication, assessment and documentation of patients' pain

Nurses need to be informed about the patient's pain to be able to take appropriate measures to alleviate pain. However, communication, assessment, and documentation of pain by nurses is often a problem for hospitalized patients. In this study we aimed to overcome the main barriers by developing, implementing, and evaluating a Pain Monitoring Program (PMP) for nurses. The PMP consists of two components: educating nurses about pain, pain assessment and pain management; and implementing daily pain assessment by means of a numeric rating scale. We describe the effects of the PMP on communication about pain between nurses and patients and between physicians and patients, agreement between patients' pain intensity and nurses estimations of patients' pain intensity, and documentation about pain in the nursing records. Factors that might influence communication, assessment, and documentation are also discussed. The effects of the PMP were measured in a quasi-experimental design with a nonequivalent control group. In total, 703 patients participated: 358 patients in the control group and 345 in the intervention group. Results of the control group showed that communication about pain between nurses and patients, agreement between patients' and nurses pain ratings, and documentation about pain in nursing records, remain inadequate. Patients' pain intensity and age were related to communication, assessment, and documentation. Communication and documentation is better in patients with moderate to severe pain than in patients with mild pain, and assessment is better in patients with mild pain. Older patients communicate less with nurses and physicians about pain, and nurses document less about pain in nursing records for older patients compared with younger patients. The PMP proved to be effective in improving nurses' assessment of patients' pain and documentation about pain in nursing records. Patients' pain intensity and care setting were related to the efficacy of the PMP. Communication about pain between patients and nurses, and between patients and physicians did not improve as a result of the PMP. Based on this study it can be concluded that in using a simple method such as the numeric rating scale, together with an education program, attention is focused in a systematic way on patients' pain complaints and creates a common language between patients and nurses. Because the PMP proved effective in a heterogenous population in multiple care settings, it is recommended to implement the PMP in nursing practice.     

The Experiences of Clinical Academic Nurses: A Meta-Aggregation

ObjectiveHistorically, clinical academic careers were only available for dental and medical professions. The title of a clinical academic nurse is recognized as a role that concurrently engages in both clinical practice and research. This systematic review aimed to synthesis qualitative evidence to understand the experiences of clinical academic nurses.Data SourcesA meta-aggregation systematic review was conducted. Key search terms were used in CINAHL and MEDLINE. The review has been reported according to ENTREQ checklist. This meta-aggregation review followed the principles from Joanna Briggs Institute (JBI) and the reviewers conducted a methodological quality assessment on all included studies. Qualitative studies which explored experiences of clinical academic nurses were included.ConclusionA total of 2,202 articles identified five studies met the inclusion criteria. Five synthesized findings from the included qualitative studies, related to (i) clinical academic preparation, (ii) challenges, (iii) enablers, (iv) clinical practice, and (v) role expectation of clinical academic nursing roles. The meta-aggregation has identified that although there are numerous clinical academic nursing discussion articles, commentaries, and editorials on the topic area, few empirical studies have explored the perceptions and experiences of clinical academic roles in nursing.Implications for Nursing PracticeThis systematic review has highlighted the variety of reported experiences of clinical academic nursing in relation to implications for practice, research, and leadership. Clinical academic roles are being developed across the nursing professions outside of medicine, and effective leadership it is important to support sustainable career pathways and curricula and to enable the evaluation of these roles. This review has made an important contribution to the literature by highlighting several issues to consider in developing and safeguarding the progress already made in clinical academic nursing career pathways.     

Understanding Nurse Characteristics that Influence Assessment and Intention to Treat Pain in Postoperative Patients: An Integrative Literature Review

ObjectivesAn understanding of nurse characteristics that influence pain management, which are potentially amenable to change, can help to refine and improve nurse education and practice, resulting in better patient outcomes. The purpose of this review was to identify nurse characteristics that influence their assessment of and intention to treat postoperative pain.DesignIntegrative literature review.Data sourcesA systematic search of electronic databases (CINAHL, Scopus, PsycINFO, Medline, and Embase), using these constructs “pain assessment”, “pain management”, “postoperative pain”, “nurses”, “cultural beliefs” and “nurses’ perceptions” was conducted for the period 2000 to October 2020.Review/Analysis methodsFollowing a systematic screening process, the included articles were analyzed and synthesized to identify themes and subthemes.ResultsA total of 40 articles were included with three main themes identified: nurse knowledge; nurse sociocultural factors, personal beliefs and attitudes, and other characteristics; and believing or doubting the patient. There was evidence that targeted education interventions can improve nurse knowledge and nurses’ clinical practice in relation to pain management. What was less clear was which nurse attitudes and biases influenced their pain management practice or how these could be changed.ConclusionsMore studies are needed to investigate the influence of cultural characteristics on pain assessment and management. There is a need for further quantitative studies that explore the relationship between nurse characteristics and their pain management practice. Intervention studies using innovative educational approaches that change attitudes and biases, and improve practice are needed.     

Evidence-based assessment of acute pain in older adults: current nursing practices and perceived barriers

OBJECTIVES: To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population. METHODS: Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults. RESULTS: Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain. CONCLUSIONS: Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.