| | Concept Analysis of Nurses' Identification of Pain in Demented Patients in a Nursing Home: Development of a Hybrid ModelReceived 25 October 2009; received in revised form 16 May 2010; accepted 26 May 2010. published online 26 July 2010.
Corrected Proof Abstract Pain is a subjective feeling, with no known biologic markers. Proof of its presence and measurement of intensity rely entirely on self-reporting by the patient. The hampered or abrogated ability of demented patients to report their pain is a major difficulty in pain assessment and management. The purpose of this study was to clarify and conceptualize pain identification in demented patients by nurses. The hybrid model of concept development was used in the development of a conceptual structure of pain in demented patients. Data were collected by literature review (theoretical phase) and among nurses caring for demented patients in three nursing homes in South Korea (fieldwork phase). The 13 nurses involved each reported >3 years' nursing home experience. In a hybrid model, pain identification in demented patients by nurses constituted an active daily process of integrating patient expressional cues during periods of pain and pain relief and involving three dimensions: identification schemes based on the stage and type of dementia, connecting assessments after each intervention, and cognitive efforts to establish the origin of pain. Identification of pain in demented patients by nurses is a complex process. More research is needed to formulate an assessment tool and pain management strategies for patients with dementia. Pain is a serious problem among frail elderly people. Deconditioning, gait disturbances, falls, slow rehabilitation, polypharmacy, cognitive dysfunction, and malnutrition are among the many common geriatric conditions that are potentially worsened by the experience and treatment of pain (Ferrell et al., 1995, Horgas and Elliott, 2004). However, pain is a subjective feeling, with no known biologic markers. Proof of its presence and measurement of its intensity rely entirely on self-reporting by the patient. A major difficulty in assessing and managing pain in the presence of advanced dementia is the inability of these patients to self-report their experience of pain (Gabre and Sjoquist, 2002, Molony et al., 2005). Nevertheless, observational data from nursing home patients with advanced dementia and data from subjects with mild-to-moderate dementia suggest that dementia does not alter the fundamental experience of pain (Cohen-Mansfield & Lipson, 2002). However, patients with dementia are often unable to express pain adequately, recall a painful episode that may have occurred earlier, request analgesics, or operate patient-controlled analgesia pumps (Morrison and Siu, 2000, Scherder et al., 2003). Identifying and managing pain in the context of dementia is difficult. The consequences of unidentified or poorly treated pain are many and include exacerbation of preexisting cognitive dysfunction, development of depression, possible inhibition of immune function, and the worsening of medical conditions (Abbey et al., 2004). For individuals who have no ability to report pain, an outside observer must describe the discomfort by interpreting the patient's body language (Gabre and Sjoquist, 2002, Molony et al., 2005). A factor contributing to lack of pain treatments for cognitively impaired patients has been a lack of appropriate tools to help recognize and document pain (Abbey et al., 2004). Despite the preponderance of research on pain, relatively few investigations have focused on pain in older adults in general or on people with dementia in particular. Practitioners must be knowledgeable about pain treatment and use both pharmacologic and nonpharmacologic strategies to relieve pain. Moreover, clinicians must be aware of the barriers to effective pain management and work to overcome them. In doing so, practitioners must be knowledgeable about pain identification in patients with dementia (Horgas and Elliott, 2004, Molony et al., 2005). Little is known about behavioral pain indicators for this population, and health care workers and patient caregivers may not recognize behavioral pain cues. The phenomenon of pain in cognitively impaired elders is not well understood (Epps, 2001, Molony et al., 2005). It is important that nurses be aware that cognitively impaired elders may not experience or express their pain in a manner similar to younger people. Although it has been suggested that elders with cognitive impairment do not experience pain, this idea has not been adequately demonstrated. No single pain assessment instrument has been shown to effectively detect pain in this population, therefore nurses must use considerable skill to ascertain and alleviate needless suffering in cognitively impaired elders. The assessment of pain in the cognitively impaired and institutionalized elder relies on the nurse's ability to detect pain cues. Nurses working with these elders must have well developed pain assessment skills. Nurse administrators must ensure that pain assessment education is available to those providing direct patient care and that the possible presence of pain is assessed regularly (Epps, 2001, Molony et al., 2005, Scherder and Bouma, 2000). To develop effective pain management to detect and manage the pain of patients with dementia, the phenomena of pain identification in cognitive-impaired patients within nursing contexts should be explored. To clarify and conceptualize the phenomenon of nurses' pain identification in demented patients within nursing contexts, the following questions were addressed by the present study: 1.What are the characteristics of pain identification in demented patients within the nursing context? 2.What are the attributes of pain identification in demented patients by nurses? 3.What is the structure of pain identification in demented patients by nurses? Methods  The three phases of the concept development (theoretical, fieldwork, and analytic phases) were studied by using a hybrid model that was oriented toward developing concepts through a qualitative investigation of phenomena that occurred during participant observation and interviews (Schwartz-Barcott, Patterson, Lusardi, & Farmer, 2002). The study was approved by the Ethical Review Board of Korea University (KU-IRB-09-01-P-1). The purpose of the study was explained to subjects, who were also informed that participation was voluntary. Subjects were assured that the information they provided would remain confidential. Findings 1. Theoretical Phase: Review of the Literature A concept is a complex mental formulation. Concept clarification requires a thoughtful and systematic process, for which a literature review is central. Appropriately, we conducted a PubMed search using the terms “pain,” “dementia,” and “assessment.” The intent was to investigate the existing knowledge about nurse-related pain identification in demented patients to delineate a working definition to initiate the fieldwork phase. The dictionary definition of pain comprises physical and mental aspects. Physical pain is defined as the feelings experienced in the body. Mental pain is defined as emotional or mental sufferings, or particular experiences of this suffering. The dictionary definition of identification is “the act or process of recognizing something” (Longman Corpus Network, 1995). Therefore, pain identification in patients with dementia can be considered to be the act or process of recognizing the physical and emotional sensations associated with pain. The aim of the present analysis of pain identification in patients with dementia was to develop pain management strategies that relied on the effective detection of pain by the attending nurses. The review of the literature revealed three distinct dimensions for the concept of pain identification in demented patients by nurses: categorizing patients, an assessment involving circular steps dealing with both pain management and identification, and cognitive efforts aimed at identifying the possible origins of pain. The literature review led to the identification of seven defining attributes for how health team members, including nurses, identify pain in patients with dementia. Categorizing Patients in Dealing with Pain Declining Verbal Expression of Pain with Cognitive Decline The reporting of pain decreases as cognitive impairment increases. In addition, poor verbal skills lead to difficulties in communicating pain (Gabre and Sjoquist, 2002, Pradines and Pradines, 2004). Pain assessment in patients with dementia should start with a self-report of pain (Horgas & Elliott, 2004). However, for individuals who have no ability to report pain, an outside observer must describe the discomfort experienced by interpreting the body language of the patient (Gabre & Sjoquist, 2002). The need-driven dementia-compromised behavior model indicates that dementia-related behavior occurs because of an inability of the caregiver to comprehend the needs of the afflicted person and an inability to make these needs known. Behaviors are seen as attempts to communicate physical or mental distress when the needs are not met (Kovach et al., 2005, Pradines and Pradines, 2004, Schwartz-Barcott et al., 2002). Self-report and observational measures of pain are examined from the perspective of a model of human communication. This model examines the experience of pain as affected by intrapersonal and contextual factors, in a process where it is encoded into expressive behavior (Gabre and Sjoquist, 2002, Hadjistavropoulos and Craig, 2002). Both observational and self-report measures are essential in the assessment of pain because of the unique information that each type contributes (Hadjistavropoulos & Craig, 2002). Differences Due to Type of Dementia To examine whether a change in the perception of qualitative and quantitative aspects of pain is typical for a specific type of dementia, differentiation between the various types of dementia is required (Sherman, 2003). It is apparent that differences exist in the expression of pain according to the type of dementia. For example, compared with the nondemented elderly, Alzheimer dementia (AD) patients experience less quantitative intensity of pain and suffer qualitatively less pain (Bathgate, Snowden, Varma, Blackshaw, & Neary, 2001). The same study found no change in AD patients, compared with nondemented elderly, in the threshold level of nociceptive stimuli, whereas the level of tolerance to experimentally induced pain increased. In contrast to AD, vascular dementia (VD) might lead to an increase in pain experience due to deafferentiation. Indeed, it has been observed that VD patients use about three times as many analgesics as AD patients (Crystal et al., 2000). It has been hypothesized that patients with “possible” VD would indicate experiencing more pain intensity and pain affect from commonly occurring painful conditions such as arthrosis/arthritis more than elderly people with a normal mental status, and that patients with cerebrovascular dementia report experiencing more pain from common painful conditions more than the elderly without dementia (Scherder et al., 2003). Assessment Mode: Circular Steps Dealing with Management and Identification of Patient Pain Identifying Antecedents and Consequences The literature review revealed that the preparations of nurses for pain identification are circular and include antecedents and consequences (Kovach, Noonan, Griffe, Muchka, & Weissman, 2002). Antecedents are those events or incidents that must occur before the occurrence of the concept. Consequences are those events or incidents that occur as a result of the occurrences of the concept (Walker & Avant, 2005). Scherder and Bouma (2000) suggested that the preparations of nurses for pain identification and the ability of the patient to express pain include nonverbal and verbal responses about pain, and that any type of expression of pain can be both antecedent and consequence of pain identification in patients with dementia. According to Kovach et al. (2002), pain identification in patients requires several steps, and at each step knowledge about comprehension of pain scale, physical assessment skills to detect pain, general knowledge related to the causes of pain in the elderly, use of analgesics, and monitoring skills to detect signs of relieving pain from behavioral symptoms are antecedents in the aspects of nurses' preparations. Moreover, this awareness of pain identification of patients with dementia would aid other aspects of nursing care. Expression of pain by a patient prompts the cycle of pain identification and intervention steps, and the changed pattern of the patients' expression of pain can be a consequence of pain identification of patients with dementia (Kovach et al., 2002, Molony et al., 2005). Comparison of the Pain Expression of Patients with Their Habitual Behavioral Patterns Most older people suffer from chronic pain from musculoskeletal sources, which causes suffering from chronic pain (Ferrell et al., 1995), most commonly due to osteoarthritis. To avoid pain, the affected person may need to stop doing physical activities, change his/her gait pattern, and, eventually, use assistive devices. Avoidance of activity is an adaptive response to pain, and older adults are less active than their younger counterparts (Seomun, Chang, Lee, Lee, and Shin, 2006). Weiner, Peterson, Ladd, McConnell, and Keefe (1999) found that nursing home nurses identified lying down as a pain indicator. These studies suggested that inactivity may be an indicator of pain in elders with dementia. Disruptive behaviors may be a response of elders with dementia who cannot express their pain. Therefore, among severely cognitively impaired elders, disruptive behaviors such as agitation, verbal abusiveness, and aggression have been identified as pain indicators (Kovach et al., 2005, Pradines and Pradines, 2004). Cognitive Identification of the Possible Origins of Pain Response Due Mainly to Acute Pain The somatic sensory cortical areas are preserved in AD, which preserves a person's ability to experience acute painful stimuli (Snow et al., 2004). Scales for measuring pain are useful for identifying factors that trigger acute episodes or exacerbations of pain or for identifying the effects of specific treatments (Wynne, Ling, & Remsburg, 2000). Biobehavioral responses (heart rate, respiratory rate, sinus arrhythmia, self-reported anxiety, and pain and facial expression) can be used to measure acute pain in patients with varying degrees of dementia compared with healthy individuals (Manfredi, Breuer, Meier, & Libow, 2003). Accounting for Basic Underlying Pathology Pain is common in elderly people, and requires skilled nursing home care. The majority of the elderly in both community and institutional settings experience significant pain problems, with arthritis being the most common underlying cause (Mann, Tomita, Hurren, & Charvat, 1999). These authors suggested that to identify the pain in demented patients, nurses should first conduct a physical assessment to look for physical causes of discomfort and then review the patient's history for potential causes of the present pain, such as an old fracture site. The assessment is comprehensive and takes into account basic underlying pathologies, such as osteoarthritis, osteoporosis, and cancer (Kovach et al., 2002, Weiner and Hanlon, 2001). Identifying Other Contributing Pathologies The impact of pain depends on the specific ways that a person deals with, adjusts to, and reduces or minimizes pain and the distress caused by the movements (Kovach et al., 2002, Melanson and Downe-Wamboldt, 2003). Weiner and Hanlon (2001) suggested that assessment should be comprehensive and should consider other contributory pathologies, such as muscle spasm and myofascial pain. Combining Modifying Co-morbidities As dementia progresses and verbal skills diminish, caregivers and medical staff are forced to rely increasingly on nonverbal/behavioral cues of physical and emotional pain (Frampton, 2003). Kovach et al. (2002) suggested that nurses should conduct an affective assessment to identify factors contributing to mood changes in assessing pain. Behaviors associated with pain in the elderly are not likely to be overt and may instead be quite subtle. Excess sleep resulting from exhaustion secondary to pain could be disregarded if not carefully and specifically looked fort (Morrison & Siu, 2000). Factors influencing coping strategies are mood, religious belief, perceived control over pain, role of interpersonal relationships, and the level of functional deterioration, with perceived helplessness being a dimension that is closely related to the perceived control over pain (Sherman, 2003). Modification of comorbidities such as depression, anxiety, fear, and sleep disturbance must be considered in pain assessment (Kovach et al., 2002, Weiner and Hanlon, 2001, Zieber et al., 2005). Defining Attributes for Pain Identification in Demented Patients The literature review led to the identification of three defining attributes concerning the identification of the pain of patients with dementia. As the first attribute, patients can be categorized in dealing with pain, keeping in mind the declining verbal expression for pain as deterioration advances, and considering the differences due to the specific types of dementia. The second attribute is the assessment mode, which comprises circular steps dealing with both managing and identifying the pain. This attribute involves the identification of antecedents and consequences, and comparing the pain expressions of patients with their habitual behavioral patterns. The third attribute is cognitive identification of the possible origins of pain and involves the perception of an observable response, mostly coming from acute pain, taking into account the basic underlying pathology and combining modifying comorbidities. 2. Findings of the Fieldwork Fieldwork was performed to clarify and specify the meanings and characteristics of pain identification in demented patients by nurses using in-depth interviews. The 13 nurses each had >3 years' nursing home experience. The subjects were sampled from three nursing homes in Seoul, South Korea. In most cases, each subject was interviewed three times for 1-2 hours each time. Open-ended questions were used to help them specify the meanings, characteristics, and uses of the nurse's pain identification in demented patients, and all of the interviews were taped. In general, the respondents confirmed the meanings and characteristics specified in the literature. However, one feature of pain assessment is that pain identification and management are accomplished in a circular fashion. In the theoretical phase, the two steps were expected to be circular, and we could verify that from the fieldwork phase. That is, after pain was identified, nursing assessment and intervention were immediately provided, and then pain was identified again. Assessment, Intervention, and Reassessment in Sequence Focusing on Physical Pain, Then on Psychological Pain Most of the nurses were very familiar with their demented patients and knew a lot about the common expressions of each patient under their care. When nurses failed to identify every possible physical origin of pain, they investigated recent number of visits of family members to gather the data about demented patient's recent events related to mood changes from the tending family member. A nurse with 18 years of clinical experience considered her demented patient's pain to be emotional pain: “She must have emotional pain. When I had checked vital signs, abdominal pain, and range of motion (ROM), every check was proved as okay. So I checked a recent visit of her family, and I knew it has been a long time since she met her son, and she saw other patients' families' visits yesterday. So I will call her son to ask a visit her soon.” Integrating Pain Cues Based on Patient Responses about Intervention The nurses described how they identified valid interventions for pain relief in identifying pain processes. As an example, one nurse with 9 years of clinical experience indicated how she had cared for her demented patients in pain: “I noticed diminished behavioral patterns [from] usual: increasing wandering, change of positions, expressing anger in daily routine care, and defensive attitudes against physical therapy in patients' pain identification. I noticed her inability to raise her arms when I tried to dress her indicating musculoskeletal pain and finger stiffness indicating rheumatoid arthritic pain. When I consider pain from underlying diseases, I tried to find out typical symptoms of pain due to those diseases to then plan appropriate interventions to relieve pain effectively. And, if I could not figure out any physical origins of pain, I tried to communicate with my patient about her surroundings to get clues about pain.” Step-by-Step Guidance Based on Outcome of Each Intervention The nurses frequently described several assessing steps that were guided by the outcome from the previous intervention. Typically, the first check involved daily living patterns, which might change owing to underlying diseases. The dominant assumption that the nurses had when they identified pain was that pain could be identified by pain-related words and behaviors of the patients themselves. A nurse with 9 years of clinical experience stated: “When I identified patient's pain, basically I noticed the patient's different behavioral patterns [from] usual, such as sleep disturbance, refusal to eat meals, and reluctance to move. It is all in a day's work that when I check patient's pain, I start inspection on patients' skin color, especially bruises, and then edema in joints in consideration of patient's wandering and being hit by chairs or a post in the hallway. If I cannot find out anything by inspections, I examine by hand to figure out one after the other cues related to origins of pain with a close observation of patient's pain expressions. When I identify the patient's pain sites, I notice patient's repetitive verbal expressions, unusual body movement, and painful looks, as a general rule. If I medicate with a pain-killer, I check patient's pain intensity frequently from action time of analgesics until identification of patients' pain relief.” A nurse with 7 years of clinical experience stated: “If I notice a painful look, moaning, and limitations of [range of motion], I do overall physical assessment to find out the focus area of pain in consideration of fractures due to a fall, etc. If I confirm patient's fracture with integration of several evidences, I immediately arrange the transfer of the patient to the emergency department in the hospital and notify the patient's family.” A nurse with 10 years of clinical experience stated: “If I notice patient's discomfort with a continuous high fever in patient's vital sign, I suspect infections of upper respiratory tract or urinary tract. I initially check the patient's lung sounds and, in the case of women, I check especially the clarity and odor of urine in consideration of cystitis. Then I report those symptoms to a doctor after interventions for hydration.” A nurse with 18 years of clinical experience stated that: “If I confirm the patient's pain coming from the gastrointestinal system, I check the patient's bowel sounds first, and then the amount of intake and output, stool status, and constipation and diarrhea. If patient's pain is not relieved by simple interventions, such as insertion of a laxative and administration of a diarrhea remedies, and then I notice patients' abdominal distension, I suspect a bowel obstruction. It is very important to discriminate the origins of pain, which might be physical or nonphysical. If the patient's pain expression is changed after intervening with distraction therapy, which is the nonpharmacologic intervention, I suspect the patient's pain might be coming from emotional distress.” The subjects confirmed the meanings and characteristics specified in the literature, but those that emerged were more nurse specific regarding identification of pain and more reflective in their attempts to correctly assess the pain state of the demented patient in their care. A nurse with 18 years of clinical experience remarked: “The demented patients are generally very old people with divergent symptoms coming from several sources such as aging and underlying diseases. Of course, to identify the patient's pain, we should be aware of the signs that patients are in pain. However, before dealing with patient's pain, we should have knowledge about actions and side effects of psychotropic drugs that a lot of demented patients take, and the types and side effects of analgesics that we can administer. Especially, nurse's assessing skills should be refined according to patient's divergent status such as aging, and each patient's underlying disease [and] physical conditions such as patients with difficulties in swallowing, etc. For individualized pain interventions, nurses should be educated to identify every cue related to pain coming from the patient's body, even though patients express pain in the same and very simple ways.” Categorizing patients in dealing with pain comprises keeping in mind the declining verbal expression for pain as deterioration advances and considering the differences due to specific types of dementia. Illustrative of this, a nurse with 13 years of clinical experience stated: “I think the stage of dementia is more significant than types of dementia in assessing patients' pain because, in the early stage of dementia, in most cases they can express their pain accordingly. However, in advanced dementia, it is very difficult [for them] to identify their pain with their verbal expressions as deterioration advances. It is easier to identify VD patients' pain than AD patients' pain, because a lot of them can communicate their pain, but I think they have a tendency to express their pain with aggressive attitudes. They have a lot of physical problems, such as paralysis, and in general are likely to be impatient. However, AD patients seldom express their pain.” Cognitive efforts to identify possible origins of pain require the recognition of observable responses mostly coming from acute pain, taking into account the basic underlying pathology and combining modifying comorbidities. These have been identified in the literature and were confirmed during some of the interviewes with the nurses. As an illustrative example, a nurse with 9 years of clinical experience stated: “I know patients are in pain when patients' looks rapidly change. In most of those cases, the causes of pain can be detected in a close observation and palpations, and I can hear the patients moaning and groaning as well. But, when I identify the pain of patients with diabetes or palsy, I basically assume [from my clinical experiences] that their senses are dull. If patients with respiratory problems are in pain, their overall looks are revealing. If patients complain of joint pain and joint edema and fever are identified, I assume that they are in arthritic pain.” A nurse with 18 years of clinical experience stated: “Newly admitted patients sometimes suffer from the unfamiliar environments, and they can experience emotional pain. Even the overcast weather might be considered as an influencing factor in identification of patients' pain.” 3. Analytic Phase: Conceptual Delineation through Integration of the Literature Data and the Fieldwork Results The in-depth interviews highlighted that for nurses, pain identification in demented patients is complex, involving several different attributes, components, and structures. The conclusions listed below were drawn by integrating the fieldwork data and the ideas gleaned from the literature review. In this phase, the researchers stepped back from the details of fieldwork and reexamined the findings in the light of the initial research focus. The definition in the theoretical phase was revised to reflect these aspects by refining three attributes identified in the fieldwork phase. Furthermore, throughout the data analysis of the theoretical and fieldwork phases, three facets of nurse-mediated pain identification in demented patients were delineated: an active process integrating every expressional cue of patients until pain relief was achieved, a cyclic process that began upon a patient's expression of pain, and an active process of comparison based on a patient's habitual expressive patterns. The conceptual structure of nurses' pain identification in demented patients was constructed by integrating the above conclusions, as shown in Figure 1. Pain identification in demented patients by nurses is defined as the three aforementioned facets. Pain identification constitutes three dimensions with several attributes: schematizing based on stages of dementia and types of dementia, checking and interconnecting the steps that sequentially follow one another after intervention, and cognitively identifying the origins of pain. The three dimensions are as summarized in the preceding paragraph. Discussion The nursing profession views pain from a holistic perspective and has focused on promoting comfort as one of the main purposes of nursing intervention throughout its history (Montes-Sandoval, 1999). Because alleviating pain with a determined attitude is a critical component in nursing situations and has a significant effect on comfort, it is necessary to attain clear conceptualization of the identification of pain by nurses in the context of care for the cognitively impaired elderly. Caring has been defined as a process of expert nursing practice, interpersonal sensitivity, and intimate relationship (Finfgeld-Connett, 2008). These components are well reflected by our findings. In the literature, pain identification in demented patients in terms of the assessment of pain communication skills of cognitively impaired elders by nurses involves an emphasis on individually developed intuitive perceptions from clinical experiences with cognitively impaired elders with pain (Epps, 2001, Horgas et al., 2007). Consistent with this, the present fieldwork data also identified pain identification in demented patients by nurses as an action involving the recognition of pain in their patients by the clustering of pain cues within a practice context. Based on the theoretical and fieldwork data, pain identification in demented patients by nurses is likely to rely on intuitive knowledge, which is an aspect of the pattern of personal knowledge. As such, pain identification may be credibly achieved through reflection and actualization by individual nurses (Agan, 1987, Fuchs-Lacelle et al., 2008, Pesonen et al., 2009). Although there seems to be a general agreement that pain identification in demented patients by nurses should be elaborated through the personal clinical experiences acquired during nursing, pain identification in demented patients and use of related nursing and medical knowledge for nurse-mediated pain identification can be expected to vary based on the clinical judgment of patients' status and conditions by individual nurses. The literature on pain identification in demented patients by nurses has focused mainly on research on how nurses discriminate a patient as being pain free in the absence of a sophisticated means of pain communication by the patient. In that research, nurse knowledge of their patients' individual daily habitual behaviors and patterns was identified as an important tool in identifying pain. The present study reaffirms this view. Tsai and Chang (2004) recommended that assessing pain in elderly people with dementia should involve the observation of pain behaviors during active movement, because inactivity and specific motor patterns can be considered to be indicators of pain. The subjects of the present study also identified that assessing pain in elders with dementia involves a reciprocal relationship between nurse-mediated pain management and the responses of patients to their management, and between patients' habitual behaviors and behavioral changes that arise because of nursing interventions. Pain identification in demented patients by nurses is often used as a modality to deliver comfort and care. Comfort may be conceptualized, not as a static state, but as an active process of pursuing equilibrium. The results of the present study indicate that nurse-mediated pain identification in demented patients is based on the resolve of nurses to promote their patients' comfort, which is an ethical and self-regulating intent and has a much deeper meaning beyond the simple notion of patient assessment. Nursing Implications Nursing has always focused on promoting comfort as one of the main purposes of nursing interventions. Because the identification of pain is an inevitable nursing action, it has a significant ramification for the comfort and care of dementia patients. In the gerontologic nursing context, it is necessary to attain a clear conceptualization of nurse-mediated pain identification in demented patients. The results of the present study indicate that the concept of pain identification in demented patients by nurses represents a serial nursing effort that is derived from their experience of caring for demented patients, and is a nursing activity that can benefit from directed training. References Abbey et al., 2004. 1.Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L. The Abbey pain scale: A 1-minute numerical indicator for people with end-stage dementia. International Journal of Palliative Nursing. 2004;10(1):6–13. MEDLINE Agan, 1987. 2.Agan RD. Intuitive knowing as a dimension of nursing. Advances in Nursing Science. 1987;10(1):63–70. MEDLINE Bathgate et al., 2001. 3.Bathgate D, Snowden JS, Varma A, Blackshaw A, Neary D. Behaviour in frontotemporal dementia, Alzheimer's disease and vascular dementia. Acta Neurologica Scandinavica. 2001;103(6):367–378. MEDLINE Cohen-Mansfield and Lipson, 2002. 4.Cohen-Mansfield J, Lipson S. The underdetection of pain of dental etiology in persons with dementia. Journal of Alzheimer's Disease and Other Dementias. 2002;17(4):249–253. Crystal et al., 2000. 5.Crystal HA, Dickson D, Davies P, Masur D, Grober E, Lipton RB. The relative frequency of “dementia of unknown etiology” increases with age and is nearly 50% in nonagenarians. Archives of Neurology. 2000;57(5):713–719. MEDLINE |
CrossRef
Epps, 2001. 6.Epps CD. Recognizing pain in the institutionalized elder with dementia. Geriatric Nursing. 2001;22(2):71–77. Ferrell et al., 1995. 7.Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management. 1995;10(8):591–598. Abstract |
Full-Text PDF (708 KB)
|
CrossRef
Finfgeld-Connett, 2008. 8.Finfgeld-Connett D. Meta-synthesis of caring in nursing. Journal of Clinical Nursing. 2008;17(2):196–204. Frampton, 2003. 9.Frampton M. Experience assessment and management of pain in people with dementia. Age and Ageing. 2003;32(3):248–251. MEDLINE |
CrossRef
Fuchs-Lacelle et al., 2008. 10.Fuchs-Lacelle S, Hadjistavropoulos T, Lix L. Pain assessment as intervention: A study of older adults with severe dementia. Clinical Journal of Pain. 2008;24(8):697–707.
CrossRef
Gabre and Sjoquist, 2002. 11.Gabre P, Sjoquist K. Experience and assessment of pain in individuals with cognitive impairments. Special Care in Dentistry. 2002;22(5):174–180. MEDLINE |
CrossRef
Hadjistavropoulos and Craig, 2002. 12.Hadjistavropoulos T, Craig KD. A theoretical framework for understanding self-report and observational measures of pain: a communications model. Behaviour Research and Therapy. 2002;40(5):551–570. MEDLINE |
CrossRef
Horgas and Elliott, 2004. 13.Horgas AL, Elliott AF. Pain assessment and management in persons with dementia. Nursing Clinics of North America. 2004;39(3):593–606. Full Text |
Full-Text PDF (226 KB)
|
CrossRef
Horgas et al., 2007. 14.Horgas AL, Nichols AL, Schapson CA, Vietes K. Assessing pain in persons with dementia: Relationships among the noncommunicative patient's pain assessment instrument, self-report, and behavioral observations. Pain Management Nursing. 2007;8(2):77–85. Abstract | Full Text |
Full-Text PDF (141 KB)
|
CrossRef
Kovach et al., 2002. 15.Kovach CR, Noonan PE, Griffie J, Muchka S, Weissman DE. The assessment of discomfort in dementia protocol. Pain Management Nursing. 2002;3(1):16–27. Abstract | Full Text |
Full-Text PDF (207 KB)
|
CrossRef
Kovach et al., 2005. 16.Kovach CR, Noonan PE, Schlidt AM, Wells T. A model of consequences of need-driven, dementia-compromised behavior. Journal of Nursing Scholarship. 2005;37(2):134–140. MEDLINE |
CrossRef
Longman Corpus Network, 1995. 17.Longman Corpus Network and British National Corpus. Longman Dictionary of Contemporary English. 3rd ed.. Upper Saddle River, NJ: Pearson/Prentice Hall; 1995;. Manfredi et al., 2003. 18.Manfredi PL, Breuer B, Meier DE, Libow L. Pain assessment in elderly patients with severe dementia. Journal of Pain and Symptom Management. 2003;25(1):48–52. Abstract | Full Text |
Full-Text PDF (56 KB)
|
CrossRef
Mann et al., 1999. 19.Mann WC, Tomita M, Hurren D, Charvat B. Changes in health, functional and psychosocial status and coping strategies of home-based older persons with arthritis over three years. Occupational Therapy Journal of Research. 1999;19(2):126–147. Melanson and Downe-Wamboldt, 2003. 20.Melanson PM, Downe-Wamboldt B. Confronting life with rheumatoid arthritis. Journal of Advanced Nursing. 2003;42(2):125–133. MEDLINE |
CrossRef
Molony et al., 2005. 21.Molony SL, Kobayashi M, Holleran EA, Mezey M. Assessing pain as a fifth vital sign in long-term care facilities: Recommendations from the field. Journal of Gerontological Nursing. 2005;31(3):16–24. MEDLINE Montes-Sandoval, 1999. 22.Montes-Sandoval L. An analysis of the concept of pain. Journal of Advanced Nursing. 1999;29(4):935–941. MEDLINE |
CrossRef
Morrison and Siu, 2000. 23.Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. Journal of Pain and Symptom Management. 2000;19(4):240–248. Abstract | Full Text |
Full-Text PDF (120 KB)
|
CrossRef
Pesonen et al., 2009. 24.Pesonen A, Kauppila T, Tarkkila P, Sutela A, Niinisto L, Rosenberg PH. Evaluation of easily applicable pain measurement tools for the assessment of pain in demented patients. Acta Anaesthesiologica Scandinavica. 2009;53(5):657–664. Pradines and Pradines, 2004. 25.Pradines V, Pradines B. Agitation expressing pain in demented people with communication disorders. Journal of Psychological Neuropsychiatric. 2004;2(4):271–274. Scherder and Bouma, 2000. 26.Scherder EJ, Bouma A. Visual analogue scales for pain assessment in Alzheimer's disease. Gerontology. 2000;46(1):47–53.
CrossRef
Scherder et al., 2003. 27.Scherder EJ, Slaets J, Deijen JB, Gorter Y, Ooms ME, Ribbe M. Pain assessment in patients with possible vascular dementia. Psychiatry. 2003;66(2):133–145. MEDLINE |
CrossRef
Schwartz-Barcott et al., 2002. 28.Schwartz-Barcott D, Patterson BJ, Lusardi P, Farmer BC. From practice to theory: Tightening the link via three fieldwork strategies. Journal of Advanced Nursing. 2002;39(3):281–289. MEDLINE |
CrossRef
Seomun et al., 2006. 29.Seomun GA, Chang SO, Lee PS, Lee SJ, Shin HJ. Concept analysis of coping with arthritic pain by South Korean older adults: Development of a hybrid model. Nursing & Health Sciences. 2006;8(1):10–19. MEDLINE |
CrossRef
Sherman, 2003. 30.Sherman AM. Social relations and depressive symptoms in older adults with knee osteoarthritis. Social Science and Medicine. 2003;56(2):247–257. MEDLINE |
CrossRef
Snow and O'Malley, 2004. 31.Snow, A.L., O'Malley, K., J., Cody, M., Kunik, M.E., Ashton, C.M., Beck, C. (2004). A conceptual model of pain assessment for noncommunicative persons with dementia. Gerontologist, 44(6), 807-817. Tsai and Chang, 2004. 32.Tsai PF, Chang JY. Assessment of pain in elders with dementia. Medsurg Nursing. 2004;13(6):364–369. MEDLINE Walker and Avant, 2005. 33.Walker, L.O., & Avant, K.C. (2005). Strategies for theory construction in nursing (4th ed., pp. 63-86). Upper Saddle River, NJ: Pearson/Prentice Hall. Weiner et al., 1999. 34.Weiner D, Peterson B, Ladd K, McConnell E, Keefe F. Pain in nursing home residents: An exploration of prevalence, staff perspectives, and practical aspects of measurement. Clinical Journal of Pain. 1999;15(2):92–101. MEDLINE |
CrossRef
Weiner and Hanlon, 2001. 35.Weiner DK, Hanlon JT. Pain in nursing home residents: Management strategies. Drugs and Aging. 2001;18(1):13–29.
CrossRef
Wynne et al., 2000. 36.Wynne CF, Ling SM, Remsburg R. Comparison of pain assessment instruments in cognitively intact and cognitively impaired nursing home residents. Geriatric Nursing. 2000;21(1):20–23. Zieber et al., 2005. 37.Zieber CG, Hagen B, Armstrong-Esther C, Aho M. Pain and agitation in long-term care residents with dementia: Use of the Pittsburgh Agitation Scale. International Journal of Palliative Nursing. 2005;11(2):71–78. MEDLINE ∗ College of Nursing, Korea University, Seoul, Korea † Department of Nursing, Far-East University, Eumseong, Korea ‡ Department of Nursing, CHA University, Pochon, Korea  Addrress correspondence to Suk Yong Kil, PhD, RN, Associate Professor, Department of Nursing, College of Health Science CHA University, 198-1 Donggyo-dong, Pochon-si, Gyeonggi-do 487-010, Korea.
Supported by a National Research Foundation of Korea grant funded by the Korean government (KRF-2008-531-E00095). PII: S1524-9042(10)00086-X doi:10.1016/j.pmn.2010.05.007 © 2010 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved. | |
|
FULL TEXT
