To Örebro University

Background: Pain assessment in people living with dementia is a challenge due to the complexity of pain and dementia and the difficulties in self-reporting. In home healthcare, nurses are frequently involved in pain assessment situations and there is a need to explore how home healthcare teams' manage pain assessment in this setting.

Aim: The study aimed to explore home healthcare teams' experiences of pain assessment among care recipients with dementia.

Design: An exploratory qualitative design was used.

Methods: Open-ended individual interviews were conducted with thirteen registered nurses and ten nursing assistants, working in three different home healthcare teams in one municipality in western Sweden. Philosophical hermeneutics was utilised to interpret the home healthcare teams' experiences.

Results: Four interpretations emerged: the need for trusting collaboration, the use of multiple assessment strategies, maintenance of staff continuity in care and assessment situations, and the need for extended time to assess pain.

Conclusions: The home healthcare teams recognise pain assessment in people with dementia as involving a complex interaction of sensory, cognitive, emotional and behavioural components in which efforts to acquire understanding of behavioural changes mainly guides their assessments. The solid team coherence between registered nurses and nursing assistants aided the assessment procedure. To assess pain, the teams used multiple methods that complemented one another. However, no systematic routines or appropriate evidence-based pain tools were used.

Implications for Practice: The team members'concern for care recipients when assessing pain is evident and needs to be acknowledged by the organisation which is responsible for the quality of care. Future studies should focus on further exploration of nurses' experiences with pain and dementia in home healthcare settings and address what nurses identify and how they deal with their findings. It is imperative to investigate how organisations and nurses can ensure best practices and how the implementation of evidence-based routines for assessing pain may aid in pain assessment situations.

Aims and objectives: To interpret certified nursing assistants' perception of pain in people with dementia in nursing care practice.

Background: Detection and understanding of pain in people with dementia remains a challenge due to their difficulty in verbalising their pain. Nursing assistants provide daily nursing care and therefore play a vital role in pain detection. Nevertheless, pain research from the nursing assistants' perspective is sparse.

Design: A qualitative approach within the interpretive tradition was adopted.

Methods: Individual interviews with twelve certified nursing assistants, all working in dementia care, were conducted and interpreted using philosophical hermeneutics.

Results: Nursing assistants' perception of pain is on three levels. Each level consists of a theme. The first theme Being in the facing phase' refers to the initial perception of the person's expressions. The second theme Being in the reflecting phase' means ability to reflect more deeply on one's perception, together with other colleagues and next of kins. The third theme Being in the acting phase' means perception arising from preventive and protective care focusing on contributing to well-being. The themes served as a basis for comprehensive understanding, where perception of pain arises from closeness, compassion and dialogue based on personhood, accompanied by professional knowledge of pain and dementia.

Conclusion: Nursing assistants' perception of pain is based on ethical concerns and on their own subjective pain experiences rather than on medical skills. Their perception derives from fundamental values that are important aspects of nursing care. Interdisciplinary solidarity may strengthen cooperation amongst CNAs and RNs to achieve best pain management practice.

Relevance to clinical practice: Attention to nursing assistants' perception of pain needs to be highlighted when they are front-line staff and have developed important pain detection skills. Their skills are essential complements and must be used in the development of pain management in dementia care practice.

BACKGROUND: Pain assessment in persons with dementia is well known as a challenging issue to professional caregivers, because of these patients´ difficulties in verbalising pain problems. Within municipal dementia care in Sweden, pain assessment has become problematic for registered nurses, as they have entered a new role in their nursing profession, from being clinical practitioners to becoming consultant advisers to other health care staff.

AIM: To present municipal registered nurses´ view of pain assessment in persons with dementia in relation to their nursing profession as consultant advisers.

METHODS: Purposive sampling was undertaken with 11 nurses invited to participate. Data were collected by focus groups. Qualitative content analysis was used to analyse the data.

FINDINGS: Four categories were identified to describe registered nurses´ view of pain assessment: estrangement from practical nursing care, time consuming and unsafe pain documentation, unfulfilled needs of reflection possibilities, and collaboration and coordination.

CONCLUSIONS: The performance of pain assessment through a consultant advising function is experienced as frustrating and as an uncomfortable nursing situation. The nurses feel resistance to providing nursing in this way. They view nursing as a clinical task demanding daily presence among patients to enable them to make accurate and safe assessments. However, due to the consultative model, setting aside enough time for the presence seems difficult to accomplish. It is necessary to promote the quality of systematic routines in pain assessment and reflection, as well as developing professional knowledge of how pain can be expressed by dementia patients, especially those with communication difficulties.