View PDF

Executive Summary

Objectives

The objectives of this paper were (a) to identify barriers to successful pain assessment in older adults with dementia, and (b) to identify possible strategies for overcoming these barriers.

Method

A database search was conducted for literature relating specifically to barriers to pain assessment in older adults with a diagnosis of dementia and methods for overcoming these barriers. In addition, further studies, that were initially retrieved following a database search for literature for a systematic review on Assessment of Pain in Older Adults with Dementia in Acute, Sub Acute, and Residential Care, were earmarked for this paper when it became apparent that there was a need for a separate paper focusing on barriers to, and strategies for, successful pain assessment in older adults with dementia. All studies were critically appraised b two independent reviewers and data was extracted using instruments specifically developed for the systematic review. Where disagreement existed between reviewers regarding inclusion or level of evidence, an Expert Reference Group or third reviewer was consulted.

Results

A number of barriers to successful pain assessment in older adults with dementia were identified in the literature. These barriers can be divided into two realms: staff considerations and patient considerations. Staff considerations included lack of recognition of pain in patients with dementia; lack of sufficient education and/or training regarding pain in patients with dementia; misdiagnosis or late diagnosis; inadequate assessment tools; restrictions imposed by nursing role; and the need for objective and sufficient evidence. Patient considerations included the subjective nature of pain; the possible existence of a ‘no pain’ subset of people with de-mentia; the type of pain experienced; and stoic attitudes. Several strategies were proposed to overcome these barriers and included knowing the person; knowing by diversity/intuitive perception; improved training and education; the development and implementation of adequate tools; the use of existing data; and increasing diligence when working with this population.

Conclusions

This review has found that pain is frequently undetected, misinterpreted, or inaccurately assessed in older adults with dementia. At particular risk are those patients who are non-communicative and are therefore unable to articulate or convey their pain, who are often dismissed as being incapable of perceiving or recalling pain. More extensive training and education regarding the experience, assessment, and management of pain in the dementia patient is urgently needed, as is the development and implementation of an effective pain assessment tool specifically designed for detecting and measuring pain in older adults in all stages of dementia.

Filed under: Dementia, Pain on June 3rd, 2009 | No Comments »

View Final Report (PDF)

Executive Summary

Introduction

 With a rapidly ageing population and more frail older people accessing health services, it is imperative that nurses are adequately prepared during their undergraduate education to meet the needs of these clients. 

In order to address this need, along with issues such as recruitment and retention, the Australian Government Department of Health and Ageing (DoHA) commissioned the development of the Aged Care Core Component in Undergraduate Nursing Curricula Principles Paper (Queensland University of Technology, 2004). To promote the adoption of the Aged Care Core Component in Undergraduate Nursing Curricula Principles, the Australian Government further commissioned the development and implementation of four initiatives. James Cook University (JCU) was contracted to oversee the execution of these initiatives. In late 2005, the Australian Centre for Evidence Based Aged Care successfully secured tender for two of these initiatives, namely, the Development of Best Practice Models for aged care clinical placements for undergraduate nursing students and the Development of an on-line clearing house of aged care education material for use and access by university Schools of Nursing. This document reports on the results of the first of the above named initiatives.

 The project on which this report is based was conducted during the period between January and September 2006, and followed the project outline and steps detailed in the James Cook University Aged Care Core Component in Undergraduate Nursing Curricula Principles Initiative 2 Request for Proposal: ‘conduct a review of the literature for evidence on key elements and Best Practice Models of aged care clinical placements; consult with key informants to identify key elements of best practice for aged care clinical placements and Best Practice Models of aged care clinical placements in Australia [including representatives from the Council of Deans of Nursing and Midwifery (CDNM), people with relevant expertise in education, and aged care nursing industry representatives]; collate and analyse the data gathered in the proceeding steps; identify key elements of best practice for aged care clinical placements and Best Practice Models in Australia; develop outlines of Best Practice Models for aged care clinical placements and publish in forms suitable for promotion and dissemination throughout all Schools of Nursing and health service providers; identify practical recommendations for implementation of best practice aged care clinical placements for all Schools of Nursing and health services providing clinical placements; compile a report of results.’

Project Objective

The aim of this project, as guided by the James Cook University Aged Care Core Component in Undergraduate Nursing Curricula Principles Initiative 2 Request for Proposal, was to ‘identify key elements of best practice related to aged care clinical placements and best practice models of aged care clinical placements to provide a stimulating learning environment for undergraduate nursing students’. This report has therefore been prepared for Australian Schools of Nursing and aged care facilities, in addition to Australian hospitals, institutions, clinicians and educators involved in the delivery of undergraduate aged care clinical placements.  It is envisaged that the elements of best practice identified through this project, and the subsequently developed outline of best practice, will be adopted by those involved in undergraduate aged care clinical placements in order to ensure best practice and thereby enhance the clinical placement experience.

Method

The project team liaised with James Cook University and DoHA throughout the project. The following methodology was adopted:

1. A review of the literature was conducted for evidence on key elements of best practice and best practice models of aged care clinical placements.
2. A National Reference Group (NRG), including representation from key stakeholder groups identified by the project team and JCU as having relevant expertise in education and the aged care industry, was established in March 2006 and consulted via teleconference at two crucial points during the project.  The first teleconference was held in March 2006, in the early stages of the project; the NRG was presented with an overview of the project, the key findings of the literature review, and asked for their comments and to also nominate individuals or organisations with relevant expertise in aged care that might be interested in participating in a focus group for the project. The second teleconference was held in June 2006, following the focus group consultations and collation of findings; the NRG was presented with the main findings from the focus groups and asked to comment on the findings. Communication with the members of the NRG was also maintained throughout the project through email correspondence, and all members were invited to comment on the outline of best practice and the draft of the final report.
3. In order to ensure wide stakeholder contribution, focus groups were conducted with:
   1. representatives from Australian Schools of Nursing
   2. representatives from aged care facilities, hospitals, professional organisations and industry nominated by the NRG as experienced in aged care nursing and/or education.

A total of 12 focus groups were conducted, 11 via teleconference, during April and May 2006, with a total of 56 participants. The information obtained during each focus group was built upon to inform subsequent focus groups.

1. An email based publicity campaign was conducted for on-line submission of innovative clinical placement practices.
2. Collation and analysis of data gathered in the preceding steps was undertaken, revealing a preference for best practice principles.
3. Key elements of ‘best practice’ for aged care clinical placements in Australia were identified.
4. An outline of ‘best practice principles’ for aged care clinical placements was developed
5. The outline of ‘best practice principles’ for aged care clinical placements was distributed to all Australian Schools of Nursing, as well as health service providers for comment.
6. The Final Report was compiled, taking account of feedback and including recommendations for implementation of best practice and further considerations.

Data Analysis

Qualitative data from the National Reference Group, focus group interviews and web based responses were transcribed and analysed using constant comparison methods developed by Glaser and Strauss (1967) to identify concepts and then develop codes and themes. Once analysis was complete, the arising key themes were consolidated into principles of best practice.

Findings

The literature search revealed that there are currently no published journal articles reporting models of ‘best practice’ for aged care undergraduate clinical placements. Moreover, only five models of undergraduate nursing clinical placement were found. Whilst these were not models of ‘best practice’, each of the models contained elements that should be considered when developing such a model. It was found that an Australian model of best practice for undergraduate aged care clinical placements in residential aged care is currently being developed. The literature highlighted a number of areas for consideration in a ‘best practice’ model of undergraduate aged care clinical placements.

Consultations with both the National Reference Group and focus groups identified a preference for ‘principles’, which included elements of models regarded as successful, rather than any one particular ‘model’, and highlighted key principles associated with better practice that could inform any model and varying contexts. The results from the literature and the consultations were sufficiently consistent to allow the development of an agreed set of principles.

Conclusion

This report documents the results of an investigation into best practice undergraduate clinical placements in aged care nursing. The outcomes of the literature review and consultations with stakeholders that were conducted as part of this project did not reveal a preference for any particular model (setting non-specific) of aged care clinical placement delivery; however, they did reveal a preference for a set of ‘best practice principles’ that can be applied to models and address the unique circumstances of each university and health care service offering undergraduate aged care nursing clinical placements.

While it is clear that more research is required and current successful practices need to be made more available through publication as articles in peer reviewed journals, it is recommended that for implementation of best practice aged care clinical placements for all Australian Schools of Nursing and health services providing clinical placements, these principles are adopted. Of equal importance is that models that incorporate these principles undergo future evaluation.

Several vignettes are included in this report as examples of how these principles may be practically adopted. Recommendations for further considerations are also made.

Best Practice Principles

1. All stakeholders should agree and mutually understand definitions related to clinical placements.
2. Universities and industry organisations should have formal agreements/contracts that specify clearly the respective roles and responsibilities.
3. Reciprocal arrangements should be put in place to facilitate ongoing collaborative partnerships both during and between clinical placements.
4. All stakeholders should have a shared understanding of clinical placement requirements, student scope of practice and expected student learning outcomes.
5. Academics should be easily assessable to clinical facilitators and industry organisations.
6. Students on gerontic nursing (see definitions p 10) clinical placements should be exposed to the continuum of care for older people.
7. Academics responsible for gerontic placements should ensure objectives relate to person-centred, holistic care rather than tasks.
8. Person centred care should take account of cultural, spiritual, sexual and religious differences and preferences.
9. Standards, criteria and processes should be agreed upon and published to guide selection of clinical placement venues.
10. Provided objectives can be achieved, clinical placements should be arranged near to where students live - particularly in rural areas.
11. Industry organisations accepting students should demonstrate positive attitudes and practices toward older people, and invest in gerontic nursing education for their staff.
12. Industry organisations should ensure appropriate orientation for students and where relevant facilitators.
13. Students should have access to IT while on placement.
14. Students should be provided with a list of responsibilities they are expected to fulfil to enhance their placement experience.
15. Academics and facilitators should have credible gerontic nursing and clinical teaching skills and knowledge and a positive approach to older people and gerontic nursing
16. Facilitators should be familiar with all relevant structures, processes and policies of the industry organisation and university
17. Expected outcomes of the clinical placement should determine selection of venues/ shifts worked;
18. Expected outcomes should be clearly articulated, published and made available to all stakeholders.
19. Collaborative approaches to teaching and learning should be established and sustained.
20. Where possible, interdisciplinary learning should be encouraged and supported.

Filed under: Clinical Placements, Education on February 10th, 2009 | No Comments »