Importance Of Behavioral Observation Scales For Pain Management In Elderly Patients With Cognitive Impairment (Essay).

Elder people come in the hospital with various acute and chronic painful diseases and health issues such as dementia, fractures, heart disease and many more. Majority of patients comes with cognitive impairments too. Currently, all nurses in the hospital use pain intensity scales to quantify pain and the same tool is used for all patient irrespective of difference in degree of cognitive function of patients.

Identify nursing practice area requiring change

Current practice description

My health care setting deals mainly with geriatric care and the pain assessment and pain management is one of the core responsibilities of nurses in the hospital. Elder people come in the hospital with various acute and chronic painful diseases and health issues such as dementia, fractures, heart disease and many more. Majority of patients comes with cognitive impairments too. Currently, all nurses in the hospital use pain intensity scales to quantify pain and the same tool is used for all patient irrespective of difference in degree of cognitive function of patients. Hence, verbal and numerical self-rating is taken from patient to determine the severity of pain The key tool that is employed for this purpose is verbal descriptor scale (Booker & Herr, 2015).  

Reason for change in current practice

Currently, the health care setting is using verbal and numerical self-report tool to conduct pain assessment and there is a need to change this nursing practice and include behavioral observation scales and physiological response too. This new approach to nursing practice is particularly importance for geriatric care because severity of pain is often misinterpreted by using self-report scale. This is because self-report scales mainly depend on the patient’s response and report about pain. However, in case of elderly people with cognitive impairment and impaired functional abilities, they may not be able to effectively communicate about the severity of pain. Secondly, patients who do not have knowledge about pain scale or those with poor education may not understand how to express about pain (Booker & Herr, 2015). Hence, communication barrier such as alterations in cognitive abilities in elderly people and communication problem in patients lead to non-detection and under treatment of pain (Schofield, 2014).. Evidence also points out that elderly patients are most commonly diagnosed with dementia or delirium, which presents serious challenges for nurse in conducting pain assessment. Therefore, the validity of self-report scale becomes low with increase in cognitive impairment and direct questioning and interview with patients become difficult. Hence, it is proposed to used behavioral observation scales and approach that focus on cognitive disabilities of elderly person while conducting pain assessment. The advantage of this approach is that this method has a broader scope and in case of elderly patients with severe cognitive impairment, behavioral pain scale may offer effective mechanism to effectively measure pain and manage them (Brown, 2011).

While trying to implement the behavioral observational tool and wider approach to pain assessment by focusing on cognitive impairment, the nurses, elderly people, clinician. Health care provider and support staff will play a key role supporting the practice change. The main role of the health care provider in implementing practice change would be to identify the most valid and reliable tools that can be used for pain assessment in elderly people. They will also play a role in investing for such tools and making it available in the health care setting (Grol et al., 2013). Secondly, the clinician and other support staffs will play a role in training all those people who will be comprehensively using the tool on a daily basis. This will maximize the effectiveness of using the tool. In addition, the most vital role will be played by nurse in supporting the change process as they need to be aware about using the tool in a effective manner. Their knowledge and efficiency in using the tool is likely to promote pain assessment process. Their knowledge and competence in using the tool will also promote taking appropriate pain report form elderly patients irrespective of their disability (Ngu et al., 2015).

Role of key stakeholders in supporting proposed practice change

Article 1: The research by Apinis et al., (2014) investigated about combining interdisciplinary evaluation along with validated observation tool for pain detection in older adults with cognitive impairments. The sample for the study included 59 residents with limited communication ability and their pain behavior was assessed by the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and the Pain Assessment in Advanced Dementia (PAINAD). The study finding showed that although both the pain assessment tool had high correlation, however weaker association was found between both the tools and interdisciplinary evaluation. This might be due to the limitation in the interdisciplinary evaluation process where nurses are not present during evaluation process all the time. Hence, the main conclusion from the study was that interdisciplinary team should not just rely on subjective data for pain assessment, they must include objective measure of pain by using tools like PACSLAC or PAINAD. This would greatly reduce the risk of pain under treatment and assessment.

Article 2:

Due to the evidence of high incidence of under detection of pain in dementia patients, Lichtner et al., (2014) systematically reviewed the psychometric properties and clinical utility of different pain assessment tools used in health care setting. Although the research included a large number of studies related to pain assessment, however in majority of the papers, no data was available regarding the psychometric properties of the tool. Ambiguity was found in studies regarding the reliability of different studies. Even of the reliability was calculated in few studies, it could not be validated because reliability check was carried out for small sample of patients. Hence, the study gave the indication that there is little evidence to prove the clinical utility of the tools, and more study is needed particularly to evaluate the psychometric property of each tool.

Article 3:

Husebo, Ostelo, & Strand, (2014) investigated about the performance of the Mobilization-observation-Behavior-Intensity-Dementia-2 (MOBID-2) in the area of test-retest reliability, standard error of measurement and responsiveness to change. A cluster randomized controlled trial was done with dementia patients and the participants were tested with MOBID-2 pain scale at baseline and after 2 weeks and 4 weeks interval. The study results revealed that the pain scale is responsive if step wise protocol for treatment of pain is followed. Overall, the study supported the tool’s ability to evaluate effect of pain treatment overtime.

Article 4:

The narrative review by Oosterman et al., (2016) gives idea about using facial expressions in pain assessment for dementia patients. The study pointed out that facial expression descriptors are present in many pain behavior observation tools, however exact definition varies for all scales. Secondly, behavioral changes in patient such apathy, emotional disorders and disinhibition may act as confounding factors when using facial expression for pain assessment. Hence, these factors need to be considered. The study also pointed out the limitation of health care professionals in recognizing pain and recommended giving special training to staffs on facial expression and using observation scale for pain assessment.

Article 5:

Evidence Critique Table

The research by Ford et al., (2015) was based on using the established recommendation of using non-verbal pain behavior to assess pain in non-verbal patients with dementia. The research mainly aimed to evaluate the psychometric properties of the NOPPAIN (Non-communicative Patient Pain Assessment Instrument) pain assessment tool by secondary analysis of data obtained by Snow et al., (2004). The NOPPAIN tool mainly focused on six non-verbal pain behaviors such as facial expressions, changes in activities, body movements, and alteration in interpersonal interaction, vocalization and mental status change during pain assessment. The evaluation of the performance of the tool in 83 older adults with dementia revealed that pain words, pain faces and pain noises was the most common pain behavior identified in participants. Secondly, pain faces and pain vocalization played an important role in identifying non-verbal pain behavior in older adults. The study also gave implications for health care staffs that greater cultural competency may improve pain identification process in vulnerable group.

After the review of findings from five evidences regarding behavioral observation based tool for pain assessment in older patient with cognitive impairment, it is recommended that the NOPPAIN tool can act as the best tool for improving pain assessment process in nurses. The efficacy of NOPPAIN tool was studied by Ford et al., (2015) and the research presented the advantage of the tool in identifying non-verbal pain behavior in patients. The use of this tool along with improving the cultural competency of the nurses and other staffs can go a long way in mitigating all the barriers associated with pain assessment in elderly people. The main speciality of the NOPPAIN tool is that it focused on assessing pain both at rest and during movement. The nurses at the hospital can observe pain in patient under the following conditions:

• Pain behavior during bathing, transfer and dressing
• Assessing pain behavior by means of pain word, pain noises, pain faces, rubbing, restlessness and pain faces.
• Measurement of pain behavior intensity
• Pain thermometer for rating pain intensity (Corbett et al., 2014)

The content of the NOPPAIN tool was evaluated by Snow et al., (2004) first, and then the accuracy of the tool was further done by Okimasa et al., (2016) as the study revealed that reliability and validity of the tools was high in non-verbal patients with pain issues. Compared to the Abbey pain scale, NOPPAIN is an easy to use tool and it has more checklist items for pain evaluation too.

Although the validity of the NOPPAIN tool has been proved by the research studies, however to effectively implement the tool and brings changes in nursing practice process, there is a need to give training to nurses. This form of change will be brought by adapting Lewin’s three model of change. The main advantage of taking this model for practice change is that it is the simplest model without any complexity and it can be easily adapted. The layout of change proposed through the three stage change process is easily to implement and it is reflective of systematic process of implementing and managing change in the organization too (Hussain et al., 2016). The unfreeze phase act as the foundation for developing a solid rationale for change and making people understand the potential benefits of changing their tune or practice. The second stage is mainly the preparation stage where people are educated and new policies related to the change are implemented. The final stage is a more stable stage where everyone is prepared to work in the direction of new practice (Sallis, Owen, & Fisher, 2015). Hence, It can be said that Kewin’s change model is effective as it explains the striving forces needed to maintain the status quo and push for change (Hussain et al., 2016).

To make staffs familiar with the change, unfreezing stage is important. At this stage, all nurse must be made aware why previous method of pain assessment is not feasible for older patients and why NOPPAIN tool is needed to improve the pain detection and treatment process. This will help nurses to change the attitudes and behavior related to pain assessment practice (Manchester et al., 2014). The second stage is the movement stage where the staffs needs to be prepared for the change by giving them training to fully understand the features of the tool. Secondly, as the tool mainly focuses on behavioral observation of patient, giving cultural competency training will be necessary. This will help nurses to observe subtle pain behavior of patient and incorporate those unique observations to pain screening (Hadjistavropoulos et al., 2014). The change will proceed to the refreeze stage when no staffs will face issues in using the tool and no under detection of pain is observed in the clinical setting.

While implementing the new pain assessment tool, NOPPAIN at the health care setting, certain barriers may also affect the change process. For instance, the poor communication skills of staffs may limit the pain assessment process. It will hinder their ability to understand pain voices and pain behavior. Secondly, all nursing staff may be well-aware and comfortable with previous tool and they may resist using such tools (Ford et al., 2015). Hence, this challenge can be addressed mainly by giving training regarding proper use of the tool and improving their competency in assessment process. This is because different cultural group may have different method of expressing pain and nursing staffs need to be aware of such subtle differences in verbalizing pain or expressing it through their behavior.  

There are ethical implications of implementing new practice change in the geriatric care setting. This includes informing all staffs regarding the validity of the tool and taking permissions from relevant authorities to include them in every day practice. This is important because evidence based practice is always mandated by stakeholders as this is essential process to maintain health care quality and safety. Showing evidence regarding the efficacy of the new practice will ensure all stakeholders that relevant evidence is accessed to include the new tool for health care service delivery. Secondly, all the nursing must be readily informed about the tool so that no error arises and all staffs have positive intention to use the tool. Taking ethical consent for using the tool is also necessary to maintain distributive justice. According to the ethics of evidence implementation in health care too, it is essential that evidence implementation must be evaluated (Hutton, Eccles, & Grimshaw, 2008). Hence, major ethical actions for the organization are to consider rights of access to the tool and consideration regarding practice change associated with the tool.

Reference:

Apinis, C., Tousignant, M., Arcand, M., & Tousignant-Laflamme, Y. (2014). Can adding a standardized observational tool to interdisciplinary evaluation enhance the detection of pain in older adults with cognitive impairments?. Pain Medicine, 15(1), 32-41, https://doi.org/10.1111/pme.12297

Booker, S. S., & Herr, K. (2015). The state-of-“cultural validity” of self-report pain assessment tools in diverse older adults. Pain Medicine, 16(2), 232-239.

Brown, D. (2011). Pain assessment with cognitively impaired older people in the acute hospital setting. Reviews in pain, 5(3), 18-22.

Corbett, A., Achterberg, W., Husebo, B., Lobbezoo, F., de Vet, H., Kunz, M., ... & de Waal, M. (2014). An international road map to improve pain assessment in people with impaired cognition: the development of the Pain Assessment in Impaired Cognition (PAIC) meta-tool. BMC neurology, 14(1), 229.

 Ford, B., Snow, A. L., Herr, K., & Tripp-Reimer, T. (2015). Ethnic differences in nonverbal pain behaviors observed in older adults with dementia. Pain Management Nursing, 16(5), 692-700.10.1016/j.pmn.2015.03.003

Grol, R., Wensing, M., Eccles, M., & Davis, D. (Eds.). (2013). Improving patient care: the implementation of change in health care. John Wiley & Sons.

Hadjistavropoulos, T., Kaasalainen, S., Williams, J., & Zacharias, R. (2014). Improving pain assessment practices and outcomes in long-term care facilities: A mixed methods investigation. Pain Management Nursing, 15(4), 748-759.

Husebo, B. S., Ostelo, R., & Strand, L. I. (2014). The MOBID?2 pain scale: Reliability and responsiveness to pain in patients with dementia. European journal of pain, 18(10), 1419-1430, 10.1002/ejp.507

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2016). Kurt Lewin's process model for organizational change: The role of leadership and employee involvement: A critical review. Journal of Innovation & Knowledge. 

Hutton, J. L., Eccles, M. P., & Grimshaw, J. M. (2008). Ethical issues in implementation research: a discussion of the problems in achieving informed consent. Implementation Science, 3(1), 52.

Lichtner, V., Dowding, D., Esterhuizen, P., Closs, S. J., Long, A. F., Corbett, A., & Briggs, M. (2014). Pain assessment for people with dementia: a systematic review of systematic reviews of pain assessment tools. BMC geriatrics, 14(1), 138,
https://doi.org/10.1186/1471-2318-14-138

Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., & Owens, M. G. (2014). Facilitating Lewin's change model with collaborative evaluation in promoting evidence based practices of health professionals. Evaluation and program planning, 47, 82-90.

Ngu, S. S., Tan, M. P., Subramanian, P., Rahman, R. A., Kamaruzzaman, S., Chin, A. V., ... & Poi, P. J. (2015). Pain assessment using self-reported, nurse-reported, and observational pain assessment tools among older individuals with cognitive impairment. Pain management nursing, 16(4), 595-601.

Okimasa, S., Saito, Y., Okuda, H., Fukuda, T., Yano, M., Okamoto, Y., ... & Ohdan, H. (2016). Assessment of cancer pain in a patient with communication difficulties: a case report. Journal of medical case reports, 10(1), 148.

Oosterman, J. M., Zwakhalen, S., Sampson, E. L., & Kunz, M. (2016). The use of facial expressions for pain assessment purposes in dementia: a narrative review. Neurodegenerative disease management, 6(2), 119-131

Sallis, J. F., Owen, N., & Fisher, E. (2015). Ecological models of health behavior. Health behavior: theory, research, and practice. 5th ed. San Francisco: Jossey-Bass, 43-64.

Schofield, P. A. (2014). The assessment and management of peri?operative pain in older adults. Anaesthesia, 69(s1), 54-60.

Snow, A. L., O'Malley, K. J., Cody, M., Kunik, M. E., Ashton, C. M., Beck, C., ... & Novy, D. (2004). A conceptual model of pain assessment for noncommunicative persons with dementia. The Gerontologist, 44(6), 807-817.