Question:

The hospital treats elderly people with chronic pain and other health issues.

A large number of patients are also suffering from cognitive impairments.

Presently, all nurses in the hospital use pain intensification scales to quantify pain. They also use the same tool for all patients regardless of cognitive function.

Answer to Question: NURS725 Translational Research Methods

Identify nursing practice areas that need to undergo changeCurrent practice description

My primary responsibility in the hospital’s health care setting is to provide geriatric and pain management services.

Senior citizens come to the hospital with various chronic and acute painful conditions, as well health issues like heart disease, fractures, and dementia.

The majority of patients are also suffering from cognitive impairments.

All nurses at the hospital currently use pain intensity measures to quantify pain. Patients with different cognitive abilities can use the same tool.

In order to assess the severity of pain, patients are asked for their verbal and numeric self-ratings (Booker, Herr, 2015).

Reasons to change the current practice

At the moment, pain assessment in health care is performed using numerical and verbal selfreporting tools. There is an urgent need to improve this practice by including behavioral observation and physiological response.

Geriatric care is especially affected by this new approach to nursing practice. Self-report scales often misinterpret the severity of pain.

This is because selfreport scales depend mainly on the patient’s response and reporting about pain.

Elderly people with cognitive impairment and impaired functional ability may be unable to accurately communicate the severity or intensity of their pain.

Booker & Herr 2015 also stated that patients may not have the knowledge or education necessary to understand pain.

Communication barriers, such as cognitive impairments in older people or communication problems among patients, can lead to the non-detection, and sometimes even under-treatment of pain (Schofield 2014.

Research also suggests that elderly patients are most likely to have dementia or delirium. This poses serious challenges for nurses who need to perform pain assessments.

The validity of self-reporting scales becomes less valid with cognitive impairment, so it is more difficult to ask patients questions and conduct interviews.

In order to assess pain, it is recommended that behavioral observation scales be used. These scales are designed to focus on cognitive disabilities and elderly people.

This method offers a wider scope, and for elderly patients with severe cognitive impairment, the behavioral pain scale may provide an effective mechanism to measure and manage their pain (Brown 2011).

Support for Proposed Practice Change: Role Of Key Stakeholders

It is important to have the clinician, elderly persons, and nurses involved in the implementation process of the behavioral observational instrument and a wider approach for pain assessment that focuses on cognitive impairment.

The practice change will be supported by the support staff and health care provider.

The main function of the health care provider is to identify the most accurate and reliable tools that can help elderly patients with pain assessment.

Grol et.al., (2013). They will also be responsible for investing in such tools and making them accessible in the health-care setting.

The clinician and other support staff will also play a key role in training the individuals who will be using this tool daily.

This will improve the effectiveness and efficiency of the tool.

A nurse’s role is crucial in supporting the transformation process. Nurses must be educated about the best way to use the tool.

Their proficiency and efficiency with the tool are likely to facilitate pain assessment.

Their competence in using this tool will encourage the generation of appropriate pain reports from elderly patients, regardless their disability (Ngu. et al.2015).Evidence Critique Table

Full APA citation for at most 5 sources

Evidence Strength (1-7), and Evidence Hierarchy1. Apinis, C., Tousignant, M., Arcand, M., & Tousignant-Laflamme, Y. (2014).

A standardized observational tool can be used to enhance the detection or pain in older adults with cognitive impairments. Pain Medicine, 15(1), 32-41, https://doi.org/10.1111/pme.12297

Qualitative quantitative studies of correlation and level IV2. Lichtner, V., Dowding, D., Esterhuizen, P., Closs, S. J., Long, A. F., Corbett, A., & Briggs, M. (2014).

A systematic review on systematic reviews of pain assessment instruments for people with dementia. BMC geriatrics, 14(1), 138,https://doi.org/10.1186/1471-2318-14-138

Level I and systematic review3. Husebo, B. S., Ostelo, R., & Strand, L. I. (2014).

The MOBID2 pain scale: Reliability, responsiveness and pain control in dementia patients.

European journal for pain, 18(10). 1419-1430. 10.1002/ejp.507

Level II and randomized controlled trials4. Oosterman, J. M., Zwakhalen, S., Sampson, E. L., & Kunz, M. (2016).

A narrative review: The use of facial expressions in pain assessment for dementia: Neurodegenerative disease management, 6(2), 119-131, https://discovery.ucl.ac.uk/1478129/1/Sampson_1478129_Revision%20Neurodeg%20Dis%20Manage.pdf

Level VII and narrative evaluation5. Ford, B., Snow, A. L., Herr, K., & Tripp-Reimer, T. (2015).

An ethnic variation in nonverbal pain behaviors in dementia-prone older adults. Pain Management Nursing, 16(5), 692-700.10.1016/j.pmn.2015.03.003

Level I and Integrative Review

Summary of Evidence

Article 1: Apinis, et. al. (2014) studied the use of an interdisciplinary evaluation in conjunction with a validated observation method for pain detection in older adults suffering from cognitive impairments.

The study’s sample included 59 residents who had limited communication ability. Their pain behavior and communication were assessed using two tools: the Pain Assessment Checklist (PACSLAC) for seniors with limited communication (PAINAD).

It was revealed that both the pain assessment tool and interdisciplinary assessment had strong correlations. However, there was a weaker association between them.

This might be because nurses cannot always be present during interdisciplinary evaluations.

The main conclusion was that the interdisciplinary team should not rely on subjective information for pain assessment. They should include objective measures of pain through tools like PACSLAC/PAINAD.

This would greatly reduce pain risk during assessment and treatment.

Article 2

Lichtner et.al. (2014) performed a systematic review of the psychometric properties, clinical utility, and clinical implications of various pain assessment instruments used in health care.

Although there was a lot of research on pain assessment, not all papers had data about the psychometric properties.

Study results regarding reliability of different studies revealed ambiguity.

Even though the reliability was calculated using a limited number of studies, it couldn’t be confirmed because reliability testing was only done for a small amount of patients.

This study revealed that there is very little evidence for the clinical utility, and that further research is needed to examine the psychometric characteristics of each tool.

Article 3Husebo, 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.

The study involved dementia patients being tested with the MOBID-2-based pain scale. Patients were tested at baseline, two weeks and four weeks later.

The study revealed that the scale responds when a stepwise protocol for pain treatment is followed.

Overall, the study showed that the tool can be used to evaluate the impact of pain treatment over time.

Article 4

Oosterman (2016) provides a narrative review of the potential use of facial expressions to assess pain in dementia patients.

Although many pain behavior observation tools include facial expressions, their precise definitions differ for every scale.

Confounding factors for pain assessment may include disinhibition, emotional disorders, and apathy.

These factors should be considered.

The study also found that the ability of health professionals to recognize pain is limited. Staff should be trained on facial expressions, and how to use observation scales for pain assessment.

Article 5

Ford et.al. (2015) based their research on the use of non-verbal behavior for pain assessment in dementia patients.

The primary purpose of this research was to assess the psychometric properties the NOPPAIN (Noncommunicative Patient Pain Assessment Indicator) pain assessment tool through secondary analysis data obtained from Snow and al. (2004).

The NOPPAIN tool focused on six non-verbal behaviors that can be used to assess pain. This included facial expressions as well as changes in activities and body movements. It also allowed for alteration in interpersonal interactions, vocalization, mental status changes, and vocalization.

In 83 seniors with dementia, the most common pain behavior was pain words, pain voices and pain faces.

It was also found that non-verbal pain behavior can be identified in older adults through pain vocalization and pain faces.

The findings of the study have implications for health-care staff. They may be able to identify pain in more vulnerable individuals with greater cultural competence.

Recommendation to Best Practice

Following a review of five studies on the efficacy of the NOPPAIN tool in pain assessment for older patients with cognitive impairment, it was recommended that it be used.

Ford et.al. (2015) evaluated the efficacy the NOPPAIN tool and discovered that the tool can identify non-verbal symptoms in patients.

The combination of this tool with cultural competence for nurses and staff can make it easier to assess pain in seniors.

The NOPPAIN tool has a main focus on assessing pain during movement and at rest.

These are the conditions that the hospital nurses can observe pain in patients:

Bad behavior when bathing, dressing, and transfer occurs

Pain behavior can be assessed using pain words, pain noises or pain faces.

Measurement of pain behavior intensity

Corbett and colleagues (2014).

Snow et.al. (2004) first evaluated the NOPPAIN Tool’s content, then Okimasa (2016) assessed its accuracy. Their study revealed that the NOPPAIN Tool’s reliability was high in patients who were not verbal and had pain issues.

NOPPAIN, which is more user-friendly than the Abbey scale for pain assessment, has more checklist items.

Identification Of The Practice Change Model To Bring About The Change

The research has confirmed the validity of NOPPAIN. But, in order for the tool to be implemented effectively and to bring about change in nursing practice, training must be given to nurses.

Lewin’s three change models will help bring this form of change.

The best thing about this model for practice is its simplicity and adaptability.

The three-stage model of change proposes is easy to implement. This is also reflective of the organizational process of managing and implementing change (Hussain (2016)).

The unfreeze period is crucial for creating a strong reason for change and making people realize the potential benefits of changing their practices or tunes.

The second stage involves the preparation phase, where people are educated about the changes and new policies are implemented.

The final stage involves a stable stage in which everyone is prepared for the change.

Kewin’s Change Model is therefore effective in explaining the striving forces required to maintain the status-quo and push for changes (Hussain und al., 2016).

The unfreezing stage is crucial in making staff understand the changes.

Every nurse should be aware at this point that older patients cannot use the old method of pain assessment and why NOPPAIN is required to improve their pain detection and treatment.

This will allow nurses to change their attitude and behavior regarding pain assessment practices (Manchester and al., 2014).

The second stage of the process is the movement stage. This stage requires staff to be trained to fully grasp the tools features and prepare for the change.

A second requirement is to provide cultural competency training as the tool mostly focuses on patient behavior observation.

This will allow nurses and doctors to see subtle symptoms of patient pain and to incorporate these observations to help with pain screening (Hadjistavropoulos und al., 2014.).

The refreeze stage will follow, where staff will no longer have difficulties in using this tool. Additionally, pain under detection will no longer be an issue in the clinical setting.Barrier To Implementation Of Change

The implementation of NOPPAIN’s new pain assessment tool at the healthcare setting may be hindered by certain obstacles.

Staff members with poor communication skills may prevent pain assessment from happening.

It may hinder their ability understanding pain voices and pain behavior.

A second problem is that all nurses may be comfortable with their previous tools, but they might not use them anymore (Ford, et al. (2015)).

This challenge can be addressed by providing training and improving competency in assessment.

This is because different cultures have different methods of expressing their pain. Therefore, nurses need to be aware that there are subtle differences in how they communicate it verbally and through their actions.

Implementing Practice Changes: The ethical implications

New practice changes in geriatric settings can have ethical implications.

This includes informing staff of the existence of the tool and getting permissions from relevant authorities for them to be included in everyday practice.

This is crucial because stakeholders are always required to use evidence-based practice. It is vital for maintaining quality and safety in health care.

Stakeholders will need to be able show evidence of the effectiveness of the proposed practice in order for them to agree on the inclusion of the new tool in their health care service delivery.

Second, nursing staff must be made aware of the tool to ensure no errors are made and staff have a positive intent to use it.

In order to preserve distributive justice, the tool requires ethical consent.

Evaluating evidence implementation is an essential part of the ethics in evidence implementation in healthcare (Hutton Eccles & Grimshaw (2008)).

Therefore, it is important for the organization to take into account rights of access and consideration about practice changes associated with the tool.Reference:Apinis, C., Tousignant, M., Arcand, M., & Tousignant-Laflamme, Y. (2014).

A standardized observational tool can be used to enhance the detection or pain in older adults with cognitive impairments. Pain Medicine, 15(1), 32-41, https://doi.org/10.1111/pme.12297Booker, S. S., & Herr, K. (2015).

The state-of”cultural validity” of selfreport pain assessment instruments in diverse older adults. Pain Medicine, 16(2), 232-239.Brown, D. (2011).

Assessment of pain in older cognitively impaired patients 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).

A roadmap for pain assessment in impaired cognition. BMC neurology, 14(1), 229. Ford, B., Snow, A. L., Herr, K., & Tripp-Reimer, T. (2015).

An ethnic variation in nonverbal pain behaviors in dementia-prone older adults. Pain Management Nursing, 16(5), 692-700.10.1016/j.pmn.2015.03.003Grol, R., Wensing, M., Eccles, M., & Davis, D. (Eds.). (2013).

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A mixed method investigation to improve pain assessment in long-term care facilities.

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The MOBID?2 pain score: Reliability of pain in dementia patients.

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A systematic review on systematic reviews of pain assessment instruments for people with dementia. BMC geriatrics, 14(1), 138,https://doi.org/10.1186/1471-2318-14-138Manchester, J., Gray-Miceli, D. L., Metcalf, J. A., Paolini, C. A., Napier, A. H., Coogle, C. L., & Owens, M. G. (2014).

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