Pain Management in the Cognitively Impaired, Non-Communicative Hip Fracture Patients: What are the Factors Influencing Nurse Decision Making with Analgesia in Older Adults Suffering a Hip Fracture who are Cognitively Impaired and Limited/Non Communicative.
Abstract
Aim
The aim of this review is to identify the factors, represented as barriers and facilitators that influence the nurse decision making process with analgesia and the cognitively impaired following hip fracture. It is anticipated that the findings will identify evidence based factors and initiatives that can be translated into local guidelines, initiatives and protocols to improve intervention and outcomes in this client group. Following implementation and audit of new initiatives, findings and evidence to support care delivery will be disseminated through publication.
Background
Hip fracture is acknowledged to be a major factor contributing to further disability, morbidity and mortality inflicting the older generation, representing high treatment costs and extended bed occupancy with extensive use of stakeholder resources. Analgesia administered to those who are cognitively impaired and suffering acute pain has been recognised as suboptimal with pain assessment tools sporadically used, and those suffering cognitive impairment identified as receiving 50% less analgesia than those who are cognitively intact. The consequences for the individual representing avoidable suffering and harm, compromised outcomes and risk of hospital acquired adverse events such as delirium.
The concept of misconceptions and bias in relation to the pain experience of those suffering dementia has been demonstrated to exist even quite recently despite a wealth of previous studies dedicated to improving pain management extending back more than twenty years.
The theoretical frameworks for decision making, clinical reasoning and clinical judgement are symbolic of knowledge and skills acquisition and professional development. In relation to this systematic review, the factors that will be identified that influence the nurse decision making represent the adverse interruptions or facilitating forces to the clinical reasoning, clinical judgement and finally the clinical decision-making process and adoption of evidence based practice.
Method
A systematic search of the literature was conducted accessing the databases C.I.N.A.H.L, Proquest- 16 databases, Pubmed/ Ovid (Medline) and the British Nursing Index. The initial key words used to conduct the literature search were: – Dementia; Analgesia and Nursing.
A total of nine studies met the inclusion criteria and were taken forward for critical appraisal by two reviewers utilising the Joanna Briggs Institute (J.B.I.) tools for critical appraisal. From these seven studies were selected for data extraction.
Results
The Systematic review identified three themes representing factors that directly and indirectly influence nurse decision making with cognitively impaired individuals suffering acute pain. Patient related, Care Giver Related and System related factors indicating both barriers and facilitators to pain management in this client group.
Patient related factors include communication with those who are cognitively impaired and behavioural manifestations, combined with sensory deficits and patient reluctance to accept medication.
Care giver related factors identified as lack of knowledge of pain and dementia and fear of overdose, inconsistent prescribing and treatment plans, lack of expert and peer consultation, and finally constraints with nurse-physician communication. Additionally, although evidence based intervention to assess and treat acute pain is acknowledged as best practice, adoption and implementation of effective intervention at the interface of care was demonstrated to be compromised and not consistent at the delivery stage. The deficit between knowledge, beliefs and practice evident.
System related factors represented as lack of availability and access to expert and pharmacists. Lack of time to assess pain and administer medication. Lack of non-pharmacological alternatives/time to deliver non pharmacological alternatives.
Recommendations
Recommendations focus on multidisciplinary and multidimensional intervention, incorporating organisational, managerial, educational and clinical concepts:-
1.The implementation of numerical scoring Assessment tools, although supportive to pain assessment are lower priority to address the problem of compromised analgesic administration and pain management than introduction of education resources, system change and organisational support.
2.Organisational support relating to review of workforce capacity and skill mix.
3.Managerial initiatives to support and facilitate time and resources for educational and evidence based improvements in both medical and nursing understanding of the complexities and manifestations of dementia and related pain expression, understanding of pharmacology and specific effects of opiates on the mentally frail individual.
4.Clinically and educationally, at the interface of care, access to and intervention from Specialist dementia and pain experts, availability of electronic educational resources, agreed competencies specific to level of experience and roles to support and develop appropriate assessment skills and decision making, standardised prescribing practice protocols to treat what is acknowledged as a condition associated with severe and distressing pain in the acute phase. This to include an indication on case notes that staff should Assume Pain Presence (APP) and administer regular/ around-the- clock analgesia (A visible stamp or sticker)
5.Regular analgesia to include Intravenous paracetamol and oramorph in addition to regional local anaesthesia by means of Fascia Iliaca Compartment Block.
6.Audit and feedback at ward level to address compliance and understanding of new initiatives.
7. Future retrospective audit /study to compare pre and post introduction of initiatives on incidence of Delirium, Urinary and respiratory tract infection, pressure sores, malnutrition and dehydration, and effects on length of stay and clinical and social outcomes.