Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

The pain cues of cognitively impaired elderly people: an ethnoscientific study of gerontological nurses’.. 1995

You don't seem to have a PDF reader installed, try download the pdf

Item Metadata

Download

Media
ubc_1995-0144.pdf
ubc_1995-0144.pdf [ 4.19MB ]
Metadata
JSON: 1.0086742.json
JSON-LD: 1.0086742+ld.json
RDF/XML (Pretty): 1.0086742.xml
RDF/JSON: 1.0086742+rdf.json
Turtle: 1.0086742+rdf-turtle.txt
N-Triples: 1.0086742+rdf-ntriples.txt
Citation
1.0086742.ris

Full Text

THE PAIN CUES OF COGNITIVELY IMPAIRED ELDERLY PEOPLE AN ETHNOSCIENTIFIC STUDY OF GERONTOLOGICAL NURSES' PERSPECTIVES By BELINDA BERNICE PARKE B . S . N . , Univers i ty of V i c t o r i a , 1989 A THESIS SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING In THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept th i s thes i s as conforming to the required standard UNIVERSITY OF BRITISH COLUMBIA March, 1995 (c) Bel inda Bernice Parke,. 1995 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of K l l A M i ^ The University of British Columbia Vancouver, Canada Date JV\CXACA\ , l9QsT DE-6 (2/88) Abstract The Pain Cues of Cognitively Impaired E l d e r l y People: An E t h n o s c i e n t i f i c Study of Gerontological Nurses' Perspectives. Many gaps exi s t i n our a b i l i t y to detect and assess pain i n cognitively impaired e l d e r l y people. In t h i s study, an ethnoscientific approach was used to access gerontological nurses' knowledge of pain i n the c o g n i t i v e l y impaired elderly. In keeping with an e t h n o s c i e n t i f i c approach, judgement sampling, a non- p r o b a b i l i t y method for selection of knowledgable informants was used to select s i x gerontological nurse p a r t i c i p a n t s . A l l informants were over the age of t h i r t y and had between six and f i f t e e n years of experience working with cognitively impaired e l d e r l y people. Two data c o l l e c t i o n procedures were used; story t e l l i n g interviews and retrospective chart reviews. The story t e l l i n g interviews involved a systematic exploration of gerontological nurses' observations and perceptions caring for cognitively impaired e l d e r l y people i n pain. Formal e l i c i t a t i o n procedures were used as the framework for the interviews. As such, both the questions and the answers were discovered by the nurse informants. The second data source, retrospective chart reviews, focused on the written language other nurses used to describe pain. The chart review was intended to give breadth to the data that was c o l l e c t e d i n the interviews. Twenty-one charts of c o g n i t i v e l y impaired e l d e r l y people were reviewed, sixteen were included i n the study and f i v e were excluded. A process of constant comparative analysis was used to determine the meanings nurses attached to the words and phrases they used to describe t h e i r observations. The findings from t h i s study revealed that nurses use three pain cue groupings, overt behaviour, appearance and sounds. In addition, the findings revealed that the gerontological nurses i n t h i s study were able to integrate "knowing the patient" with knowing by i n t u i t i v e perception. Together, each method of knowing enhanced the nurses a b i l i t y to i n f e r that pain was a problem for an impaired elder. i v TABLE OF CONTENTS Abstract Table of Contents L i s t of Figures Acknowledgement Chapter One: Introduction Background to the Problem 1 Statement of the Problem 3 Purpose 5 Research Question 5 D e f i n i t i o n of Terms 5 Assumptions 7 Conceptual Framework 7 Significance of Study 15 Summary . 15 Chapter Two: Review of the Literature 17 Introduction 17 Pain Assessment 17 Comparative Studies with Infants 23 Descriptive Information: Cognitively Impaired E l d e r l y 24 Summary 2 6 Chapter Three: Method 28 Introduction 28 Selection of Participants 29 Sample 3 0 Data C o l l e c t i o n Procedures 32 Interview method 32 Retrospective chart review ; 35 Data Analysis 3 6 Strategies to Achieve Rigor 3 9 C r e d i b i l i t y 39 A u d i t a b i l i t y 41 E t h i c a l Considerations 41 Summary 43 Chapter Four: Findings... 44 Introduction . 44 The Problem of Pain Recognition 46 Individual v a r i a t i o n 46 Absence of confirmation 50 Reasoning Pain Problems: The Making of Inferences.... 52 Change i n elders' status 53 i v v i v i i 1 V Confirming the presence of pain 54 Pain Cues of Cognitively Impaired E l d e r l y People 59 Overt behaviour.... 60 Sounds 63 Appearance 66 Summary 68 Chapter Five: Discussion of the Findings 71 Introduction 71 Nurses Knowledge of Pain Cues 72 Nurses' Way of Realizing Pain Was Present 75 Knowing the Patient 76 Recognizing change 78 Clustering pain cues .... 78 Having relationships 80 I n t u i t i v e Perception 84 Summary 86 Chapter Six: Summary, Conclusions, and Implications 88 Summary 88 Conclusions 91 Implications for Nursing Practice 92 C l i n i c a l p r actice 92 Administrative practice 94 Implications f o r Nursing Education 96 Curriculum development 96 F a c i l i t y based inservice programming 98 Implications for Nursing Research 98 References 101 Appendix A: Question Guide 107 Appendix B: Information Letter to F a c i l i t y 109 Appendix C: Information Letter to Informant 110 Appendix D: Consent Form I l l v i Figures Figure 1: Domains of the Pain Experience 7 Figure 2: T r a d i t i o n a l Pain Assessment 11 Figure 3: Pain Assessment-Cognitively Impaired E l d e r l y 13 Figure 4: Problem of Pain Recognition 46 Figure 5: Overt Behaviour Pain Cues 61 Figure 6: Sound Pain Cues 64 Figure 7: Appearance Pain Cues 66 Figure 8: Rea l i z ing Pain i s Present 75 Acknowledgements So many people have helped to bring t h i s t h e s i s into being. I have f e l t enormously supported by professors, colleagues, friends, and family. Their patience, generosity, words of encouragement, and understanding have assisted me to complete t h i s t h e s i s . For t h e i r e f f o r t s i n guiding me through the research process, I wish to extend a thank-you to the members of my thesis committee, Professors Anna Marie Hughes, S a l l y Thorne and Carol J i l l i n g s . My sincere appreciation i s extended to the six gerontological nurses who agreed to p a r t i c i p a t e i n t h i s study and to Holy Family Hospital for supporting t h i s research i n t h e i r f a c i l i t y . I have had the good fortune to work with administrators who are dedicated to nursing and the development of nursing knowledge. A s p e c i a l thank-you to Jeannette and Pat for keeping the pathway open f o r me to attend and complete graduate school. I am g r a t e f u l to my friends and colleagues who so w i l l i n g gave t h e i r time to l i s t e n to my ideas. A s p e c i a l heart f e l t thanks goes to Carolynn, Jessie, and Mary E l l e n . Your gentle probing, questioning, and reassurance helped me to "keep the f a i t h " . To my family, your humour, a b i l i t y to forgive, and willingness to love unconditionally i s awesome. Thank- you Brent, Shaun, and Jennifer for helping me to move through the d i f f i c u l t moments and for sharing the joy of happy moments. I t r u l y believe I couldn't have managed without your support and encouragement. Together, you are my greatest blessing. Chapter One Introduction Pain i s a universal human experience which has the p o t e n t i a l to a f f e c t the qua l i t y of an i n d i v i d u a l ' s l i f e . C l i n i c i a n s , researchers and scholars have been struggling to understand the phenomenon of pain f o r centuries. This study was designed to contribute to our understanding of pain problems i n a growing population of cognitively impaired e l d e r l y people. The findings generated from t h i s study have important a p p l i c a t i o n i n the detection of pain and i t s management i n t h i s population. Background to the Problem E l d e r l y people tend to suffer from a v a r i e t y of p a i n f u l conditions, many of which are chronic and degenerative i n nature ( F e r r e l l , 1991). The prevalence of pain i n the e l d e r l y i s estimated to range from 45% to 80%, with a predominance of chronic musculo-skeletal problems l i k e o s t e o - a r t h r i t i c conditions ( F e r r e l l , F e r r e l l & Osterweil, 1990; Marzinski, 1991; Roy & Thomas, 1986). The number of elderly people l i v i n g i n Canada i s growing. "Demographic projections for the year 2011 ind i c a t e that people aged 65 and older w i l l c onstitute s l i g h t l y over 15% of the Canadian population i n comparison to 10.7% i n 1986" (Beckingham, 1993, p8) . 2 Some el d e r l y people are cognitively impaired. The prevalence of moderate to severe cognitive impairment i n populations over age s i x t y - f i v e i s estimated to be between four and seven percent. The incidence of cognitive impairment sharply increases to f i f t e e n percent i n those who are over the age of e i g h t y - f i v e (Chenitz, Stone & Salisbury, 1991; Forbes, Jackson & Kraus, 1987; Katzman, 1986). As a subgroup of the e l d e r l y population, i t i s reasonable to assume that many co g n i t i v e l y impaired e l d e r l y also experience pain. As the e l d e r l y population i n Canada increases, the numbers of cognitively impaired e l d e r l y people w i l l increase with a corresponding increase i n the number of impaired elders who experience pain. A review of the l i t e r a t u r e on pain i n the c o g n i t i v e l y impaired elderly y i e l d s d e s c r i p t i v e information but no s c i e n t i f i c research s p e c i f i c to t h i s group. The pain research available has focused p r i m a r i l y on the development of tools to measure the i n t e n s i t y of pain i n adults, who can a r t i c u l a t e t h e i r experience, or i n young children. Related research on chronic pain i n adults and pain assessment i n infants and neonates has some limited value i n helping us understand the pain experience of the c o g n i t i v e l y impaired elderly. Yet, because of the differences between these populations, i t was f e l t that an 3 e t h n o s c i e n t i f i c study of nurses caring f o r c o g n i t i v e l y impaired e l d e r l y people would make a s i g n i f i c a n t contribution i n determining the most appropriate ways of assessing t h e i r pain. Statement of Problem The problem of detecting and assessing pain i n the co g n i t i v e l y impaired elderly was the major focus of t h i s e t h n o s c i e n t i f i c study. The detection of pain through accurate assessment i s hindered i n the e l d e r l y by several factors. These factors are the subjective nature of pain, the lack of appropriate assessment t o o l s , nurses' lack of knowledge, misunderstandings about pain perception i n r e l a t i o n to aging and the chronic long term nature of pain. In addition, pain i n the e l d e r l y i s often experienced concurrently with depression and sensory impairments (McCaffery & Beebe, 1989; Watt-Watson, 1987; Watt-Watson & Donovan, 1992) . In the cognitively impaired e l d e r l y the d i f f i c u l t y of detecting pain i s further compounded by co-existing factors such as aphasia, chemical and/or mechanical r e s t r a i n t s , altered states of consciousness, and also memory loss and loss of i n t e l l e c t u a l functioning. E x i s t i n g pain assessment tools r e l y heavily on a person's a b i l i t y to describe his or her experience. This i s a s i g n i f i c a n t drawback when attempting to 4 assess pain i n the cognitively impaired e l d e r l y as they cannot verbally express t h e i r pain experience i n ways that are understandable. In addition, the to o l s that are a v a i l a b l e for assessing pain are too d i f f i c u l t f o r co g n i t i v e l y impaired e l d e r l y people to understand, even i f they can respond, and therefore are not useful. The detection of pain i n t h i s group remains problematic and as a r e s u l t many cognitively impaired e l d e r l y l i v e i n pain which, i f detected, could be re l i e v e d . Although many gaps remain i n our a b i l i t y to detect and assess pain i n t h i s group, some gerontological nurses have an a b i l i t y to detect, assess and manage pain problems i n co g n i t i v e l y impaired elderly people. I t appears that t h i s a b i l i t y i s not consciously known or r e a d i l y taught to other nurses. The focus of t h i s investigation i s nurses' perspectives because of: (a) t h e i r r o l e and r e s p o n s i b i l i t y f o r ensuring that the most appropriate care i s provided i n the most timely way, and (b) t h e i r observed a b i l i t i e s to assess and manage pain problems i n c o g n i t i v e l y impaired e l d e r l y people. The nurses' observations are pi v o t a l i n prompting comfort through accurate assessment and implementation of pain management strategies. Currently there i s no accepted nursing method to i d e n t i f y the presence of pain i n the co g n i t i v e l y impaired elderly. In t h i s study, an 5 e t h n o s c i e n t i f i c approach was used to access gerontological nurses' knowledge of pain i n the c o g n i t i v e l y impaired elderly. By i d e n t i f y i n g the knowledge held by some gerontological nurses, i t may be possible to create a knowledge base whereby other nurses can be taught how to i d e n t i f y and assess pain i n t h i s group. Purpose The purpose of t h i s e t h n o s c i e n t i f i c study was to determine the cues that gerontological nurses use to i n f e r that pain i s a problem for a c o g n i t i v e l y impaired e l d e r l y person. Research Question What are the cues that gerontological nurses use to i n f e r that pain i s a problem for a c o g n i t i v e l y impaired e l d e r l y person? D e f i n i t i o n of Terms A number of key terms used i n t h i s study are defined as: Cues: Signs, symptoms, verbal and nonverbal behaviour of a cognitively impaired elder that are used to i n f e r existence of pain along with a l l other pertinent information related to chart documentation, l e v e l of p a r t i c i p a t i o n i n a c t i v i t i e s of d a i l y l i v i n g / s o c i a l a c t i v i t i e s , and use of family descriptions of past pain behaviour. 6 Gerontological Nurse: By t i t l e and p o s i t i o n a Registered Nurse, Nursing Assistant, Continuing Care Aide, or Licensed P r a c t i c a l Nurse who has the s k i l l and knowledge necessary to care for a c o g n i t i v e l y impaired e l d e r l y person i n a long term care f a c i l i t y . Pain: "An unpleasant sensory and emotional experience associated with actual or p o t e n t i a l t i s s u e damage, or described i n terms of such damage" (International Association for the Study of Pain, 1986, p. S217). Pain Behaviour: A l l forms of observable expression, verbal and nonverbal, generated by the i n d i v i d u a l that r e f l e c t s the presence of and t h e i r response to a stimulus that i n i t i a t e s a pain experience. E l d e r l y : I t i s acknowledged the term " e l d e r l y " holds both p o s i t i v e and negative connotations. Terms such as "older adult" are recognized as less value laden. S t i l l , the term e l d e r l y was chosen f o r t h i s i n v e s t i g a t i o n because i t most suited the population over 65 years of age. It was the term most commonly used by nurses working i n long term care f a c i l i t i e s at the time of t h i s investigation. Cognitively impaired e l d e r l y person: An i n d i v i d u a l , aged 65 years or older, who has "acquired a p e r s i s t e n t i n t e l l e c t u a l -impairment with compromise i n 7 mental a c t i v i t y : language, memory, v i s u o s p a t i a l s k i l l s , personality/affect and cognition" (Shapira, Schlesinger & Cummings, 1986, p 699). Assumptions 1. A l l people have the capacity to experience pain. 2. Pain exists in people who can v e r b a l l y express when " i t hurts", as well as i n people who are cognitively impaired and cannot verbally express when " i t hurts" (McCaffery & Beebe, 1989). 3. Aging does not a f f e c t the a b i l i t y to f e e l pain. 4. Pain involves both the body and the mind. Conceptual Framework The conceptual framework for t h i s study i s an expansion of Loeser and Egan's (1989) d e s c r i p t i o n of a pain experience (See Figure One: Domains of the Pain Experience). PAIN PAN BEHAVIOR SUFFERING t PAW f NOCICEPTION EXPERIENCE Figure One: Domains of the Pain Experience (Loeser & Egan, 1989). 8 Loeser and Egan characterize the pain experience of a l l people as involving four domains: nociception, pain, s u f f e r i n g , and pain behaviour. The domains of nociception, pain, and suffering are thought of as "personal, private, internal events whose existence can only be inferred" (p. 5) . Nociception i s the stimulus that i n i t i a t e s the pain experience. I t occurs at the c e l l u l a r l e v e l , involves thermal, chemical, and/or mechanical t i s s u e i n j u r y and r e s u l t s i n the stimulation of peripheral pain receptors, known as nociceptors (Loeser & Egan, 1989) . Peripheral nociceptors transmit the "pain" impulse along A-delta or C-fibers. "A-delta f i b e r s are responsible for the transmission of sharp, w e l l - l o c a l i z e d pain sensation. C-fibers are responsible f o r transmission of d u l l , burning or d i f f u s e pain sensations" (Watt-Watson & Donovan, 1992, p. 402). Perception of the nociceptive impulse into the nervous system results i n the sensation of pain (Donovan, 1989; International Association f o r the Study of Pain (IASP), 1986; Loeser & Egan, 1989). This marks the beginning of the second domain. " I t [pain] i s unquestionably a sensation i n a part or parts of a body, but i s also always unpleasant" (IASP, 1986, p. S217) . Pain i s a subjective experience, e x i s t i n g whenever the experiencing person says i t does 9 (McCaffery & Beebe, 1989) . The perceived pain can be modulated by various factors, such as past experiences, meaning of the pain event, past coping strategies, cultu r e and personal factors such as fatigue or sadness. The sensation and perception of pain leads to the personal experience of suffering, the t h i r d domain i n Loeser & Egan's (1989) description of a pain experience. Suffering i s defined as a subjective, negative a f f e c t i v e response (Copp, 1974; Davitz & Davitz, 1981; Loeser & Egan, 1989). Suffering involves p h y s i c a l experiences with psychological and s p i r i t u a l associations (Watson, 1989). The degree of s u f f e r i n g experienced by a person i n pain i s influenced by the sensation and perception of the pain and i t s r e l a t i o n s h i p to the psychological and s p i r i t u a l meaning of the event. Pain behaviour i s the f i n a l domain of Loeser and Egan's (1989) description of a pain experience. Pain behaviours, as previously defined, include a l l forms of observable behaviours that r e f l e c t the presence of and response to nociception. Behaviours of the pain s u f f e r e r are the only d i r e c t access to the pain experience that the nurse has (Donovan, 1989; Loeser & Egan, 1989). Loeser and Egan's (1989) description of a pain 10 experience has been expanded by t h i s investigator to incorporate pain assessment. In conceptualizing the t r a d i t i o n a l pain assessment approach, (See Figure Two: T r a d i t i o n a l Pain Assessment) the nurse i n i t i a t e s the assessment process following the patient's verbal declaration of pain. The nurse i s the person on the health care team providing d i r e c t care that includes assessing and implementing pain management strategies. Each nurse brings nursing education/training, t h e o r e t i c a l knowledge, personal experiences, e x p e r i e n t i a l knowledge, culture, values and b e l i e f s to the s i t u a t i o n (Griepp, 1992). These variables can enhance or impede the nurse's interaction with anyone i n pain. The nurse w i l l or w i l l not believe the person's report of pain and t h i s decision w i l l influence the c l i n i c a l judgement of the nurse. C l i n i c a l judgement i s a complex i n t e l l e c t u a l process of decision making that includes formulating interpretations regarding what action to take. Action r e f e r s to the interventions the nurse chooses or does not choose to implement. To take no action i s perceived i n the t r a d i t i o n a l approach to pain assessment as a conscious decision not to i n i t i a t e nursing interventions. Both the actions and the non- actions are the r e s u l t of c l i n i c a l judgement. 11 ACTION f CLINICAL JUDGEMENT BeBevesX p e f s o n EcJucaMcxi /Tro in ina Theoret tco) k n o w l e d g e "*" D o e s n o t / b e l i e v e p e r s o n Pers o o o ) e x p e r i e n c e Ml IDV 1 — Exper ien to l N u s l n g K n o w l e d g e MUIWL 1 V o l u e s / b e t e f s / c u t u r e V e r b d s t a t e m e n t 'I h o v e p c ' n * . PAIN EXPERIENCE F i g u r e Two: T r a d i t i o n a l P a i n Assessment 12 For the purposes of t h i s study i t i s assumed that pain i n the cognitively impaired e l d e r l y involves the four domains, nociception, pain, suffering, and pain behaviours as outlined by Loeser and Egan (1989). However, since a verbal declaration w i l l not be the event that triggers a nursing assessment, a second conceptualization i s used as a framework to i l l u s t r a t e pain assessment i n the cognitively impaired e l d e r l y . (See Figure Three: Pain Assessment Cognitively Impaired E l d e r l y ) . Cognitively impaired e l d e r l y people are unable to give r e l i a b l e verbal information about t h e i r experience. They cannot verbally express t h e i r pain experience i n ways that are understood. Consequently, c o g n i t i v e l y impaired elderly people do not v e r b a l l y report, "I have pain." Because cogni t i v e l y impaired e l d e r l y people do not state they have pain nor do they v a l i d a t e the nurses' "hunch," i t i s conceivable that nurses' assessment of pain could be incomplete or, worse, not i n i t i a t e d . Because of the absence of r e l i a b l e verbal cues, c l i n i c a l judgement i s complex when assessing pain i n the c o g n i t i v e l y impaired e l d e r l y . Pain assessment i n t h i s group r e l i e s , to a greater degree, on formulating interpretations regarding what to observe i n a s i t u a t i o n and making i n f e r e n t i a l decisions about the 13 meaning of c l i n i c a l data (Spross & Braggerly, 1989) ACTION t CLINICAL JUDGEMENT Infers Pdn Is o E d u c c r i i o n / T ' o l n i n g T h e o r e t i c a l k n o w l e d g e Doei]Not Infer Poin Is a Problem P e r s o n a l e x p e r i e n c e F jqDer ien la l Nurs ing K n o w l e d g e j V o l u e s / b e l l e f s / c u t t u r e N o V e r b a l S l o i e m e n t PAIN EXPERIENCE Figure Three: Pain Assessment-Cognitively Impaired Elderly 14 In the t r a d i t i o n a l model, the patient validates the meaning nurses give to what they observe. This i s not so with cognitively impaired e l d e r l y people. C l i n i c a l data are derived from observing, evaluating behaviours and other cues, as well as making inferences. The subjective and i n v i s i b l e nature of pain d i c t a t e s the need for nurses to go beyond what i s accepted practice i n order to deal e f f e c t i v e l y with pain problems i n the cognitively impaired e l d e r l y . To make inferences about a cognitively impaired e l d e r l y person's pain and suffering, the nurse must r e l y on " i n t u i t i v e i n s t i n c t s , and also what i s observed, both v e r b a l l y and nonverbally" (Dudley & Holm, 1984, p. 185). Together, the pain behaviours and other cues enable the nurse to i n f e r that pain i s or i s not a problem for a cognitively impaired e l d e r l y person. Thus, Loeser and Egan's (1989) description of a pain experience orients us to: (a) the notion that pain i n a l l people involves four domains, nociception, pain, s u f f e r i n g , and pain behaviour, and (b) the point at which the pain assessment process begins. When comparing t r a d i t i o n a l pain assessment (Figure Two) with pain assessment i n the cognitively impaired e l d e r l y (Figure Three), the reader can see that the expected verbal cue "I have pain," which p r e c i p i t a t e s nursing 15 assessment of pain i s not present with c o g n i t i v e l y impaired e l d e r l y people. Without the conventional cue, "I have pain," nurses must use i n f e r e n t i a l diagnostic reasoning and c l i n i c a l judgement to decide what action they w i l l or w i l l not take. This study helped i d e n t i f y the pain cues of cognitively impaired e l d e r l y people through the observations nurses make and the i n f e r e n t i a l diagnostic reasoning they use to determine that pain i s a problem for a cognitively impaired e l d e r l y person. Si g n i f i c a n c e of the study Comfort and control of pain are important goals f o r nursing practice. Regardless of time, s e t t i n g , language, or culture, responding to the pain experience of the e l d e r l y i s central to gerontological nursing. This study has provided a clearer understanding of how c o g n i t i v e l y impaired elderly people express t h e i r pain by systematically capturing the knowledge held by some gerontological nurses. In addition, the findings from t h i s study lay the necessary ground work for future development of a nursing assessment t o o l s p e c i f i c to the c o g n i t i v e l y impaired e l d e r l y . Summary This chapter has introduced the problem of pain i n the e l d e r l y , the purpose of the study, the research question, d e f i n i t i o n s , and the sign i f i c a n c e of the 16 problem from the perspective of nursing and the c o g n i t i v e l y impaired elderly. The conceptual framework o f f e r s a description of the relat i o n s h i p between a person i n pain and key variables a f f e c t i n g the nurse's assessment. Extension of Loeser & Egan's (1989) de s c r i p t i o n of a pain experience provides d i r e c t i o n f o r and c l a r i t y to nurses' pain assessment process f o r the co g n i t i v e l y impaired elderly. In the following chapter, relevant background l i t e r a t u r e i s provided. This research l i t e r a t u r e i s reviewed and discussed to provide a background f o r what i s already known and to establish the r a t i o n a l e f o r the study. Chapter Three describes the process used to implement the methodology of the study. Findings from the data are presented i n Chapter Four. Chapter Five o f f e r s an interpretation of the findings as they were presented i n Chapter Four. The discussion i n Chapter Five i s presented within the context of the l i t e r a t u r e reviewed. A summary of the study and the implications of the r e s u l t s for nursing practice, education, and research w i l l form the conclusions expressed i n Chapter Six. 17 Chapter Two Review of the Literature Introduction The l i t e r a t u r e on pain predominantly discusses assessment and management of acute and chronic pain i n c o g n i t i v e l y able adults, young children and i n f a n t s . A search of the l i t e r a t u r e has yielded l i m i t e d d e s c r i p t i v e information but no s c i e n t i f i c research on pain assessment i n the cognitively impaired e l d e r l y . This review w i l l focus on pain assessment i n adults with chronic degenerative problems and infants who are developmentally unable to a r t i c u l a t e t h e i r pain experience. Descriptive information on pain assessment i n the cognitively impaired e l d e r l y concludes t h i s chapter. The information drawn from these sources provided the base for determining the a p p l i c a b i l i t y of borrowing t h i s research to develop a method of assessing pain i n the cognitively impaired e l d e r l y . As well, the l i t e r a t u r e review placed t h i s study i n the context of available pain research. Pain Assessment The pain assessment l i t e r a t u r e has focused p r i m a r i l y on methods to measure pain. Most often the words "assessment" and "measurement" are used interchangeably with a variety of scales. The scales that have been developed to measure 18 pain experiences have frequently been the focus of studies to determine t h e i r r e l i a b i l i t y and v a l i d i t y (Melzack, 1983; Melzack & Wall, 1982). These scales can be c l a s s i f i e d as descriptive, v i s u a l , numerical and behaviourial. H i s t o r i c a l l y , pain researchers and c l i n i c i a n s have r e l i e d on the patient's s e l f - r e p o r t to measure pain (Le Resche & Dworkin, 1988) . The most commonly used self-report methods are numerical or verbal category scales. Each scale attempts to quantify the patient's subjective experience of pain. To date, these scales have measured pain as a s p e c i f i c sensory qu a l i t y varying only i n i n t e n s i t y . Tests to determine t h e i r a p p l i c a b i l i t y for assessing pain i n the c o g n i t i v e l y impaired elderly are lacking; however t h e i r u t i l i t y i s problematic and needs to be investigated i f they are to be for use i n t h i s population of people. Melzack and Wall (1982) attempted to capture the multidimensional aspect of pain i n the development of the M c G i l l Pain Questionnaire. This t o o l has gained wide use i n c l i n i c a l practice. However, language s k i l l and/or i n t e l l e c t u a l understanding are prerequisites f o r a l l s e l f report tools including the McGill Pain Questionnaire. Behavioral scales and observational procedures are also i d e n t i f i e d i n the l i t e r a t u r e as methods for 19 assessing pain (Fordyce, 1983; McCaffery & Beebe, 1989; McDaniel, Anderson, Bradley, Young, Turner, Agudelo, & Keefe, 1986). Fordyce (1983) postulates that "the nature of the pain, i t s intensity, impact, and even i t s very existence are discernable only by something the s u f f e r i n g person says or does: pain behaviour" (p. 145). As a r e s u l t Fordyce offers a behaviour based approach to pain assessment i n the form of an A c t i v i t y Pattern Indicator (API) to measure verbal and nonverbal behaviour. The behavioral domains included i n the API are: 1. Pain behaviours: V i s i b l e or audible indicators of suffering or l i m i t e d functions; 2. Functional impairments: Indicators of al t e r a t i o n s or limitations i n performance of l i f e demands; 3. Health care u t i l i z a t i o n : Included are medication consumption and number of ho s p i t a l i z a t i o n s ; and 4. Associated or " r i p p l e e f f e c t " problems: Examples being depression, t o x i c i t y and cognitive dysfunctions related to over medication consumption or the i n a b i l i t y to work. Fordyce (1983) concluded that i n " c l i n i c a l pain, one 20 cannot measure "pain". One can measure only pain behaviour or analogues thereof" (p 52). In a series of four studies, McDaniel et a l . (1986) attempted to te s t the r e l i a b i l i t y and v a l i d i t y of a behavioral pain observation method f o r assessing the pain of rheumatoid a r t h r i t i s (RA) patients. The behavioral observation method included three categories of behaviour: 1. Position: Standing, s i t t i n g , r e c l i n i n g ; 2. Movement: Pacing, s h i f t i n g ; and 3. Pain: guarding, bracing, grimacing, sighing, r i g i d i t y , passive rubbing, active rubbing and self-stimulation. Subjects i n a l l four studies were co g n i t i v e l y i n t a c t adults, able to a r t i c u l a t e t h e i r experience and v a l i d a t e the investigators' observations. McDaniel and colleagues concluded that "the behaviourial observation method provides useful and r e l a t i v e l y objective information regarding RA pain" (pl79). The authors were able to support claims of r e l i a b i l i t y and v a l i d i t y f o r the behavioral observation method. Other researchers have investigated nonverbal behaviours to measure chronic pain (Craig & Prkachin, 1983; Le Resche & Dworkin, 1988; Turk & Flor, 1987; Vlaeyen, Van Eek, Groenman & Schuerman, 1987) . The r e s u l t s of these studies have yielded an impressive 21 array of behaviours believed to be associated with pain. The behaviours observed can be categorized as posture, which includes standing, s i t t i n g or r e c l i n i n g ; f a c i a l expressions, such as grimacing, s p e c i f i c configurations of fear, sadness, and disgust; ve r b a l i z a t i o n s , such as self-reports or complaints of pain, asking for help and repeated requests f o r analgesics; vocalizations, which are heard as sighing, crying, groaning, moaning, and other non-language sounds; functional a b i l i t y as evidenced by an increase or decrease i n mobility, a decline i n a c t i v i t y , tolerance, and endurance, with a proportional increase i n fatigue. The usefulness of these studies i s af f e c t e d by the fact that the subjects f o r each study were adults who could a r t i c u l a t e t h e i r experience and confirm or deny the researchers' conclusions. Cognitively impaired adults over age s i x t y - f i v e were not included i n the samples. Further, not a l l pain behaviours i d e n t i f i e d i n these studies were appropriate measures fo r assessing pain i n the c o g n i t i v e l y impaired e l d e r l y , as some of the behaviours used to measure pain required s k i l l s , knowledge and a b i l i t i e s that are beyond the capacities of cognitively impaired e l d e r l y people. In a review a r t i c l e by Turk and F l o r (1987), the 22 v a l i d i t y and u t i l i t y of a "pain behaviour construct" was explored. A f t e r review of the a v a i l a b l e research, Turk and Flo r concluded that, "when s p e c i f i c observable pain behaviours are monitored i n a c l i n i c a l s e t t i n g and subjective pain ratings are obtained concurrently, . . . the exact timing and context of the assessment as well as type of behaviour assessed seem to be c r u c i a l " (p. 285). Similarly, the use of e x i s t i n g behavioural observation tools for assessing pain i n the co g n i t i v e l y impaired elderly may not have the same r e l i a b i l i t y and v a l i d i t y as demonstrated with other population not only because the type of pain, the pain behaviours being measured, but also the timing and context of the assessments d i f f e r . So, the accuracy and appropriateness of using ex i s t i n g behavioural observational methods cannot be guaranteed for assessing pain i n the cognitively impaired e l d e r l y . However, observable pain behaviours may be the only v i a b l e source of data from the cog n i t i v e l y impaired e l d e r l y . I d e n t i f i c a t i o n of the pain behaviours of co g n i t i v e l y impaired elderly through the i n t u i t i v e knowledge of gerontological nurses provides the base information needed to validate the use of a pain behaviour construct within t h i s group. 23 Comparative Studies with Infants In considering pain assessment i n the c o g n i t i v e l y impaired elderly, the usefulness of comparisons drawn with infants was explored. Like the c o g n i t i v e l y impaired elderly, infants cannot use language to t e l l t h e i r pain experiences (McGrath, 1987). "Health professionals and parents must r e l y on e i t h e r the i n f a n t s ' behaviours or t h e i r bodies' p h y s i o l o g i c a l changes i n order to assess t h e i r pain" (p. 149). Research on pain i n infants has been conducted around p a i n f u l procedures such as heelst i c k s , circumcision, tissue trauma and immunizations (Davis fie Calhoon, 1989; Franck, 1986; F u l l e r , H o r i i , & Conner, 1989; M i l l s , 1989; Shapiro, 1989). These studies have shown that infants' responses to acute pain may include general body movements, s p e c i f i c f a c i a l expressions, and crying patterns. Anand, P h i l and Hickey (1987), i n a review of pain and i t s e f f e c t s i n the human neonate and fetus, c l a s s i f y behavioral changes associated with pain into four areas: simple motor responses, f a c i a l expressions, crying and complex behaviourial responses. Other pote n t i a l i n d i c a t o r s of i n f a n t pain have been i d e n t i f i e d as increased heart rate, increased respiratory rate and changes i n transcutaneous oxygen levels (Fuller, H o r i i & Conner, 1989). Much of the research on pain i n infants has 24 been associated with acute pain experiences and i n s i t u a t i o n s where physical indicators are e a s i l y assessed. L i t t l e of t h i s research was concerned with the pain producing chronic health problems a f f l i c t i n g the c o g n i t i v e l y impaired elderly. As such, use of the behavioural categories of infants i n acute pain may were not appropriate for understanding and assessing pain i n the cognitively impaired e l d e r l y . M i l l s (1989) attempted to describe the behaviours of infants i n prolonged pain. In addition to those l i s t e d by F u l l e r et a l . (1989), M i l l s concluded that infant/parent interaction decreased i n infants with prolonged pain compared with those without pain. Since pain associated with chronic health problems i s usually prolonged, these conclusions may be more applicable to the issue of assessing pain i n the c o g n i t i v e l y impaired e l d e r l y . Descriptive Information: Cognitively Impaired E l d e r l y Cognitive impairment i n r e l a t i o n to pain i n the e l d e r l y has been reported i n the l i t e r a t u r e as: (a) a condition that may mask the presentation of pain, (b) a condition exacerbated because of the presence of pain, and/or (c) a related variable requiring evaluation when assessing pain i n the cognitively impaired e l d e r l y ( F e r r e l l , 1991; F e r r e l l , F e r r e l l & Osterweil 1990; Marzinski, 1991; Roy & Thomas, 1986). The l i t e r a t u r e 25 on assessing pain as a symptom for co g n i t i v e l y impaired e l d e r l y people has focused attention on observational procedures and behaviourial indicators (Herr & Mobily, 1991; Hurley, V o l i c e r , Hanrahan, Houde, V o l i c e r , 1992; Marzinski, 1991; Parke, 1992). The ava i l a b l e knowledge regarding behavioural indicators i s des c r i p t i v e , based on the c l i n i c a l observations of the authors, and i s not the r e s u l t of research. The behaviourial indicators described i n the l i t e r a t u r e can be categorized according to nurses' observations of non-verbal behaviour, including v o c a l i z a t i o n s and mobilization; p r e c i p i t a t i n g , a l l e v i a t i n g , and aggravating factors; and the impact of the pain experience on a c t i v i t i e s of d a i l y l i v i n g , such as appetite, p a r t i c i p a t i o n i n s o c i a l events and tolerance for a c t i v i t i e s . To t h i s researcher's knowledge no information i s available i n the l i t e r a t u r e that: 1. Systematically validates the d e s c r i p t i v e behaviours i d e n t i f i e d i n the l i t e r a t u r e as potential indicators of pain i n the cognitively impaired elderly; 2. I d e n t i f i e s s p e c i f i c assessment tool s for measuring the e f f i c a c y of pain management strategies for cognitively impaired e l d e r l y , or; 26 3. Explains the significance and/or r e l a t i o n s h i p of external factors, such as the type of pain experienced or the timing and the context of the assessments, to the behaviours c i t e d i n the l i t e r a t u r e as potential i n d i c a t o r s of pain i n the cognitively impaired e l d e r l y . Therefore, t h i s current study was designed to provide a systematic method of c o l l e c t i n g and analyzing information that could ultimately support or refute the current descriptive information available. Summary The l i t e r a t u r e presented attempts to place the current study within the context of a v a i l a b l e pain assessment research. The use of behavioural observation methods appears to be a v a l i d and r e l i a b l e measure of pain i n adults who are able to give s e l f - reports and confirm the researcher's conclusions. However, the use of existing behavioural observational t o o l s and the application of existing behavioural i n d i c a t o r s for assessing the pain experience of co g n i t i v e l y impaired elderly people has not been demonstrated. Differences i n the c h a r a c t e r i s t i c s of the populations, the pain experience and the assessment processes studied make the appropriateness of t r a n s f e r r i n g what i s known from d i f f e r e n t populations to the cog n i t i v e l y impaired e l d e r l y questionable. 27 This study was designed to gain knowledge of pain assessment i n the cognitively impaired e l d e r l y by determining how gerontological nurses i n f e r that pain i s a problem for cognitively impaired e l d e r l y people. Chapter Three w i l l describe the method used to gather and analyze data on pain that i s s p e c i f i c to c o g n i t i v e l y impaired elderly people. 28 Chapter Three Method Introduction T r a d i t i o n a l methods for detecting and assessing pain r e l y upon the person's s e l f report. Cognitively impaired e l d e r l y cannot provide a verbal s e l f report of t h e i r pain. Therefore, other ways must be used to assess t h e i r pain. I t i s believed that the culture of gerontological nursing i n long term care f a c i l i t i e s has embedded within i t knowledge about the pain experience of c o g n i t i v e l y impaired el d e r l y people. An ethnoscience design was chosen to guide t h i s i n v e s t i g a t i o n because i t permits the researcher to obtain "insights into the meaning of p a r t i c u l a r things and events as understood by the participants of the c u l t u r e " (Evaneshko & Kay, 1982, p49). The e t h n o s c i e n t i f i c approach f a c i l i t a t e s c u l t u r a l understanding from the subject's point of view (Leininger, 1978; 1985; Ragucci, 1972; Robertson & Boyle, 1984). This method concentrates on c l a r i f y i n g how people interpret t h e i r world from the way they t a l k about t h e i r experience (Leininger, 1978). Consequently, t h i s study was designed to i d e n t i f y the cues gerontological nurses use to i d e n t i f y pain i n c o g n i t i v e l y impaired elderly people and to access nurses' knowledge i n r e l a t i o n to how c o g n i t i v e l y 29 impaired e l d e r l y people express t h e i r pain. In t h i s chapter the selection of p a r t i c i p a n t s , data c o l l e c t i o n procedures and method of data analysis are discussed. This chapter concludes with the s t r a t e g i e s used by the researcher to maintain r i g o r f o r the i n v e s t i g a t i o n and a description of e t h i c a l consideration. S e l e c t i o n of Participants Nurses who were acknowledged by others as having the a b i l i t y to i d e n t i f y pain problems i n c o g n i t i v e l y impaired e l d e r l y people were the informants chosen f o r t h i s study. A l l nurse informants were selected from a long term care f a c i l i t y providing r e s i d e n t i a l care serv i c e s to p h y s i c a l l y and mentally f r a i l people. The e l d e r l y people l i v i n g i n the f a c i l i t y had a r e l a t i v e l y stable chronic i l l n e s s and/or a functional d i s a b i l i t y r e q u i r i n g continuous nursing supervision. Guidance for i d e n t i f y i n g appropriate informants was drawn from Spradley (1979). Spradley has suggested that thorough enculturation and current involvement i n the cultu r e are p i v o t a l i n the determination of good informants. Thorough enculturation can occur through education and experience. "An informant should have at l e a s t a year of f u l l time involvement i n a c u l t u r a l scene. I f i t i s a part-time interest . . . three to four years involvement i s needed" (p48). 30 The c r i t e r i a for informant s e l e c t i o n i n t h i s study included: 1) greater than one year f u l l time or four years part time experience working i n a long term care f a c i l i t y ; 2) being educated as either Registered Nurse, Nursing Assistant, Continuing Care Aid or Licensed P r a c t i c a l Nurse; 3) being considered part of the health care team by the f a c i l i t y ; 4) providing nursing care to a cognitively impaired e l d e r l y person i n pain; 5) being i d e n t i f i e d by a Nurse Administrator or designate, Head Nurse, Director of Care, C l i n i c a l Nurse S p e c i a l i s t or a nurse peer as having knowledge about pain assessment i n the cognitively impaired e l d e r l y . Sample Judgement sampling as i d e n t i f i e d by Evaneshko and Kay (1982) was the method used to select s i x nurse informants to p a r t i c i p a t e i n the study. Judgement sampling involves the use of certain c r i t e r i a f o r the s e l e c t i o n of informants. This type of sampling method was chosen because "the nature of c u l t u r a l data precludes the necessity of large [numbers of] randomly- selected informants ..., only a small number of key informants need be interviewed as c u l t u r a l knowledge i s shared by the group" (Evaneshko & Kay, 1982, p50) . This method of sampling allowed the researcher to go to the source of the information needed for the study. 31 A two step process was used to r e c r u i t nurse informants. In step one, the f a c i l i t y C l i n i c a l Nurse S p e c i a l i s t (CNS) for gerontology, i n collaboration with the nursing supervisor, i d e n t i f i e d p o t e n t i a l nurse informants. Each potential nurse informant was recognized as having the c l i n i c a l knowledge necessary to i d e n t i f y pain problems i n the c o g n i t i v e l y impaired e l d e r l y . The CNS d i s t r i b u t e d the information l e t t e r and contacted each potential informant to determine i f they would agree to being contacted by the researcher. In step two, the researcher contacted the p o t e n t i a l nurse informants to provide f u l l d i s c l o s u r e of the study. Consent to p a r t i c i p a t e was signed by a l l informants at the beginning of the f i r s t interview meeting. Three Registered Nurses and three Nursing Assis t a n t s were interviewed. A l l informants were over the age of t h i r t y , three were over the age of f i f t y . Each was employed i n the same f a c i l i t y f o r more than two years. Three of the nurses had greater than eleven years experience at the f a c i l i t y with which they were curr e n t l y employed. A l l had between s i x and f i f t e e n years of experience working with cogn i t i v e l y impaired e l d e r l y people, with the exception of one nurse who had greater than f i f t e e n years experience working with c o g n i t i v e l y impaired elderly people. A l l Registered 32 Nurses held a diploma and were currently registered i n the province of B r i t i s h Columbia. Each Nursing A s s i s t a n t had taken a recognized nursing a s s i s t a n t course and had a c e r t i f i c a t e of completion. One Registered Nurse held a B r i t i s h diploma of Advanced Nursing Studies. A second Registered Nurse had a Pub l i c Health Diploma. A l l informants were english speaking Canadian c i t i z e n s with diverse c u l t u r a l backgrounds. The c u l t u r a l backgrounds included: English, Jamaican, German and F i l i p i n o . Data C o l l e c t i o n Procedures Two interviews with each participant and a retrospective chart review were the two methods of data c o l l e c t i o n used i n t h i s investigation. Interview method The i n i t i a l interview was used to e l i c i t information and generate c u l t u r a l l y relevant questions (Robertson & Boyle, 1984). The interview involved a systematic exploration of gerontological nurses' observations, perceptions and r e f l e c t i o n s of caring f o r c o g n i t i v e l y impaired elderly people i n pain. Formal E l i c i t a t i o n Procedures (FEP) were used as the framework for the interviews. FEP's required that both the questions and the answers be discovered by the informants (Evaneshko & Kay, 1982; Spradley, 1972, 1979) . As a r e s u l t , questions d i f f e r e d between informants because they were "continually [being] modified, explained, elaborated and redirected as necessary to get at comprehensive understanding" (Evaneshko & Kay, 1982, p50). The researcher came to the interview with a l i s t of broad questions to be used as t r i g g e r s to i n i t i a t e discussion (See Appendix A: Question Guide). The i n i t i a l interview had two parts. In Part One, nurse informants were asked to speak about a current experience caring for a cognitively impaired e l d e r l y person i n pain. In Part Two, nurse informants were asked to speak about the past experiences they had caring for cognitively impaired el d e r l y people i n pain. An attempt was made to have the nurse informants remember and discuss a range of experiences. I t was necessary to e l i c i t a wide range of pain s t o r i e s to obtain the maximum va r i a t i o n of how nurses perceive that pain presents i n cognitively impaired e l d e r l y people. Obtaining maximum va r i a t i o n was important f o r t h i s study because these s t o r i e s were used to gain access to the range of pain cues that nurse informants use to i n f e r pain problems. The c l i n i c a l experiences nurse informants shared ranged between subtle and more extreme cases of co g n i t i v e l y impaired elderly i n pain. The current experience was used to ground the data i n e x i s t i n g 34 p r a c t i c e as well as contrast and compare i t to memories of past experiences. The contrasting and comparing was necessary to gain a more comprehensive description of how nurses perceive pain cues i n the co g n i t i v e l y impaired e l d e r l y . In Part Two of the i n i t i a l interview, nurse informants were asked to think of the most uncomfortable cognitively impaired e l d e r l y person they had provided care for, make a mental picture of the person, and then describe him or her (Hurley, V o l i c e r , Hanrahan, Houde & Volicer, 1992). Trigger questions were used to stimulate the informants' memory of past experiences caring for that person i n order to r e c o l l e c t the pain cues they perceived. Nurse informants were asked to compare t h e i r story to the current experience they described i n Part One of the interview. Nurse informants were then asked to describe other s i t u a t i o n s involving pain i n the cog n i t i v e l y impaired e l d e r l y . Depending on the content of the s t o r i e s , the researcher probed to e l i c i t a range of s t o r i e s d e p i c t i n g varying degrees of pain s u f f e r i n g . The pain cues described were compared to the current s i t u a t i o n . The comparisons demonstrated s i m i l a r i t i e s and diff e r e n c e s i n the cues i d e n t i f i e d . The researcher then used t h i s data to i d e n t i f y patterns, r e l a t i o n s h i p s 35 and c e n t r a l themes from the story data. The i d e n t i f i c a t i o n of patterns, relationships and c e n t r a l themes was necessary to develop a c l a s s i f i c a t i o n system of c u l t u r a l l y relevant terms. The meanings the informants gave to t h e i r observations provided i n s i g h t into t h e i r understanding of the pain experience of c o g n i t i v e l y impaired e l d e r l y people. A second interview occurred with nurse informants to v e r i f y , elaborate and challenge the emerging categories, relationships and patterns i d e n t i f i e d i n the analysis by the researcher. A l l interviews were tape recorded and transcribed verbatim. Retrospective chart review method Although participant interviews were the main source of data for t h i s study, patient charts were used as a second data source. The retrospective chart review focused on the written language that nurse informants used when documenting t h e i r observations of pain i n cogni t i v e l y impaired el d e r l y people. The goal of the retrospective chart review was to i d e n t i f y c u l t u r a l l y relevant written words other nurses use to describe pain. The chart review was intended to give breadth to the data that was coll e c t e d i n the interviews. The researcher conducted the retrospective chart review to s p e c i f i c a l l y i d e n t i f y pain descriptors. 36 Pain descriptors are defined as the words, terms, and or phrases that form the written language nurses use when documenting t h e i r observations of pain i n c o g n i t i v e l y impaired e l d e r l y people. The procedure for the retrospective chart review involved: (a) i d e n t i f y i n g the charts of c o g n i t i v e l y impaired e l d e r l y people with a documented incidence of pain i n either the problem l i s t or nursing care plan and (b) reviewing and examining the recordings made by nurses dating back one year from the date of the chart review. Charts meeting the above c r i t e r i a were i d e n t i f i e d for the researcher by the C l i n i c a l Nurse S p e c i a l i s t . Twenty-one charts of cognitively impaired e l d e r l y people were reviewed, but only sixteen were included i n the study. Five were excluded from the study f o r the following reasons: (a) three residents were under the age of s i x t y - f i v e and (b) two residents were considered not impaired s u f f i c i e n t l y to be perceived as c o g n i t i v e l y impaired by the nursing s t a f f . A l l areas of the chart containing nursing documentation were reviewed. This included nursing assessment, progress notes, kardex, careplan and medication p r o f i l e . Data Analysis The data analysis phase of t h i s study began at the onset of data c o l l e c t i o n and continued throughout the 37 study. A process of constant comparative analysis was i n i t i a t e d a f t e r the f i r s t interview and chart review (Goetz & LeCompte, 1984) . The process of constant comparative analysis enabled the researcher to understand the words, phrases, perceptions, cognitions, and interpretations nurse informants have of c o g n i t i v e l y impaired e l d e r l y people i n pain (Goetz & LeCompte, 1984; Leininger, 1978, 1985; Spradley, 1980). At the beginning of the study, the researcher was attempting to i d e n t i f y only the pain cues that nurses use to i n f e r pain i n the cognitively impaired e l d e r l y . However, as nurse informants were t e l l i n g t h e i r s t o r i e s , the researcher began to r e a l i z e the words spoken by the informants were only meaningful i n l i g h t of the context i n which the words were spoken. I t became cl e a r from the constant comparative analysis process that the u t i l i t y of pain cues would be depend on the meanings the words and phrases held for nurse informants. The words, i n i s o l a t i o n of the context they were spoken i n , would not further our understanding of pain in the cognitively impaired e l d e r l y . Consequently, the data analysis phase f o r t h i s study had two goals. The f i r s t goal was to i d e n t i f y the words nurses use to l a b e l t h e i r observations. The words nurses used to l a b e l t h e i r observations became the pain cues. The 38 second goal was to determine the meanings nurses attached to the words and phrases they used to describe t h e i r observations when i n f e r r i n g that pain was a problem f o r a cognitively impaired e l d e r l y person. To achieve both goals the researcher u t i l i z e d a four step process (Goetz & LeCompte, 1984). The four step data analysis process involved: (a) i d e n t i f y i n g broad categories of pain cues, (b) grouping words and/or phrases associated with the broad categories, (c) determining the attributes of each pain cue within the broader category and f i n a l l y , (d) reviewing the pain cues for s i m i l a r i t i e s and differences between the broad categories. Pain cues were the unit of analysis f o r t h i s i n v e s t i g a t i o n . The interview data and the retrospective chart review data were reviewed for key words and/or phrases. Broad groupings emerged from the s o r t i n g of the words and phrases. Further comparing, contrasting, aggregating and ordering of the data re s u l t e d i n the i d e n t i f i c a t i o n of three broad categories of pain cues. In the process of s o r t i n g and ordering the data, patterns, relationships, and c u l t u r a l l y relevant labels emerged, which gave i n s i g h t i n t o the pain cues that gerontological nurses used i n t h e i r decision making processes. The interviews and the retrospective chart review 39 each provided a unique way of understanding how nurse informants perceive and know when a c o g n i t i v e l y impaired e l d e r l y person i s i n pain. Obtaining a v a r i e t y of pain s t o r i e s was important f o r the analysis phase because i t provided the researcher with an opportunity to learn about the variations of pain these nurses f e l t were present i n cognitively impaired e l d e r l y people. Strategies to Achieve Rigor The strategies to achieve r i g o r i n t h i s i n v e s t i g a t i o n are grouped under the headings of c r e d i b i l i t y and a u d i t a b i l i t y (Guba & Lincoln, 1984; Sandelowski, 1986). C r e d i b i l i t y C r e d i b i l i t y was ensured through informant s e l e c t i o n procedures, multiple interviews, the use of tr i a n g u l a t i n g data sources, and by bracketing the researcher's own understanding and knowledge of pain i n the c o g n i t i v e l y impaired e l d e r l y . During the selection of participants, steps were taken to ensure that nurse informants had knowledge and current experience. The data c o l l e c t i o n procedures were intended to capture a variety of the nurse informants' experiences caring for c o g n i t i v e l y impaired e l d e r l y people i n pain. The use of two interviews helped to e s t a b l i s h 40 rapport between the researcher and nurse informants, f a c i l i t a t i n g the sharing of information and allowing the researcher to validate the interpretations and conclusions drawn from the data analysis phase. Triangulating data sources allowed the researcher to cross check the data each approach provided as well as gain a greater representation of data. The researcher's own s k i l l and knowledge on pain i n the c o g n i t i v e l y impaired e l d e r l y i s acknowledged. The r i s k of researcher bias was addressed by: (a) having an awareness that the researcher's knowledge may p o t e n t i a l l y threaten or l i m i t access to the nurse informant's knowledge and information, and (b) attempting to openly set aside the pain knowledge held by the researcher. This was done by employing a process of bracketing during the data c o l l e c t i o n and analysis phases of the investigation (Lamb & Huttlinger, 1989) . Bracketing was accomplished through the use of a journal to record personal impressions, ideas, and feelings that occurred following each interview with nurse informants. The journal was used throughout data analysis to maintain awareness of the d i s t i n c t data provided by the nurse informants and the pre-existing knowledge of the researcher. 41 A u d i t a b i l i t v A u d i t a b i l i t y as proposed by Guba and Lincoln (1984) requires that the researcher demonstrate evidence of a clear decision t r a i l . The decision t r a i l c l e a r l y j u s t i f i e s what was actually done and why. Consequently, another researcher can follow the process of the study. This would include the investigators thinking, t h e i r decisions and the implementation of the methodology. A u d i t a b i l i t y i n t h i s study i s established p r i m a r i l y by the l o g i c of the researcher's decisions, which are made e x p l i c i t i n the writing of t h i s report. E t h i c a l Considerations The following steps were taken to protect the nurse informants and cognitively impaired e l d e r l y involved i n t h i s investigation: 1) Procedures were followed and approval obtained from U.B.C. Behavioral Sciences Screening Committee and the f a c i l i t y ' s Research Review Committee. In addition, a l e t t e r was sent to the administration of the f a c i l i t y explaining the purpose of the study and asking f o r permission to complete the study i n the f a c i l i t y (See Appendix B). 2) A l l potential nurse informants were i n i t i a l l y contacted by the f a c i l i t y administration or t h e i r designate. Once the participant agreed to have t h e i r name given to the researcher, the researcher contacted 42 the p o t e n t i a l participant d i r e c t l y to give f u l l d i s c l o s u r e about the study and seek t h e i r consent to p a r t i c i p a t e i n the study. 3) A l e t t e r was presented to each nurse informant explaining the purpose of the study, the procedure f o r data c o l l e c t i o n , and that t h e i r p a r t i c i p a t i o n was voluntary (see Appendix C) . 4) A l l participants were t o l d v e r b a l l y and i n wr i t i n g that p a r t i c i p a t i o n was voluntary, that they may withdraw from the study at any time, that there would be no monetary compensation and that no r i s k s were anti c i p a t e d with p a r t i c i p a t i n g . 5) A written consent was obtained from a l l nurse p a r t i c i p a n t s (see Appendix D). 6) Taped materials were kept c o n f i d e n t i a l . Each nurse informant was assigned a code number. The code number was used to id e n t i f y the tape recordings and the t r a n s c r i p t s . No i d e n t i f y i n g information was obtained during the chart review. 7) Storage of data: A l l recordings and t r a n s c r i p t s are stored i n a locked cabinet i n the researcher's work area. The researcher transcribed the taped recordings, so only the researcher/student and two f a c u l t y advisors had access to the recordings and t r a n s c r i p t s . Tapes and transcriptions w i l l be destroyed when a l l scholarly work i s completed. 43 Summary The methodology selected to guide t h i s i n v e s t i g a t i o n was based on an e t h n o s c i e n t i f i c design g i v i n g access to the c u l t u r a l l y based, i n t u i t i v e knowledge of gerontological nurse informants. In keeping with t h i s approach, judgement sampling, a non- p r o b a b i l i t y method for selection of knowledgeable informants was used to select s i x gerontological nurse informants. The procedures for data c o l l e c t i o n centred on indepth story t e l l i n g by nurse informants of co g n i t i v e l y impaired elderly people i n pain. A l l s t o r i e s were audiotaped and transcribed verbatim over a two week period. The tran s c r i p t s were analyzed using a constant comparative method of data analysis. The retrospective chart review data was combined with the interview data to uncover both the written and spoken language of nurse informants. Together these data sources were used to group the pain cues gerontological nurses use when i n f e r r i n g pain problems i n the co g n i t i v e l y impaired el d e r l y . The s t o r i e s described by the nurse informants form the findings, f o r t h i s study and are presented i n the next chapter. 44 Chapter Four Findings Introduction This chapter presents the researcher's i n t e r p r e t a t i o n of two data sets: nurses' written accounts of cognitively impaired e l d e r l y people i n pain, and the st o r i e s nurse informants t o l d about pain i n the cog n i t i v e l y impaired elderly. The f i r s t , the written accounts discovered i n the retrospective chart review, r a r e l y contained descriptive data to indicate what events, observations, or pain cues lead the nurses to conclude that pain was the problem. Most often, the nurses only recorded that the ind i v i d u a l was experiencing pain. When descriptive data was recorded i n the chart, the recorded words were the same words nurse informants spoke when t e l l i n g t h e i r s t o r i e s of c o g n i t i v e l y impaired elders i n pain. Consequently, most of the data contained within the chart did not provide new information. Nevertheless, the recorded words describing pain are re f l e c t e d i n the findings reported i n a l a t e r section of t h i s chapter. The second data set, stories t o l d by nurses, was the main source of data used to i d e n t i f y pain cues. The researcher believed that a l l nurse informants shared s i m i l a r knowledge of gerontological nursing and experiences caring for cognitively impaired e l d e r l y 45 people. Shared knowledge and experience enabled the nurse informants to develop a common language and c u l t u r a l understanding of pain. The researcher believed that nurse informants' expe r i e n t i a l knowledge held important covert information about pain i n c o g n i t i v e l y impaired elderly people. As a method of data c o l l e c t i o n , s t o r y t e l l i n g allowed the researcher access to t h i s information, which would address the question of t h i s study. The purpose of the study directed the researcher to search f o r pain cues i n the analysis. However, i n the process of analyzing the data for pain cues, the researcher discovered that the pain cues, i n i s o l a t i o n from the context by which nurses used the cues, were meaningless. As a re s u l t , t h i s chapter w i l l present the pain cue findings within the context of "how" the nurses used the cues. The nurses' c l i n i c a l reasoning process i s revealed i n "how" they used the cues to r e a l i z e a cognitively impaired el d e r l y person was i n pain. Consequently, the findings are organized and presented i n a manner that r e f l e c t s the knowledge nurse informants' have about pain i n cognitively impaired e l d e r l y people. The findings are presented i n three sections. Section One explains the d i f f i c u l t y nurses experienced 46 recognizing pain. Section Two focuses on the reasoning process nurse informants used to make inferences about pain, and f i n a l l y , Section Three w i l l present the pain cues nurse informants used to reason pain problems. The Problem of Pain Recognition A l l nurse informants held the view that pain was a common and pervasive problem i n co g n i t i v e l y impaired e l d e r l y people. However, i n spite of t h i s view, nurse informants reported that recognizing pain i n t h i s population was a d i f f i c u l t c l i n i c a l challenge. The d i f f i c u l t y was attributed to ind i v i d u a l v a r i a t i o n and the i n a b i l i t y of cognitively impaired e l d e r l y people to confirm t h e i r pain experience. Individual variation Individual vari a t i o n was a central feature i n a l l the s t o r i e s . According to nurse informants, i n d i v i d u a l v a r i a t i o n occurred i n : (a) the way c o g n i t i v e l y impaired elderly people expressed t h e i r pain and (b) the type of pain they experienced (See Figure 4: The Problem of Pain Recognition). PROBLEM OF PAIN RECOGNITION 1 1 1 1 Individual Virislioa Absence of Confirmation I 1 Pain Expression Type of Piin Figure 4: The Problem of Pain Recognition 47 For the f i r s t component of "i n d i v i d u a l v a r i a t i o n , " pain expression ranged from extreme, which was described as loud and.overt, to the more subtle, as with the s i l e n t sufferer whom nurses described as quiet and withdrawn. The " s i l e n t s u fferer" was described by one nurse as looking "normal": . . . they can get used to the pain, a f t e r having i t so long. I mean people get used to things I think and they can look l i k e normal and yet s t i l l have pain. This was contrasted with someone who was quite demonstrative, even though, i n no way verbal: [This e l d e r l y woman] never c r i e s out when she i s moved but she w i l l b i t e i n the arm or pinch as the nurse or caregiver t r i e s to l i f t her out of the bed. But she never c r i e s out or t e l l s us that she has pain. I know for a f a c t that she would have pain i n her pos i t i o n . In the f i r s t account, the nurse inferred that pain of long duration becomes part of the cog n i t i v e l y impaired e l d e r l y person's l i f e experience, which suggested that pain i s no longer expressed i n ways that would a s s i s t the nurse to recognize i t . Paradoxically, the second account i l l u s t r a t e d the expression of pain as overt and out of the normal range of accepted behaviour. Each account i s d i f f e r e n t , but each account represented pain to the nurse informants. Together, the accounts i l l u s t r a t e v a r i a t i o n . Individual v a r i a t i o n i n pain expression emerged 48 again, when nurse informants characterized c o g n i t i v e l y impaired e l d e r l y people i n pain. A l l nurse informants made reference to the same set of cues. However, the combination of cues nurses used varied among the s t o r i e s , suggesting that cues for pain are i n d i v i d u a l l y defined f o r each s p e c i f i c elder. As an example, a l l nurse informants spoke of moaning and groaning, but some informants spoke of moaning and groaning i n combination with r e p e t i t i v e movements. Other nurse informants spoke of moaning and groaning i n combination with shaking the bed r a i l s , taking clothes o f f , or moving the jaw i n a chewing-like motion. S t i l l others described cognitively impaired el d e r l y people i n pain as r e s i s t i n g care, grimacing, shivering and shuddering, or as having a flushed complexion, per s p i r i n g and looking worried. In contrast, when nurse informants were asked to t e l l s t o r i e s of cognitively impaired e l d e r l y people who were not experiencing pain, t h e i r s t o r i e s focused on the absence of the same set and combination of cues. Further, these elders were described as being "connected with the outside world," and "knowing what was happening." One nurse described the difference t h i s way: . . . i f they are able to move they w i l l even give you a l i t t l e hug. But i f they are not f e e l i n g well, they just sort of l i e there and give no response at a l l . 49 In t h i s account, the elder's interest i n a f f e c t i o n and a b i l i t y to reciprocate a f f e c t i o n indicated to the nurse that no pain was being experienced. The "type of pain" experienced by c o g n i t i v e l y impaired e l d e r l y people was the second way i n d i v i d u a l v a r i a t i o n occurred (See Figure 4: The Problem of Pain Recognition). During an i n i t i a l review of the findings, i t appeared that nurse informants spoke of f i v e d i s t i n c t types of pain: s p i r i t u a l pain, mental pain, emotional pain, physical pain, and pain r e l a t e d to unresolved issues of l i v i n g . However, a f t e r c a r e f u l a n a l y s i s , s p i r i t u a l , mental, emotional and pain associated with "unresolved issues of l i v i n g " proved c l o s e l y i n t e r r e l a t e d . The following account i l l u s t r a t e s how nurse informants distinguished p h y s i c a l pain from what they recognized as "something" d i f f e r e n t : Besides physical pain, there i s also s p i r i t u a l pain. Many people who come to us haven't resolved t h e i r issues of l i v i n g . I t ' s hard to know i n the elderly, what type of pain they are experiencing because you have [both the] physical pain and the emotional pain of years past. As i n t h i s account, the findings indicate c o g n i t i v e l y impaired elderly people experience more than physical pain. I t i s however, d i f f i c u l t to determine with confidence that there were four other d i s t i n c t types of non-physical pain experienced by t h i s 50 group of people. There i s an indication, however, that p h y s i c a l pain i s distinguished from something d i f f e r e n t , possibly another kind of pain, which nurse informants referred to and named d i f f e r e n t l y . Absence of confirmation Absence of confirmation was the second factor i d e n t i f i e d by nurse informants as complicating pain recognition i n cognitively impaired e l d e r l y people (See Figure 4: The Problem of Pain Recognition). Nurses spoke of individuals who "say nothing" to indicate e i t h e r that they were i n pain or that they were comfortable and not i n pain. Reliable verbal confirmation from cognitively impaired elders was absent i n a l l the stories t o l d by nurse informants. The absence of confirmation was portrayed i n a story about an elderly man who developed gangrene i n h i s foot. The nurse informant described the man as groaning and moaning with laboured r e s p i r a t i o n s . He appeared tense and would not eat. The man "wouldn't say e i t h e r way" i f he had or did not have pain. In the absence of confirmation, the nurse interpreted her observations as pain. She employed a v a r i e t y of s t r a t e g i e s to decrease his pain assuming i t was from h i s foot and then looked for a decrease i n the groaning, moaning and laboured r e s p i r a t i o n s , which she had l a b e l l e d as pain cues. In the course of events, a 51 nursing assistant reported that the man had had a large bowel movement (BM). The nurse concluded by s t a t i n g : His breathing improved, he slept and h i s moaning stopped. So you r e a l l y have to assess the whole person when you are dealing with behaviour, groaning and pain symptoms because i t i s n ' t always what you think i t i s . As i l l u s t r a t e d i n t h i s account, the absence of confirmation had a s i g n i f i c a n t impact on nurses' a b i l i t y to know with assurance that the man's behaviour, as interpreted by the nurse, was due to pain. I t i s clear that even aft e r c a r e f u l thought and de l i b e r a t i o n , the behaviour and sounds made by c o g n i t i v e l y impaired el d e r l y people can e a s i l y be misinterpreted by nurses. In another account, a nurse gave the " i t i s n ' t always what you think i t i s " theme further depth: Mainly she screams. Lots of us suspect she has pain at the moment, but we can't pin down exactly what i t i s . Her legs are quite contracted so i t i s quite possible that she has l o t s of spasms i n her legs, but there seems to be some abdominal pain too. Sometimes when she screams you can be quite convinced that she i s i n agonizing pain. Then you r e a l i z e the lady next to her has the radio on or the l i g h t s on, or what ever. She stops screaming as soon as you f i n d out what i t i s . I t ' s d i f f i c u l t to t i e down. Lots of us f e e l she i s d e f i n i t e l y i n some kind of pain. In t h i s account, screaming i s the el d e r l y person's form of communicating that something i s wrong. The elder could not confirm her experience or immediate needs i n a way the nurse would c l e a r l y understand the meaning of 52 her scream. Consequently, without confirmation the nurse continued to wonder i f the problem was pain. Even when cognitively impaired e l d e r l y people had the a b i l i t y to speak, the nurses were not confident that an elder's response was r e l i a b l e . In one story, a nurse asked an elder i f he was experiencing pain and the elder responded, "you are being mean to me." From t h i s nurse's perspective, the elder's response was a " t o t a l l y inappropriate thing to say." This response, therefore did not confirm the nurses suspicions and so she continued to wonder i f the elder was experiencing pain. The finding that cognitively impaired e l d e r l y people are unable to contribute to the problem solving process by affirming t h e i r pain experience c l e a r l y makes the detection and assessment of pain by nurses d i f f i c u l t . The absence of such information has lead the nurses i n t h i s study to seek out alternate ways of understand t h e i r observations. Reasoning Pain Problems: The Making of Inferences Despite the d i f f i c u l t y they encountered i n recognizing pain, the nurses speculated and made inferences based on t h e i r observations. To reason pain problems, nurse informants noticed a change i n the e l d e r s ' status and took steps to confirm that the change represented pain. 53 Change i n the elder's status A combination of factors, which varied from story to story, represented a change i n the elder's status. In some s t o r i e s nurses spoke of a change i n the c o g n i t i v e l y impaired elder's behaviour, while i n other s t o r i e s , they spoke of a change i n the elder's appearance and/or the sounds they made. Not every nurse could c l e a r l y a r t i c u l a t e the changes they observed, but a l l emphatically stated that the change represented something was "wrong" or " d i f f e r e n t " with the impaired elder. For example, one nurse explained: Her face i s r e a l l y flushed and you know she doesn't have a temperature. So she i s communicating something i s wrong. She looks d i f f e r e n t . I think sometimes when you look c a r e f u l l y you see pain. In t h i s account, the informant noticed a change i n the e l d e r l y person's appearance. The flushed face represented "something was wrong" and was attributed, not to an increase i n body temperature, but to pain. In other examples, nurse informants spoke of " i n t e r n a l l y f e e l i n g something i s wrong" or " i t i s my i n s t i n c t that says something i s wrong." This was i l l u s t r a t e d i n the following account: You know i f you work with certain residents over the years. If something i s d i f f e r e n t about them, somehow you just pick i t up. You can i n t e r n a l l y f e e l something i s wrong. I guess I work with them day i n and day out, you know i t i s my i n s t i n c t that says, "well, 54 so and so doesn't look r i g h t . " In another account a nurse stated: I f you are used to the individual you know there i s something d i f f e r e n t . I f something i s d i f f e r e n t about them, somehow you ju s t pick i t up. You i n t e r n a l l y f e e l something i s wrong because she i s not being h e r s e l f . The accounts show the importance of knowing the elder. The nurses' a b i l i t y to i d e n t i f y the change was at t r i b u t e d to knowing the elder. Frequency of contact and duration of contact f a c i l i t a t e d the nurses' a b i l i t y to i d e n t i f y changes i n the elders' status. Each nurse talked about "knowing" a c o g n i t i v e l y impaired el d e r l y person by being with them "over the years" or "working with them so much of the time." Knowing a cognitively impaired el d e r l y person meant the nurses were f a m i l i a r with the elder's i n d i v i d u a l c h a r a c t e r i s t i c s , preferences, l i k e s and d i s l i k e s . Knowing the cognitively impaired e l d e r l y person gave the nurses the knowledge necessary to r e a l i z e when subtle changes had occurred, thereby enabling them to make inferences about pain. Confirming the presence of pain Confirming, part of nurses' reasoning process, involved substantiating that the changes they observed represented pain. Confirming the presence of pain involved: (a) assimilating other kinds of information into t h e i r assessment process, (b) using a process of 55 t r i a l and error, and (c) consulting i n t e r d i s c i p l i n a r y team members to reach consensus. "Assimilating other relevant information" included: the el d e r l y person's diagnoses and medical h i s t o r y , the nurses' knowledge of pathophysiology and, the nurses' personal experience with p a i n f u l conditions. Together t h i s additional information enabled the nurse to learn the meaning of the pain cues. Nurse informants reported having greater confidence i n making inferences about pain problems when they had information about the elder's "diagnoses" and "medical history." I f the diagnosis caused pain, the nurses assumed the cognitively impaired e l d e r l y person a f f l i c t e d with the condition also would experience pain. To f u l l y appreciate the implications of the diagnoses, nurse informants indicated that knowledge of the "pathophysiology" was important. As one nurse informant explained: Another thing I use too i s the [my] c e r t a i n understanding of the physiological disease. Like a r t h r i t i s or i f someone has gangreneous toes, you know they are quite l i k e l y to have pain. So you look for the signs. In t h i s account, the nurse took d i r e c t i o n from her knowledge of the disease process and looked for symptoms of pain. In addition, nurses' "personal experience" with 56 the same or s i m i l a r diagnoses enabled them to more f u l l y appreciate the elder's experience. Appreciation f o r the elder's s i t u a t i o n gave the. nurses greater confidence to make inferences about pain. One informant suggested that: . . . most of them have a r t h r i t i s or b u r s i t i s or rheumatism and i f you've ever had a touch of i t yourself, you know what they are going through. I have had a touch of i t i n my shoulder. I can only l i e on that side for so long. These people are getting turned every two or three hours. They are pretty sore and uncomfortable by that time. In t h i s account, the nurse related her personal experience with pain to the elder's experience with pain. This enabled the nurse to empathize, but more importantly, to recognize the elder's s i t u a t i o n as p a i n f u l . The process of " t r i a l and error" involved i d e n t i f y i n g pain cues, implementing one or more treatment intervention(s), and observing the c o g n i t i v e l y impaired elders' response to the interventions. Many times nurse informants reported that they would administer a treatment and look f o r a return to what they had i d e n t i f i e d as the elder's usual or expected status. An intervention was e f f e c t i v e when the pain cues subsided and the elder's expected status reemerged. Thus, the nurses made inferences about pain r e t r o s p e c t i v e l y from the elder's response to nursing interventions. 57 In the process of t r i a l and error, the nurses reported going through "a l i s t of things" to confirm the presence of pain. This i s i l l u s t r a t e d by the following excerpt: They l e t you know something i s wrong even i f they can't say anything. So you go check i t out. Reposition them and t r y to make them comfortable. I f they continue to make noises or gestures you know that's not a good po s i t i o n . You look for red areas. You know they have been ly i n g too long on that side or maybe they have t h e i r arm pinned under them. You can't always t e l l r e a l l y . I t ' s j u s t that you are hoping you get the r i g h t thing. In t h i s account, the process of t r i a l and error involved reading the cognit i v e l y impaired person's s p e c i f i c pain cues, getting the intervention r i g h t , and then using that knowledge again with the same person or with a d i f f e r e n t person. "Getting i t r i g h t " indicated that the treatment or intervention t r i e d was e f f e c t i v e . In a s i m i l a r story, another nurse informant stated, "She grimaces a l o t but again she w i l l do that i f she doesn't l i k e the porridge too. So i t i s ju s t a t r i a l and error approach." In both accounts, the nurses kept on t r y i n g , hoping to get i t r i g h t . A l l nursing interventions used by informants to confirm the presence of pain were ro l e s p e c i f i c . Consequently, Registered Nurses primarily used the administration of analgesics to confirm the presence of pain. One nurse t o l d a story of an e l d e r l y woman diagnosed with gangrenous toes. I n i t i a l l y , the e l d e r l y 58 woman received no analgesic: A f t e r she had a couple of doses of the analgesia I remember being t o t a l l y struck by her face. I t seemed r e a l l y wrinkled and screwed up. Then there was t h i s sort of calm relaxed look about her face and I thought, ah she was i n pain, there was no doubt. S t i l l another nurse reported: One of the things we are doing now i s to give her analgesics to see i f there i s a difference i n her behaviour afterwards. I t seems that there i s a change for a while afterwards. She i s calmer and more relaxed. In each account, the nurse informants described how they administered analgesics to the e l d e r l y person suspected of experiencing pain and then monitored the elder's response to the treatment. The absence of pain cues, following the administration of the medication, indicated an improvement i n the elder's condition. Retrospectively, each nurse concluded that pain was present and was successfully treated. Nursing assistants primarily used comfort care interventions such as repositioning, touch, or conversation to d i s t r a c t the elder who experienced pain. As one informant explained: Sometimes I rub the area. Touch i s important. Talking to them can help too. I think i t i s soothing. They [elders] can get a message by the way you t a l k to them. Other nursing assistants simply stated they "just report to the R.N., because she i s the team leader." 59 "Consulting the health care team" emerged from the data as the f i n a l method nurse informants used to confirm t h e i r suspicions of pain i n c o g n i t i v e l y impaired elders. In a l l situations, nurse informants reported discussing t h e i r perceptions and observations with other nurses and health care professionals. Everyone did not always agree, but there was a concerted e f f o r t to get ideas from other nurses, as well as physicians, pharmacists, and physiotherapists. Through m u l t i d i s c i p l i n a r y discussion, a consensus would be reached about the presence of pain. To i l l u s t r a t e c o l laboration, one nurse stated: . . . well, I often t a l k to others about i t to see what t h e i r opinions are. I t i s always in t e r e s t i n g to talk to someone who i s new to the s i t u a t i o n . Others may see something I haven't seen or haven',t been observant to. The nurse recognized her need to collaborate with others to solve pain problems. In such instances, nurses f e l t that consensus about t h e i r i n t e r p r e t a t i o n s made them more confident that they had reached accurate conclusions. Pain Cues of Cognitively Impaired E l d e r l y People The pain cues i d e n t i f i e d i n t h i s study have been organized into three major groupings: overt behaviour, sounds, and appearance. The grouping of pain cues has provided a framework for viewing and understanding the meaning that nurses gave to the cues. The groupings 60 meaning that nurses gave to the cues. The groupings cannot be considered conclusive because the meaning, type, and number of pain cues are dependent upon the c o g n i t i v e l y impaired person's expression of pain. However, the grouping of pain cues can serve as an example of what, i n t h i s segment of the population, would suggest pain. The majority of stories t o l d by nurse informants were about cognitively impaired e l d e r l y people's responses to nursing care. Through the d e l i v e r y of nursing care, the elder's change i n status was recognized and interpreted as pain cues by nurse informants. This was p a r t i c u l a r l y true f o r the nursing a s s i s t a n t s who bathed, fed, moved and repositioned c o g n i t i v e l y impaired elderly people. A l l pain cue groupings represent a change i n either overt behaviour, sounds or appearance. Overt behaviour Overt behaviour pain cues were organized into three subgroups: aggressive behaviour, restlessness/agitation, and a c t i v i t i e s of d a i l y l i v i n g (See Figure 5: Overt Behaviour Pain Cues). 61 Overt behaviour" ^Aggressive, behaviour Restlessness/- ogltatlon ••Striking out • • Pinching •Hitting •Biting •Scratching •Activities of. dally living Draws legs up Stretches Repetatlve movements Clenched hands •Guarding limb •Holds on to bed rolls —•Grabs staff for support •Pushes away, refuses to move Appetite •Decreased eating Sleep •Decreased sleeping Resistance *to care Figure 5: Overt Behaviour Pain Cues The f i r s t subgroup, aggressive behaviour, inc luded s t r i k i n g out, which involved pinching, h i t t i n g , b i t i n g , and s c r a t c h i n g . As an example one nurse informant s ta t ed , "although they won't t a l k , they w i l l h i t you or they w i l l push your hands away." In another example the nurse reported: She doesn't want to be moved. [She shows] she i s uncooperative by pinching or b i t i n g the s ta f f , . . . these people are p h y s i c a l l y aggressive and assert ive . In t h i s remark, the aggressive behaviours represented uncooperativeness, which the nurse in terpre ted as p a i n . Nurses reported being able to d i f f e r e n t i a t e reasons for aggression. For example, one nurse spoke of being able to d i s t ingui sh anger-behaviour from p a i n - behaviour: 62 Okay, one way for me to know the anger from the pain i s when I'm doing something, caring f o r t h i s person. Lets say, for example, there i s something wrong with t h e i r legs and I touch t h e i r legs. If they s t r i k e and h i t me, then r i g h t away I know i t ' s not anger, i t ' s pain that she i s s t r i k i n g out at or reacting to. Anger, i f i t ' s just anger there i s a difference, the difference i s i n the face. The anger can be i n the eyes, you can t e l l d i f f e r e n t things by a person's eyes. In t h i s account, the nurse understood the meaning of the elder's s t r i k i n g out behaviour by associating knowledge of the elder's physical condition with the s t r i k i n g out behaviour. Consequently, the informant concluded that the nursing care had exacerbated the pain experience. As a re s u l t , s t r i k i n g out represented pain to the nurse. S i m i l a r l y , nurses distinguished fear behaviour from pain behaviour. In the following example, the nurse interpreted the cognitively impaired e l d e r l y person's fear as sel f - p r o t e c t i v e behaviour, thereby d i s t i n g u i s h i n g pain behaviour from fear behaviour. The ones that are a f r a i d w i l l s t r i k e out a l i t t l e . Like I say, i t i s a defensive mechanism. Like, "you're not going to hurt me." I don't think they are t r y i n g to hurt anyone i n the nursing s t a f f but they do occasionally. Sometimes we're i n the wrong place at the wrong time and we get slugged i n the face or something. Nurse informants defined the second subgroup, restlessness and agitation, as a type of physical 6 3 a c t i v i t y : drawing the legs up, stretching, r e p e t i t i v e movements and clenched hands. Each type of physical a c t i v i t y occurred randomly without association to nursing care. One informant explained: Residents w i l l move around al o t . Sometimes they w i l l p u l l at t h e i r clothes and sometimes they open and close t h e i r hands. That i s t h e i r way to say they have pain. Overt behaviour pain cues also included changes i n a c t i v i t i e s of d a i l y l i v i n g (See Figure 5). A c t i v i t i e s of d a i l y l i v i n g r e f l e c t e d a change i n the elders' usual pattern of functional a b i l i t y . As an example, one nurse informant reported: I f they are not sleeping and I figure they should be, you know, i f they are normally a good eater and now they are not drinking r i g h t , they might not be able to t e l l you "no", but they turn t h e i r mouth away and I think,' "what's wrong? Something i s up here." Things l i k e that. In t h e i r accounts, the nurse informants spoke s p e c i f i c a l l y of elders who re s i s t e d care by guarding a limb, holding on to bed r a i l s , grabbing s t a f f f o r support, and pushing or refusing to move. Sounds Sounds, the second group of pain cues, are organized as verbalizations and vocalizations (See Figure 6: Sound Pain Cues). 64 •Verbalizations •Says has pain ^ Antisocial behaviour •Complains •Critical Silence - Blames Sounds— does not speak •Groans •Vocalizations •Moans •Whimpers •Screams Cries 1 •Babbles Figure 6: Sound Pain Cues Verbalizations occurred primarily when s t a f f caregivers provided nursing care or when informants asked the impaired elders " i f they had pain." As noted e a r l i e r , the nurses generally perceived that the information given by cognit i v e l y impaired elderly people able to speak was unreliable. A subset of cognitively impaired e l d e r l y people who are able to speak was portrayed by informants as ex h i b i t i n g a n t i s o c i a l behaviour. Nurse informants defined a n t i s o c i a l behaviour as: complaining, c r i t i c a l of nursing care and blaming the .nurses f o r si t u a t i o n s that were out of the nurse's control. In these cases, nurses understood the i r r i t a b l e nature of the ver b a l i z a t i o n s to mean pain, even when the elder d i d not a f f i r m the nurse's conclusion. 65 Nurse informants named vocalizations as groans, moans, whimpers, screams, c r i e s and babbles and always interpreted a negative qu a l i t y to the sound. Vocalizations occurred while s t a f f caregivers provided nursing care and when the elders were alone without anyone near them. Nurses reported that p i t c h and volume of a sound enabled them to d i f f e r e n t i a t e between the sounds they heard. One informant explained: She moans d i f f e r e n t degrees of moans. . . Volume and loudness are the same thing, so i t ' s i n the p i t c h . The p i t c h i s h e a r t f e l t , from deep down inside, l i k e a whimper or a moan when there i s pain. The nurse informant recognized pain i n the elder by the q u a l i t y of the sound, s p e c i f i c a l l y the p i t c h of the sound. Another nurse informant reported that she was able to di s t i n g u i s h between a fear-scream and a scream communicating pain: Well, the fear and the nightmare scream i s a s h r i l l screech. With a pain sound, i t doesn't have that fear sound to i t . I t i s more subdued, a lower type of a sound I would say. The findings indicate that nurses are able to d i s t i n g u i s h the meaning of sounds made by c o g n i t i v e l y impaired e l d e r l y people i n pain. To understand the meaning of the sound, distinguishing the c h a r a c t e r i s t i c s of the sound appeared important, as e l d e r l y people make sounds for reasons other than pain. 66 Appearance The t h i r d group of pain cues, appearance, i s represented by f a c i a l expressions and body language (See Figure 7: Appearance Pain Cues). Appearance • Facial "expression" * Expressionless - •Wincing •Pleading •Grlmoclng — •Darkness •Eyes - •Mouth • •Brows - .Body Languoge •Complexion : •Miserable •Tense •Lock of concentration •Perspires Figure 7: Appearance Pain Cues •Stores •Looks post you •Blinks ropldly •Tlghtens-up •Ughts-up •Opens •Pinched •Wrinkled. •Folded •Flushed look The f a c i a l expressions i n Figure 7 represented a negative a f f e c t , which emanated predominately from the eyes, mouth and brows, p a r t i c u l a r l y with grimacing. The eyes, mouth, and eyebrows changed i n a v a r i e t y of ways: tightening, lightening-up or opening; pinched, wrinkled or folded. Nurse informants described darkness as "a clouding" of the f a c i a l features, as t h i s story i l l u s t r a t e s : She was i n pain and somebody brought i n a two month old baby. She saw the baby and r i g h t away you could see the expression on her face. I t was t o t a l l y d i f f e r e n t . She was a 67 t o t a l l y d i f f e r e n t person. She didn't t a l k but I'm sure i n her subconscious i t reminded her of her daughter. When the baby was taken away the pained look, not physical pain but mind pain, came back. Right away you could t e l l by her face. . . . I t was unreal. The expression i n the face t e l l s us a l o t . I mean ri g h t away the eyes t e l l you. There are no tears but there i s a darkening. A very dark look. No noises, the mouth becomes withdrawn. I t t e l l s me the person i s saddened by what they are seeing. I wish I had a camera. This informant seemed to be describing a lightening and then a darkening i n the f a c i a l expression of a co g n i t i v e l y impaired person i n pain. When the researcher asked, "What would you l i k e the camera to capture?", the informant responded: I would l i k e the camera to capture the expression. Like from pleasure to pain and then back again from pain to pleasure. I see i t i n the mouth. I see i t i n the eyes." The nurse informant went on to describe the eyes as tightening and squinting, the mouth as being pinched or wrinkled. In contrast to negative a f f e c t i v e expressions, nurse informants described some cognitively impaired e l d e r l y people as "expressionless". Elders described as expressionless had "a look". One nurse informant explained: Guess that look of not being able to concentrate on anything else. I t i s re f l e c t e d i n the eyes of the person. They kind of look past you and there i s hope for j u s t some r e l i e f of the pain. 68 Elders appearing "expressionless" were characterized as s t a r i n g and "looking past the nurse." The message the elder communicated to the nurse was "pleading", "a hope fo r r e l i e f . " The " s i l e n t s u fferer" described e a r l i e r , was another example of the expressionless, withdrawn person. One nurse informant stated, "she j u s t l i e s there and stares a l o t , " and another said, "she was q u i e t l y i n pain." These descriptions further i l l u s t r a t e how varied the appearance of pain can be i n c o g n i t i v e l y impaired elderly people. Body language, the second subgroup, consisted of the elder's o v e r a l l appearance (See Figure 7). Nurse informants described elders i n pain as tense, miserable, unhappy or as lacking the a b i l i t y to concentrate. In some situations, the nurse informants used more objective descriptors, such as a flushed complexion, the hands clenched, or the elder p e r s p i r i n g . In a l l , body language communicated a negative message, which nurse informants interpreted as d i s t r e s s related to pain. Summary The d i f f i c u l t y of recognizing pain i n the c o g n i t i v e l y impaired e l d e r l y was a central theme i n the data analysis. Individual v a r i a t i o n and the absence of confirmation impeded the nurses' a b i l i t y to know when 69 c o g n i t i v e l y impaired e l d e r l y people were i n pain. As a r e s u l t , the nurse informants i n t h i s study made i n f e r e n t i a l diagnoses about pain. To make inferences, the nurse informants noticed a change i n the elder, searched for a meaning to explain t h e i r observations and then developed ways to validate t h e i r hunches and confirm the presence of pain. Nurses reported confirming t h e i r hunches about pain by assimilating information, using a process of t r i a l and error, and team consensus. In t h i s way, nurses made inferences and confirmed the pain problems of c o g n i t i v e l y impaired e l d e r l y i n d i v i d u a l s r e t r o s p e c t i v e l y . The gerontological nurses i n t h i s study used cues to i d e n t i f y pain i n cognitively impaired e l d e r l y people. The findings indicated that pain cues represented a combination of changes i n overt behaviours (aggressive behaviour, restlessness/agitation, and a c t i v i t i e s of d a i l y l i v i n g ) , sounds (verbalization and v o c a l i z a t i o n ) , and appearance ( f a c i a l expressions and body language). Together, the pain cue groupings were not mutually exclusive but represented a sampling of presenting behaviours that ultimately provided d i r e c t i o n f o r nurses' assessment of pain i n t h i s population of people. 70 Cle a r l y , the findings of t h i s study indicate gerontological nurses have found creative ways to detect, assess and corroborate the presence.of pain i n c o g n i t i v e l y impaired elderly people. How the nurses i n t h i s study used cues i n t h e i r c l i n i c a l reasoning process w i l l provide the foundation for discussing these findings. Chapter Five w i l l place the current findings within the context of existing knowledge. The meaning gerontological nurses give to pain cues provides new in s i g h t into how some nurses r e a l i z e when a c o g n i t i v e l y impaired e l d e r l y person i s experiencing pain. The i n t e r p r e t i v e discussion to follow i s supported by the conceptual framework described i n Chapter One. The concept of nurses' "knowing" provides a framework to c l a r i f y how the nurses i n t h i s study think about and reason pain problems i n cognitively impaired e l d e r l y . 71 Chapter Five Discussion of the Findings Introduction This chapter w i l l discuss the findings of the study as reported i n Chapter Four. The purpose of the discussion i s to provide explanation regarding nurses' knowledge of pain cues and how nurses used cues to i n f e r pain was present i n cognitively impaired e l d e r l y people. In Chapter Two, the l i t e r a t u r e review established that l i t t l e was known about pain i n c o g n i t i v e l y impaired el d e r l y people. The information that was a v a i l a b l e was descriptive i n nature and only captured the authors' perspectives. However, t h i s l i t e r a t u r e served as a base for discussing t h i s study's findings on nurses' knowledge of pain cues. The conceptual framework supporting t h i s study oriented us to: (a) the subjective and i n v i s i b l e nature of pain, (b) the absence of r a t i o n a l verbal pain cues from cognitively impaired e l d e r l y people, and (c) the need for nurses to make observations and formulate in t e r p r e t a t i o n s i n order to gain meaning from c l i n i c a l data (See Figure Three: Pain Assessment Cognitively Impaired Eld e r l y People, p.13). Consequently, i t was expected that i d e n t i f y i n g pain i n c o g n i t i v e l y impaired e l d e r l y people was a d i f f i c u l t task for nurses to do. 72 S t i l l , some gerontological nurses were able to r e a l i z e when a cogni t i v e l y impaired el d e r l y person was experiencing pain. This study sought to capture that knowledge i n ways that could be shared and learned. A d d i t i o n a l research and t h e o r e t i c a l knowledge provided a base from which to understand the "way" these nurses became able to i d e n t i f y when impaired elders were i n pain. The nursing l i t e r a t u r e on "knowing" provided the necessary structure to discuss the s p e c i a l features of these gerontological nurses' ways of knowing. As such, nurses' knowledge of pain cues and nurses' way of knowing pain was present are used to provide the organizational framework for discussing how the nurses i n t h i s study used pain cues. Nurses' Knowledge of Pain Cues The findings of t h i s study have affirmed the behaviourial indicators of pain described i n the i n i t i a l l i t e r a t u r e review (Herr & Mobily, 1991; Marzinski, 1991; Mobily & Herr, 1992). The behaviourial indicators included: verbal and non-verbal behaviour, mobilization, and the impact of the pain experience on a c t i v i t i e s of d a i l y l i v i n g . In comparing the findings of t h i s study to the findings from other studies (Herr & Mobily, 1991; Marzinski, 1991; Mobily & Herr, 1992), differences have also emerged. The primary difference was i n the 73 way the other authors grouped pain cues. For example, Herr and Mobily (1991) spoke of "general observations", which combined f a c i a l expressions, vocalizations and observed body movements. Herr and Mobily did not make a d i s t i n c t i o n between vocalizations and v e r b a l i z a t i o n s as d i d the nurses i n t h i s study. D i f f e r e n t i a t i n g the sounds made by impaired elders has c l i n i c a l s i g n i f i c a n c e because sounds were the impaired elders' way of communicating "something i s wrong". In some cases, the sounds cued the nurse to investigate and search out reasons to explain what was "wrong". In addition, t h i s study provided greater d e s c r i p t i v e d e t a i l on the changes of the f a c i a l features of c o g n i t i v e l y impaired elderly people i n pain. The d e s c r i p t i v e d e t a i l offered f a c i l i t a t e d v i s u a l i z i n g the appearance of elders i n pain. Marzinski (1991) came at the issue of pain i n the demented el d e r l y through the nursing assessment process and determined that "behaviours" were indi c a t o r s of pain. Marzinski named the indicators as "pain behaviours", but did not delineate between the behaviours. This study adds to the work of Marzinski by further delineating potential pain behaviours as aggression, restlessness/agitation, and changes i n a c t i v i t i e s i n d a i l y l i v i n g (See Figure 4: Overt Behaviour Pain Cues, p.61). 74 Hurley et a l . , (1992) assessed discomfort i n advanced Alzheimer's patients. A l l the pain cue groupings reported by the nruses i n t h i s study were included i n Hurley's study. However, Hurley's study provided an expanded repertoire of cues, which included noisy breathing, negative vocalizations, various f a c i a l expressions, frown, relaxed body language, tense body language, and fidgeting. The idea that nurses use varied groups of pain cues i s a s i g n i f i c a n t finding because the use of varied pain cue groupings supports the notion that pain cues i n i s o l a t i o n of context i s less meaningful. When pain cues are understood within the context of an e l d e r s ' s i t u a t i o n , the pain cues have more c l i n i c a l meaning and s i g n i f i c a n c e for pain assessment. This points to the idea that no one cue or one combination of cues, outside a p a r t i c u l a r situation, i s s o l e l y i n d i c a t i v e of pain. This, therefore, d i r e c t s nurses to use other information i n combination with pain cues to search f o r answers to explain t h e i r observations. There was a high degree of s i m i l a r i t y o v e r a l l between the pain cues described i n the l i t e r a t u r e and those described by the nurses i n t h i s study. In addi t i o n to supporting existing l i t e r a t u r e the findings from t h i s study has: (a) contributed greater d e t a i l to the e x i s t i n g description of pain cues, (b) categorized 75 some of the pain cues d i f f e r e n t l y , (c) encouraged nurses to look beyond one set of pain cues, and (d) suggested that nurses use pain cues wi th in the context of the e lders ' s i t u a t i o n when i d e n t i f y i n g p a i n . Nurses' Way of Rea l i z ing Pain was Present Geronto logica l nurses' way of r e a l i z i n g p a i n was present was hardly acc identa l . The nurses i n t h i s study were s k i l l e d at l i s t e n i n g and understanding. For nurses to r e a l i z e pain was present, two ways of "knowing" were i n operation, knowing by "knowing the person," and "knowing by i n t u i t i v e perception" (See Figure 8: Rea l i z ing Pain i s Present) . KNOWING THE PERSON Recognizing Change \—i Clustering Pain Cues ( • X. y ( f " e a " I ' n 8 \ r \ . / V T X P A I N H A / \ J Having Relationships -f- INTUITIVE PERCEPTION Figure 8: Rea l i z ing Pain i s Present Knowing, by "knowing the person" permitted the nurses to recognize change and c lus t er i n d i v i d u a l l y def ined pain cues. Nurses' a b i l i t y to recognize change and 76 c l u s t e r pain cues was enhanced through the development of r e l a t i o n s h i p s . As i l l u s t r a t e d i n Figure 8, to know an elder was i n pain required that the nurses integrate and incorporate into t h e i r c l i n i c a l reasoning process, "knowing the person" and knowing by " i n t u i t i v e perception"i No one element i n i s o l a t i o n could explain how the nurses i n t h i s study r e a l i z e d pain was present. I t i s necessary to consider the elements as a whole, i n t e r r e l a t e d and connected, to form one unit. I t i s the u n i t as a whole that gives understanding to the way gerontological nurses i n t h i s study r e a l i z e d pain was present i n cognitively impaired e l d e r l y people. To understand the whole, i t i s useful to discuss each element. Knowing the Patient To "know" a cognitively impaired e l d e r l y person was to be f a m i l i a r with t h e i r p a r t i c u l a r personal c h a r a c t e r i s t i c s , regular patterns, preferences, l i k e s and d i s l i k e s . I t was through the process of being f a m i l i a r with the elderly person that the nurses were able to recognize when something was d i f f e r e n t or wrong. To the nurse informants, f a m i l i a r i t y was the base f o r "knowing" a cognitively impaired e l d e r l y person. Knowing, by "knowing the person," centres on those p a r t i c u l a r things that are meaningful to the 77 i n d i v i d u a l . Knowing the person was important to r e a l i z e pain was present because each cognitively impaired e l d e r l y person provided nurses with t h e i r own set of pain cues. No matter how the pain experience was presented, whether subtle or extreme, nurses were required to learn the meaning of the cues because the elder could not v e r b a l l y say what they wanted the nurse to know. Consequently, to know the cognitively impaired e l d e r l y person meant the nurse would: (a) know when a change i n the elders' status occurred and (b) understand what the elder intended when he or she behaved i n a c e r t a i n way. The nurse informants attributed "knowing" the e l d e r l y person to "spending years caring f o r them." Working with and caring for an elderly person over time provided the nurses opportunity to learn the elder's usual patterns of responding to a variety of s i t u a t i o n s . "Spending time" with the elder gave h i s t o r i c a l context to the nurses' observations. Consequently, to learn the elder's usual patterns of responding and to understand the meaning of those response patterns, repeated exposure and frequency of experiences with the same elde r l y person were required. The greater the duration of time spent with an elder, the more opportunity the nurse had to learn the 78 p a r t i c u l a r idiosyncrasies of that e l d e r l y person. As such, knowing by "knowing the person", enabled the nurses to recognize change and cluster pain cues. Recognizing change To the nurses, recognizing change meant "something was wrong" with the e l d e r l y person. The conceptual framework indicated that no verbal declaration such as, "I have pain" was made by cognitively impaired e l d e r l y people (See Figure Three: Pain Assessment Cognitively Impaired Eld e r l y Person, p. 13). However, the findings suggest that change was the mechanism that i n i t i a t e d the c l i n i c a l reasoning process and triggered the nurses to assess for pain. As such, for the c o g n i t i v e l y impaired e l d e r l y described i n t h i s study, the notion of "change" replaced the verbal declaration "I have pain". The v a r i a t i o n described by nurse informants indicated that pain i n cognitively impaired e l d e r l y people was highly i n d i v i d u a l . The finding that each elder presented with his or her own set of pain cues makes the g e n e r a l i z a b i l i t y of one set of pain cues f o r a l l c o g n i t i v e l y impaired e l d e r l y i n d i v i d u a l s inappropriate. However, the notion of "change" may be a generalizable c h a r a c t e r i s t i c of pain i n d i c a t o r s . Clustering pain cues In t h i s study, the accuracy of predicting pain was based on the nurse's a b i l i t y to c l u s t e r cues into 79 recognizable patterns, which Carnevali and Thomas (1993) r e f e r to as cue cl u s t e r i n g . "The capacity to coalesce s a l i e n t cues i n relevant patterns i s c r u c i a l to e f f i c i e n t and e f f e c t i v e diagnosing" (p. 55). The capacity to coalesce cues comes from nursing knowledge and c l i n i c a l experience (Carnevali & Thomas, 1993). The process of cue cl u s t e r i n g moves the nurse toward a p a r t i c u l a r diagnostic l a b e l . In a p a r t i c u l a r s i t u a t i o n , nurses w i l l r e c a l l a pattern of cues that i s synonymous with a s p e c i f i c diagnostic l a b e l . The pattern of cues once linked to a diagnostic l a b e l w i l l become the "recognition features" for a s p e c i f i c condition or phenomena (Carnevali & Thomas, 1993). In t h i s study, clusters of i n d i v i d u a l l y defined cues became the "recognition features" for pain i n c o g n i t i v e l y impaired e l d e r l y people. The "recognition features" for pain are derived from the pain cue groupings: overt behaviour, appearance, and sounds. Nurses' a b i l i t y to c l u s t e r i n d i v i d u a l l y defined pain cues enabled them to make i n f e r e n t i a l diagnoses of pain. C o l l e c t i v e l y , the nurses agreed that they were able to c l u s t e r pain cues because they: (a) had many experiences caring for cognitively impaired e l d e r l y people i n pain and (b) held s p e c i f i c and i n d i v i d u a l knowledge of the person for whom they cared, which was gained from having long-standing, affectionate 80 r e l a t i o n s h i p s with that person. Having relationships Knowing, by knowing another as a person comes about through involvement and connection with others i n the context of relationships (Carper, 1978; Tanner, et a l , 1993). The development of relationships with impaired elders was central to the nurses' a b i l i t y to form hypotheses about the meaning of cue c l u s t e r s i n order to i n f e r that pain was a problem. The nurses i n t h i s study shared events and experiences with elders over long periods of time. Contact over long periods of time lead to the development of emotional relationships that became attachments. To nurse informants, t h e i r attachments with elders gave them the a b i l i t y to comprehend meaning and achieve a sense of understanding about s p e c i f i c events. Relationships with cognitively impaired elders enabled the nurses to develop the capacity to empathize. The capacity to empathize required that nurses become involved and engaged with the people i n t h e i r care (Carper, 1978). Nurses i n t h i s study were engaged with the elders i n t h e i r care when they spoke of understanding the discomfort experienced by elders with diagnoses known to be p a i n f u l . In addition, the nurses repeatedly spoke of t h e i r 81 own personal pain experience. For example, when nurses spoke of "having a touch of a r t h r i t i s , b u r s i t i s or rheumatism, you know what they are going through," they were speaking from a point of empathy. Cle a r l y , the nurses' own personal experiences granted them in s i g h t i n t o the elder's experience. The exchange of experiences, coupled with empathy, implied to the researcher that relationships existed between the nurses and the elders. This i s i l l u s t r a t e d by an informant who stated, "when you've been with them f o r so long you just know." Close a f f e c t i v e relationships developed when the nurses provided intimate care to the elders. Nurses gained understanding of elders as people through conversations with family members and by having access to biographical information on the impaired elder's l i f e and the contributions they made p r i o r to t h e i r dementing i l l n e s s . Horwitz and Shindelman (1983) have suggested that close a f f e c t i v e relationships are the norm i n caregiving. They describe the a f f e c t i v e r e l a t i o n s h i p as in v o l v i n g past and current closeness, shared a c t i v i t i e s and confiding i n one another. Although the nurses i n t h i s study did not report having conversations with or confiding i n co g n i t i v e l y impaired e l d e r l y people, they a l l reported sharing intimate 82 a c t i v i t i e s with the elder while providing personal care. C o l l e c t i v e l y , the nurses expressed a closeness that was evident i n the emotions they expressed, and the affectionate gesturing with hugs and smiles that occurred between the nurses and the elders. Hence, through the development of relationships, nurses were able to: (a) make claims about t h e i r observations, and (b) say what was d i f f e r e n t about a c l i n i c a l s i t u a t i o n . Consequently, relationships with impaired elders gave strength to the inferences nurses made about pain. According to Tanner, Benner, Chesla, and Gordon (1993) , the phenomenology of "knowing the patient" involves knowledge of the patient's usual pattern of responses and knowledge of the patient as a person. Knowing the patient's usual pattern of responses involved: "(1) responses to therapeutic measures; (2) routines and habits; (3) coping resources; (4) phys i c a l c a p a c i t i e s and endurance; and (5) body topology and c h a r a c t e r i s t i c s " (p. 275). Although t h i s study found that nurses included knowledge of an elder's usual pattern of responses to t h e i r c l i n i c a l reasoning processes, the nurses described and l a b e l l e d d i f f e r e n t patterns from those described by Tanner et a l . The nurses i n t h i s study spoke of knowing the elder's usual pattern of responses but only i n terms of functional a b i l i t y and usual patterns of behaviour. 83 Functional a b i l i t y included aspects of a c t i v i t i e s of d a i l y l i v i n g such as eating, sleeping, and p a r t i c i p a t i n g i n dressing; mobilizing, which would include the elder's willingness to re p o s i t i o n i n bed, or move to a chair from a bed; and i n t e r e s t i n s o c i a l i z i n g with others on the unit, which would involve p a r t i c i p a t i n g i n conversations and s o c i a l a c t i v i t i e s with volunteers, family members and other s t a f f caregivers. Further, the nurses i n t h i s study described the pattern of responses within the context of change from an expected or usual pattern to one that was a t y p i c a l for the elder. An a t y p i c a l pattern indicated pain to the nurses. In addition, the gerontological nurses' sense of "knowing the patient" was associated with the: (a) duration of time spent caring for a given i n d i v i d u a l and (b) development of relationships that became attachments. This i s i n contrast to the nurses i n Tanner's study, who made an association to change but the context of the change was not connected to an a f f e c t i v e r e l a t i o n s h i p with the patient that developed over time spent with the patient. As a r e s u l t , the findings from t h i s study expand the work of Tanner et a l . , (1993) from the c r i t i c a l care nurses' way of "knowing the patient," to the gerontological nurses' way of "knowing the patient." The sp e c i a l features of 84 gerontological nurses' way of "knowing the person" made i t possible for nurses to r e a l i z e pain was present i n co g n i t i v e l y impaired el d e r l y people. I n t u i t i v e Perception Knowing by i n t u i t i v e perception i s a process that enables the nurse to gain immediate understanding without the a b i l i t y to verbally give reason or ra t i o n a l e (Benner & Tanner, 1987; Schraeder & Fisher, 1987) . I n t u i t i v e perception i s knowledge that i s embedded i n practice and develops through previous encounters with si m i l a r situations (Benner & Wrubel, 1982) . For the nurses i n t h i s study, i n t u i t i v e perception developed from having many r e l a t i o n s h i p s and experiences with many d i f f e r e n t c o g n i t i v e l y impaired e l d e r l y people i n pain. In essence, i n t u i t i v e perception i s knowing by d i v e r s i t y , where as "knowing the person" i s based i n knowing the p a r t i c u l a r . In t h i s study, nurses had the a b i l i t y to r a p i d l y recognize subtle changes without -being able to c l e a r l y v e r b a l i z e t h e i r perceptions, suggesting that they knew more about the cognitively impaired e l d e r l y person than they could say. For example, nurses talked about "a f e e l i n g inside" that something was wrong, or that they " j u s t picked up" the pain cues. In other examples, the nurses reported that t h e i r " i n s t i n c t s " t e l l them, or that they " i n t e r n a l l y f e e l something i s wrong because 85 the person i s not being h e r s e l f . " I t was not easy f o r the nurses to describe how they were able to grasp the meaning of a si t u a t i o n for an impaired e l d e r l y person. I t appeared that the nurses, i n part, r e a l i z e d pain was present because they were able to learn and remember the "recognition features" of pain across cases. The nurses then associated those "recognition features" (when appropriate) to new c l i n i c a l s i t u a t i o n s . Therefore, the notion of i n t u i t i v e perception as implied by the nurses i n t h i s study, was rooted i n exposure to multiple and concurrent c l i n i c a l experiences. Nurses' a b i l i t y to cl u s t e r pain cues i l l u s t r a t e d the interplay between knowing the person and i n t u i t i v e perception. For example, as stated e a r l i e r , a c o g n i t i v e l y impaired e l d e r l y person w i l l provide nurses with t h e i r own set of pain cues. As a r e s u l t , knowing by "knowing the person" i s esse n t i a l to c l u s t e r i n g i n d i v i d u a l l y defined pain cues i n order to make i n f e r e n t i a l diagnoses of pain. However, nurses' a b i l i t y to clus t e r cues i s heighten when they integrate learning from past c l i n i c a l experience to new c l i n i c a l experiences. To make sense of the pain cues and t h e i r i n t u i t i v e perceptions, nurses pulled i n other information. Other types of information included the 86 c o g n i t i v e l y impaired elder's diagnoses, knowledge of the pathophysiology of diseases known to be p a i n f u l and t h e i r own experience with p a i n f u l conditions. This a d d i t i o n a l information gave further meaning to the pain cues nurses observed i n cognitively impaired e l d e r l y people. Summary This chapter has discussed the findings of the current study i n r e l a t i o n to the t h e o r e t i c a l perspectives of other authors. The purpose of t h i s discussion was to explain and provide c l a r i t y to the fin d i n g s while placing t h i s study within the context of e x i s t i n g knowledge and research. Nurses' knowledge of pain cues was not e a s i l y a r t i c u l a t e d nor were t h e i r problem solving approaches t r a d i t i o n a l . Nurses' proficiency i n problem solving pain issues f o r cognitively impaired elders was rooted i n t h e i r a b i l i t y to practice from a wide base of knowledge, which was grounded i n the context of r e l a t i o n s h i p s . I t i s clear from the findings that t h i s breadth of knowledge comes from a v a r i e t y sources and takes time to acquire. I t was evident that the gerontological nurses i n t h i s study used a complex c l i n i c a l reasoning process. The c l i n i c a l reasoning process incorporated knowing, by "knowing the person" and knowing by i n t u i t i v e 87 i n t u i t i v e perception. Knowing, by "knowing the person" involved recognizing change, c l u s t e r i n g cues, and having relationships with elders. I n t u i t i v e perception was r e f l e c t i v e of knowledge embedded within c l i n i c a l p r a c t i c e . The l i t e r a t u r e presented i n t h i s chapter augments much of t h i s study's findings but also leaves some questions unanswered. Chapter Six w i l l provide the summary, conclusions and the implications of t h i s study. An attempt w i l l be made to further define the unanswered questions by o f f e r i n g future d i r e c t i o n f o r nursing practice, education and research. 88 Chapter Six Summary, Conclusions f and Implications Summary The purpose of t h i s study was to determine the cues that gerontological nurses use to i n f e r that pain i s a problem for cognitively impaired e l d e r l y people. Motivation for t h i s study arose from the observation that: (a) some gerontological nurses hold the s p e c i a l i z e d s k i l l and knowledge that i s necessary to recognize pain, and (b) a better understanding of the knowledge held by those gerontological nurses could provide information that could be shared and thus, would improve the quality of care provided to co g n i t i v e l y impaired people who suffer pain. The researcher held that gerontological nurses' knowledge of pain was embedded in the culture of the long term care f a c i l i t i e s that employ gerontological nurses. L i t e r a t u r e was reviewed to i d e n t i f y the current status of knowledge on pain assessment i n c o g n i t i v e l y impaired e l d e r l y people. Clearly, l i t t l e was known about pain i n t h i s population of el d e r l y people. As a r e s u l t , related l i t e r a t u r e on pain i n infants and young ch i l d r e n was reviewed. Unfortunately, population differences made the u t i l i z a t i o n of t h i s pain l i t e r a t u r e inappropriate. The method, an ethnoscience design of q u a l i t a t i v e 89 research, was appropriate for t h i s study because i t allowed the researcher access to the c u l t u r a l knowledge held by gerontological nurses through t h e i r written and spoken language. Two data sources, s t o r y t e l l i n g interviews and retrospective chart reviews, provided the data necessary to i d e n t i f y how some gerontological nurses detected pain i n cognitively impaired e l d e r l y people. The interviews were designed to permit systematic exploration of gerontological nurses' perceptions of c o g n i t i v e l y impaired e l d e r l y people i n pain, which ultimately lead to the discovery of pain cues. Six nurses, three Registered Nurses and three Nursing Assistants were interviewed. Each had greater than two years experience working i n the same f a c i l i t y . A l l had between s i x and f i f t e e n years of experience working with the cognitively impaired elderly. The long term care f a c i l i t y that employed the nurse informants provided r e s i d e n t i a l care services to p h y s i c a l l y and mentally f r a i l e l d e r l y people. The f a c i l i t y was located i n Greater Vancouver. A l l interviews were audiotaped and transcribed verbatim. The major themes that emerged from the data were v e r i f i e d with the p a r t i c i p a n t s . The retrospective chart reviews were designed to add breadth to the potential number of pain cues 90 i d e n t i f i e d by the nurses i n the interviews. Twenty-one charts were reviewed, but only sixteen were included i n the study. Five charts were excluded from the study because they did not meet the established i n c l u s i o n c r i t e r i a . Unfortunately, the retrospective chart reviews d i d not y i e l d useful information beyond what was gleaned from the interviews. Consequently, the primary data source for t h i s study became the s t o r i e s nurses t o l d . A process of constant comparative analysis permitted the researcher to: (a) i d e n t i f y the words nurses used to label t h e i r observations, and (b) determine the meanings nurses attached to the words they used to describe t h e i r observations when i n f e r r i n g pain was a problem for cognitively impaired e l d e r l y people. The pain cues i d e n t i f i e d i n t h i s study are grouped as overt behaviour, sounds, and appearance. Each group of cues represented a change i n the elder's status. These observable changes, referred to as pain cues, were elder s p e c i f i c . The findings revealed that pain recognition i n c o g n i t i v e l y impaired elderly people was a d i f f i c u l t c l i n i c a l challenge because of: (a) i n d i v i d u a l v a r i a t i o n i n the presentation of pain cues and (b) the absence of confirmation. However, the nurses i n t h i s study responded to the challenge by adopting a 91 complicated c l i n i c a l reasoning process. The c l i n i c a l reasoning process involved integrating two types of knowing; knowing by "knowing the patient" and knowing by i n t u i t i v e perception. Knowing by "knowing the patient" focused on the nurses' knowledge of a p a r t i c u l a r i n d i v i d u a l . In contrast, knowing by i n t u i t i v e perception focused on knowledge by d i v e r s i t y , which the nurses gained from having many c l i n i c a l experiences with many d i f f e r e n t c o g n i t i v e l y impaired e l d e r l y . Both, "knowing the patient" and knowing by i n t u i t i v e perception f a c i l i t a t e d the nurses' a b i l i t y to make i n f e r e n t i a l diagnoses of pain. The findings from t h i s study are generally congruent with the anecdotal recordings reported i n the de s c r i p t i v e l i t e r a t u r e . This study has generally affirmed that nurses recognize and i n f e r pain problems according to how a cognitively impaired e l d e r l y person behaves, appears, and/or by the sounds he or she makes. In keeping with the l i m i t s inherent i n a small q u a l i t a t i v e study, g e n e r a l i z a b i l i t y of the findings are li m i t e d to those who participated i n t h i s study. Conclusions Three primary conclusions are suggested by the findings from t h i s study. F i r s t , i n the midst of tremendous v a r i a t i o n and i n the absence of confirmation, experienced gerontological nurses are 92 able to r e a l i z e when a cognitively impaired e l d e r l y person i s i n pain. Nurses make inferences about pain by recognizing change, cl u s t e r i n g cues, and having r e l a t i o n s h i p s with cognitively impaired e l d e r l y people over time. As well, they apply learning from past c l i n i c a l experience to new si t u a t i o n s . Secondly, the pain cues nurses used to i n f e r pain can be grouped as overt behaviour, appearance and sounds. However, the cues that represent pain are i n d i v i d u a l l y defined, may overlap more than one group, and are meaningful only i n the context of the impaired elder's experience. Consequently, pain cues i n i s o l a t i o n of context do not seem to be r e l i a b l e and v a l i d indicators. I t seems l i k e l y that no s i n g l e set of cues can universally represent pain i n t h i s population. Thirdly, i n d i v i d u a l l y relevant pain cues often represent a change i n the elder's status. Therefore, the notion of change seems to be a d i s t i n g u i s h i n g c h a r a c t e r i s t i c of cues in d i c a t i v e of pain. As such, the notion of change may be a generalizable c h a r a c t e r i s t i c of pain i n c o g n i t i v e l y impaired e l d e r l y people. Implications for Nursing Practice C l i n i c a l practice From the perspective of d i r e c t c l i n i c a l p r a c t i c e , 93 the findings give d i r e c t i o n for nursing assessment of pain problems. A pain experience i s not s t a t i c and simultaneously a f f e c t s several aspects of an elder's l i f e . Consequently, nurses' assessment of pain must be ongoing and include physical, mental, and s o c i a l well being. The finding that pain cues are i n d i v i d u a l l y defined according to an elder's experience requires that nurses u t i l i z e a framework for decision making i n pr a c t i c e that i s "resident" or c l i e n t focused. I t would follow that i n c l i n i c a l practice, nurses would move away from standardized pain assessment and treatment plans to individualized approaches that were based i n the context of the elder's experience. When c l i n i c a l decisions are made about pain issues, i t i s essential to accurately communicate information to a l l levels of s t a f f caregivers, on a l l s h i f t s . This would enhance the qual i t y of care provided to older adults and move s t a f f caregivers toward a collaborative practice that improves continuity of care. New and improved pain assessment data c o l l e c t i o n t o o l s could f a c i l i t a t e communication by enabling nurses to acquire and consistently document, relevant and timely information. A s s i s t i n g s t a f f caregivers to c o l l e c t appropriate information would f a c i l i t a t e the 94 nurses' a b i l i t y to make comparisons between the elder's t y p i c a l and at y p i c a l behaviours. A process of comparative analysis would support e f f e c t i v e problem so l v i n g and ensure that timely adjustments were made to the care plan. Administrative practice From a nursing administrative perspective, the findings from t h i s study have implications f o r the: (a) organization of nursing care delivery systems, (b) creation of infrastructures to promote communication and (c) implementation of a documentation system f o r nurses to record t h e i r observations. Each system has an impact on nurses' a b i l i t y to acquire the pertinent information necessary for problem solving pain issues. Currently, nursing care delivery systems i n many long term care f a c i l i t i e s have incorporated s t a f f caregiver rotation among large numbers of elders l i v i n g on the unit, some as frequently as every week. This type of rotation does not foster knowing by "knowing the person", which includes the development of close a f f e c t i v e relationships, because the s t a f f caregivers are not with the elder for a sustained period of time. Care delivery systems that authorize s t a f f caregivers to remain with a group of elders f o r an extended period of time would promote knowing by "knowing the patient". As i s evident from the findings 95 of t h i s study, knowing the patient enhances pain assessment. Nurses would be i n a better p o s i t i o n to grasp the meaning of changes and behaviourial cues i n a more timely manner. Organizing care through the establishment of permanent teams would foster "knowing the patient". However, a new challenge emerges when care d e l i v e r y on a u n i t i s established i n a permanent team format. The challenge i s to balance opportunities to "know the patie n t " with opportunities to c u l t i v a t e i n t u i t i v e perception from experience with d i f f e r e n t c o g n i t i v e l y impaired e l d e r l y people i n pain. A solut i o n to the challenge of balancing knowing the p a r t i c u l a r with knowing by d i v e r s i t y i s through team membership. Teams con s i s t i n g of members who know the idiosyncrasies of p a r t i c u l a r elders and members who are expert by v i r t u e of experience with elders i n pain would bring the advantages of knowing the patient and knowing by i n t u i t i v e perception together into a single c o l l a b o r a t i v e team. Infrastructures that enable the exchange of relevant information are needed to improve communication on the nursing unit. Such i n f r a s t r u c t u r e s might include regularly scheduled care conferences, nursing care rounds and resident care reviews. Sharing experiences and expertise encourages consistency i n 96 care plan development, fosters learning, and ensures that the most appropriate information f o r promoting comfort i s available and shared with a l l relevant s t a f f caregivers. The finding that nurses record only the diagnosis of pain and not the factors supporting t h e i r diagnosis implied to the researcher that communication through documentation only may be inadequate to fos t e r consistent care delivery. This points to the need f o r a nursing assessment data base t o o l . A nursing assessment data base t o o l for pain would: (a) promote more accurate, relevant, and consistent data c o l l e c t i o n , (b) support novice nurse p r a c t i t i o n e r s i n t h e i r s k i l l development, (c) ensure that each nurse used the same set of pain cue indicators to measure the effectiveness of interventions, and (d) fos t e r s i m i l a r i n t e r p r e t a t i o n of pain cues amongst nurses caring f o r the same group of elders. Implications for Nursing Education Curriculum development I t i s generally accepted that e l d e r l y people s u f f e r from a variety of painfu l conditions. As such, the s p e c i a l features of assessing c o g n i t i v e l y impaired e l d e r l y people for pain should be added to the current c u r r i c u l a . Nursing educators have a r o l e to heighten students' awareness for the high incidence of pain i n 97 the c o g n i t i v e l y impaired e l d e r l y . I t follows then, that students would be oriented toward a standard f o r gerontological nursing practice that i s proactive and focused on individualized approaches to pain assessment i n t h i s population of people. Classroom time and p r a c t i c a l experience are both necessary to develop s k i l l s that w i l l improve care f o r c o g n i t i v e l y impaired elders i n pain. Classroom time d i r e c t e d toward understanding the concept of pain and other t h e o r e t i c a l underpinnings i s necessary for nursing students to gain the f u l l benefit of t h e i r c l i n i c a l experiences. Seminar discussions provide a u s e f u l format for students to debrief from c l i n i c a l experiences, hear other students' questions, and t e s t some of t h e i r own ideas and learning. Nursing students need to be encouraged to c l i n i c a l l y analyze what they observe i n practice and hear from other students. P r a c t i c a l experience for nursing students must permit opportunities for students to work with experts i n the f i e l d , as knowledge held by gerontological nurses i s not e a s i l y accessible i n p r i n t . In addition, students need to be encouraged to bring t h e i r own personal and professional e x p e r i e n t i a l knowledge to practice. From the study findings, nurses who were able to relate personal experiences to c l i n i c a l practice spoke of having greater empathy and 98 f o r e s i g h t to recognize pain i n the non-verbal older adult. Pri o r professional experiential learning needs to be given c r e d i b i l i t y and incorporated into new c l i n i c a l learning. F a c i l i t y based inservice programming With regard to continuing education, the findings from t h i s study suggest that s t a f f caregivers i n long term care f a c i l i t i e s would benefit from education on pain assessment and management i n the e l d e r l y . Many f a c i l i t i e s have formal and informal educational opportunities for s t a f f . However, with an increase i n workload, i t i s becoming a challenge for s t a f f to attend in-service education during t h e i r working s h i f t . As a r e s u l t f a c i l i t i e s need to be creative and develop opportunities for learning that are not burdensome to the s t a f f caregiver. Examples of such opportunities could be nursing rounds during lunch hours, c l i n i c a l conferencing f a c i l i t a t e d by expert c l i n i c i a n s , and s e l f learning modules for motivated s t a f f learners. Implications for Nursing Research Several findings i n the current study r a i s e d questions that can only be answered by future research. F i r s t , i t would be useful to conduct the i d e n t i c a l study i n another long term care f a c i l i t y . R e p l i c a t i n g the study i n another f a c i l i t y would help determine i f the c u l t u r a l knowledge held by the nurses i n the 99 current f a c i l i t y i s consistent with that of gerontological nurses i n other long term care f a c i l i t i e s . I t would be useful to know i f the pain cues and strategies i d e n t i f i e d i n t h i s study's findings held true as a common understanding for a l l nurses working i n long term care. Having the findings of t h i s study r e p l i c a t e d would further strengthen the v a l i d i t y of t h i s study's conclusions. Secondly, more studies are needed to confirm the pain cue categories and to confirm the g e n e r a l i z a b i l i t y of change as a c h a r a c t e r i s t i c of pain i n the co g n i t i v e l y impaired elderly. Thirdly, the nurses i n t h i s study c o n s i s t e n t l y spoke of physical pain, but also referred to a non- phy s i c a l pain experience, which they named eithe r s p i r i t u a l , mental, or emotional. Research i s needed to explore the non-physical pain experiences of co g n i t i v e l y impaired elderly people. I t i s important to understand the experiences i n greater d e t a i l to ensure that appropriate nursing interventions are applied to the appropriate pain experience. F i n a l l y , research i s needed to understand the impact of current care delivery systems on nurses' a b i l i t i e s to recognize and manage pain problems. I f we accept the finding that nurses are better able to recognize pain i n the cognitively impaired e l d e r l y when 100 they develop relationships with the elders i n t h e i r care, the care delivery system as i t currently e x i s t s discourages the development of such r e l a t i o n s h i p s . Investigating the current care delivery systems i n r e l a t i o n to c l i n i c a l outcomes seems p a r t i c u l a r l y important i n the present climate of f i s c a l r e s t r a i n t . In conclusion, the findings from t h i s study have contributed to our understanding of pain i n c o g n i t i v e l y impaired e l d e r l y people. Gerontological nurses who have par t i c i p a t e d i n t h i s study are c l e a r l y knowledgeable and have a wealth of information, much of which has not yet been r e f l e c t e d i n our pr a c t i c e l i t e r a t u r e . Discovering the knowledge held by gerontological nurses can a s s i s t other nurses i n learning and promoting comfort measures i n c o g n i t i v e l y impaired e l d e r l y people. Continued research i s necessary to reveal the spe c i a l features of gerontological nurses' ways of knowing. References 101 Anand, K. J. S., P h i l , D., & Hickey, P. R. (1987). Pain and i t s effects i n the human neonate and fetus. The New England Journal of Medicine, 317, 1321-1329. Beckingham, A.C. (1993). Aging i n Canada. In A.C. Beckingham & B. W. DuGas (Ed.), Promoting healthy aging: A nursing and community perspective (pp. 3- 49). St. Louis: Mosby Co. Benner, P., & Tanner, C. (1987). C l i n i c a l judgement: How expert nurses use i n t u i t i o n . American Journal of Nursing, 87(1), 23-31. Benner, P., & Wrubel, J. (1982). S k i l l e d c l i n i c a l knowledge: The value of perceptual awareness. Nurse Educator. May-June, 11-17. Carnevali, D. L., & Thomas, M. D. (1993). Diagnostic reasoning and treatment decision making i n nursing. Philadelphia: J. B. Lippincott Company. Carper, B. A. (1978). Fundamental patterns of knowing i n nursing. Advances i n Nursing Science, 1(1) , 13- Chenitz, W. C. , Stone, J. T., & Salisbury, S. A. (1991). C l i n i c a l gerontology nursing: A guide to advanced practice. Toronto: W. B. Saunders Company. Copp, L, A. (1974). The spectrum of s u f f e r i n g . American Journal of Nursing. 74, 491-495. Craig, D., & Prkachin, K. M. (1983). Nonverbal measures of pain. In P. Melzack (Ed.), Pain management and assessment (pp. 173-179). New York: Raven Press. Davis, D. H., & Calhoon, M. (1989). Do preterm infants show behaviourial responses to p a i n f u l procedures? In S. G. Funk, E. M. Tornquist, M. T. Champagne, L. A. Copp, & R. A. Wiese (Eds.), Key- aspects of comfort (pp. 35-45). New York: Springer. 102 Davitz, J . R., & Davitz, L. L. (1981). Inferences of patient's pain and psychological d i s t r e s s : Studies of nursing behaviours. New York: Springer Co. Donovan, M. I. (1989). Relieving pain: The current bases for practice. In S. G. Funk, E. M. Tornquist, M. T. Champagne, L. A. Copp, & R. A. Wiese, (Eds.), Key aspects of comfort (pp. 25-31). New York: Springer Co. Dudley, S. R., & Holm, K. (1984). Assessment of the pain experiences i n r e l a t i o n to selected nurse c h a r a c t e r i s t i c s . Pain, 18, 179-186. Evaneshko, V., & Kay, M. (1982). The ethnoscience research technique. Western Journal of Nursing Research, 4, 49-63. F e r r e l l , B. A. (1991). Pain management i n e l d e r l y people. American G e r i a t r i c Society. 39, 64-63. F e r r e l l , B. A., F e r r e l l , B. R., & Osterweil, D. (1990). Pain i n the nursing home. Journal of American G e r i a t r i c Society, 38., 409-414. Forbes, W. F., Jackson, J. A., & Kraus, A. S. (1987). I n s t i t u t i o n a l i z a t i o n of the el d e r l y i n Canada. Toronto: Buttersworth. Fordyce, W. E. (1983). The v a l i d i t y of pain behaviour measurement. In R. Melzack (Ed.), Pain measurement and assessment (pp. 145-153). New York: Raven Press. Franck, S. L. (1986). A new method to q u a n t i t a t i v e l y describe pain behaviour i n infants. Nursing Research. 35, 28-31. F u l l e r , B. F., H o r i i , Y. & Conner, D. (1989). Vocal measures of infant pain. In S. G. Funk, E. M. Tornquist, M. T. Champagne, L. A. Copp, & R. A. Wiese, (Eds.), Key aspects of comfort (pp. 46-51). New York: Springer. GoetzJ. P., & Le Compte, M. D. (1984). Ethnography and q u a l i t a t i v e design in educational research. New York: Academic Press. Greipp, M, E. (1992). Under medication for pain: An e t h i c a l model. Advances i n Nursing Science. 15 (1), 44-53 . 103 Guba, E.G., & Lincoln, Y. S. (1984). E f f e c t i v e evaluation. San Francisco: Jossey-Bass. Herr, K. A., & Mobily, P. R. (1991). Complexities of pain assessment i n the e l d e r l y : C l i n i c a l considerations. Journal of Gerontological Nursing. 17(4), 12-19. Horwitz, A., & Shindleman, L. (1983). Reciprocity and a f f e c t i o n : Past influences on current caregiving. Journal of Gerontological Social Work. 5(3), 5-20. Hurley, A, C., V o l i c e r , B, J., Hanrahan, P, A., Houde, S., & V o l i c e r , L. (1992). Assessment of discomfort i n advanced Alzheimer patients. Research i n Nursing and Health. 15, 369-377. International Association for the Study of Pain. (1986). Pain terms: A current l i s t with d e f i n i t i o n s and notes on usage. Pain, 35, S216- S221. Katzman, R. (1986). Alzheimer's disease. New England Journal of Medicine. (4), 964-972. Lamb, G.S., & Huttlinger, K. (1989). R e f l e x i v i t y i n nursing research. Western Journal of Nursing Research. 11(6), 765-772. Leininger, M. (1978). Transcultural nursing: Concepts, theories, practices. New York: John Wiley & Sons. Leininger, M. (1985). Ethnoscience method and componential analysis. In M. M. Leininger (Ed.), Q u a l i t a t i v e research methods i n nursing (pp. 237- 249). Orlando, FL: Grune & Stratton. Le Resche, L., & Dworkin, S. F. (1988). F a c i a l expressions of pain and emotions i n chronic TMD patients. Pain, 35, 71-78. Loeser, J. D., & Egan, K. J. (Eds.). (1989). Managing the chronic pain patient: Theory and practice at the u n i v e r s i t y of Washington m u l t i d i s c i p l i n a r v pain centre. New York: Raven Press. Marzinski, L. R. (1991) . The tragedy of dementia: C l i n i c a l l y assessing pain i n the confused, nonverbal e l d e r l y . Journal of Gerontological Nursing, 17, 25-28. 104 McCaffery, M., & Beebe, A. (1989). Pain: C l i n i c a l manual for nursing practice. Toronto: Mosby. McDaniel, K. L. , Anderson, K. O., Bradley, L. O., Young, L. D., Turner, R. A., Agudelo, C. A. & Keefe, F. J . (1986). Development of an observational method for assessing pain behaviour i n rheumatoid a r t h r i t i s patients. Pain, 24, 165-184. McGrath, P. A. (1987). An assessment of children's pain: A review of behaviourial, p h y s i o l o g i c a l and d i r e c t s c a l i n g techniques. Pain, 31, 147-176. Melzack, R. (1983). Pain measurement and assessment. New York: Raven Press. Melzack, R., & Wall, P. D. (1982). The challenge of pain. New York: Basic Books. M i l l s , M. N. (1989). Acute pain behaviour i n infants and toddlers. In S. G. Funk, E. M. Torniquist, M. T. Champagne, L. A. Copp, & R. A. Wiese (Eds.), Key aspects of comfort (pp- 52-59). New York: Springer. Mobily, R. P., & Herr, A. K. (1992). Back pain i n the e l d e r l y . G e r i a t r i c Nursing. March/April, 110-116. Parke, B. (1992). Pain i n the cogni t i v e l y impaired e l d e r l y . Canadian Nurse, 88(7), 17-20. Ragucci, A. T. (1972). The ethnographic approach and nursing research. Nursing Research. 21, 319-321. Robertson, M. H. B., & Boyle, J. S. (1984). Ethnography: . Contributions to nursing research. Journal of Advanced Nursing, 9, 43-49. Roy, R., & Thomas, M. R. (1986). A survey of chronic pain i n the el d e r l y population. Canadian Family Physician, 32., 513-516. Sandelowski, M. (1986) . The problem of r i g o r i n q u a l i t a t i v e research. Advances i n Nursing Science, 8, 27-37. Schraeder, B., & Fischer, D. (1987). Using i n t u i t i v e knowledge in the neonatal intensive care nursery. H o l i s t i c Nursing Practice, 1(3), 45-51. 105 Shapira, J . , Schlesinger, R., & Cummings, J . L. (1986). Distinguishing dementias. American Journal of Nursing, 6, 698-702. Shapiro, C. (1989). Pain i n the neonate: Assessment and intervention. Neonatal Network. 8, 7-18. Spradley, J . P. (1972). Foundations of c u l t u r a l knowledge. In J. P. Spradley (Ed.), Culture and cognitions: Rules, maps and plans (pp.3-38). San Francisco: Chandler Publishing Co. Spradley, J . P. (1979). The ethnographic interview. New York: Holt Rinehart & Winston. Sradley, J. P. (1980). Participant observation. New York: Holt Rinehart & Winston. Sross, A. J., & Baggerly, J . (1989). Models of advanced practice. In A. B. Hamric & J . A. Spross (Eds.), The c l i n i c a l nurse s p e c i a l i s t i n theory and pra c t i c e , (2nd ed.). (pp. 19-40). Philadelphia: W.B. Saunders Co. Tanner, A. C., Benner, P., Chesla, C , & Gordon, R. D. (1993) . The phenomenology of knowing the patient. Image: Journal of Nursing Scholarship, 2J5(4) , 273- 280. Turk, D. C , & Flor, H. (1987). Pain > pain behaviours: The u t i l i t y and li m i t a t i o n s of the pain behaviour construct. Pain, 31, 277-295. Vlaeyen, J . W. S., Van Eek, H., Groenman, H. N., & Schuerman, J. A. (1987). Dimensions and components of observed chronic pain behaviour. Pain. 31, 65- 75. Watson, J. (1989). Human caring and su f f e r i n g : A subjective model for human science. In L. Taylor and J . Watson (Eds.), They s h a l l not hurt: Human su f f e r i n g and human caring (pp. 125-135). Boulder Colorado: Colorado Associated University Press. Watt-Watson, J. H. (1987). Nurses' knowledge of pain issues: A survey. Journal of pain and symptom management, 2, 207-211. 106 Watt-Watson, J. H., & Donovan, M. I. (1992). Pain management: Nursing perspective. Toronto: Mosby Year Book. Appendix A QUESTION GUIDE PART ONE: Current Experience 1. I'm interested i n learning how nurses i d e n t i f y pain i n the c o g n i t i v e l y impaired elderly, how you see things. I want to understand things from your point of view. 2. Who are you caring for r i g h t now that i s c o g n i t i v e l y impaired and i n your opinion i n pain? T e l l me about them. 3. What made you f e e l (resident) was i n pain? 4. What kinds of things did you see/hear that made you believe (resident) was i n pain? 5. What are you looking for when you are assessing (resident) f o r pain? 6. Have you seen t h i s often i n other cognitively impaired people? 7. How do you normally recognize a cognitively impaired person i s i n pain? 8. What does i t mean when you see (behaviours)? 9. Could you describe how t h i s s i t u a t i o n i s d i f f e r e n t from other s i t u a t i o n s where residents behaviours are not pain related? PART TWO: Past Pain Stories 1. Think of the most uncomfortable cognitively impaired e l d e r l y person you ave provided care for. Think of the most extreme case. Make a mental picture of that person, (pause give time to remember) T e l l me about that person. 2. What things stand out i n your mind? 3. Could you describe how t h i s s i t u a t i o n i s d i f f e r e n t from the s i t u a t i o n with (resident). 4. Can you think of another resident that f i t s t h i s p i c t u r e How are they d i f f e r e n t . How are they similar? (repeat) 5. How do you pick up information when i t i s more subtle? How normal can a cognitively impaired e l d e r l y person look and s t i l l be i n pain? When you sense a resident i s i n pain, how do you confirm your hunch? Is there anything else you would l i k e to t e l l me? In your opinion who else do you work with that i s knowledgable about pain i n the cognitively impaired el d e r l y ? DEMOGRAPHIC NURSE INFORMANT DATA Age: 19-24 31-35 41-45 51-55 > 60 25-30 36-40 36-50 56-60 Gender: Male Female C u l t u r a l Background, P o s i t i o n within the f a c i l i t y : RN NA LPN _ Other Level of nursing education: No formal t r a i n i n g Diploma Baccalaureate Graduate Degree NA C e r t i f i c a t e Other Number of years employed i n the f a c i l i t y : less than 1 2 to 5 " 6 to 10 greater than 11 Years of experience working with cognitively impaired e l d e r l y : 4 to 6 , 6 to 10 11 to 15 greater than 15 — A p p e n d i x D T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A 111 School of Nursing T. 206-2211 Wcsbrook Mall Vancouver. B.C. Canada V6T 2B5 Fax: (604) 822-7466 T i t l e : The Pain Cues of Cognitively Impaired E l d e r l y : An E t h n o s c i e n t i f i c Study of Gerontological Nurses' Perspectives. Investigator: Belinda Parke, RN, BSN Faculty Advisor: Ann Marie Hughes, RN, Ed. D. This i s to c e r t i f y that I, agree to p a r t i c i p a t e as a volunteer i n the above named study. The purpose of the study i s to investigate how nurses i n f e r that pain i s a problem f o r a c o g n i t i v e l y impaired e l d e r l y person. I have read the l e t t e r of explanation and understand the purpose of the study. I agree to be interviewed on two occasions and that each interview w i l l be tape recorded. I understand that there are no r i s k s associated with t h i s study and that I am free to refuse to answer any questions or to withdraw from the study at any time. I have had the opportunity to ask any questions I wish of the researcher and a l l the questions I have asked have been answered to my s a t i s f a c t i o n . I understand that there i s no monetary compensation but that the information gained may lead to development of assessment techniques that could allow a l l nurses to more e a s i l y assess pain i n the c o g n i t i v e l y impaired e l d e r l y . I understand that information from t h i s study w i l l be used i n presentations and publications, but i n ways that c o n f i d e n t i a l i t y w i l l be maintained. I acknowledge r e c e i p t of a copy of t h i s consent. Signed. Date

Cite

Citation Scheme:

    

Usage Statistics

Country Views Downloads
Japan 3 0
United States 2 0
China 2 10
City Views Downloads
Tokyo 3 0
Ashburn 2 0
Beijing 2 0

{[{ mDataHeader[type] }]} {[{ month[type] }]} {[{ tData[type] }]}

Share

Share to:

Comment

Related Items