Background

The assessment of pain in cognitively impaired seniors is a complicate clinical challenge for emergency department (ED) nurses, especially in case of severe dementia where communication abilities may be deeply affected. Observational and behavioral tools are the preferred pain assessment methods for those with cognitive impairment, but particular aspects of EDs (i.e. time pressure, lack of familiarity with patients and their relatives, the coexistence of acute and chronic problems) may make it difficult their utilization. Moreover, existing literature shows heterogeneity regarding pain evaluation and nurses’ approach for this vulnerable patient group.

Thus, our aim was to describe ED nurses’ experience and perceptions regarding this topic. Moreover, we sought to reveal critical issues and strategies implemented in the ED to adequately assess pain in those with cognitive problems. 

Methods

A multicentric qualitative study, with a descriptive phenomenological approach, was performed. ED nurses working in three hospitals of Southeastern Tuscany health agency (Italy) were enrolled with purposive sampling. Semi-structured interviews composed by 12 guiding questions were carried out. Focus groups took place in accordance with anti-COVID19 rules in force at the time of their conduction (adequate social distancing or videoconferencing). All data were audiotaped, transcripted verbally and analyzed with Colaizzi’s method.

Results

Four focus groups were conducted, with the participation of 22 nurses, between 23rd Sept and 30th Oct 2020. Nurses were predominantly male (n=12, 54.5%) and had an average ED experience of 9.22 years (SD=7.68).

Five themes emerged from the data analysis: 1) Nurses’ perception of pain assessment; 2) Support role of family members and caregivers; 3) Nurses’ awareness of the pain assessment tools currently used in the EDs; 4) Clinical assessment as a support for pain assessment; 5) Community nurses as a support for clinical evaluation in the continuum of care.

ED nurses find it difficult to assess pain in the cognitively impaired seniors. While specific tools have been made available over time, the Visual Analog Scale (VAS) and the Numerical Rating Scale (NRS) are still widely used; anyway, this is seen as a limitation in the evaluation process. In effect, direct observation or the help of a family member are preferred to self-assessment tools. As a matter of fact, given the dynamism of the ED, nurses are oriented to respond quickly at the patients’ needs. The importance of cooperation between nurses involved in the different phases of the patient pathway is rising; collaboration with community nurses could reinforce an adequate pain assessment by ED nurses.

Conclusion

ED nurses do not seem adequately trained to use specific pain assessment tools for the cognitively impaired seniors; given the communication obstacle, the choice and validation of a single, quick and easy to apply tool could lead ED nurses to focus reliably on the patient and to evaluate him in the most correct way possible.

Furthermore, the increasing importance of transitional care suggests the implementation of appropriate communication methods between ED nurses and both family members and community nurses to improve pain management through the entire care process.

References

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