Cognitively impaired older adults cannot verbally express their pain experience in ways that gerontological nurses* can easily understand. As such, the problem of detecting and assessing pain in cognitively impaired older adults is a major challenge for gerontological nurses.
The detection of pain through accurate assessment is hindered in cognitively impaired older adults by the subjective nature of pain, the lack of appropriate assessment tools, nurses' lack of knowledge, and misunderstandings about pain perception and aging. The difficulty of detecting pain is further compounded by co-existing factors such as aphasia, chemical and mechanical restraints, altered states of consciousness, sensory impairments, depression, and memory loss and loss of intellectual functioning (Ferrell, 1991; Ferrell, Ferrell, & Osterweil, 1990; Forrest, 1995; Herr & Mobily, 1991; Marzinski, 1991; McCaffery & Beebe, 1989; Watt- Watson, 1987; Watt- Watson & Donovan, 1992). As well, it is not uncommon for older adults to experience acute pain (pain newly acquired with a brief duration) concurrently with chronic pain (pain persisting past the normal time of healing) to further complicate clinical problem solving for gerontological nurses (International Association for the Study of Pain, 1986).
In addition, the prevalence in nursing of an objectivist rationality (Hiraki, 1992) means that nurses are often required to collect objective clinical data to validate their assessments that a cognitively impaired older adult is in pain. The extent to which nurses are then required to translate "intuitive knowledge" into visible, objective measures only recently has become the focus of systematic exploration (Parke, 1995). Yet, with all the barriers nurses face in detecting pain, some gerontological nurses are able to realize when an impaired older adult is experiencing pain.
The ability of some gerontological nurses to know when an impaired older adult is experiencing pain raises the question: When there are no visible cues (or only ambiguous cues), are there interpretive processes in operation that assist gerontological nurses in detecting pain? This article will report on a study of gerontological nurses' knowledge about pain cues in cognitively impaired older adults and how nurses bring together objective, scientific knowledge with intuitive knowledge to realize that an impaired older adult is in pain.
Historically, pain assessment literature has focused primarily on scales to measure pain. In some clinical settings, these scales are referred to as either pain management tools or case management tools. In either case, these one-dimensional tools can be classified as verbal, visual, or numerical (Forrest, 1995; Le Resche & Dworkin, 1988; Melzack, 1983; Melzack & Wall, 1982; Young, 1997). Each relies on the clients' ability to describe their pain experience and are intended to measure intensity, not differentiate between chronic and acute pain.
Figure 1. Traditional pain assessment.
Figure 2. Pain assessment for cognitively impaired older adults.
Behavioral tools and observational procedures are also identified in the literature as methods for assessing pain in various populations from neonates to older adults (Davis & Calhoon, 1989; Fordyce, 1983; Franck, 1986; Fuller, Horii, & Conner, 1989; McCaffery & Beebe, 1989; McDaniel et al., 1986; McGrath, 1987; Shapiro, 1989). Little of this research is concerned with the painproducing health problems afflicting cognitively impaired older adults.
Other researchers have investigated nonverbal behaviors to measure pain (Craig & Prkachin, 1983; Le Resche & Dworkin, 1988; Turk & Flor, 1987; Vlaeyen, Van Eek, Groenman, & Schuerman, 1987). The results of these studies have yielded an impressive array of behaviors believed to be associated with pain. The behaviors observed can be categorized as posture, which includes standing, sitting, or reclining; facial expressions, such as grimacing, specific configurations of fear, sadness, and disgust; verbalizations, such as self-reports or complaints of pain, asking for help and repeated requests for analgesics; vocalizations, which are heard as sighing, crying, groaning, moaning, and other nonlanguage sounds; and functional ability as evidenced by an increase or decrease in mobility, a decline in activity, tolerance, and endurance, with a proportional increase in fatigue. Not all the behaviors identified in these studies were appropriate measures for assessing pain in cognitively impaired older adults. Many of the behaviors required skills, knowledge, and thinking abilities beyond the capacity of cognitively impaired older adults.
Pain Assessment and Cognitively Impaired Older Adults
Pain as a "symptom" to be assessed in cognitively impaired older adults requires complex clinical assessment and interpretative nursing skills (Ferrell et al., 1990; Forrest, 1995; Herr & Mobily, 1991; Marzinski, 1991). Cognitive impairment has been reported in the pain literature (Ferrell, 1991; Ferrell et al., 1990; Forrest, 1995; Herr & Mobily, 1991; Marzinski, 1991; Parke, 1992; Roy & Thomas, 1986) as:
* A condition that may mask the presentation of pain.
* A condition exacerbated because of the presence of pain.
* A related variable requiring evaluation when assessing pain.
Only recently has pain assessment in cognitively impaired older adults been systematically investigated (Ferrell, Ferrell, & Rivera, 1995; Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992; Parmelee, Smith, & Katz, 1993). Results from these studies suggest that no one pain assessment tool is ideal for all cognitively impaired older adults; pain assessment tools are more useful if suited to an individual's abilities; and cognitively impaired older adults' selfreports of pain are valid and require nursing assessment.
The Discomfort Scale, an objective tool to measure discomfort in noncommunicative older adults with Alzheimer's disease and researchbased pain management protocols have demonstrated clinical utility (Hurley et al., 1992; Young, 1997). Each offers a framework to systematically assess pain in older adult populations, particularity populations with cognitive impairments.
To this author's knowledge, no information is available in the literature to validate the descriptive behaviors identified as potential indicators of pain in cognitively impaired older adults. Also, no information exists in the literature to explain the significance of external factors, such as the type of pain experienced (acute or chronic), the timing of assessments, or the context in which pain assessments occur, to the "pain" behaviors cited in the literature.
Knowing in Nursing
Many authors (Benner, 1984; Benner & Tanner, 1987; Benner & Wrubel, 1982; Carper, 1978; Davies, 1993; Kidd & Morrison, 1988; Mitchell, 1994; Tanner, Benner, Chesla, & Gordon, 1993; Urden, 1989; White, 1995) have tried to explain and describe how nurses:
* Acquire new knowledge.
* Apply acquired knowledge to clinical practice.
* Integrate past learning with new learning.
* Acquire knowledge derived from clinical practice.
* Make decisions and use decision-making processes to transfer theoretical knowledge into practice.
It is clear from this review of the literature that there is diversity in the ways nurses acquire and apply knowledge to clinical practice. Further, nurses appear to make judgments about individuals' responses within the context of their clinical practice by recognizing similarities and differences between and among clients. No research to date has described the special features of the way gerontological nurses' acquire and apply knowledge about pain to cognitively impaired older adults.
Figure 3. Pain cues.
The conceptual framework supporting this investigation is an extension of Loeser and Egan's (1989) method of describing a pain experience that involves four domains: nociception, pain, suffering, and pain behavior. Their description of a pain experience has been expanded for this study to incorporate pain assessment (Figure 1).
Figure 4. Realizing pain is present.
In operationalizing the traditional pain assessment approach, the nurse initiates the assessment process following the client's verbal declaration of pain. Each nurse brings nursing education and training, theoretical and experiential knowledge, personal experiences, culture, values, and beliefs to the situation. These variables can enhance or impede the nurse's interaction with a client in pain and consequently, influence their clinical judgment.
Clinical judgment is a complex intellectual process of decision making that includes formulating interpretations regarding what action to take. Action refers to the interventions the nurse chooses or does not choose to implement. To take no action is a conscious decision not to initiate an intervention. Both the actions and the nonactions are the result of clinical judgment, and both involve a process of interpretation.
Cognitively impaired older adults are unable to provide reliable verbal information about their experience. They do not verbally report, "I have pain." Because cognitively impaired older adults do not state they have pain nor do they validate nurses' "hunches," it is conceivable that nurses' assessment of pain could be incomplete or, worse, not initiated in this population. As such, a second conceptualization is used to illustrate a revised model for pain assessment in cognitively impaired older adults (Figure 2).
In the traditional model (Figure 1), the client validates the meaning nurses give to what they observe. This is not so with cognitively impaired older people; the verbal cue, "I have pain," does not occur to initiate the assessment process (Figure 2). As a result, gerontological nurses are required to formulate inferences of pain based on interpretations from clinical data obtained from observing, listening, and evaluating behaviors and other cues. It is usual and expected that nurses observe, listen, and evaluate when assessing pain. However, skilled gerontological nurses do not simply observe; they also evaluate cognitively impaired older adults in relation to what they already know about them, that which is usual or expected for a particular client. Actions then are taken in relation to what the nurses observe, hear, or recognize as something different for the older adult.
An ethnographic design with judgment sampling was used to select six knowledgeable gerontological nurse informants (Evaneshko & Kay, 1982; Goetz & Le Compte, 1984; Leininger, 1978, 1985; Ragucci, 1972; Robertson & Boyle, 1984). AU informants (four RNs, two nursing assistants) were selected from a longterm care facility providing residential care services to physically and mentally frail people. Informant selection was guided by Spradley (1979). Accordingly, established criteria included:
* Having more than 1 year fulltime or 4 years part-time facility nursing experience.
* Being educated as either a RN or a nursing assistant.
* Being considered part of the health care team by the facility.
* Being identified by a nurse administrator or designate, head nurse, director of care, clinical nurse specialist, or nurse peer as having knowledge about pain assessment in cognitively impaired older adults.
RNs, LPNs, and nursing assistants, within the scope of their education and training, contribute information to the pain assessment process. It is the responsibility of the RN, however, to assimilate all information and formally determine the diagnosis of pain. Ultimately (as in this study), the skill and knowledge of the RN directs the plan of care. As such, nursing assistants were included as informants for this study.
All informants were female, more than 30 years old, and had between 6 and 15 years experience working with cognitively impaired older adults in the facility. Each informant had formal training from an accredited program in nursing at either the nursing assistant or RN level.
Indepth clinical story-telling using formal elicitation procedures involved a systematic exploration of informants' observations, perceptions, and reflections of caring for cognitively impaired older adults who were assumed to be in pain (Evaneshko & Kay, 1982; Robertson & Boyle, 1984; Spradley, 1972, 1979). The interviews had two parts. In Part One, nurse informants were asked to speak about a current experience of caring for a cognitively impaired older adult they believed to be in pain. The current experience was used to ground the data in existing practice as well as contrast and compare it to memories of past experiences.
In Part Two, nurse informants were asked to think about caring for a cognitively impaired older adult they believed was in extreme pain, make a mental picture of the person, and then describe the person. To obtain the maximum variation in how nurses perceived pain presented in cognitively impaired older adults, an attempt was made to have the nurse informants remember and discuss a range of experiences.
A procedure of constant comparative analysis was initiated after the first interview and continued through the data collection phase. All stories were audiotaped and transcribed verbatim over a 2-week period.
The findings from this study are presented in two parts: the pain cues the nurse informants used to formulate interpretations and how the nurse informants realized pain was present. Gerontological nurses' ways of knowing became evident in how the nurses used the pain cues to realize an older adult was experiencing pain.
A pain cue represented a change in overt behaviors (aggressive behavior, restlessness/agitation, and activities of daily living), sounds (verbalization and vocalization), or appearance (facial expressions and body language) (Figure 3). Each impaired older adult presented with his or her own set of pain cues making the generalizability of one set of pain cues for all cognitively impaired older adults inappropriate. The notion of "change," however, may be a generalizable characteristic of pain in cognitively impaired older adults. The way the nurses used the pain cues revealed the clinical reasoning process they employed to develop the inference that a cognitively impaired older adult was in pain.
Nurses' Ways of Realizing Pain is Present
Gerontological nurses' ways of realizing pain was present was hardly accidental. Two ways of knowing were in operation: knowing simply by knowing the person and knowing by intuitive perception (Figure 4).
As illustrated in Figure 4, no one element in isolation can explain how the nurses in this study realized pain was present. It is necessary to consider the elements as a whole, interrelated and connected to form one unit. It is the whole unit that provides understanding to the ways the nurses realized pain was present. To understand the whole, it is useful to discuss each element separately.
Knowing the Person. To know a cognitively impaired older person meant to be familiar with their particular personal characteristics, regular patterns, preferences, likes, and dislikes. It was through the process of familiarity with the older adult that nurses were able to recognize when something was different or wrong. By knowing the person, gerontological nurses became aware of what was meaningful to the older adult. Individualized knowledge was critical, because each cognitively impaired older adult provided nurses with their 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 impaired older adults could not verbalize what they wanted the nurses to know.
When asked how they acquired their detailed knowledge, the nurses attributed their knowing the older adult to spending years caring for them. Spending time with the older adult provided historical context to the observations. Consequently, to learn the older adults' usual patterns of response and understand the meaning of the responses, repeated exposure and frequent experience with same older adults were required. The greater the duration of time spent with an older adult, the more opportunity the nurses had to learn the particular idiosyncrasies of those older adults. Having relationships with cognitively impaired older adults enabled the nurses to recognize change, understand the meaning of the change, and cluster pain cues.
Recognizing change was the mechanism that initiated the clinical reasoning process and triggered the nurses to assess for pain. As such, the notion of change replaced the verbal declaration, "I have pain."
Clusters of individually defined pain cues became the recognition features for pain in cognitively impaired older adults. The recognition features for pain were derived from the pain cue groupings: overt behavior, appearance, and sounds (Figure 3). The nurses' ability to cluster pain cues enabled them to make inferential diagnoses of pain. Collectively, the nurses agreed that they were able to cluster pain cues because they had many experiences caring for cognitively impaired elderly people in pain and held specific and individual knowledge of the impaired older adult, which they gained from having long-standing, affectionate relationships with those people.
Having relationships with impaired older adults was central to the nurses' ability to form hypotheses about the meaning of pain cue clusters to infer pain was a problem. To these nurse informants, their relationships with impaired older adults gave them the ability to comprehend meaning and achieve a sense of understanding about specific events, make claims about their observations, and say what was different about a clinical situation. Consequently, relationships with impaired older adults gave strength to the inferences nurses made about pain.
Intuitive Perception. For the gerontological nurses in this study, intuitive perception developed from having relationships and experiences with many different cognitively impaired older adults in pain. In essence, intuitive perception was knowing by diversity, whereas knowing the person was based on knowing the particular.
From the ways the gerontological nurse informants referred to their role, it appeared they had the ability to rapidly recognize subtle changes without being able to clearly verbalize their perceptions. This suggested they knew more about the cognitively impaired older person than they could articulate. For example, the nurses talked about "a feeling inside" that something was wrong or that they "just picked up" the pain cues. In other examples, nurses reported that their "instincts tell them" or that they "internally feel something is wrong because the person is not being herself." In part, they realized 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 other clinical situations. Therefore, the notion of intuitive perception, as it was implied in the gerontological nurses' story-telling, was rooted in exposure to multiple and concurrent clinical experiences.
Confirming the Presence of Pain: Validating Hunches
Confirming, which was part of the nurses' reasoning process, involved substantiating that the changes they observed represented pain. Confirming the presence of pain involved:
* Assimilating other kinds of information into their assessment process.
* Using a process of trial and error.
* Consulting interdisciplinary team members to reach consensus.
In this way, nurses made inferences and confirmed the pain experiences of cognitively impaired older adults retrospectively.
Assimilating other relevant information included the older adults* diagnoses and medical histories, the nurses' knowledge of pathophysiology, and the nurses' personal experiences with painful conditions. Together this additional information aided the nurses in determining whether the cues represented pain.
The process of trial and error involved identifying pain cues, implementing treatment interventions, and observing the cognitively impaired older adults' responses to the interventions. Many times nurse informants reported they would administer a treatment and look for a return to the older adults' usual or expected status. An intervention was effective when the pain cues subsided and the older adults' expected status reemerged.
A process of trial and error involved recognizing the cognitively impaired person's specific pain cues, getting the intervention right, and then using that knowledge again with the same person or with a different person. Getting it right meant the treatment or intervention was effective in relieving the pain.
Consulting the health care team emerged as the final method nurse informants used to confirm their suspicions of pain. In all situations, nurse informants reported discussing their perceptions and observations with other nurses, physicians, pharmacists, and physiotherapists. Through multidisciplinary discussion, a consensus would be reached about the presence of pain.
IMPLICATIONS FOR NURSING PRACTICE
Despite the small number of nurse informants in this study, the findings can inform the practice of nurses working with cognitively impaired older adults. The finding that pain cues are individually defined according to an older adults' experiences encourages nurses to use an elderfocused decision-making framework. It would follow that in clinical practice, nurses would move away from standardized pain assessment and treatment plans to individualized approaches based on the context of the older adults' experiences.
From a nursing administrative perspective, the findings have implications for the organization of care delivery systems.
Care delivery systems that facilitate nurses and other caregivers to remain with a group of older adults for an extended period of time would promote knowing the client. Nurses would, in a more timely manner, acquire pertinent information and grasp the meaning of changes in the older adults' status. As an example, the establishment of permanent teams could foster knowing the client. The challenge then becomes trying to balance opportunities to know the client with opportunities to cultivate knowing by diversity, which comes from experience with many cognitively impaired older adults in pain.
The findings reveal that pain recognition in cognitively impaired older adults was a difficult clinical challenge. Despite the difficulty they encountered in recognizing pain, the gerontological nurses in this study speculated, made inferences, and attempted to confirm the presence of pain by validating their intuitions. The nurses' proficiency in solving pain problems for cognitively impaired older adults was rooted in their ability to practice from a wide base of knowledge. It is clear from the nurses' stories that this breadth of knowledge comes from a variety of sources and takes time to acquire. It was evident from the stories that gerontological nurses' ways of knowing involved a complex clinical reasoning process of recognizing change and clustering pain cues within a practice context that supported nurses having relationships with cognitively impaired older adults.
Several questions arise from this study that can only be answered by future research. These include:
* Do the identified pain cues hold true for other gerontological nurses in their assessment of cognitively impaired older adults?
* Is change a generalizable characteristic of pain in cognitively impaired older adults?
* How do current care delivery systems impact nurses' ability to recognize and manage pain problems in cognitively impaired older adults?
* Do gerontological nurses' ways of realizing older adults are in pain transcend to other aspects of caring for cognitively impaired older adults?
When knowledge of a person is brought together with intuitive perception, gerontological nurses can succeed in recognizing, assessing, and effectively treating pain problems in cognitively impaired older adults.
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