Effectiveness of nurses’ skills to manage pain in patients with dementia

1.0 Introduction

The ageing revolution, where there has been a growth in the ageing population in society has been associated with a high risk of dementia. Pain is a common experience among dementia patients. Pain has been defined differently in health literature. However, in the spirit of patient centres care, this review adopts the definition by McMcCaffery (1968) which says that pain is what the patient says it is. According to Flo et al. (2014), pain is often signalled through verbal communication, which in turn becomes increasingly deteriorated among people with dementia. Pain progresses over time as an individual’s inability to communicate their needs becomes increasingly difficult. Due to this, pain is quite underrated and is often not easy to recognize. Assessment and management of pain among patients with dementia can be quite a challenging effort, even with growing scientific advancements. For aged people and even the rest of the population, pain management protocols and tools have been incorporated into both international and national guidelines such as NICE guidelines (Corbett et al., 2014). As the ageing population grows, there is a need for more resources and attention to be directed towards establishing the best ways to assess and manage pain to reduce the burden of dementia on families, society and the government.

1.1 Rationale of the study

According to the Alzheimer's Society (2019), there is a need for more research and careful planning for the future to enhance recognition and ascertain that the right form of support and care is offered to people with dementia. This is especially necessary with the persistently high figures or incidence of dementia. Currently, 850,000 people are living with dementia in the UK. This means that at least one of every seventy-nine people in the UK has dementia. Additionally, at least 1 in 14 people who are aged above 65 years in the UK have dementia. This is projected to rise to 1.5 million people in total by 2040 based on the current rate of prevalence in the UK population. A larger population of people with dementia in the UK are found in England, with more than 748,000 within the English borders, 66,000 in Scotland, 46,000 in Wales and 22,000 in Ireland (Smedsrud, 2020). As such, there needs to be even higher research and planning in England to address the growing and persistent challenge. According to Smedsrud (2020), dementia has been seen as a time bomb, which the government cannot deal with effectively without more research and planning. Steady growth in prevalence is expected in the next 25 years. With public health England rolling out programs aimed at enhancing the livelihoods of people and NHS looking for opportunities to enhance the quality of care amid budgetary constraints, there is a need for more research and effort to address the rising challenge of dementia.

Nurses are especially at the centre of care. The nurse acts as a direct link to a wide range of multidisciplinary teams that care for people with dementia. According to Horgas and Elliott (2004), practice nurses play a central position in gathering and sharing comprehensive dementia information as well as support to help people who are living with dementia to effectively manage their health and enhance their quality of life. As such, nurses help to coordinate care as well as work collaboratively with patients and the multidisciplinary team to improve the quality of life of the patients. Consequently, the NMC (2018) standards of professional practice and the NHS encourages nurses to be at the forefront of quality improvement in the healthcare system and help to continually address the challenges arising in the healthcare environment. To effectively play this role, nurses need to have the necessary skills and attitudes to assess the patients and provide appropriate management and care (Husebo et al., 2011). As such, it is necessary to examine whether the nurses feel like they are equipped with the right skills, identify areas of weakness and provide recommendations on how to enhance the care as well as care outcomes. This review aims to serve this purpose.

1.2 Aims of the study

The focus of the current review is on pain management among people with dementia. Most importantly, the study examines the role of nurses in managing pain among dementia patients and focuses on their skills. The review aims to fulfil the following specific objectives:

Objectives

• To examine if nurses have effective skills for management of pain in adults with dementia in communication settings
• To highlight areas that need improvement and recommendations for practice.

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1.3 Background

With the rising challenges and incidence of dementia, there is increasing research in the area of dementia care. Studies such as Smedsrud (2020) reveal a significant gap in the area of delivery of care to people with dementia. Recognizing dementia remains a challenge even though there is evidence which suggests that early detection and intervention significantly improve outcomes and enhance the quality of care. However, in a study by Surr et al. (2016), 66% of the participants who had memory issues reported being interested in a memory test, while 81% of them reported that they wished to speak to general practitioners when they thought they have dementia. Despite the interest in reporting and seeking help, Kim and Park (2017) posits that there is a big gap in the delivery of care to people with dementia in general practice. As such, many people live and struggle with pain related to dementia, and they do not receive enough help. Additionally, Surr et al. (2016) posit that there is a wide range of complexities and barriers to the management of dementia and in some cases, it involves the perception of the nurses and healthcare providers that nothing much can be done to support the patients and improve their quality of life. In literature, the value of enhancing the practice nurse to include recognition and management of dementia has been highlighted. However, the evidence on the role of the practice nurse in the management of the condition is not quite clear (Smedsrud, 2020). The skillset of nurses in the management of pain among dementia patients has also not been widely examined.

1.4 Parameters

This research adopts an integrative literature review to explore the available evidence on the skills of nurses in managing pain among adults with dementia. Aveyard (2018) posits that integrative literature review has been widely employed to gather and assess evidence about certain topics. It allows a researcher to review, synthesize and critique interpretive literature on a specific topic in a manner that allows the generation of new perspectives and frameworks. Aveyard (2019) posits that an integrative literature review starts with the formulation of a research question. A research question specifies the scope of the study and hence informs the steps involved in the literature search. For the current review, the PICO framework was employed to formulate the research question. The first parameter, in this case, is the population of focus. The population of focus for this study is adults with dementia. However, the study focuses on examining the skills of nurses in managing pain in adults with dementia. On the other hand, the intervention of focus is pain management, as the review examines how nurses manage pain among this population. In terms of context, the study focuses on community settings, which include nursing homes and acute care facilities, while the outcome is to reduce or remove pain. The framework is outlined in appendix 3. Based on these parameters, the following research question is adopted:

Do nurses possess effective skills to manage pain among adults with dementia?

1.5 Inclusion and exclusion criteria

For eligibility, only studies which were published in the past 10 years were included for review. This is to ensure that the evidence is up to date, hence can effectively inform contemporary practice in nursing. Secondly, only studies which were conducted in Europe were included. This is because the EU influenced the health care systems in these countries and evidence from these contexts would be more relevant to the UK context as compared to any other part. Only studies conducted in English were included because there was not enough time for interpretation and translation. To get authentic data, only primary research and articles that had been peer-reviewed were included in the study. The detailed eligibility criteria are outlined in appendix 4.

1.6 Search process and results

The search was conducted on two different websites, which are EBSCO and CIHNAL. Additionally, sources which include reference lists of previous studies were also employed in the search process. Firstly, the researcher pasted the entire research question in the two databases. 105 hits were identified from EBSCO while 201 articles were retrieved from CIHNAL. In total, 306 articles were retrieved. The Boolean operator “OR” was employed to help include studies that employed similar words, such as replacing skillsets for skills. This according to Aveyard et al. (2019) ensures that all the relevant articles have been included in the study. On the other hand, the Boolean operator “NOT” was employed to exclude searches that did not meet the inclusion criteria. For instance, it was employed to exclude studies that were conducted in the community. The typical search process, application of the inclusion and exclusion criteria as well as the final results are outlined in the PRISMA statement in Appendix 1.

• summary of the findings

In total, ten papers fulfilled the inclusion criteria as outlined in the themes table in the appendix. Two studies were based in Turkey, three in Australia, and the rest of the studies were from the United Kingdom. All the studies were, however, published in English. Four studies were identified as quantitative while six of them were quantitative. After examining the findings of the primary research, three main themes emerged. These are nurse-patient relationships, application of pain management guidelines, and use of opioids in pain management. The selected studies were then appraised based on their methodologies and themes based on the CASP checklist as indicated in appendix 5. The CASP checklist allows the reviewer to outline the validity of the findings in the studies and their applicability to the wider population. The articles were assessed and presented in a thematic table in appendix 2 as guided by Garrad (2007).

In general, the studies highlighted the experiences of nurses in pain management among adults with dementia in the community. These include acute care facilities and residential homes. The findings focus on the adequacies and effectiveness of nurses’ skills in using different interventions such as opioids in pain management. The evidence also maps the need for training among nurses to improve their skills and points out the role of guidelines for managing pain in adults with dementia and the need for improvement in existing guidelines.

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Chapter 2: Literature review

Use of guidelines for pain management   

There has been growing research on the role of nurses in the management of pain among adults with various mental health conditions. The skill set and skills of nurses have especially been an area of interest. Barry et al. (2012), for instance, examined the skills, beliefs and attitudes that nurses in the home nursing context possess as regard management of pain among residents with dementia. The study also examined how this could be managed by the demographic features of the respondents. The study employed a questionnaire that was administered to 244 nurses in a nursing home in Northern Ireland. 99 percent of all the nursing homes in Northern Ireland were represented in the sample. The study uses a large sample, which according to Bryman (2016) enhances the validity and generalizability of the findings. Nevertheless, the quantitative approach is limited as does not consider the subject opinions that may provide details about the experiences of nurses. Additionally, the transferability of the findings is limited by the fact that it is based on one residential home. Nevertheless, Almalki (2016) posits that quantitative data leads to objective findings that help eliminate researcher bias. Based on the CASP checklist for quantitative research, the study has a clearly outlined aim and methodology, even though questionnaires do not seem appropriate to investigate the views and experiences of nurses (Church et al., 2019). Nevertheless, the study provides important insights into the experience and skills of nurses in managing pain in adults with dementia. The findings indicated that while all the nurses and managers of the nursing homes provided care for patients with dementia, only 60% of them claimed to employ pain management guidelines in the nursing home. Residents showed a good understanding and skills of pain in patients with dementia. However, they indicated that the main difficulties surrounded the accurate evaluation and assessment of pain. While they understood the pain among dementia patients, nursing managers were unsure about the right approach to manage pain among residents with dementia. The nurses and managers of the nursing homes also had similar concerns about the use of opioid analgesics for managing pain in older people. However, managers and nurses that had received recent training on the same were also less likely to have concerns about the use of opioids. The findings also indicated that the beliefs of the respondents about the use of painkillers to manage pain were highly ambivalent and were impacted by the country in which they received nursing education.

De Witt Jansen et al. (2017) explored the experiences of the nurses within the nursing home in the management of pain in people with advanced dementia in their final month of life. The aim was to assess the difficulties, challenges, facilitators as well as areas that required more support. The study employed a qualitative design where semi-structured interviews as well as thematic analysis to examine patterns in data. Data was collected from twenty-four registered nurses who were caring for people that were dying and had advanced dementia. Based on the CASP checklist, the study meets most of the criteria as it provides a clearly defined purpose and methodology as well as the process of selecting the sample. Additionally, semi-structured interviews provide the desired flexibility for the researcher to investigate subjective views and establish details on the skills and experiences of nurses in managing pain. However, there is a higher risk of bias in interpreting such findings, which is not addressed in the study as required by (Nadelson and Nadelson, 2014). Additionally, while sample sizes are not emphasized in qualitative studies, the sample for the study was too small to comfortably generalize the evidence to the larger UK population of nurses. Besides, the study offers important views on the skills of nurses in managing pain among patients with dementia. Three main themes were identified from the results. Firstly, there were challenges in administering analgesia. Other themes were interactive learning and development as well as the nurse-physician relationship. Nurse-related problems included uncertainty on the best approach to administering analgesia and this differed across different settings. In general, nurses found it quite challenging to achieve effective pain management for patients with dementia. One of the main barriers identified by nurses includes the lack of the right skills to assess pain and apply effective management for pain. The findings are also supported by Robinson et al. (2014) also examined the skills of managing dementia among nurses and primary care providers. The study was based on a survey of 279 nurses as well as 164 family members of people with dementia within nursing homes. Unlike De Witt Jansen et al. (2017), Robinson et al. (2014) employ a large sample, which enhances the generalizability of the findings and increases both validities. As shown by Almalki (2016) quantitative data is objective and the risk of researcher bias is low. Based on the CASP checklist, ethical approval is gained, and the methodology and purpose of the study are also effectively explained. However, the study does not cater for the subjective and detailed experiences of the respondents, given the limitations of closed-ended questions in the survey. nevertheless, the research is comprehensive as it looks at both the views of the families as well as the nurses. The findings indicated that there were deficits in dementia skills in both cohorts in several areas. Among them, there were limited skills among nurses regarding the manifestation and experiences of pain among patients in dementia patients.

Communication and Nurse-patient relationship

Burns and McIlfatrick (2015) examined the attitudes and skills of nurses regarding both the assessment and management of pain among patients with dementia. The study employed a cross-sectional survey design in which a questionnaire that comprised three different sections was distributed to nurses in seventeen different nursing homes within the UK region. The results indicated that the majority of nurses had strong skills in both assessment and management of pain among patients with dementia. Nevertheless, there was uncertainty regarding the choice of analgesic, use of dementia-specific pain assessment guidelines and the safety of opioids. The main barriers to effective pain management among patients with dementia, therefore, included poor staffing, workload pressures and lack of medical support within the healthcare context. The researchers also found that healthcare providers training in terms of pain assessment and decision-making on the best medication to provide to people with dementia.

Gilmore-Bykovskyi and Bowers (2013) examined the factors that influenced decision-making to pharmacologically treat or manage pain among patients with dementia within nursing residential homes. A grounded dimensional analysis was employed in 15-in-depth semi-structured interviews with thirteen nurses from skilled nursing facilities. The findings indicated that nurses experienced varying degrees of certainty based on suspected responses to pain and pain management among residents. The ability to effectively make decisions about pain management was based on features such as whether the pain was visible or non-visible. The findings from the interviews also indicated that suspected pain among patients with dementia was often conceptualized as a shift in behaviour, where nurses responded by trying different interventions in an attempt to bring back the patients to the baseline. While early identification was considered necessary for effective management, nurses often do not have the skills and effective guidelines to assess and manage pain early enough before the situation has deteriorated. In this regard, pain management is often reactionary based on observable patient features. In this regard, residents diagnosed with dementia were considered to be at the greatest risk of experiencing undertreatment, underassessment as well as delayed management or treatment of pain among patients with dementia.

Jansen et al. (2018) employed teleconferencing technology to linkup nurses and other healthcare professionals across multiple disciplines and settings in real-time clinics. The paper evaluated the clinics by physicians and nurses including the self-efficacy and skills in the management of pain for patients in an advanced stage of dementia. The paper employed a mixed method inquiry or study design that involved both participation in self-efficacy pre-and post-echo clinic, quantitative surveys on the skills of the nurses and physicians and an exploration of the experiences of nurses by the use of focus groups. The study employed a census approach to sampling. Evaluations were conducted by the use of an electronic monkey survey, while a Mann-Whitney U test was employed to examine the differences between self-efficacy and skills scores in ECHO participation. A-priory 0.05 was employed to examine the statistical significance of the differences in skills. In the final results, ten nurses and ten physicians completed the evaluations. They reported improvement in self-efficacy and skills after participation in ECHO. Improved skills after participation were associated with reduced time and a high level of self-efficacy in pain management among people with dementia. The researchers hence argued that training and education for nurses and physicians for pain management can significant hence service provision.

Karlsson et al. (2013) examined how certified nurses perceived pain and pain management among people with dementia during their practice. The study employed a qualitative approach in the interpretive traditions where twelve individual interviews were administered to certified nurses who were working in dementia care. The interviews were conducted as well as interpreted by the use of philosophical hermeneutics. The findings categorized the perception and management of pain among nurses at 3 levels. Which included the facing phase, reflecting phase and acting phase. The facing face involved reflection of the pain at a deeper level with the help of other health care providers. The acting phase involved the perception that arose from the protective and preventive care that focused on contributing to the wellbeing of the patient. These stages, according to the study, served as an exhaustive as well as dialogue based on personhood, accompanied by professional understanding, skills and skills of dementia.

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References

Flo, E., Gulla, C., & Husebo, B. S. (2014). Effective pain management in patients with dementia: benefits beyond pain. Drugs & ageing, 31(12), 863-871.

Corbett, A., Husebo, B. S., Achterberg, W. P., Aarsland, D., Erdal, A., & Flo, E. (2014). The importance of pain management in older people with dementia. British Medical Bulletin, 111(1).

Horgas, A. L., & Elliott, A. F. (2004). Pain assessment and management in persons with dementia. Nursing Clinics, 39(3), 593-606.

Husebo, B. S., Ballard, C., & Aarsland, D. (2011). Pain treatment of agitation in patients with dementia: a systematic review. International journal of geriatric psychiatry, 26(10), 1012-1018.

Smedsrud, R. (2020). How to Recognize Signs of Pain in Those with Dementia. Retrieved from https://www.hrrv.org/blog/how-to-recognize-signs-of-pain-in-those-with-dementia/

Aveyard, H., & Bradbury-Jones, C. (2019). An analysis of current practices in undertaking literature reviews in nursing: Findings from a focused mapping review and synthesis. BMC medical research methodology, 19(1), 1-9.

Kim, S. K., & Park, M. (2017). Effectiveness of person-centred care on people with dementia: a systematic review and meta-analysis. Clinical interventions in ageing, 12, 381.

Surr, C. A., Walwyn, R. E., Lilley-Kelly, A., Cicero, R., Meads, D., Ballard, C., ... & Wallace, D. (2016). Evaluating the effectiveness and cost-effectiveness of Dementia Care Mapping™ to enable person-centred care for people with dementia and their carers (DCM-EPIC) in care homes: study protocol for a randomised controlled trial. Trials, 17(1), 1-17.

Aveyard, H. (2018). Doing a literature review in health and social care: A practical guide.

Barry, H. E., Parsons, C., Peter Passmore, A., & Hughes, C. M. (2012). An exploration of nursing home managers' skills and attitudes towards the management of pain in residents with dementia. International journal of geriatric psychiatry, 27(12), 1258-1266.

De Witt Jansen, B., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfactrick, S. J., ... & Parsons, C. (2017). Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study. Journal of clinical nursing, 26(9-10), 1234-1244.

Burns, M., & McIlfatrick, S. (2015). Nurses' skills and attitudes towards pain assessment for people with dementia in a nursing home setting. International Journal of Palliative Nursing, 21(10), 479-487.

Gilmore-Bykovskyi, A. L., & Bowers, B. J. (2013). Understanding nurses’ decisions to treat pain in nursing home residents with dementia. Research in gerontological nursing, 6(2), 127-138.

Robinson, A., Eccleston, C., Annear, M., Elliott, K. E., Andrews, S., Stirling, C., ... & McInerney, F. (2014). Who knows, who cares? Dementia skills among nurses, care workers, and family members of people living with dementia. Journal of Palliative Care, 30(3), 158-165.

Jansen, B. D. W., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfatrick, S. J., ... & Parsons, C. (2018). Evaluation of the impact of telementoring using ECHO© technology on healthcare professionals’ skills and self-efficacy in assessing and managing pain for people with advanced dementia nearing the end of life. BMC health services research, 18(1), 1-12.

Karlsson, C., Sidenvall, B., Bergh, I., & Ernsth‐Bravell, M. (2013). Certified nursing assistants’ perception of pain in people with dementia: a hermeneutic enquiry in dementia care practice. Journal of Clinical Nursing, 22(13-14), 1880-1889.

Nadelson, S., & Nadelson, L. S. (2014). Evidence‐based practice article reviews using CASP tools: a method for teaching EBP. Worldviews on Evidence‐Based Nursing, 11(5), 344-346.

Bryman, A. (2016). Social research methods. Oxford university press.

Almalki, S. (2016). Integrating Quantitative and Qualitative Data in Mixed Methods Research--Challenges and Benefits. Journal of education and learning, 5(3), 288-296.

Church, S. P., Dunn, M., & Prokopy, L. S. (2019). Benefits to qualitative data quality with multiple coders: Two case studies in multi-coder data analysis. Journal of Rural Social Sciences, 34(1), 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appendix 1: PRISMA Statement

The PRISMA flow diagram below maps out the procedure through which article identification, screening, and selection were done.

From reference lists of other studies (n = 5)

From EBSCO and CIHNAL (n = 301)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Appendix 2

Authors and titles	Aims and objectives	Research methods and ethics issues	Population and sample size	The strengths and weaknesses of the methodology are Findings	Main findings	Implications for practice
Barry, H. E., Parsons, C., Peter Passmore, A., & Hughes, C. M. (2012). An exploration of nursing home managers' skills and attitudes towards the management of pain in residents with dementia. International journal of geriatric psychiatry, 27(12), 1258-1266.	To examine the skills, beliefs and attitudes that nursing in the home nursing context hold as regards the assessment and management of pain among residents with dementia.	-       Primary quantitative   -       ethical approval gained	244 nurses in the nursing home in Northern Ireland.	Strengths -       A large sample size of 244 -       Ethical approval gained -       The quantitative method that allowed for objective data Weaknesses -       Could not examine the subjective view of nurses -       A low response rate of 39% -       transferability of results because the data was only from one institution	-       Pain management depended on accurate assessment -        while all the nurses and managers of the nursing homes provided care for patients with dementia, only 60% of them claimed to employ pain management guidelines in the nursing home. Residents showed a good understanding and skills of pain in patients with dementia.	Accurate assessment of pain and training in standardized methods for pain management is essential to enhance pain management among nurses
De Witt Jansen, B., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfactrick, S. J., ... & Parsons, C. (2017). Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study. Journal of clinical nursing, 26(9-10), 1234-1244.	To examine the difficulties, challenges, facilitators as well as areas that required more support.	-       Exploratory study -       Semi-structured interviews -       Ethical approval gained	Twenty-four registered nurses who were caring for people that were dying and had advanced dementia	Strengths -       Thematic analysis helps to compare the main views raised by the respondent -       Allows for deeper analysis based on subjective views -       Based on various residential and hospice homes, hence generalizability is enhanced   Weaknesses -       Based on a limited sample -       Potential bias due to researcher interpretation of the results	there were challenges in administering analgesia. Other themes were interactive learning and development as well as the nurse-physician relationship. Nurse-related problems included uncertainty on the best approach to administering analgesia and this differed across different settings	Nurses believe that pain management is essential for people who are dying of dementia. But a lot needs to be done to support nurses in terms of resources and skills to support people with dementia
Cleary, J., & Doody, O. (2017). Nurses' experience in caring for people with intellectual disability and dementia. Journal of Clinical Nursing, 26(5-6), 620-631.	To explore the experience of nurses in caring for adults with dementia and intellectual disability and dementia	qualitative Husserlian descriptive phenomenological methodology   Ethical approval gained	Eleven nurses from acute care facilities in London	Strengths -       Comprehensive insight based on thematic analysis -       A rigorous process of thematic analysis -       Data extracted by two researchers increase the validity researchers -       Based on various residential and hospice homes, hence generalizability is enhanced   Weaknesses -       Based on a limited sample -       Potential bias due to researcher interpretation of the results	Three key themes were identified: ‘knowledge of dementia,’ 'person-centred care' and 'transitioning within the service.’	The study highlights the need for initiative-taking planning, life story books of the patient, and funding to support clients and staff.     .
Robinson, A., Eccleston, C., Annear, M., Elliott, K. E., Andrews, S., Stirling, C., ... & McInerney, F. (2014). Who knows, who cares? Dementia skills among nurses, care workers, and family members of people living with dementia. Journal of Palliative Care, 30(3), 158-165.	To examine examined the skills of managing dementia among nurses and primary care providers.	- Primary quantitative research - ethical approval gained	279 nurses as well as 164 family members of people within nursing homes	Strengths -       Relies on a large sample which increases transferability -       Data is comprehensive as it draws from both families and nurses -       Use of quantitative methods to ascertain validity and objectivity of the findings Weaknesses -       The subjective experience and views of the respondents are not included -       Transferability of the findings may be limited by the fact that the research is based in one residential home	The findings indicated that there were deficits in dementia skills in both cohorts in several areas. Among them, there were limited skills among nurses regarding the manifestation and experiences of pain among patients in dementia patients.	It is important that deficits in dementia knowledge are identified and addressed to improve pain management and overall dementia care
Burns, M., & McIlfatrick, S. (2015). Nurses' skills and attitudes towards pain assessment for people with dementia in a nursing home setting. International Journal of Palliative Nursing, 21(10), 479-487.	To examine the attitudes and skills of nurses regarding both the assessment and management of pain among patients with dementia.	-       cross-sectional survey design to where a questionnaire that comprised three different sections -       Ethical approval was gained	Unspecialized number of nurses in seventeen different nursing homes within the UK region	Strengths -       Conducted in seventeen different nurses' homes, which increases the generalizability -       A cross-sectional study allows for time to gain more comprehensive findings -       Findings are objective due to quantitative techniques Weaknesses -       The sample size is unspecified -       Due to the use of Cross-sectional research, it is not possible to assess the individual experience of patients and nurses in a subjective manner	-       Nurses possessed the right skills but were uncertain about the selection of the right medication to manage pain	It is important to identify the dementia knowledge deficits among nurses and conduct relevant training to enhance pain management
Gilmore-Bykovskyi, A. L., & Bowers, B. J. (2013). Understanding nurses’ decisions to treat pain in nursing home residents with dementia. Research in gerontological nursing, 6(2), 127-138.	To examine the factors that influenced decision-making to pharmacologically treat or manage pain among patients with dementia within the nursing residential homes.	-       Grounded dimensional analysis -       In-depth semi-structured interviews -       Ethical approval gained	Thirteen nurses from skilled nursing facilities.	Strengths -       Interviews allow for comprehensive and rich data based on the opinions and experiences of the nurses -       A high level of transferability was based on different nursing institutions Weakness -       Potential researcher bias in interpreting the interviews -       Based on a small sample	nurses experienced varying degrees of certainty based on suspected responses to pain and pain management among residents. The ability to effectively make decisions about pain management was based on features such as whether the pain was visible or non-visible. -       nurses often do not have skills and effective guidelines to assess and manage pain early enough	There is a need for training to help nurses to assess and manage pain early enough before the situation has deteriorated.
De Witt Jansen, B., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfactrick, S. J., ... & Parsons, C. (2017). Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study. Journal of clinical nursing, 26(9-10), 1234-1244.	To explore the nursing experiences of nurses in acute care, hospice and nursing facilities in managing pain in people with dementia in their final days in life.	Primary qualitative research using semi-structured interviews   It is not clear whether ethical approval was gained	24 registered nurses caring for people dying from dementia from three hospices ten nursing homes, and two acute facilities across a region of the UK	Strengths -       A team of four researchers participate in the extraction of data hence increasing the validity -       High generalizability as data was collected from different settings including hospices, nursing homes and acute care facilities Weaknesses Based on a relatively limited sample, which can affect the generalizability of the findings	Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development.	Achieving effective pain management in dementia is quite challenging. Nurses need to be supported through needs-based training to enhance their skills
Jansen, B. D. W., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfatrick, S. J., ... & Parsons, C. (2018). Evaluation of the impact of telementoring using ECHO© technology on healthcare professionals’ skills and self-efficacy in assessing and managing pain for people with advanced dementia nearing the end of life. BMC health services research, 18(1), 1-12.	To evaluate the clinics by physicians and nurses including the self-efficacy and skills in the management of pain for patients in an advanced stage of dementia.	-       Primary quantitative research -       Mann-Whitney U test was employed to examine the differences between self-efficacy and skills scores in ECHO participation -       Ethical approval gained	-       Ten nurses and ten physicians completed the evaluations	Strengths -       The use of the Mann-Whitney U test is increasing the accuracy of the findings -       Drawing data from different points of view of both nurses and physicians increases reliability -       Data was objective due to quantitative techniques Weaknesses -       Extremely limited sample, which reduces transferability	They reported improvement in self-efficacy and skills after participation in ECHO. Improved skills after participation were associated with reduced time and a high level of self-efficacy in pain management among people with dementia.	training and education for nurses and physicians for pain management can significant hence service provision.
Karlsson, C., Sidenvall, B., Bergh, I., & Ernsth‐Bravell, M. (2013). Certified nursing assistants’ perception of pain in people with dementia: a hermeneutic enquiry in dementia care practice. Journal of Clinical Nursing, 22(13-14), 1880-1889.	To examine how certified nurses’ perceived pain and pain managed among people with dementia during their practice	-       Qualitative research using interviews -       Ethical approval was gained  -	Twelve certified nurses	Strengths -       Data is drawn from certified nurse hence increases credibility -       Themes were discussed by the research team to enhance accuracy Weaknesses -       Potential biases during interpretation of data	The findings categorized the perception and management of pain among nurses at 3 levels. Which included the facing phase, the reflecting phase and the acting phase. The facing face involved reflection of the pain at a deeper level with the help of other health care providers. The acting phase involved the perception that arose from the protective and preventive care that focused on contributing to the wellbeing of the patient.	- The stages, according to the study, served as an exhaustive as well as dialogue based on personhood, accompanied by professional understanding, skills and skills of dementia
Monroe, T. B., Misra, S. K., Habermann, R. C., Dietrich, M. S., Cowan, R. L., & Simmons, S. F. (2014). Pain reports and pain medication treatment in nursing home residents with and without dementia. Geriatrics & gerontology international, 14(3), 541-548.	The purpose of this pilot study was to determine if a diagnosis of dementia influenced pain self-reports and pain medication use in a group of verbally communicative nursing home (NH) residents.	cross-sectional chart audit and a seven-question structured pain interview   ethical approval was achieved	Fifty-two long-stay NH residents capable of self-consent	Strengths -       A rigorous process of data extraction conducted by five scholars -       Data drawn from different facilities hence enhancing the credibility of the findings -       Data is comprehensive and exhaustive and is drawn from the subjective viewpoints of residents Weakness -       Small sample limits generalizability	Nurses in long-term care might assume that residents with dementia cannot reliably self-report their pain; however, suffering from untreated severe pain could exacerbate cognitive impairment, worsen functional impairment and severely impair sleep.	A brief, focused pain interview might be one method for increasing the detection of moderate to severe pain in verbally communicative NH residents with dementia.

 

 

 

Appendix 3:  PICO framework

Population	Adults with dementia
Intervention	Pain management
Comparison/context	Community
Outcome	Effective skills

 

Appendix 4: Eligibility criteria

Criteria	Inclusion	Exclusion
Year of publication	After 2011	Before 2011
Setting	Europe	Outside Europe,
Language	English	Not published in English
Participants	Adults with dementia/nurses	Not focuses on nurse/ dementia management
Methods	Peer reviewed	Non-pee reviewed
Exposure of interest	dementia	Other mental conditions other than dementia
Design	Primary research	Secondary research