Andrews, SM and Dipnall, JF and Tichawangana, R and Hayes, KJ and Fitzgerald, JA and Siddall, P and Poulos, C and Cunningham, C, An exploration of pain documentation for people living with dementia in aged care services, Pain Management Nursing pp. 1-7. ISSN 1524-9042 (2019) [Refereed Article]
© 2019 American Society for Pain Management Nursing.
Aim: To investigate the quality and completeness of pain documentation for people living with dementia, and assess the extent to aged care staff are engaged in documentation processes.
Design: A three-month retrospective documentation audit.
Setting and Participants: The audit was conducted on the files of 114 residents with moderate to very severe dementia, across four Australian residential aged care facilities.
Methods: Data was collected on each resident's pain profile (n=114). One hundred and sixty-nine (169) pain episodes were audited for quality and completeness of pain documentation and the extent to which aged care staff (RNs/ENs and PCAs) were engaged in the documentation of pain management.
Results: Twenty-nine percent of pain episodes had no documentation about how resident pain was identified and only 22% of the episodes contained an evidence-based (E-B) assessment. At least one intervention was documented for 89% of the pain episodes, the majority (68%) being non-pharmacological. Only 8% of pain episodes had an E-B evaluation reported. Thirteen percent (13%) of episodes contained information across all four pain management domains (Identification/ problems, assessment, intervention and evaluation). Documentation by PCAs was evident at all points in the pain management pathway. PCAs were responsible for considerately more episodes of assessment (50% vs 18%) compared to nursing staff.
Conclusion and Clinical Implications: Despite the high prevalence of pain in people with dementia in aged care settings, current pain management documentation does not reflect best practice standards. Future capacity building initiatives must engage PCAs, as key stakeholders in pain management, with support and clinical leadership of nursing staff.
|Item Type:||Refereed Article|
|Research Division:||Medical and Health Sciences|
|Research Field:||Aged Care Nursing|
|Objective Group:||Health and Support Services|
|UTAS Author:||Andrews, SM (Dr Sharon Andrews)|
|Web of Science® Times Cited:||1|
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