Nurses' experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study

AIMS AND OBJECTIVES: To explore hospice, acute care and nursing home nurses' experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

BACKGROUND: Pain management in end-stage dementia is a fundamental aspect of end of life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care.

DESIGN: A qualitative study using semi-structured interviews and thematic analysis to examine data.

METHODS: 24 registered nurses caring for people dying with advanced dementia were recruited from ten nursing homes, three hospices, and two acute hospitals across a region of the United Kingdom. Interviews were conducted between June 2014 and September 2015.

RESULTS: Three core themes were identified: challenges administering analgesia, the nurse-physician relationship, and interactive learning and practice development. Patient-related challenges to pain management were universal across care settings; nurse- and organisation-related barriers differed between settings. A need for interactive learning and practice development, particularly in pharmacology, was identified.

CONCLUSIONS: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

RELEVANCE TO CLINICAL PRACTICE: Nurses considered pain management fundamental to end of life care provision; however, nurses working in acute care and nursing home settings may be under-supported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology. This article is protected by copyright. All rights reserved.

“There’s a Catch-22”. The complexities of pain management for people with advanced dementia nearing the end of life: a qualitative exploration of physicians’ perspectives

Background: Pain management is a cornerstone of palliative care. The clinical issues encountered by physicians when managing pain in patients dying with advanced dementia, and how these may impact on prescribing and treatment, are unknown. Aim: To explore physicians’ experiences of pain management for patients nearing the end of life, the impact of these on prescribing and treatment approaches, and the methods employed to overcome these challenges. Design: Qualitative, semi-structured interview study exploring: barriers to and facilitators of pain management, prescribing and treatment decisions, and training needs. Thematic analysis was used to elicit key themes. Settings/Participants: Twenty-three physicians, responsible for treating patients with advanced dementia approaching the end of life, were recruited from primary care (n=9), psychiatry (n=7) and hospice care (n=7). Results: Six themes emerged: diagnosing pain, complex prescribing and treatment approaches, side-effects and adverse events, route of administration, importance of sharing knowledge and training needs. Knowledge exchange was often practised through liaison with physicians from other specialties. Cross-specialty mentoring, and the creation of knowledge networks were believed to improve pain management in this patient population. Conclusions: Pain management in end-stage dementia is complex, requiring cross-population of knowledge between palliative care specialists and non-specialists, in addition to collateral information provided by other health professionals and patients’ families. Regular, cost- and time-effective mentoring and ongoing professional development are perceived to be essential in empowering physicians to meet clinical challenges in this area.

Building public policy on shifting sands: the case of the National Asset Management Agency

Over the last thirty years, there has been an increased demand for better management of public sector organisations (PSOs). This requires that they are answerable for the inputs that they are given but also for what they achieve with these inputs (Hood 1991; Hood 1995). It is suggested that this will improve the management of the organisation through better planning and control, and the achievement of greater accountability (Smith 1995). However, such a rational approach with clear goals and the means to measure achievement can cause difficulties for many PSOs. These difficulties include the distinctive nature of the public sector due to the political environment within which the public sector manager operates (Stewart and Walsh 1992) and the fact that PSOs will have many stakeholders, each of whom will have their own specific objectives based on their own perspective (Boyle 1995). This can
result in goal ambiguity which means that there is leeway in interpreting the results of the PSO. The National Asset Management Agency (NAMA) was set up to bring stability to the financial system by buying loans from the banks (which were in most cases, non-performing loans). The intention was to cleanse the banks of these loans so that they could return to their normal business of taking deposits and making loans. However, the legislation, also gave NAMA a wide range of other responsibilities including responsibility for facilitating credit in the economy and protecting the interests of taxpayers. In more recent times, NAMA has been given responsibility for building social housing. This wide-range of activities is a clear example of a PSO being given multiple goals which may conflict and is therefore likely to lead to goal ambiguity. This makes it very difficult to evaluate NAMA’s performance as they are attempting to meet numerous goals at the same time and also highlights the complexity of policy making in the public sector. The purpose of this paper is to examine how NAMA dealt with goal ambiguity. This will be done through a thematic analysis of its annual reports over the last five years. The paper’s will contribute to the ongoing debate about the evaluation of PSOs and the complex environment within which they operate which makes evaluation difficult as they are
answerable to multiple stakeholders who have different objectives and different criteria for measuring success.