Aim: The overall aim of the thesis was to explore and describe registered nurses’ (RNs) and certified nursing assistants’ (CNAs) experiences of detection and assessment of pain in older people with cognitive impairment and dementia. A further aim was to evaluate the Abbey Pain Scale-SWE (APS-SWE) in dementia care practice. Methods: An exploratory and descriptive design was used in Study I. An exploratory and interpreting design was used in Study II and Study III. A prospective, descriptive, observational and instrumental design was used in Study IV. Focus group interviews (I) and individual interviews (II, III) were applied to explore and describe RNs’ and CNAs’ experiences of pain assessment in people living with dementia. Qualitative content analysis (I) and philosophical hermeneutics (II) were used to analyse qualitative data. Observation, instrument, and questionnaire were applied to evaluate reliability and face validity of the APS-SWE for pain assessment. Descriptive statistics and reliability analyses were used to analyse quantitative data (IV). Results: RNs in special housing accommodation settings experiences that pain assessment in people with dementia is challenging primarily due to their changed RN consultant role, which to a great extent is directed into administrative and consultative tasks rather than bedside care. This has led to decreased time in daily nursing care, preventing recognising symptoms of pain. This have also led to that RNs are dependent on information from CNAs who are the front-line staff providing daily care (I). CNAs’ perception of signs of pain in people with dementia emerges from being present in the care situation and alertness on physical and behavioural changes that could be due to pain, and from providing the care in a preventive, protective and supportive way to prevent painful situations occurring (II). RNs and CNAs working in home healthcare team use a variety of strategies to detect and assess pain. A trustful work relationship based on staff continuity and a good relation to the person in need of care facilitates pain assessment situations (III). Systematic observation of older people living in special housing accommodation during rest and mobility using the APS-SWE demonstrates that the scale has adequate internal consistency, reliability, and face validity for pain assessment (IV). Conclusions: This thesis found that the RNs’ and CNAs’ detections and assessments of pain rely on solid cooperation, staff continuity, and good knowledge of the person cared for. It was also revealed that there is a lack of using appropriate and assisting pain tools. The APS-SWE show adequate reliability and face validity and can serve as a useful pain tool to assist in detection and assessment of pain in older people who are limited in verbalising pain recognisable. Further evaluation of how the person-centred perspective is applied in pain assessment situations is needed in order to evaluate positive outcomes in people with dementia. Further psychometric evaluation of the APS-SWE in clinical dementia care practice is needed to strengthen validity and reliability. / <p>Study IV</p><p>Karlsson C, Ernsth Bravell M, Ek K, Johansson L &amp; Bergh I (2014): Reliability and face validity of the Abbey Pain Scale-SWE in Swedish dementia care practice. Submitted June, 2015.</p>

Patients’ recovery after surgery is one of the most important health processes in planned hospital healthcare and has a direct impact on welfare and welfare systems. Therefore, what nurses do in the im­mediate postoperative period is of vital importance. This thesis addresses the question of understanding how nurses work in managing post-operative pain by exploring their daily nursing practices and experiences in responding to the patient in pain within a Thai cultural context. The project applied a qualitative methodology where the local culture and its day-to-day practices of pain management were studied by using observations, focus groups, in-depth interviews and a critical incident interview approach with nurses. Informants were recruited at a public hospital in Bangkok in a surgical ward. In all, 100 hours of observations, 39 interviews and 69 descriptions of critical incidents related to nurse’s pain management were gathered. The data analysis followed the principles of qualitative research. The findings showed that, although there is a clearly defined approach to pain management, the response system followed by the nurses to address patients’ pain is complex and includes much lead time between assessing patients’ pain and the nurses responding to the pain. Furthermore, nurses are caught in what is labeled a patient pa­radigm, where evidence of pain often is double- and triple-checked by scoring and recording signs that are then subject to confirmation by a third party. Underpinning this is a culture of pain management cultivated between the nurses that rests first and foremost on their own experiences and a working/professional culture where nurses offer each other practical help in urgent situations, but seldom discuss event-based strategies together. Nevertheless, when nurses described situations when they were successful in practicing pain management, they considered their own engagement and their availability of time, space and therapeutic options to be important. Keywords: Culture of nursing, Nursing in pain management, Pain assessment, Perception of pain, Pain management, Pain post-operative

Bakgrund: Smärta är ett komplext och omfattande problem inom sjukvården. Utan adekvat behandling kan smärta leda till sämre livskvalitet för patienten. Sjuksköterskan har en viktig och betydelsefull roll i att identifiera och bedöma patientens smärta då en optimalt utförd smärtbedömning är en förutsättning för adekvat smärtlindring. Att se människan bakom patienten är en viktig aspekt för att identifiera smärta ur ett helhetsperspektiv. Syfte: Syftet var att undersöka sjuksköterskors bedömning av patienters smärta. Metod: En litteraturöversikt baserad på elva vetenskapliga artiklar, med både kvantitativ och kvalitativ design. Resultat: Resultatet presenteras i fyra olika huvudteman. Verbal kommunikation, Observation av patienters smärta med subteman: smärtbeteenden och fysiologiska tecken, Hjälpmedel för smärtbedömning och Sjuksköterskans förförståelse och tidigare erfarenheter av smärta. Inga evidensbaserade rutiner eller riktlinjer följdes. Diskussion: Resultatet diskuterades med anknytning till personcentrerad vård och konsensus begreppet människa. Smärtbedömningen utfördes oftast utifrån sjuksköterskans egen tolkning och var inte alltid anpassad efter den enskilda individen. Patienter som har smärta är i behov av att bli sedda och smärtbedömda utifrån deras individuella behov. Sjuksköterskor har därför en central roll i att individanpassa bedömningen av smärta. / Background: Pain is a complex and major problem in health care. Without adequate treatment, pain can lead to decreased quality of life for the patient. The nurse has an important and significant role in identifying and assessing the patient's pain when an optimally performed pain assessment is a prerequisite for adequate pain relief. To see the person behind the patient is a key aspect of identifying pain from a holistic perspective. Aim: The aim was to explore the nurses' assessment of pain in patients. Method: A literature review based on eleven scientific articles, with both quantitative and qualitative design. Results: The results are presented in four main themes. Verbal communication, Observation of patients' pain subthemes: behaviors related to pain and physiological signs, Pain assessment tools and Nurse's preunderstanding and past experiences of pain. No evidence-based rutines or guidelines were followed. Discussion: The results were discussed related to person-centered care and the concept of human. Pain assessment was usually carried out on the basis of the nurse's own interpretation and were not always tailored to the individual. Patients who have pain need to be seen and pain assessed on their individual needs. Nurses have therefore a major role to individualize the assessment of pain.

Bakgrund: Smärta är en personlig upplevelse och kan inte jämföras mellan individer. Smärtskattning är grundläggande för att ge adekvat smärtlindring och behandling. I vården används olika slags skattningsskalor och instrument. Trots detta visar studier på att patienters smärta underskattas och även underbehandlas. Syfte: Syftet med studien är att ta reda på om sjuksköterskor verksamma på kirurgisk avdelning samt patienter med smärta inneliggande på kirurgisk avdelning anser att smärtskattning med hjälp av visuell analog skala (VAS) och numeric rating scale (NRS) fungerar vid bedömning av smärta. Vidare önskar studien undersöka om respondenterna anser att smärtskattning sker i tillräcklig utsträckning. Studien ämnar även undersöka om det föreligger någon skillnad mellan de två grupperna. Metod: Studien är en kvantitativ tvärsnittsstudie där enkäter delades ut till patienter och sjuksköterskor på två kirurgiska vårdavdelningar.                                                                                              Resultat: En tydlig majoritet bland respondenterna svarade att de förstod hur smärtskattningen fungerar. Sjuksköterskorna och patienterna var ense om att VAS och NRS ansågs som ett bra sätt att förmedla smärta. Signifikant skillnad kunde utläsas vad gäller smärtskattningsfrekvens. Bland patienterna i studien ansåg 83% att de smärtskattades tillräckligt ofta medan bara knappt hälften av sjuksköterskorna ansåg att smärtskattning skedde i tillräcklig utsträckning. På frågan om patienterna fick information muntligt om VAS och NRS visade resultatet på en signifikant skillnad mellan grupperna. Slutsats: Patienter och sjuksköterskor anser att VAS och NRS är bra sätt att skatta smärta och att förståelsen för dessa skattningsverktyg är god. Brister i hur ofta smärtskattning sker kan ses i studien både inför och efter given smärtlindring. / Background: Pain is a personal feeling and cannot be compared between individuals. Pain assessment is essential to give adequate treatment and pain relief. Different types of pain assessment tools are used in the health service. Although pain assessment is shown to be important, studies have shown that patients pain is underestimated and undertreated. Aim: The aim in this study is to determine whether nurses at surgical wards and patients with pain at surgical wards believe that VAS and NRS is suitable as tools to asses’ pain. Furthermore this study aims to examine if the respondents believe that the pain assessment is measured often enough. This study also wants to look into if there are any differences between the two groups.   Methods: The study is a quantitative cross-sectional study where questionnaires were handed out to nurses and patients in two surgical wards. Results: A majority among the respondents understood how the pain assessment is meant to be used. The nurses and the patients agreed that VAS and NRS were seen as good tools to mediate ones pain. In the question about the frequency of rating pain a significant difference was seen between the two groups. Among the patients 83% thought that their pain was rated often enough while barley half of the nurses thought that the pain was measured often enough. There was a significant difference between the two groups when the respondents were asked about verbal information concerning VAS and NRS. Conclusion: Patients and nurses believe that VAS and NRS are an effective way to rate pain and that the understandings for these assessment tools are good. The inadequacy of pain rating frequency can in this study be seen both before and after given analgesics.

Bakgrund: Smärta och äldre personer är centrala delar i sjukvården. Smärta är en subjektiv upplevelse och påverkar en person både psykiskt och fysiskt. Smärta är komplext och det finns många anledningar till att smärta uppkommer. Många äldre personer i samhället får inte korrekt smärtlindring vilket kan bero på attityder och felaktiga bedömningar.  För att underlätta bedömningen av smärta finns det instrument som vårdpersonal kan ta hjälp av för att underlätta bedömningen av äldre personers smärta. Syfte: Att beskriva hur äldre personer upplever smärta och hur den handhas på vårdenheter. Metod: En litteraturöversikt som byggts på tio vetenskapliga artiklar. Artiklarna har hämtats från CINAHL complete. Sökord som har använts i studien: Perception, aged, analgesia, nursing, pain, pain assessment, older adults, aged 80 and over, patient, pain measurement, interviews. Den teoretisk referensram som användes var Katie Erikssons teori om lidande som syftar på att lidandet är en del av livet och är ett skydd för den enskilda individen. Resultat: Analysen av resultatdelarna delades upp i tre teman: Smärta och äldre, som belyser hur smärta kännetecknas hos äldre. Identifiering och bedömning av äldre personers smärta, belyser bedömningen av äldre personers smärta och bedömningsinstrument för att mäta smärta samt hur smärta hanteras, som belyser behandling av smärta hos äldre personer. Diskussion: De två teman som togs upp i diskussionen var smärta och äldre samt bedömning av äldre personers smärta. Dessa har diskuterats mot Katie Erikssons teori om lidande och konsensus begreppet vårdande. / Background: Pain and elderly people are central parts of healthcare. Pain is a subjective feeling affecting humans both psychologically and physically. Pain is complex and there are many reasons why pain arises. Many elderly people in society do not get the right pain relief, which may be due to attitudes or incorrect assessments. To facilitate the assessment of pain, there are instruments that health professionals can use to assess the pain of the elderly. Aim: To describe elderly people’s perception of pain and how it’s administered in care settings. Method: A literature review that has been built on ten scientific articles. The articles were taken from CINAHL complete. Search terms used: Perception, aged, analgesia, nursing, pain, pain assessment, older adults, aged 80 above, patient, pain measurement, interviews. The theoretical framework was Katie Erikson's theory of suffering that refers to that suffering is part of life and is a defense for the individual. Results: The analyses of the results were divided into three themes: Pain and elderly, which illustrates how the pain is characterized in elderly. Identification and assessment of older people's pain, highlighting the assessment of older people's pain and the assessment instruments that can be used and how pain is managed, that elucidate the treatment of pain for elderly people. Discussions: The two themes addressed in the discussion were pain and elderly, and assessment of elderly people’s pain. These were discussed against Katie Erikson's theory about suffering and the consensus term care.

Bakgrund: Mycket i litteraturen tyder på att ouppmärksammad och underbehandlad smärta hos äldre demenssjuka är vanligt förekommande. Detta strider mot principerna om människors lika värde, den enskildes värdighet och det humana i att lindra. Det finns många typer av demenssjukdom och attityden förekommer att demenssjuka inte känner smärta. Demenssjuka har ofta problem med att kommunicera eller lokalisera smärtan. Observations- och självsmärtskattningsinstrument används inte i större utsträckning. Syfte: Syftet med denna litteraturstudie var att belysa smärtproblematik och smärtlindring i omvårdnaden av äldre personer med demenssjukdom. Metod: Detta är en litteraturstudie där tio kvantitativa vetenskapliga artiklar har analyserats med hjälp av en manifest innehållanalys. Artiklarnas resultat presenteras i fyra kategorier med underkategorier som beskriver smärtproblematik och smärtlindring hos äldre patienter med demenssjukdom. Resultat: Äldre med demenssjukdom var ofta underbehandlade för smärta och risken ökade med stigande kognitiv nedsättning. Underskattning av smärta var vanligt förekommande även när smärtskattningsinstrument användes. Personer med förmodad vaskulär demens rapporterade ofta mer smärta och med Alzheimers sjukdom mindre smärta än icke-dementa äldre. Hos en del demenssjuka uteblev förväntningseffekten av analgetika. Slutsats: Underbehandling av smärta hos demenssjuka äldre var vanligt förekommande och mer forskning behövs om smärtbedömning hos kognitivt nedsatta personer. / Background: Literature reveals that undiagnosed and untreated pain among older persons with dementia are common occurrences. This is in contrast to the principles of equal value among human beings, the dignity of the individual, and the alleviation of human suffering. There are many types of dementia, and there exists a belief that persons with dementia feel no pain. A common consequence of dementia is inability to communicate or locate the origin of pain. Selfassessment and observational pain scales are frequently not used. Aim: The aim of this literature review was to shed light upon the challenges associated with pain and the practice of pain relief in the care of older adults with dementia. Method: This is literature review study, where ten quantitative scientific articles have been analyzed using manifest context analysis. The results of the articles were sorted into four categories, each with subcategories, that describe the challenges associated with pain and the practice of pain relief. Results: The following result was obtained. Older persons with dementia often received inadequate pain relief, and the risk for under treatment increased with increasing level of cognitive impairment. Under treatment of pain was common even when pain assessment scales were used. Persons with assumed vascular and Alzheimer's dementia often stated that they felt more pain and less pain, respectively, than older adults with no cognitive impairment did. A group of persons with dementia were shown to experience no anticipatory effect of analgesics. Conclusion: Under treatment of pain was a common occurrence among older persons with dementia and more research is needed regarding how to estimate pain in persons with cognitive impairment.

The Numeric Rating Scale (NRS) is suitable in postoperative settings, yet, the implementation has shown varying results. This has raised issues about the pain scales contribution to the identifying and understanding of pain. The aim of this thesis was to describe the clinical utility of patients’ self-rated postoperative pain after major surgery from a healthcare professional perspective. The aim of study I and II was to describe healthcare professionals’ perceptions of the use of pain scales, and to through considering critical incidents describe care experiences and actions taken by healthcare professionals’ when assessing pain. Participants in study I (N=25) and II (N=24) were enrolled- registered nurses and physicians with clinical experiences of pain scales. The aims of study III and IV were to determine the clinical applicability of NRS mode- and maximum- measures, and the NRS mode- and median measures at rest and during activity based on patients self-rated pain. The aim in study IV was additionally to determine the number of NRS ratings needed for the calculation of these measures. The number of surgical and orthopedic patients who completed study III were: n=157 and study IV: n=479. Study I and II confirmed earlier findings of patients’ self-reported pain scores as a facilitator in the understanding of their postoperative pain. Organizational routines, documentation devices, clinical competence, continuity in care, collaborative actions, time, and individual routines were healthcare related factors affecting the use of pain scales (I, II). Patient-related facilitating factors were patients’ ability and willingness to communicate pain, while disability and unwillingness to communicate or inconsistency in verbal communication with observed behaviors were barriers (II). Time and multidimensional communication approaches could bridge these barriers (I, II). Study III and IV showed acceptable reliability for the mode, median and maximum measures. Rank correlations for individual median scores, based on four ratings, versus patients’ retrospective self-rated average pain, were moderate and strengthened with increased numbers of ratings. The Svensson method showed an individual variation within the expected outcome and a significant systematic group change towards a higher level of reported retrospective pain. The calculated pain measures, particularly concerning pain at rest, generally were lower than patients’ recall of pain. The findings described beneficial effects of patient self-reported pain, however present healthcare did not fully support the utilization of pain scales. Because of the simple measurement characteristics, the use of daily NRS average pain measures, patients’ pain can be followed until resolved. The measures could additionally become important patient reported outcome measures and thus constitute new motivators to increase the utilization of pain scales.

Bakgrund: Smärta är en av de vanligaste orsakerna till varför patienter uppsöker vård. Akut smärta beskrivs som subjektiv och individuell vilket styrker nödvändigheten av ökad kunskap och förståelse för akut smärta och patienters olika upplevelser av den.  Detta skulle kunna generera i en bättre omvårdnad, där utvecklingen från akut smärta till en kronisk långvarig smärta samt ett lidande för patienten skulle kunna minimeras. Syfte: Syftet var att beskriva patienters upplevelse av akut smärta och vårdpersonalens betydelse i samband med den. Metod: En litteraturöversikt som baseras på 13 artiklar, sju kvalitativa och sex kvantitativa. Resultat: Fyra teman identifierades; "Vikten av adekvat smärtbehandling", "Vårdpersonalens kompetens inger trygghet", "Att underkasta sig vårdpersonalen" samt "Betydelsen av kommunikation och information". Konklusion: Akut smärta är fortfarande ett stort problem och alldeles för många patienter lider av akut smärta. Vårdpersonalen har stor betydelse för dessa patienters upplevelse då det kan lindra smärtan och förebygga onödigt lidande. För att förbättra vården för patienter med akut smärta behövs en ökad förståelse och kunskap för deras subjektiva upplevelser men även betydelsen av hur sjuksköterskan agerar, behandlar och utvärderar är viktig. / Background: Pain is one of the most common reasons why patients seek healthcare. Acute pain is described as subjective and individual, which proves the need for greater knowledge and understanding of the acute pain and the patient's different experiences of it. This could generate in a better care, where the development of acute pain to chronic prolonged pain and the suffering of the patient could be minimized. Aim: The aim was to describe the patients’ experience of acute pain and the significance of health care professionals associated with it. Method: A literature review based on 13 articles, seven qualitative and six quantitative.   Results: Four themes where identified; "The importance of adequate pain management",”To submit to the health care professionals”, “How the health care professionals’ competence incites a sense of safety” and ”The significance of communication and information”. Conclusion: Acute pain is still a major problem and too many patients suffers from it. The health care professionals have a great importance for these patients’ experience since they can ease the pain and prevent unnecessary suffering. To improve care for patients with acute pain, a greater understanding and knowledge of their subjective experiences is required but also the significance of how the nurse act, treats and evaluates should be of importance.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

There are no reliable tools that evaluate pain in adult critical care patients who cannot communicate as a result of sedation or illness. This was an observational study in which postoperative cardiothoracic intensive care patients were assessed for pain using both the newly devised Corbett Pain Scale (CPS) and the Numerical Pain Scale (NPS). The CPS was evaluated for content validity, criterion validity, construct validity, test re-test reliability and internal consistency. Thirteen male and seven female patients (n=20) were enrolled and underwent a maximum of five pain assessments each. The mean total scores of the CPS (.740, SD+1.03) and the NRS (.000, SD+1.00) were compared using a paired t-test. No significant differences were found. There was poor internal consistency (-.1225) and there was insignificant correlation between the scales. Pain measurement of sedated, non-communicative patients continues to be problematic.