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Purpose: Use of physical restraints is common in nursing homes, although empirical evidence has shown it to be a hazardous measure. This article aims to understand whether there were any changes in nursing home staff's knowledge, attitudes, and practices of using physical restraints in Hong Kong, after years of deliberation on this topic., Methods: A questionnaire about the knowledge, attitude, and practice of using physical restraint was sent to all 298 staff members in four nursing homes in Hong Kong run by a nongovernmental organization. The results were compared with previous findings from 1999 using the same questionnaire., Results: Overall, the staff had satisfactory knowledge of the daily application of physical restraints, such as the operational procedure and daily assessment. Concerning the conceptual knowledge of minimizing physical restraint use, their performance in the survey was less satisfactory. For example, only 6.6% of respondents were aware that residents had a right to reject the use of physical restraints, and 70% believed that there were no good alternatives to restraints. They showed appropriate attitudes in their practice of daily use of physical restraints. Compared with the previous study in 1999, a significant improvement was found in the attitudes (p = .0014) and practice (p = .0002) of using restraints, but there was no difference in their knowledge test results (p = .29)., Conclusions: The results of this study show a significant improvement among the nursing home staff in terms of their attitudes and practice of using restraints. In-service training for nursing staff should focus more on their knowledge of ethical considerations and the hands-on practice of using alternative devices (e.g., motion detectors or anti-slip pads)., Clinical Relevance: The findings of this study suggest that in-service training for nursing staff should focus more on their knowledge of ethical considerations, the principles of using physical restraint, and the alternatives to restraint in order to fill the knowledge gaps of staff and improve the quality of care in nursing homes., (© 2018 Sigma Theta Tau International.)

Objectives: This is a cross-sectional analysis at baseline of a cluster randomized controlled trial to identify factors associated with the use of pharmacological and nonpharmacological pain treatments by nursing home residents with dementia and impaired communication., Methods: One hundred thirty-four residents with dementia and impaired communication were recruited. Nine of them were excluded because data on their pain treatments were missing, resulting in 125 for analysis. Hierarchical generalized estimating equations analyses controlling for the clustering effect of nursing homes were used to identify factors associated with the use of pharmacological and nonpharmacological pain treatments., Results: Although all participants had a confirmed pain condition, only 23 (18.4%) and 45 (36%) had received pharmacological or nonpharmacological pain treatments, respectively. Participants with a higher ability to communicate ( P  = 0.031) and fewer pain locations were found to be more likely to receive pain medications, with the impact of communication ability being greater among participants with better cognitive status than among those with poor cognitive status. Participants who had been living in the home longer and who were more dependent were less likely to receive nonpharmacological treatments., Conclusion: Suboptimal pain management was common among this population. Severe impairment in the ability to communicate is a major reason for the underuse of pain medications. Staff may become desensitized and fail to perceive subtle changes in the residents' behavior as indicative of pain, leading to the underadministering of nonpharmacological treatments. To improve this situation, it is suggested that observational pain assessments be systematically carried out in nursing homes., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Objectives: To investigate whether the implementation of the Observational Pain Management Protocol (Protocol) can improve pain management for nursing home residents with dementia., Design: A two-group, single-blinded, cluster-randomized controlled trial., Setting: Seventeen nursing homes., Participants: Hundred and twenty eight recruited residents with advanced dementia and pain-related diagnoses were allocated to either the control or the experimental conditions based on the randomized group allocated to their home., Interventions: The Protocol, which includes assessing, interpreting, and verifying the participants' observed pain scores, initiating pain-relieving interventions according to the observed pain scores, and reassessment, was implemented in the experimental homes for 12 weeks to guide the pain management of the participants. Meanwhile, the control homes continued to employ their usual pain management strategies., Measurements: These included the use of pain medications (measured by the Medication Quantification Scale) and non-pharmacological pain treatments in terms of types and frequency, as well as the participants' observational pain scores (assessed by Chinese-Pain Assessment IN Advanced Dementia)., Results: A significant increase in the frequency (95% CI: -0.13 to -0.09, P < .01) and type (95% CI: -0.05 to -0.02, P < .01) of non-pharmacological interventions used was seen in the experimental homes in comparison with the control homes. However, no statistically significant difference in the use of pain medications was observed. A significant reduction in the observational pain score (95% CI: -0.26 to -0.17, P < .001) was obtained only in the experimental home., Conclusion: This study supports the view that the Protocol is of clinical utility in enhancing the use of non-pharmacological pain-relieving interventions among residents with advanced dementia, leading to a reduction in their observational pain-related behaviors. However, the Protocol did not have any effect on the use of pain medications., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Background: Good support from and positive relations with institutional staff can enhance the psychosocial wellbeing of residents admitted to a nursing home. Nursing assistants (NAs) interact most frequently with residents and play an important role in developing good rapport with them. Most studies have described the daily interactions between NAs and residents as task oriented. Only few have attempted to explore the perspectives of NAs and residents on their daily interactions. Therefore, the aim of this study was to identify the types of daily interactions perceived by NAs and residents. We also investigated those intentions/beliefs held by NAs and residents that might direct their interactive behaviors., Methods: A descriptive, exploratory, qualitative approach was used to explore the perspectives of 18 NAs (mean age: 51) and 15 residents (mean age: 84.4) on their daily interactions. Unstructured in-depth interviews were used to collect data. All of the interviews were conducted from July to December 2013. The collected data were transcribed verbatim and analyzed by content analysis., Results: Three types of interactions were found that described the NAs' and residents' perspectives on their daily interactions: (1) physiologically-oriented daily interactions; (2) cordial interactions intended to maintain a harmonious atmosphere; and (3) reciprocal social interactions intended to develop closer rapport. One or more themes reflecting the participants' intentions or beliefs were identified from each group to support each type of interaction., Conclusions: An over-emphasis on the formal caring relationship and over-concern about maintaining a harmonious atmosphere contributed to a superficial and distant relationship between the two parties. Building close rapport takes time and involves repeated reciprocal social interactions. The findings showed that with good intentions to establish closer rapport, both NAs and residents did favors for each other. All of those favors were easily integrated in the care provided to the residents without increasing the workload of the NAs. Modifying the training given to NAs and adjusting institutional policies are crucial to raising the competence of the NAs in building good relationships with residents. Positive interactions improve the psychosocial wellbeing of the residents and encourage them to cooperate during the delivery of care, thereby improving their overall health and contributing to the NAs' job satisfaction.

Aim: To explore nursing assistants' roles during the actual process of pain management (assessment, reporting, implementation of pain-relieving interventions and re-assessment) for cognitively impaired home residents with pain., Background: Nursing assistants provide most of the direct care to residents and represent the major taskforce in nursing homes. They may develop specialized knowledge of residents' pain experience that enables them to play both a pivotal role in pain assessment and possibly a supporting role in pain treatment. Currently, there is a lack of research into nursing assistants' functions in pain management., Design: This is a descriptive, exploratory qualitative study., Methods: Forty-nine nursing assistants were recruited from 12 nursing homes, 12 of them participating in semi-structured individual interviews and 37 in 8 semi-structured focus groups. All interviews were carried out from May to September 2010. Data collected via both data collection methods were transcribed verbatim and analysed by content analysis., Results: Nursing assistants were found to play four roles in the pain management process: (1) pain assessor; (2) reporter; (3) subordinate implementing prescribed medications; and (4) instigator implementing non-pharmacological interventions., Conclusions: This study highlights the importance of nursing assistants in successful pain assessment and identifies their possible supporting roles in other aspects of pain management. However, nursing assistants' scope of practice resulted in their functions in pain management being continually undervalued by other healthcare professionals. Continuous in-service training, the use of a standardized pain management protocol and strategies for building coherent work teams in nursing homes are suggested to improve this situation., (© 2013 John Wiley & Sons Ltd.)

Background: Systematic use of observational pain tools has been advocated as a means to improve pain management for care home residents with dementia. Pain experts suggest that any observational tool should be used as part of a comprehensive pain management protocol, which should include score interpretation and verification with appropriately suggested treatments. The Observational Pain Management Protocol (Protocol) was therefore developed. This study aims to investigate the extent to which the implementation of this Protocol can improve pain management in care home residents with dementia., Methods/design: In this two-group, single-blinded, cluster-randomized controlled trial, 122 care home residents with dementia and pain-related diagnoses will be recruited from eight care homes (that is 15 to 16 residents from each care home). Invitations will be sent to all local care homes who meet the home selection criteria. The eight care homes will be randomly selected from all care homes that agree to join this trial. They will then be randomized to either the control or experimental conditions. Participants from each care home will be placed into their home's corresponding group to avoid 'contamination' effects across participants. Each intervention cycle will take 16 weeks (that is, baseline assessment and care home staff training for 4 weeks and Protocol implementation for 12 weeks). The Protocol will guide the pain management of the participants in the experimental care homes. Meanwhile, the control care homes will continue their usual pain management strategies. Intervention effects will be measured weekly during the protocol implementation period and compared with the baseline measurements, as well as between the experimental and control conditions., Discussion: Although similar pain protocols have been suggested previously, the recommendations were based on experts' opinions rather than evaluation of research studies. The feasibility and effectiveness of this kind of pain management protocol, tailored to older people with dementia, remains unknown. The findings of this trial will offer strong evidence that better strategies for pain management should be used in the care home daily routine., Trial Registration: The Chinese University of Hong Kong, Centre for Clinical Trials: CUHK-CCT00367.

Background. Despite the relatively high risk of infection in long-term residential care settings, few studies have provided a complete evaluation of infection prevention and control (IPC) practices. Therefore, we aimed to evaluate IPC practices in two nursing homes in Hong Kong in order to inform care providers and enhance the overall quality of care. Methods. This study was conducted between August 2015 and March 2016. The IPC practices of two nursing homes were evaluated using a multiple-methods design that includes field observations, focus group interviews of staff (administrators, nurses, allied health professionals, health workers, and personal care workers), and document reviews of residents' records and relevant practice guidelines of the Social Welfare Department and the Department of Health of Hong Kong. Results. Based on field observations, the two nursing homes met the IPC guidelines 80.4% and 75.0% of the time, respectively. The cleansing and disinfection of the environment and facilities were satisfactory. For focus group interviews of staff, 22 women and one man aged 35 to 59 years participated. The staff could describe the IPC measures satisfactorily. Yet what was described was not always observed to be done. No specific infection incident of interest was reported between January and December 2014. Overall, there are five areas of practice that deserve attention: long-term indwelling catheter care, naso-gastric feeding, respiratory care, hand hygiene, and care of residents and equipment on oxygen therapy. Conclusion. Areas in need of improvement included observance of the practice of handwashing, the provision of better handwashing facilities, the proper use of gloves, and the maintenance of the residents' respiratory hygiene when dining, the prevention of myiasis, and the use of better bedside alert signage. We recommend that nursing homes establish an IPC committee and assign an IPC officer to oversee IPC practices. The findings enable residential home operators to identify and prioritise the areas of care that need to be addressed in the context of IPC. [ABSTRACT FROM AUTHOR]

Abstract: Context: Pain in cognitively impaired elderly people (CIEP) often goes unrecognized. Observational pain tools (OPTs) have been designed, but with limited evidence to support their psychometric qualities. Objectives: This study compared four OPTs (the Pain Assessment IN Advanced Dementia [PAINAD], Abbey Pain Scale [Abbey PS], Pain Assessment Checklist for Seniors with Limited Ability to Communicate [PACSLAC], and Discomfort Scale—Dementia of Alzheimer Type [DS-DAT]), two self-report scales, and two proxy-report scales in assessing osteoarthritic (OA) pain among CIEP. Methods: Participants (n =124) were divided into two groups: cognitively intact and impaired. They were observed by two raters simultaneously at rest and during a standardized exercise program. Besides reliabilities, the correlation between the OPTs and the self-report/proxy-report scores was evaluated. The OPT scores collected during different activity levels were compared to establish the convergent and discriminant validity. Confirmatory factor analysis was used to evaluate the construct validity. Results: Similar and accepted patterns of reliability/validity were obtained for all OPTs, in which better levels of psychometric properties were consistently obtained during exercise. However, a single construct (OA pain) appeared only in the PAINAD and Abbey PS after deletion of the “breathing” and “physiological change” indicators, respectively. This showed that OPTs were better used to detect OA pain when pain was triggered by movement (i.e., an exercise program). Conclusion: The PAINAD and Abbey PS appeared to be more reliable and valid for assessing OA pain while using an exercise program among elderly people, regardless of their cognitive ability. [ABSTRACT FROM AUTHOR]