Clinical Audit Plan

Clinical Audit Plan

FIRST ASSESSMENT
Introduction
Failure to provide safe care within the guidelines stipulated by the National Health Service can lead to devastating outcomes to patients. According to Cherry et al. (2012), patient safety continues to be a global concern today as shown by the development of the world health organization. While hand washing might not be as glamorous as the hi-tech interventions that have permeated the healthcare sector, it nonetheless remains the single most important thing practitioners can do to avert the spread of diseases (Thoa, et al., 2015). Indeed, it is impossible to argue against the fact that a safe working environment is a caring environment.

Yokoe et al. (2014) note that adhering to correct hand hygiene practices is essential to the reduction of the risks of associated healthcare infections. In as much as multimodal programs meant for improving healthcare worker, hand hygiene adherence, has demonstrated effectiveness, their efficacy is limited and often hard to sustain. Thus, observance to hand hygiene guidelines in a great number of healthcare facilities has not been followed to the letter. Failure of hand hygiene practices has been demonstrated by nurses in acute care setting in xx hospital, who continuously score low in the monthly clinical audits. Thus raising a question of what could be the causative factors and how the problem could be solved. Realistically, acute care nurses tend to be bombarded with a lot of activities which lead to heavy workloads and thus ignorance to hand hygiene in the process of meeting the work demands.
Background
Healthcare-associated infections (HAIs) continue to affect the results of healthcare in acute care environments given their related health challenges. Every year, over 2.6 million patients in the whole world, contract HAIs that lead to an estimated 90,000 deaths, costing the health care sector over $5 billion in health care costs (Goodliffe, et al., 2014). Nevertheless, despite the growing surveillance for Healthcare-associated infections, evidence-based hand hygiene that curbs hand-to-hand or hand-to-skin infection stands out as the most effective means of reducing the risks of contracting Healthcare-associated infections in an acute care setting (Dai, et al., 2015).

However, Yokoe et al. (2014) argue that most nurses continue to exhibit noncompliance to the guidelines of proper hand hygiene. It emerges that despite knowing the guidelines, most of them opt to breach aseptic technique or misuse gloves as substitutes for hand hygiene. As such, it is important to determine the factors that hinder the acute care nurses in xx hospital from complying with laid down safety guidelines with regards to hand hygiene. If the correct hand hygiene practices were followed, patients care would improve in terms of shortening their stay, better health outcomes, decreased health costs and minimal burnout of acute care nurses. Most importantly there will be greater confidence in the entire health system hence a healthy community (Goodliffe et.al,2014).

According to CourtneyandMcCutcleon,2010, Patient Intervention Compliance and outcome (PICO) is a framework that helps to construct an answerable question that aids in searching for current evidence based practises in the clinical settings. Thus PICO format was applied in the construction of the clinical audit question as illustrated in the table below.
Clinical audit question?
Do nurses in an acute care setting in xx hospital, experience factors that hinder them from adhering to the best hand hygiene practices while caring for the patients?
Problem /population The risk of Healthcare Associated Infections
By the acute care nurses in xx hospital.
Intervention Nurses utilize soap and water or antiseptic hand rubs in order to curb transmission of infections from one patient to another in an acute care setting.
Comparison Simple hand hygiene is a mandatory practice in an acute health care setting and all nurses are expected to be consistent and conscious of it while handling acute patients.
Outcome It is reasonable to expect that nurses in acute care setting comply with the best practice of hand hygiene while caring for the acutely ill patients.
Approach
De bru’n and Pierce-smith (2013) argue that, proper search strategies need to be employed in order to yield rich results of current evidence based practises. Thus this paper, adopted a systematic review approach. Specifically, the paper searched the databases of Medline, CINAHL, Embase and Joanna briggs January 2011 up to December 2016. The paper limited itself to scholarships of human beings, with language restricted to English, data below seven years, all acute care nurses whether newly employed or old and nurses on duty. The exclusion criteria included, Data over seven years, nurses on leave or days off and community nurses. The adopted search terms include the operational filters of the EPOC coupled with designated MeSH terminology (evidence-based practice) besides free text terms (hand washing and hand hygiene, acute care settings and nurses) as advocated by studies. The EPOC approach is a widely used data collection worksheet that incorporates research objectives, settings, and design, coupled with a study’s target populace, outcomes measures, a sketch of the treatment, and the selected analysis approach and results. The inclusion criterion included studies with at least an outcome comparison with a randomized control group
Results
The study’s initial search for published works from 2011 through 2016 and current studies resulted in 10,470 hits for all the consulted databases. However, only 623 publications met the inclusion criteria. An assessment of the full text of the qualifying studies led to 590 more studies being excluded due to the lack of HH compliance outcomes or because they were not interventional. A further appraisal and quality assessment lead to 28 studies being included for analysis while the remaining were omitted due to significant quality issues.

The studies appraised revealed interesting information regarding the compliance practices of nurses in acute care settings as summarized in the table.
Factor Frequency
Lack of knowledge 10 studies reported that nurses attributed failure to comply with hand hygiene due to the lack of awareness on the importance of the same
Lack of time 15 studies observed that most nurses lacked the time to properly scrub their hands as required by guidelines
Forgetfulness 20 studies reported that while some nurses are aware of the need to comply with hand wash they just forgot
Lack of means 7 studies noted that some facilities lacked the necessary resources required for proper hand washing measures.
Skin irritation 12 studies reported that some nurses feared that the chemicals used in washing their hands could lead to skin irritation.
Lack of training 15 studies indicated that some nurses lacked the necessary training on evidence-based hand hygiene practices
Conflict between the need to provide care and self-protection 20 studies noted that some nurses were torn between protecting themselves against elements such as dry skin and providing care to the sick.
Distance to necessary and facility 8 studies claimed that the distance to the required hand wash facility demoralized the nurses
Uncomfortable equipment 5 studies cited awkward hand washing equipment as the barriers to proper hand hygiene practices among the nurses.
CONCLUSION
Using the best search strategy available, this paper has outlined the clinical audit question in a systematic way, highlighting the key factors that hinder the nurses in in xx hospital to comply with the best standard in hand hygiene practices. These factors need to be taken into consideration by the whole health care system when taking the next step in putting these guidelines into practice e.g. for the educators or nums to keep on updating the nurses on performance in their hand hygiene practices, also instructing new nurses on how to deliver the best care for patients in regard to hand hygiene.

References
Cherry, M. G., Brown, J. M., Bethell, G. S., Neal, T., & Shaw, N. J. (2012). Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22. Medical teacher, 34(6), e406-e420.
Courtney, M. D., & McCutcheon, H. (2010). Using Evidence to Guide Nursing Practice. Sydney: Churchill Livingstone.,
Pearce-Smith, N. D. B. C. (2013). Searching Skills Toolkit. : Wiley. Retrieved from https://www.ebrary.com.

Thoa, V. T. H., Van Trang, D. T., Tien, N. P., Van, D. T., Wertheim, H. F., & Son, N. T. (2015). Cost-effectiveness of a hand hygiene program on health care–associated infections in intensive care patients at a tertiary care hospital in Vietnam. American journal of infection control, 43(12), e93-e99.
Yokoe, D. S., Anderson, D. J., Berenholtz, S. M., Calfee, D. P., Dubberke, E. R., Ellingson, K. D., … & Lo, E. (2014). A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. American journal of infection control, 42(8), 820-828.
Dai, H., Milkman, K. L., Hofmann, D. A., & Staats, B. R. (2015). The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology, 100(3), 846.
Goodliffe, L., Ragan, K., Larocque, M., Borgundvaag, E., Khan, S., Moore, C., & McGeer, A. J. (2014). Rate of Healthcare Worker–Patient Interaction and Hand Hygiene Opportunities in an Acute Care Setting. Infection Control & Hospital Epidemiology, 35(03), 225-230.
Barnes, S. L., Morgan, D. J., Harris, A. D., Carling, P. C., & Thom, K. A. (2014). Preventing the transmission of multidrug-resistant organisms: modelling the relative importance of hand hygiene and environmental cleaning interventions. Infection Control & Hospital Epidemiology, 35(09), 1156-1162.

INSTRUCTIONS FOR NOW ASSESSMENT 2 WHICH IS A.Critique of the evidence and best practice .
–PLEASE FOLLOW THIS RUBRIC.
CRITERIA Excellent (> 80 %) Very good (70 – 79%) Good (60 – 69%) Fair (50 – 59%) Poor (<50%) MARK INTRODUCTION (0 marks – hurdle requirement) Introduction includes an overview of the content contained in the report, which enables the reader to know what is ahead, similar to a map. CRITIQUE OF THE EVIDENCE (70% of total mark)
CRITIQUE OF THE EVIDENCE OF YOUR TOPIC (45% of total mark)

? Provides an insightful critique of the evidence on the topic, demonstrating acute critical analysis of the evidence.

(36-40 marks)
? Provides a very good critique of the evidence on the topic and conclusions that are logical and wellarticulated.

(32-35 marks)
? Provides a good critique of the evidence on the topic with clearly expressed conclusions.

(27-31 marks)
? Fair attempt at a critique of the evidence on the topic but conclusions lack clarity.

(22-26 marks)
? Poor or missing attempt at a critique, failing to demonstrate critical analysis of the evidence with limited or no conclusions offered.

(<22 marks)

APPLICATION OF JOANNA BRIGGS INSTITUTE LEVELS OF EVIDENCE (20% of total mark)
? Competently applies the JBI hierarchy of evidence for all items of evidence.

(17-20 marks)
? Applies the JBI hierarchy of evidence & for all items of evidence.

(14-16 marks)
? Applies the JBI hierarchy of evidence for most items of evidence.

(12-13 marks)
? Applies the JBI hierarchy of evidence for some items of evidence.

(10-11 marks)
? Poor or missing attempt at applying the JBI hierarchy of evidence for items of evidence.

(<10 marks)

SUMMARISES THE EVIDENCE (15% of total mark)

? Concise & accurate synthesis of the evidence, presented as a Clinical Bottom Line, citing the evidence & JBI assessment outcome.

? Excellent use of tables to summarise and present the supporting evidence found (10-12 marks)
? Very good synthesis of the evidence, presented as a Clinical Bottom Line, citing the evidence & its JBI assessment outcome.

? Clear use of tables to summarise and present the supporting evidence found (10- 11 marks)
? Good synthesis of the evidence, presented as a Clinical Bottom Line, citing most of the evidence & its JBI assessment outcome.

? Good use of tables to summarise and present the supporting evidence found (8-9 marks)
? Fair synthesis of the evidence, presented as a Clinical Bottom Line, citing some of the evidence & its JBI assessment outcome.

? Fair use of tables to summarise and present the supporting evidence found but missed opportunities to present the evidence clearly. (7 marks)
? Poor attempt at synthesis of the evidence into a Clinical Bottom Line. Failure to cite sufficient evidence to support the conclusion drawn. Little to no JBI assessment outcomes included. ? Poor or no use of tables to present the evidence.

(<7 marks)

STANDARD OF BEST PRACTICE (10% of total mark)

? Provides a detailed and comprehensive set of best practice recommendations, including grades of recommendation, for each item.

? Presents an excellent set of best practice standards based on the Clinical Bottom Line. (9-10 marks)
? Provides a very good set of best practice recommendations, including grades of recommendation, for each item.

? Presents a very good set of best practice standards based on the Clinical Bottom Line. (7- 8 marks)
? Provides a good set of best practice recommendations, including grades of recommendation, but some statements could be worded better to offer clinicians clear directions. ? Presents a good set of best practice standards based on the Clinical Bottom Line. (6-7 marks)
? Provides a fair set of best practice recommendations, including grades of recommendation, but the expression of the statements is a little clumsy and require rewording to make clear what is expected of clinicians. ? Presents a fair set of best practice standards based on the Clinical Bottom Line.

(5-6 marks)
? Poor or missing attempt at providing a set of best practice recommendations. Statements are not structured as recommended statements of best practice and give little to no direction to clinicians as to what is expected as best practice. ? Poor or missing attempt at providing best practice standards based on the Clinical Bottom Line. (<5 marks)

REFERENCE LIST (0 marks – hurdle requirement)
All items of evidence used in the report are referenced in accordance with the APA system of referencing.
APPENDICES (10% of total mark)
? Provides a detailed and comprehensive set of appendices relevant to this report, including all items listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied, succinct and accurate. (9-10 marks)
? Provides a comprehensive set of appendices relevant to this report, including all items listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied and accurate. (7- 8 marks)
? Provides most of the appendices relevant to this report, as listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied and to the most part accurate.

(6-7 marks)
? Provides some of the appendices relevant to this report, as listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied but improvements could be made to increase the clarity of expectations. (5-6 marks)
? Provides few of the appendices relevant to this report, as listed in the Assignment instructions. Limited or no application of the JBI audit plan template, missing or inaccurate information.

AFTER YOU WRITE YOUR REFERENCE LIST USE THE DOWN BELOW GIVEN EXAMPLE TO FINALLY PRESENT THE APPENDICES.NOTE U NEED TO OUTLINE EVERYTHING AS IN ALL THESE APPENDICES PRESENT IN TABLE FORMAT .USE THE GIVEN HAND HYGIENE TOPIC AS IN ASSESSMENT ONE .THE GIVEN LAYOUT EXAMPLE IS FOR PAIN ASSESSMENT BUT YOUR TOPIC IS UNDER HAND HYGIENE(ASSESSMENT 1 GIVEN ABOVE).
APPENDICES Appendix A:
Joanna Briggs Institute Levels of Evidence – Effectiveness

Level 1 – Experimental Designs
Level 1.a – Systematic review of Randomized Controlled Trials (RCTs)
Level 1.b – Systematic review of RCTs and other study designs
Level 1c. – RCT
Level 1.d – Pseudo-RCTs

Level 2 – Quasi- experimental Designs
Level 2.a – Systematic reviews of quasi-experimental studies
Level 2.b – Systematic reviews of quasi-experimental and other lower study designs
Level 2.c – Quasi-experimental prospectively controlled study
Level 2.d – Pre-test – post-test or historic/retrospective control group study

Level 3 – Observational –
Analytic Designs
Level 3.a – Systematic review of comparable cohort studies
Level 3.b – Systematic review of comparable cohort and other lower study designs
Level 3.c – Cohort study with control group
Level 3.d – Case-controlled study
Level 3.e – Observational study without control group

Level 4 – Observational – Descriptive Studies
Level 4.a – Systematic review of descriptive studies
Level 4.b – Cross-sectional study
Level 4.c – Case series
Level 4.d – Case study
Level 5 – Expert Opinion and Bench Research
Level 5.a – Systematic review of expert opinion
Level 5.b – Expert consensus
Level 5.c – Bench research/single expert opinion

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Appendix B:
Joanna Briggs Institute Levels of Evidence – Meaningfulness
Level 1 Qualitative or mixed-methods systematic review
Level 2 Qualitative or mixed-methods synthesis
Level 3 Single qualitative study
Level 4 Systematic review of expert opinion
Level 5 Expert opinion

Appendix C:
Joanna Briggs Institute Grades of Recommendation
A “strong” recommendation for certain health management strategy where:

Grade A
1. it is clear that desirable effects outweigh undesirable effects of the strategy;
2. where there is evidence of adequate quality supporting its use;
3. there is benefit or no impact on resource use, and
4. values, preferences and the patient experience have been taken into account.
A “weak” recommendation for certain health management strategy where:

Grade B
1. desirable effects appear to outweigh undesirable effects of the strategy, although this is not as clear;
2. where there is evidence supporting its use, although this may not be of high quality;
3. there is a benefit, no impact or minimal impact on resource use, and
4. values, preferences and the patient experience may or may not have been taken into account.

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Appendix D: Managing the Evidence
Level of Evidence
Description Number of Studies
Studies
Level 1 Experimental Designs 2 Husebo, Ostelo & Strand, (2014); Lichtner, Dowding, Esterhuizen, Closs, Long, Corbett & Briggs (2014)
Level 2 Quasi-experimental design

Level 3 Observational Study – Analytic designs
8 Alexander, Plank, Carlson, Hanson, Picken & Schwebke (2005); Chan, Hadjistavropoulos, Williams & Lints-Martindale (2014); Kaasalainen, AkhtarDanesh, Hadjistavropoulos, Zwakhalen & Verreault (2013); Lints-Martindale, Hadjistavropoulos, Lix & Thorpe (2012); Mosele, Inelmen, Toffanello, Girardi, Coin, Sergi & Manzato (2012); Pautex, Herrmann, Le Lous, Fabjan, Michel & Gold (2005); Pautex, Michon, Guerdira, Emond, Le Lous, P, Samaras, … Gold (2006); Zwakhalen, Hamers, Abu-Saad & Berger (2006).
Level 4 Observational – Descriptive Studies
4 Ersek, Herr, Neradilek, Buck & Black (2010); Husebo, Strand, Moe-Nilssen, Husebo & Ljunggren (2010); Neville & Ostini (2014); Van der Steen, Sampson, Van den Block, Lord, Vankova, Pautex, Vandervoort, … Van Den Noortgate (2015)
Level 5 Expert Opinion and Bench Research
3 Hadjistavropoulos, Herr, Prkachin, Craig, Gibson, Lukas & Smith (2014); Herr, Bjoro & Decker (2006); Herr, Bursch, Ersek, Miller & Stafford (2010) Ungraded 1 Australian Pain Society (2005)
TOTAL 18

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Appendix E: Managing the Evidence each item
Authors Method Findings Level of Evidence
Australian Pain Society (2005)
Guideline Management Strategies
Recommends to use selfreporting tools whenever possible.
Recommends the use of pain behaviour observational tools together with self-report. Recommends that pain assessments should be completed during rest and activity.
Endorses the use of The Abbey and PAINAD.
Ungraded
Alexander, Plank, Carlson, Hanson, Picken & Schwebke (2005);
Observational Study
The majority of residents were unable to use verbal tools (VAS). Pain observations were completed before and after pain medication administration. Pain observed pain behaviours triggered pain management. Pain observations were made continuously, whereas patients who were able to self-report were assessed at certain times.
Level 3
Chan, Hadjistavropoulos, Williams & LintsMartindale (2014)
Observational Study
Study to validate PACSLAC-2
Pain was assessed during daily care activities.
Pain behaviour observations were limited to two occasions rather than ongoing. Study suggested not to use pain cut-off scores, as pain behaviours are dependent on the severity of the cognitive impairment.
Level 3
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Ersek, Herr, Neradilek, Buck & Black (2010)
Crosssectional Study
Pain was assessed during rest and activity. The PAINAD performed well to assess pain during movement.
Level 4
Hadjistavropoulos, Herr, Prkachin, Craig, Gibson, Lukas & Smith (2014)
Expert Consensus
Concluded that NRS, VAS and FPS are reliable tools for patients with mild to moderate cognitive impairment. VAS was not recommended for assessment for patients with severe dementia, as it had a high error rate. Observational tools reviewed were The Abbey, PAINAD, MOBID-2, PACSLC and PACSLAC-2 Advocates for observation of pain behaviours to be ongoing. Recommends the use of pain behaviour observational tools together with self-report.
Level 5
Herr, Bjoro & Decker (2006)
Expert Consensus
Observational tools reviewed were The Abbey, PAINAD, PACSLAC and DOLOPLUS-2. The review reports ongoing observations for pain behaviours.
Level 5
Herr, Bursch, Ersek, Miller & Stafford (2010)
Expert Consensus
Recommend the use of pain behaviour observational tools together with self-report
PACSLAC may be better suited for long-term assessments such as nursing homes PAINAD may be suited for more frequent pain assessments. The tool may initiate a more comprehensive assessments.
Level 5
Husebo, Ostelo & Strand (2014)
Randomised Control Trial
Use of the MOBID-2 in a RCT with 352 residents with advanced dementia. The study confirmed that increased pain scores initiated
Level 1
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pain management and the administration of analgesia.
Husebo, Strand, Moe-Nilssen, Husebo & Ljunggren (2010)
Crosssectional Study
64% of residents suffered from pain, which was higher in comparison to other studies. This may have been related to the fact that one of the units was a palliative care unit. Residents had higher use of analgesia which may be due to the high number of skilled palliative care workers in the facility.
Level 4
Kaasalainen, Akhtar-Danesh, Hadjistavropoulos, Zwakhalen & Verreault (2013)
Observational Study
The study utilised behaviour observational tools together with self-report. The study observed pain assessments during rest and activity. Large sample size of 338 participants.
Level 3
Lichtner, Dowding, Esterhuizen, Closs, Long, Corbett & Briggs (2014)
Systematic Review
Tools reviewed were The Abbey, PAINAD, PACSLAC Included different clinical settings such as acute care and nursing homes.
Reported pain observations during rest and activity.
Identified evidence for the clinical use of The Abbey.
Concluded that none of the observational pain behaviour tools is outstanding. Suggested that observational tools should not be used as a stand-alone tool.
Level 1
Lints-Martindale, Hadjistavropoulos, Lix & Thorpe (2012)
Observational Study
The study’s participants had moderate to severe dementia and limited ability to communicate. Almost half of the participants were unable to selfreport pain.
Level 3
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The study used self-reporting tool together with observational tools.
The self-reporting tool used was the Colour Analogue Scale (CAS) which is also referred to as VAS in other studies. The observational tools included were PAINAD and PACSLAC.
Mosele, Inelmen, Toffanello, Girardi, Coin, Sergi & Manzato (2012)
Observational Study
The strength of the study was the large sample size of 600 participants who were admitted to an acute geriatric unit. The study excluded non-verbal patients with severe dementia. Approximately half of the studies patients experienced pain. The study used NRS together with PAINAD.
Pain behaviour observations were made 48hrs after admission for at least 5 minutes of duration. It is unclear whether the observations were made at rest or during activity. The concurrent reliability between NRS and PAINAD was significantly higher than in previous studies which may be due to the large sample size.
Level 3
Neville & Ostini (2014)
Crosssectional study
Study consisted of people with moderate to severe dementia. Observational pain behaviour tools used were The Abbey and DOLOPLUS-2. Study concluded that the Abbey may be better suited for patients with chronic pain as the physiological assessment items (changes in temperature, heart rate, blood pressure etc.) are more relevant for assessment of
Level 4
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acute pain. DOLOPLUS-2 showed a high reliability. However there is not yet enough clinical utility.
Pautex, Herrmann, Le Lous, Fabjan, Michel & Gold (2005)
Observational Study
The studies participants were patients with dementia admitted to a geriatric hospital. It used observational pain behaviour tools together with self-report. The study reported that administration of pain medications was related to increased pain scores. The study examined selfreporting tools and compared them to the observation tool DOLOPLUS. Pain behaviours were observed during rest and activity. Almost half of the participants experienced some pain.
The study suggested using observational tools together with self-reporting tool.
Level 3
Pautex, Michon, Guerdira, Emond, Le Lous, P, Samaras, … Gold (2006)
Observational Study
A study conducted in a hospital. The patients had severe dementia. Pain self-assessment tools were examined and compared to DOLOPLUS-2. Approximately 50% of the participants experienced some pain. The study confirmed that pain management was triggered by elevated pain scores.
The study suggested to use observational tools together with self-reporting tool. There was no information whether the pain assessments
Level 3
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were completed during rest or movement.
Van der Steen, Sampson, Van den Block, Lord, Vankova, Pautex, Vandervoort, … Van Den Noortgate (2015)
Observational – Descriptive Study
Study tested observational tools: PAINAD, DOLOPLUS-2, PACSLAC Found that observational tools worked well with self-reporting tools.
Facial expression was noted to be the most observed pain related behaviour.
Level 4
Zwakhalen, Hamers, AbuSaad & Berger (2006)
Observational – Analytic Designs
The study concluded that the PACSLAC and DOLOPLUS are appropriate when assessing pain in elderly patients with severe dementia. However, it acknowledged that none of the tools have been extensively tested in a variety of care settings. None of the tools have been used on a daily basis in a clinical setting. No information was provided whether the assessments were completed during rest or activity or on frequency.
The Abbey was recommended for patients with end-stage dementia. PAINAD may not be able to detect subtle changes in behaviour as the most observed behaviour was facial expression.
Level 3

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Appendix F:
JOANNA BRIGGS INSTITUTE CLINICAL AUDIT TEMPLATE

HEALTH SERVICE: Hospital X Dementia Aged Care Medical Unit AUDIT TOPIC: Pain assessment in older patients with cognitive impairment REF NO: Do nurses on the dementia aged-care medical unit at Hospital X comply with
best practice when assessing pain in older people with cognitive impairment?
Audit Objectives: To ensure nurses on the dementia aged-care medical unit
at Hospital X comply with best practice when assessing pain in older people
with cognitive impairment.
Rationale:

At the dementia aged care medical unit at Hospital X it was observed by the
nurse educator that different pain assessment tools or no assessment tools
are used when assessing pain in cognitively impaired patients.
There is no consistent approach in pain assessment for patients who are
unable to self-report their pain. Furthermore the utilisation of a behavioural
assessment tool is dependent on the clinician’s personal preference.

The Australian Pain Society (2005) recommends the use of verbal and
observational tools for patients with milder cognitive impairment and
observation of pain related behaviour for patients with moderate to severe
dementia.

It is reasonable to expect that nurses in the dementia aged care medical unit
at hospital X comply with best practice when assessing pain, implementing a
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consistent approach in practice by utilising assessment tools for patients with
cognitive impairment.
Audit Team: XXXXX (Nurse Educator)

AUDIT DEFINITIONS Self-reporting pain assessment tools: Numerical Rating Scale (NRS) Visual Analogue Scale (VAS) Faces Pain Scale (FPS)

Observational pain behaviour tools: Pain Assessment In Advanced Dementia (PAINAD) Abbey Pain Scale (The Abbey) CLINICAL GUIDELINE: AUDIT INDICATOR 1: Patients pain self-report should be utilised whenever possible. 1: 100% of nurses on the aged-care dementia unit will utilise patients’ selfreport of pain whenever possible.
2: NRS, VAS and FPS may be used for verbal patients with mild to moderate dementia.
2: 100% of nurses on the aged-care dementia unit will use NRS, VAS or FPS for verbal patients with mild to moderate dementia.
3: Observational pain behaviour tools should be used in conjunction with patient self-report whenever possible rather than as a stand-alone tool.

3: 100% of nurses on the aged-care dementia unit will use observational pain behaviour tools in conjunction with patient self-report whenever possible.
4: The Abbey and PAINAD may be used to observe pain related behaviour.
4: 100% of nurses on the aged-care dementia unit will use either the Abbey Pain Scale or PAINAD to observe pain related behaviour.
5: No other observational pain behaviour tools should be used as there is limited evidence for their clinical utility at present.
5: 100% of nurses on the aged-care dementia unit will not use any other observational pain behaviour tools for pain assessment.
6: Pain assessments should be performed during rest and activity.

6: 100% of nurses on the aged-care dementia unit will perform pain assessment during rest and activity.
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7: Elevated pain scores should trigger pain management.
7: 100% of nurses on the aged-care dementia unit will initiate pain management for a patient with elevated pain scores.
8: Elevated pain scores should trigger comprehensive patient assessment.
8: 100% of nurses on the aged-care dementia unit will initiate a comprehensive patient assessment for a patient with elevated pain scores.

FIRST ASSESSMENT
Introduction
Failure to provide safe care within the guidelines stipulated by the National Health Service can lead to devastating outcomes to patients. According to Cherry et al. (2012), patient safety continues to be a global concern today as shown by the development of the world health organization. While hand washing might not be as glamorous as the hi-tech interventions that have permeated the healthcare sector, it nonetheless remains the single most important thing practitioners can do to avert the spread of diseases (Thoa, et al., 2015). Indeed, it is impossible to argue against the fact that a safe working environment is a caring environment.

Yokoe et al. (2014) note that adhering to correct hand hygiene practices is essential to the reduction of the risks of associated healthcare infections. In as much as multimodal programs meant for improving healthcare worker, hand hygiene adherence, has demonstrated effectiveness, their efficacy is limited and often hard to sustain. Thus, observance to hand hygiene guidelines in a great number of healthcare facilities has not been followed to the letter. Failure of hand hygiene practices has been demonstrated by nurses in acute care setting in xx hospital, who continuously score low in the monthly clinical audits. Thus raising a question of what could be the causative factors and how the problem could be solved. Realistically, acute care nurses tend to be bombarded with a lot of activities which lead to heavy workloads and thus ignorance to hand hygiene in the process of meeting the work demands.
Background
Healthcare-associated infections (HAIs) continue to affect the results of healthcare in acute care environments given their related health challenges. Every year, over 2.6 million patients in the whole world, contract HAIs that lead to an estimated 90,000 deaths, costing the health care sector over $5 billion in health care costs (Goodliffe, et al., 2014). Nevertheless, despite the growing surveillance for Healthcare-associated infections, evidence-based hand hygiene that curbs hand-to-hand or hand-to-skin infection stands out as the most effective means of reducing the risks of contracting Healthcare-associated infections in an acute care setting (Dai, et al., 2015).

However, Yokoe et al. (2014) argue that most nurses continue to exhibit noncompliance to the guidelines of proper hand hygiene. It emerges that despite knowing the guidelines, most of them opt to breach aseptic technique or misuse gloves as substitutes for hand hygiene. As such, it is important to determine the factors that hinder the acute care nurses in xx hospital from complying with laid down safety guidelines with regards to hand hygiene. If the correct hand hygiene practices were followed, patients care would improve in terms of shortening their stay, better health outcomes, decreased health costs and minimal burnout of acute care nurses. Most importantly there will be greater confidence in the entire health system hence a healthy community (Goodliffe et.al,2014).

According to CourtneyandMcCutcleon,2010, Patient Intervention Compliance and outcome (PICO) is a framework that helps to construct an answerable question that aids in searching for current evidence based practises in the clinical settings. Thus PICO format was applied in the construction of the clinical audit question as illustrated in the table below.
Clinical audit question?
Do nurses in an acute care setting in xx hospital, experience factors that hinder them from adhering to the best hand hygiene practices while caring for the patients?
Problem /population The risk of Healthcare Associated Infections
By the acute care nurses in xx hospital.
Intervention Nurses utilize soap and water or antiseptic hand rubs in order to curb transmission of infections from one patient to another in an acute care setting.
Comparison Simple hand hygiene is a mandatory practice in an acute health care setting and all nurses are expected to be consistent and conscious of it while handling acute patients.
Outcome It is reasonable to expect that nurses in acute care setting comply with the best practice of hand hygiene while caring for the acutely ill patients.
Approach
De bru’n and Pierce-smith (2013) argue that, proper search strategies need to be employed in order to yield rich results of current evidence based practises. Thus this paper, adopted a systematic review approach. Specifically, the paper searched the databases of Medline, CINAHL, Embase and Joanna briggs January 2011 up to December 2016. The paper limited itself to scholarships of human beings, with language restricted to English, data below seven years, all acute care nurses whether newly employed or old and nurses on duty. The exclusion criteria included, Data over seven years, nurses on leave or days off and community nurses. The adopted search terms include the operational filters of the EPOC coupled with designated MeSH terminology (evidence-based practice) besides free text terms (hand washing and hand hygiene, acute care settings and nurses) as advocated by studies. The EPOC approach is a widely used data collection worksheet that incorporates research objectives, settings, and design, coupled with a study’s target populace, outcomes measures, a sketch of the treatment, and the selected analysis approach and results. The inclusion criterion included studies with at least an outcome comparison with a randomized control group
Results
The study’s initial search for published works from 2011 through 2016 and current studies resulted in 10,470 hits for all the consulted databases. However, only 623 publications met the inclusion criteria. An assessment of the full text of the qualifying studies led to 590 more studies being excluded due to the lack of HH compliance outcomes or because they were not interventional. A further appraisal and quality assessment lead to 28 studies being included for analysis while the remaining were omitted due to significant quality issues.

The studies appraised revealed interesting information regarding the compliance practices of nurses in acute care settings as summarized in the table.
Factor Frequency
Lack of knowledge 10 studies reported that nurses attributed failure to comply with hand hygiene due to the lack of awareness on the importance of the same
Lack of time 15 studies observed that most nurses lacked the time to properly scrub their hands as required by guidelines
Forgetfulness 20 studies reported that while some nurses are aware of the need to comply with hand wash they just forgot
Lack of means 7 studies noted that some facilities lacked the necessary resources required for proper hand washing measures.
Skin irritation 12 studies reported that some nurses feared that the chemicals used in washing their hands could lead to skin irritation.
Lack of training 15 studies indicated that some nurses lacked the necessary training on evidence-based hand hygiene practices
Conflict between the need to provide care and self-protection 20 studies noted that some nurses were torn between protecting themselves against elements such as dry skin and providing care to the sick.
Distance to necessary and facility 8 studies claimed that the distance to the required hand wash facility demoralized the nurses
Uncomfortable equipment 5 studies cited awkward hand washing equipment as the barriers to proper hand hygiene practices among the nurses.
CONCLUSION
Using the best search strategy available, this paper has outlined the clinical audit question in a systematic way, highlighting the key factors that hinder the nurses in in xx hospital to comply with the best standard in hand hygiene practices. These factors need to be taken into consideration by the whole health care system when taking the next step in putting these guidelines into practice e.g. for the educators or nums to keep on updating the nurses on performance in their hand hygiene practices, also instructing new nurses on how to deliver the best care for patients in regard to hand hygiene.

References
Cherry, M. G., Brown, J. M., Bethell, G. S., Neal, T., & Shaw, N. J. (2012). Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22. Medical teacher, 34(6), e406-e420.
Courtney, M. D., & McCutcheon, H. (2010). Using Evidence to Guide Nursing Practice. Sydney: Churchill Livingstone.,
Pearce-Smith, N. D. B. C. (2013). Searching Skills Toolkit. : Wiley. Retrieved from https://www.ebrary.com.

Thoa, V. T. H., Van Trang, D. T., Tien, N. P., Van, D. T., Wertheim, H. F., & Son, N. T. (2015). Cost-effectiveness of a hand hygiene program on health care–associated infections in intensive care patients at a tertiary care hospital in Vietnam. American journal of infection control, 43(12), e93-e99.
Yokoe, D. S., Anderson, D. J., Berenholtz, S. M., Calfee, D. P., Dubberke, E. R., Ellingson, K. D., … & Lo, E. (2014). A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. American journal of infection control, 42(8), 820-828.
Dai, H., Milkman, K. L., Hofmann, D. A., & Staats, B. R. (2015). The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology, 100(3), 846.
Goodliffe, L., Ragan, K., Larocque, M., Borgundvaag, E., Khan, S., Moore, C., & McGeer, A. J. (2014). Rate of Healthcare Worker–Patient Interaction and Hand Hygiene Opportunities in an Acute Care Setting. Infection Control & Hospital Epidemiology, 35(03), 225-230.
Barnes, S. L., Morgan, D. J., Harris, A. D., Carling, P. C., & Thom, K. A. (2014). Preventing the transmission of multidrug-resistant organisms: modelling the relative importance of hand hygiene and environmental cleaning interventions. Infection Control & Hospital Epidemiology, 35(09), 1156-1162.

INSTRUCTIONS FOR NOW ASSESSMENT 2 WHICH IS A.Critique of the evidence and best practice .
–PLEASE FOLLOW THIS RUBRIC.
CRITERIA Excellent (> 80 %) Very good (70 – 79%) Good (60 – 69%) Fair (50 – 59%) Poor (<50%) MARK INTRODUCTION (0 marks – hurdle requirement) Introduction includes an overview of the content contained in the report, which enables the reader to know what is ahead, similar to a map. CRITIQUE OF THE EVIDENCE (70% of total mark)
CRITIQUE OF THE EVIDENCE OF YOUR TOPIC (45% of total mark)

? Provides an insightful critique of the evidence on the topic, demonstrating acute critical analysis of the evidence.

(36-40 marks)
? Provides a very good critique of the evidence on the topic and conclusions that are logical and wellarticulated.

(32-35 marks)
? Provides a good critique of the evidence on the topic with clearly expressed conclusions.

(27-31 marks)
? Fair attempt at a critique of the evidence on the topic but conclusions lack clarity.

(22-26 marks)
? Poor or missing attempt at a critique, failing to demonstrate critical analysis of the evidence with limited or no conclusions offered.

(<22 marks)

APPLICATION OF JOANNA BRIGGS INSTITUTE LEVELS OF EVIDENCE (20% of total mark)
? Competently applies the JBI hierarchy of evidence for all items of evidence.

(17-20 marks)
? Applies the JBI hierarchy of evidence & for all items of evidence.

(14-16 marks)
? Applies the JBI hierarchy of evidence for most items of evidence.

(12-13 marks)
? Applies the JBI hierarchy of evidence for some items of evidence.

(10-11 marks)
? Poor or missing attempt at applying the JBI hierarchy of evidence for items of evidence.

(<10 marks)

SUMMARISES THE EVIDENCE (15% of total mark)

? Concise & accurate synthesis of the evidence, presented as a Clinical Bottom Line, citing the evidence & JBI assessment outcome.

? Excellent use of tables to summarise and present the supporting evidence found (10-12 marks)
? Very good synthesis of the evidence, presented as a Clinical Bottom Line, citing the evidence & its JBI assessment outcome.

? Clear use of tables to summarise and present the supporting evidence found (10- 11 marks)
? Good synthesis of the evidence, presented as a Clinical Bottom Line, citing most of the evidence & its JBI assessment outcome.

? Good use of tables to summarise and present the supporting evidence found (8-9 marks)
? Fair synthesis of the evidence, presented as a Clinical Bottom Line, citing some of the evidence & its JBI assessment outcome.

? Fair use of tables to summarise and present the supporting evidence found but missed opportunities to present the evidence clearly. (7 marks)
? Poor attempt at synthesis of the evidence into a Clinical Bottom Line. Failure to cite sufficient evidence to support the conclusion drawn. Little to no JBI assessment outcomes included. ? Poor or no use of tables to present the evidence.

(<7 marks)

STANDARD OF BEST PRACTICE (10% of total mark)

? Provides a detailed and comprehensive set of best practice recommendations, including grades of recommendation, for each item.

? Presents an excellent set of best practice standards based on the Clinical Bottom Line. (9-10 marks)
? Provides a very good set of best practice recommendations, including grades of recommendation, for each item.

? Presents a very good set of best practice standards based on the Clinical Bottom Line. (7- 8 marks)
? Provides a good set of best practice recommendations, including grades of recommendation, but some statements could be worded better to offer clinicians clear directions. ? Presents a good set of best practice standards based on the Clinical Bottom Line. (6-7 marks)
? Provides a fair set of best practice recommendations, including grades of recommendation, but the expression of the statements is a little clumsy and require rewording to make clear what is expected of clinicians. ? Presents a fair set of best practice standards based on the Clinical Bottom Line.

(5-6 marks)
? Poor or missing attempt at providing a set of best practice recommendations. Statements are not structured as recommended statements of best practice and give little to no direction to clinicians as to what is expected as best practice. ? Poor or missing attempt at providing best practice standards based on the Clinical Bottom Line. (<5 marks)

REFERENCE LIST (0 marks – hurdle requirement)
All items of evidence used in the report are referenced in accordance with the APA system of referencing.
APPENDICES (10% of total mark)
? Provides a detailed and comprehensive set of appendices relevant to this report, including all items listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied, succinct and accurate. (9-10 marks)
? Provides a comprehensive set of appendices relevant to this report, including all items listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied and accurate. (7- 8 marks)
? Provides most of the appendices relevant to this report, as listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied and to the most part accurate.

(6-7 marks)
? Provides some of the appendices relevant to this report, as listed in the Assignment instructions. Application of the JBI audit plan template is correctly applied but improvements could be made to increase the clarity of expectations. (5-6 marks)
? Provides few of the appendices relevant to this report, as listed in the Assignment instructions. Limited or no application of the JBI audit plan template, missing or inaccurate information.

AFTER YOU WRITE YOUR REFERENCE LIST USE THE DOWN BELOW GIVEN EXAMPLE TO FINALLY PRESENT THE APPENDICES.NOTE U NEED TO OUTLINE EVERYTHING AS IN ALL THESE APPENDICES PRESENT IN TABLE FORMAT .USE THE GIVEN HAND HYGIENE TOPIC AS IN ASSESSMENT ONE .THE GIVEN LAYOUT EXAMPLE IS FOR PAIN ASSESSMENT BUT YOUR TOPIC IS UNDER HAND HYGIENE(ASSESSMENT 1 GIVEN ABOVE).
APPENDICES Appendix A:
Joanna Briggs Institute Levels of Evidence – Effectiveness

Level 1 – Experimental Designs
Level 1.a – Systematic review of Randomized Controlled Trials (RCTs)
Level 1.b – Systematic review of RCTs and other study designs
Level 1c. – RCT
Level 1.d – Pseudo-RCTs

Level 2 – Quasi- experimental Designs
Level 2.a – Systematic reviews of quasi-experimental studies
Level 2.b – Systematic reviews of quasi-experimental and other lower study designs
Level 2.c – Quasi-experimental prospectively controlled study
Level 2.d – Pre-test – post-test or historic/retrospective control group study

Level 3 – Observational –
Analytic Designs
Level 3.a – Systematic review of comparable cohort studies
Level 3.b – Systematic review of comparable cohort and other lower study designs
Level 3.c – Cohort study with control group
Level 3.d – Case-controlled study
Level 3.e – Observational study without control group

Level 4 – Observational – Descriptive Studies
Level 4.a – Systematic review of descriptive studies
Level 4.b – Cross-sectional study
Level 4.c – Case series
Level 4.d – Case study
Level 5 – Expert Opinion and Bench Research
Level 5.a – Systematic review of expert opinion
Level 5.b – Expert consensus
Level 5.c – Bench research/single expert opinion

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Appendix B:
Joanna Briggs Institute Levels of Evidence – Meaningfulness
Level 1 Qualitative or mixed-methods systematic review
Level 2 Qualitative or mixed-methods synthesis
Level 3 Single qualitative study
Level 4 Systematic review of expert opinion
Level 5 Expert opinion

Appendix C:
Joanna Briggs Institute Grades of Recommendation
A “strong” recommendation for certain health management strategy where:

Grade A
1. it is clear that desirable effects outweigh undesirable effects of the strategy;
2. where there is evidence of adequate quality supporting its use;
3. there is benefit or no impact on resource use, and
4. values, preferences and the patient experience have been taken into account.
A “weak” recommendation for certain health management strategy where:

Grade B
1. desirable effects appear to outweigh undesirable effects of the strategy, although this is not as clear;
2. where there is evidence supporting its use, although this may not be of high quality;
3. there is a benefit, no impact or minimal impact on resource use, and
4. values, preferences and the patient experience may or may not have been taken into account.

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Appendix D: Managing the Evidence
Level of Evidence
Description Number of Studies
Studies
Level 1 Experimental Designs 2 Husebo, Ostelo & Strand, (2014); Lichtner, Dowding, Esterhuizen, Closs, Long, Corbett & Briggs (2014)
Level 2 Quasi-experimental design

Level 3 Observational Study – Analytic designs
8 Alexander, Plank, Carlson, Hanson, Picken & Schwebke (2005); Chan, Hadjistavropoulos, Williams & Lints-Martindale (2014); Kaasalainen, AkhtarDanesh, Hadjistavropoulos, Zwakhalen & Verreault (2013); Lints-Martindale, Hadjistavropoulos, Lix & Thorpe (2012); Mosele, Inelmen, Toffanello, Girardi, Coin, Sergi & Manzato (2012); Pautex, Herrmann, Le Lous, Fabjan, Michel & Gold (2005); Pautex, Michon, Guerdira, Emond, Le Lous, P, Samaras, … Gold (2006); Zwakhalen, Hamers, Abu-Saad & Berger (2006).
Level 4 Observational – Descriptive Studies
4 Ersek, Herr, Neradilek, Buck & Black (2010); Husebo, Strand, Moe-Nilssen, Husebo & Ljunggren (2010); Neville & Ostini (2014); Van der Steen, Sampson, Van den Block, Lord, Vankova, Pautex, Vandervoort, … Van Den Noortgate (2015)
Level 5 Expert Opinion and Bench Research
3 Hadjistavropoulos, Herr, Prkachin, Craig, Gibson, Lukas & Smith (2014); Herr, Bjoro & Decker (2006); Herr, Bursch, Ersek, Miller & Stafford (2010) Ungraded 1 Australian Pain Society (2005)
TOTAL 18

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Appendix E: Managing the Evidence each item
Authors Method Findings Level of Evidence
Australian Pain Society (2005)
Guideline Management Strategies
Recommends to use selfreporting tools whenever possible.
Recommends the use of pain behaviour observational tools together with self-report. Recommends that pain assessments should be completed during rest and activity.
Endorses the use of The Abbey and PAINAD.
Ungraded
Alexander, Plank, Carlson, Hanson, Picken & Schwebke (2005);
Observational Study
The majority of residents were unable to use verbal tools (VAS). Pain observations were completed before and after pain medication administration. Pain observed pain behaviours triggered pain management. Pain observations were made continuously, whereas patients who were able to self-report were assessed at certain times.
Level 3
Chan, Hadjistavropoulos, Williams & LintsMartindale (2014)
Observational Study
Study to validate PACSLAC-2
Pain was assessed during daily care activities.
Pain behaviour observations were limited to two occasions rather than ongoing. Study suggested not to use pain cut-off scores, as pain behaviours are dependent on the severity of the cognitive impairment.
Level 3
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Ersek, Herr, Neradilek, Buck & Black (2010)
Crosssectional Study
Pain was assessed during rest and activity. The PAINAD performed well to assess pain during movement.
Level 4
Hadjistavropoulos, Herr, Prkachin, Craig, Gibson, Lukas & Smith (2014)
Expert Consensus
Concluded that NRS, VAS and FPS are reliable tools for patients with mild to moderate cognitive impairment. VAS was not recommended for assessment for patients with severe dementia, as it had a high error rate. Observational tools reviewed were The Abbey, PAINAD, MOBID-2, PACSLC and PACSLAC-2 Advocates for observation of pain behaviours to be ongoing. Recommends the use of pain behaviour observational tools together with self-report.
Level 5
Herr, Bjoro & Decker (2006)
Expert Consensus
Observational tools reviewed were The Abbey, PAINAD, PACSLAC and DOLOPLUS-2. The review reports ongoing observations for pain behaviours.
Level 5
Herr, Bursch, Ersek, Miller & Stafford (2010)
Expert Consensus
Recommend the use of pain behaviour observational tools together with self-report
PACSLAC may be better suited for long-term assessments such as nursing homes PAINAD may be suited for more frequent pain assessments. The tool may initiate a more comprehensive assessments.
Level 5
Husebo, Ostelo & Strand (2014)
Randomised Control Trial
Use of the MOBID-2 in a RCT with 352 residents with advanced dementia. The study confirmed that increased pain scores initiated
Level 1
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pain management and the administration of analgesia.
Husebo, Strand, Moe-Nilssen, Husebo & Ljunggren (2010)
Crosssectional Study
64% of residents suffered from pain, which was higher in comparison to other studies. This may have been related to the fact that one of the units was a palliative care unit. Residents had higher use of analgesia which may be due to the high number of skilled palliative care workers in the facility.
Level 4
Kaasalainen, Akhtar-Danesh, Hadjistavropoulos, Zwakhalen & Verreault (2013)
Observational Study
The study utilised behaviour observational tools together with self-report. The study observed pain assessments during rest and activity. Large sample size of 338 participants.
Level 3
Lichtner, Dowding, Esterhuizen, Closs, Long, Corbett & Briggs (2014)
Systematic Review
Tools reviewed were The Abbey, PAINAD, PACSLAC Included different clinical settings such as acute care and nursing homes.
Reported pain observations during rest and activity.
Identified evidence for the clinical use of The Abbey.
Concluded that none of the observational pain behaviour tools is outstanding. Suggested that observational tools should not be used as a stand-alone tool.
Level 1
Lints-Martindale, Hadjistavropoulos, Lix & Thorpe (2012)
Observational Study
The study’s participants had moderate to severe dementia and limited ability to communicate. Almost half of the participants were unable to selfreport pain.
Level 3
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The study used self-reporting tool together with observational tools.
The self-reporting tool used was the Colour Analogue Scale (CAS) which is also referred to as VAS in other studies. The observational tools included were PAINAD and PACSLAC.
Mosele, Inelmen, Toffanello, Girardi, Coin, Sergi & Manzato (2012)
Observational Study
The strength of the study was the large sample size of 600 participants who were admitted to an acute geriatric unit. The study excluded non-verbal patients with severe dementia. Approximately half of the studies patients experienced pain. The study used NRS together with PAINAD.
Pain behaviour observations were made 48hrs after admission for at least 5 minutes of duration. It is unclear whether the observations were made at rest or during activity. The concurrent reliability between NRS and PAINAD was significantly higher than in previous studies which may be due to the large sample size.
Level 3
Neville & Ostini (2014)
Crosssectional study
Study consisted of people with moderate to severe dementia. Observational pain behaviour tools used were The Abbey and DOLOPLUS-2. Study concluded that the Abbey may be better suited for patients with chronic pain as the physiological assessment items (changes in temperature, heart rate, blood pressure etc.) are more relevant for assessment of
Level 4
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acute pain. DOLOPLUS-2 showed a high reliability. However there is not yet enough clinical utility.
Pautex, Herrmann, Le Lous, Fabjan, Michel & Gold (2005)
Observational Study
The studies participants were patients with dementia admitted to a geriatric hospital. It used observational pain behaviour tools together with self-report. The study reported that administration of pain medications was related to increased pain scores. The study examined selfreporting tools and compared them to the observation tool DOLOPLUS. Pain behaviours were observed during rest and activity. Almost half of the participants experienced some pain.
The study suggested using observational tools together with self-reporting tool.
Level 3
Pautex, Michon, Guerdira, Emond, Le Lous, P, Samaras, … Gold (2006)
Observational Study
A study conducted in a hospital. The patients had severe dementia. Pain self-assessment tools were examined and compared to DOLOPLUS-2. Approximately 50% of the participants experienced some pain. The study confirmed that pain management was triggered by elevated pain scores.
The study suggested to use observational tools together with self-reporting tool. There was no information whether the pain assessments
Level 3
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were completed during rest or movement.
Van der Steen, Sampson, Van den Block, Lord, Vankova, Pautex, Vandervoort, … Van Den Noortgate (2015)
Observational – Descriptive Study
Study tested observational tools: PAINAD, DOLOPLUS-2, PACSLAC Found that observational tools worked well with self-reporting tools.
Facial expression was noted to be the most observed pain related behaviour.
Level 4
Zwakhalen, Hamers, AbuSaad & Berger (2006)
Observational – Analytic Designs
The study concluded that the PACSLAC and DOLOPLUS are appropriate when assessing pain in elderly patients with severe dementia. However, it acknowledged that none of the tools have been extensively tested in a variety of care settings. None of the tools have been used on a daily basis in a clinical setting. No information was provided whether the assessments were completed during rest or activity or on frequency.
The Abbey was recommended for patients with end-stage dementia. PAINAD may not be able to detect subtle changes in behaviour as the most observed behaviour was facial expression.
Level 3

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Appendix F:
JOANNA BRIGGS INSTITUTE CLINICAL AUDIT TEMPLATE

HEALTH SERVICE: Hospital X Dementia Aged Care Medical Unit AUDIT TOPIC: Pain assessment in older patients with cognitive impairment REF NO: Do nurses on the dementia aged-care medical unit at Hospital X comply with
best practice when assessing pain in older people with cognitive impairment?
Audit Objectives: To ensure nurses on the dementia aged-care medical unit
at Hospital X comply with best practice when assessing pain in older people
with cognitive impairment.
Rationale:

At the dementia aged care medical unit at Hospital X it was observed by the
nurse educator that different pain assessment tools or no assessment tools
are used when assessing pain in cognitively impaired patients.
There is no consistent approach in pain assessment for patients who are
unable to self-report their pain. Furthermore the utilisation of a behavioural
assessment tool is dependent on the clinician’s personal preference.

The Australian Pain Society (2005) recommends the use of verbal and
observational tools for patients with milder cognitive impairment and
observation of pain related behaviour for patients with moderate to severe
dementia.

It is reasonable to expect that nurses in the dementia aged care medical unit
at hospital X comply with best practice when assessing pain, implementing a
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consistent approach in practice by utilising assessment tools for patients with
cognitive impairment.
Audit Team: XXXXX (Nurse Educator)

AUDIT DEFINITIONS Self-reporting pain assessment tools: Numerical Rating Scale (NRS) Visual Analogue Scale (VAS) Faces Pain Scale (FPS)

Observational pain behaviour tools: Pain Assessment In Advanced Dementia (PAINAD) Abbey Pain Scale (The Abbey) CLINICAL GUIDELINE: AUDIT INDICATOR 1: Patients pain self-report should be utilised whenever possible. 1: 100% of nurses on the aged-care dementia unit will utilise patients’ selfreport of pain whenever possible.
2: NRS, VAS and FPS may be used for verbal patients with mild to moderate dementia.
2: 100% of nurses on the aged-care dementia unit will use NRS, VAS or FPS for verbal patients with mild to moderate dementia.
3: Observational pain behaviour tools should be used in conjunction with patient self-report whenever possible rather than as a stand-alone tool.

3: 100% of nurses on the aged-care dementia unit will use observational pain behaviour tools in conjunction with patient self-report whenever possible.
4: The Abbey and PAINAD may be used to observe pain related behaviour.
4: 100% of nurses on the aged-care dementia unit will use either the Abbey Pain Scale or PAINAD to observe pain related behaviour.
5: No other observational pain behaviour tools should be used as there is limited evidence for their clinical utility at present.
5: 100% of nurses on the aged-care dementia unit will not use any other observational pain behaviour tools for pain assessment.
6: Pain assessments should be performed during rest and activity.

6: 100% of nurses on the aged-care dementia unit will perform pain assessment during rest and activity.
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7: Elevated pain scores should trigger pain management.
7: 100% of nurses on the aged-care dementia unit will initiate pain management for a patient with elevated pain scores.
8: Elevated pain scores should trigger comprehensive patient assessment.
8: 100% of nurses on the aged-care dementia unit will initiate a comprehensive patient assessment for a patient with elevated pain scores.

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