Recognition and assessment of resident' deterioration in the nursing home setting: A critical ethnography.

AIMS AND OBJECTIVES: To explore the recognition and assessment of resident deterioration in the nursing home setting. BACKGROUND: There is a dearth of research exploring how nurses and personal-care-assistants manage a deteriorating nursing home resident. DESIGN: Critical ethnography. METHODS: Observation and semi-structured interviews with 66 participants (general medical practitioners, nurses, personal-care-assistants, residents and family members) in two Australian nursing homes. The study has been reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. RESULTS: The value of nursing assessment is poorly recognised in the nursing home setting. A lack of clarity regarding the importance of nursing assessments associated with resident care has contributed to a decreasing presence of registered nurses and an increasing reliance on personal-care-assistants who had inadequate skills and knowledge to recognise signs of deterioration. Registered nurses experienced limited organisational support for autonomous decision-making and were often expected to undertake protocol-driven decisions that contributed to potentially avoidable hospital transfers. CONCLUSIONS: Nurses need to demonstrate the importance of assessment, in association with day-to-day resident care and demand standardised, regulated, educational preparation of an appropriate workforce who are competent in undertaking this role. Workforce structures that enhance familiarity between nursing home staff and residents could result in improved resident outcomes. The value of nursing assessment, in guiding decisions at the point of resident deterioration, warrants further consideration.

Evidence-based occupational therapy for people with dementia and their families: What clinical practice guidelines tell us and implications for practice.

BACKGROUND/AIM: The first evidence-based Clinical Practice Guidelines and Principles of Care for People with Dementia in Australia have been released. The Guidelines detail a number of important evidence-based recommendations for occupational therapists. The aim of this paper is (1) to provide an overview of Guideline development, and (2) to describe the evidence supporting a recommendation for occupational therapy. Common characteristics of effective occupational therapy programmes for people with dementia are described. METHODS: Guideline development involved adaptation of existing high-quality guidelines developed overseas and 17 systematic reviews to ensure that the most recent high-quality evidence was included. One of the systematic reviews involved examining the evidence for interventions to promote independence in people with dementia. Specifically, we looked at the evidence for occupational therapy and its effect on activities of daily living, quality of life and carer impact. RESULTS: A total of 109 recommendations are included in the Guidelines. Occupational therapy was found to significantly increase independence in activities of daily living and improve quality of life. Effective occupational therapy programmes involve: environmental assessment, problem solving strategies, carer education and interactive carer skills training. CONCLUSION: Occupational therapists working with people with dementia in community settings should ensure that their time is spent on those aspects of intervention that are shown to be effective.

Clinical practice guidelines for dementia in Australia.

About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.

A meta-synthesis of factors influencing nursing home staff decisions to transfer residents to hospital.

AIM: To report a meta-synthesis of qualitative research studies exploring the role of nursing home staff in decisions to transfer residents to hospital. BACKGROUND: Nurses and nurse assistants provide the majority of care to residents living in nursing homes and may be the only health workers present when a resident deteriorates. To inform future strategies, it is vital to understand the role of nursing home staff in decisions to transfer to hospital. DESIGN AND REVIEW METHODS: A systematic review identified 17 studies to be included. The process of meta-synthesis was undertaken using the Joanna Briggs Institute's guidelines. DATA SOURCES: Qualitative research papers published between January 1989-October 2012 were identified in key databases including Cinahl, Embase, Medline and PsycInfo. RESULTS: Nursing home staff members play a key role in decision-making at the time of a resident's deterioration. Multiple factors influence decisions to transfer to hospital including an unclear expectation of the nursing home role; limited staffing capacity; fear of working outside their scope of practice; poor access to multidisciplinary support and difficulties communicating with other decision-makers. CONCLUSIONS: There is a lack of consensus regarding the role of the nursing home when a resident's health deteriorates. Nursing home staff would benefit from a clear prescription of their expected minimum clinical skill set; a staffing capacity that allows for the increased requirements to manage residents on-site, greater consistency in access to outside resources and further confidence and skills to optimize their role in resident advocacy.

Factors that influence the approach to leadership: directors of nursing working in rural health services.

AIM: To identify factors that influence directors of nursing in their approach to leadership when working in rural Victoria, Australia. BACKGROUND: In rural areas, nurses account for the largest component of the health workforce and must be equipped with leadership knowledge and skills to lead reform at a service level. METHOD: A qualitative descriptive design was used. In-depth semi-structured interviews were undertaken with directors of nursing from rural Victoria. Data were analysed using thematic analysis and a thematic network was developed. RESULTS: Empowerment emerged as the highest order category in the thematic network. This was derived from three organising themes: influence, capital and contextual understanding and the respective basic themes: formal power, informal power, self-knowledge; information, support, resources; and situational factors, career trajectory, connectedness. CONCLUSION: Rural nurse leaders contend with several issues that influence their approach to leadership. This study provides a platform for further research to foster nurse leadership in rural healthcare services. IMPLICATIONS FOR NURSING MANAGEMENT: Acknowledgement of what influences the rural nurse leaders' approach to leadership may assist in the implementation of initiatives designed to develop leadership in a manner that is contextually sensitive.

Supporting residents' expression of sexuality: the initial construction of a sexuality assessment tool for residential aged care facilities.

BACKGROUND: Sexuality is a key component of quality of life and well-being and a need to express one's sexuality continues into old age. Staff and families in residential aged care facilities often find expressions of sexuality by residents, particularly those living with dementia, challenging and facilities often struggle to address individuals' needs in this area. This paper describes the development of an assessment tool which enables residential aged care facilities to identify how supportive their organisation is of all residents' expression of their sexuality, and thereby improve where required. METHODS: Multi-phase design using qualitative methods and a Delphi technique. Tool items were derived from the literature and verified by qualitative interviews with aged care facility staff, residents and families. The final item pool was confirmed via a reactive Delphi process. RESULTS: A final item pool of sixty-nine items grouped into seven key areas allows facilities to score their compliance with the areas identified as being supportive of older people's expression of their sexuality in a residential aged care environment. CONCLUSIONS: The sexuality assessment tool (SexAT) guides practice to support the normalization of sexuality in aged care homes and assists facilities to identify where enhancements to the environment, policies, procedures and practices, information and education/training are required. The tool also enables facilities to monitor initiatives in these areas over time.

Using participatory action research to foster nurse leadership in Australian rural hospitals.

This paper outlines the processes and results of a participatory action research study undertaken to identify issues that may impact on strategies to foster nurse leadership in rural hospitals. Five Directors of Nursing from rural regions of Victoria, Australia participated. The group activities involved discussion and analysis of previous research, a review of current literature and critical reflection of the leadership performance of their organization. The analysis identified five key themes; dispel the myths, adopt big-picture thinking, connect with colleagues, reflect on your own conduct, and create organizational buy-in. It is essential to have an awareness of contextual challenges, an understanding of the importance of your own conduct as a visible leader, and the need for effective communication to inform the development of strategies that may be used to foster nurse leadership in rural hospitals. The platform to discuss and critically analyze leadership saw a group consensus that affirmed the need for any approach to nursing leadership to be tailored to the individual healthcare organization.

The person-centred care of older people with cognitive impairment in acute care scale (POPAC).

AIM: To construct and evaluate psychometric properties of the person-centred care of older people with cognitive impairment in acute care settings (POPAC) scale. BACKGROUND: Older people with cognitive impairment are admitted frequently to acute care, with needs not always met through standard practice. Best practice models have been suggested, but few assessment scales exist. METHODS: Psychometric evaluation using statistical estimates of validity and reliability based on an Australian sample of acute care nursing staff (n = 212). RESULTS: The final 15-item questionnaire consists of three subscales, 'using cognitive assessments and care interventions', 'using evidence and cognitive expertise' and 'individualizing care'. Estimates of validity and reliability were highly satisfactory. CONCLUSION: The POPAC scale makes a valuable contribution by providing valid and reliable measures of the extent to which acute nursing staff report using best practice care processes to identify and consider cognitive impairment and to employ nursing interventions to meet the needs associated with old age and cognitive impairment. IMPLICATIONS FOR NURSING MANAGEMENT: The POPAC scale is short, easy to administer and not time consuming to complete, but still provides clinically relevant information. It can be used as a conceptual fundament in developing best practice nursing care in the acute clinical setting, as well as for nursing research.

Advance planning for research participation: Time to translate this innovation into practice.

OBJECTIVES: Advance planning for research is a process that involves thinking about, discussing and expressing preferences for taking part in research during future periods of incapacity. The process may include making an advance research directive and naming trusted people to be involved in decisions about research participation. Advance research planning could help to overcome barriers to including people with dementia in research. To encourage innovation in this area, this article presents recommendations informed by a stakeholder workshop that brought together consumer representatives and representatives active in dementia, ageing and health-related research, policy-making, advocacy and service delivery in health and aged care. METHODS: An online workshop where 15 stakeholders shared perspectives and suggestions for implementing advance research planning, with a focus on research involving people with dementia. RESULTS: Raising awareness of advance research planning requires multi-faceted strategies. Training and resources are needed for researchers, ethics committees and organisations regarding this form of advance planning and the use of research directives. Like any form of advance planning, planning ahead for research must be a voluntary, informed and person-centred process. There is a lack of uniform legal rules on research involving people who lack the capacity to consent; however, advance research directives could, in principle, inform decisions about research participation. CONCLUSIONS: As a matter of law, policy and practice, people are encouraged to plan ahead in many areas of their life. Research planning has been relatively neglected, and the recommendations offered here aim to encourage innovation in research and implementation in this area.

A scoping review identifying contemporary issues in rural nursing leadership.

PURPOSE: Rural nurse leaders on a global scale are being challenged to create structures and processes to enable excellence in nursing care. The purpose of this scoping review is to offer an indication of the available literature relating to contemporary issues in rural nursing leadership. A review of contemporary issues facing rural nurse leaders is timely to assist strategy development that will achieve the goal of excellence in nursing. ORGANIZING CONSTRUCT: An interpretative scoping literature review methodological framework has been used with an emphasis on thematic construction. METHOD: Literature published between 2008 and 2012 was reviewed from five electronic databases using the key words rural, nursing, and leadership. FINDINGS: Four themes have been identified: expectations of rural nursing leadership, a highly educated workforce, competing interests, and partnering within rural healthcare systems. CONCLUSIONS: The content may resonate with rural nurse leaders and encourage a greater awareness of their relevance to leadership practices. CLINICAL RELEVANCE: The findings provide a greater awareness and understanding of contemporary issues facing rural nurse leaders and may assist with the development of context-sensitive leadership strategies to facilitate excellence in nursing care.

Effectiveness of staffing models in residential, subacute, extended aged care settings on patient and staff outcomes.

BACKGROUND: A key concern for managers and nurse administrators of healthcare settings is staffing. Determining and maintaining an appropriate level and mix of staff is especially problematic for those working in the long-term aged-care sector, where resident needs are complex and recruitment and retention of staff is challenging. OBJECTIVES: To identify which staffing models are associated with the best patient and staff outcomes. SEARCH STRATEGY: We searched the Effective Practice and Organisation of Care (EPOC) Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) in The Cochrane Library and the databases MEDLINE, EMBASE, Ageline, CINAHL, and Dissertation abstracts. We also handsearched the reference lists and bibliographies of all retrieved articles. SELECTION CRITERIA: This review considered interrupted time series studies and studies with concurrent control designs of care staff or residents of residential or subacute or extended aged-care settings that evaluated the effectiveness of staffing models and skill mixes on resident and care staff outcomes. DATA COLLECTION AND ANALYSIS: Two review authors critically appraised all studies that were retrieved based on the screening of titles and abstracts according to the EPOC Group's data collection checklist.The same two review authors independently extracted and summarised details of eligible studies using the data abstraction form developed by EPOC. MAIN RESULTS: We included two studies (one interrupted time series and one controlled before-and-after study); both evaluated a primary-care model compared with a either a team-nursing model or a usual-care model. The primary-care model was found to provide slightly better results than the comparator for some outcomes such as resident well-being or behaviour. While nursing staff favoured the primary-care model in one study, neither study found significant improvements in staff outcomes using the primary model compared with the comparator. One study evaluated the uptake of the primary-care model within their facilities and found incorporation of this model into their practice was limited. AUTHORS' CONCLUSIONS: Apart from two small studies evaluating primary care, no evidence in the form of concurrently controlled trials could be identified. While these two studies generally favour the use of primary care, the research designs of both ITS and CBA studies are considered prone to bias, specifically selection and blinding of participants and assessors. Therefore, these studies should be regarded with caution and there is little clear evidence for the effective use of any specific model of care in residential aged care to benefit either residents or care staff. Research in this area is clearly needed.

Job satisfaction amongst aged care staff: exploring the influence of person-centered care provision.

BACKGROUND: There are challenges in attracting and sustaining a competent and stable workforce in aged care, and key issues of concern such as low staff job satisfaction and feelings of not being able to provide high quality care have been described. This study aimed to explore the association between person-centered care provision and job satisfaction in aged care staff. METHODS: Residential aged care staff (n = 297) in Australia completed the measure of job satisfaction and the person-centered care assessment tool. Univariate analyses examined relationships between variables, and multiple linear regression analysis explored the extent to whichperceived person-centredness could predict job satisfaction of staff. RESULTS: Perceived person-centred care provision was significantly associated with job satisfaction, and person-centred care provision could explain nearly half of the variation in job satisfaction. The regression model with the three person-centered care subscales as predictor variables accounted for 40% of the variance in job satisfaction. Personalizing care had the largest independent influence on job satisfaction, followed by amount of organizational support and degree of environmental accessibility. Personalizing care and amount of organizational support had a statistically significant unique influence. CONCLUSIONS: As person-centered care positively correlated with staff job satisfaction, supporting staff in providing person-centered care can enhance job satisfaction and might facilitate attracting and retaining staff in residential aged care. The findings reiterate a need to shift focus from merely completing care tasks and following organizational routines to providing high quality person-centered care that promotes the good life of residents in aged care.

Improving family-staff relationships in assisted living facilities: the views of family.

AIMS: This article is a report of a study of the key influences on family-staff collaboration in low level residential aged care (assisted living) facilities in Australia as seen by the family carers of residents. BACKGROUND: Collaboration with the willing family is widely acknowledged to be important in the care of the older person. Previous work in nursing homes has shown that staff-family relationships are often ambiguous. Relatively little is known about the issue of staff-family relationships in assisted living facilities. METHODS: Using qualitative methodology twelve family carers from five assisted living facilities were interviewed and transcripts analysed thematically. Data were collected in 2006/2007. RESULTS: Four factors important to the establishment and maintenance of collaborative staff-family relationships were identified: comfort, communication, consultation and confidence. CONCLUSION: Low level care facilities need to create environments that are conducive to the establishment and maintenance of constructive staff-family relationships. A number of practice considerations for care staff to foster relationship-centred care with the family in these types of facilities are presented.

The Tool for Understanding Residents' Needs as Individual Persons (TURNIP): construction and initial testing.

AIMS AND OBJECTIVES: To construct and evaluate an intervention tool for increasing the person-centredness of care in residential aged care services. BACKGROUND: Providing care that is person-centred and evidence-based is increasingly being regarded as synonymous with best quality aged care. However, consensus about how person-centred care should be defined, operationalised and implemented has not yet been reached. DESIGN: Literature reviews, expert consultation (n = 22) and stakeholder interviews (n = 67) were undertaken to develop the Tool for Understanding Residents' Needs as Individual Persons (TURNIP). METHODS: Statistical estimates of validity and reliability were employed to evaluate the tool in an Australian convenience sample of aged care staff (n = 220). RESULTS: The 39 item TURNIP conceptualised person-centred care into five dimensions: (1) the care environment, (2) staff members' attitudes towards dementia, (3) staff members' knowledge about dementia, (4) the care organisation and (5) the content of care provided. Psychometric testing indicated satisfactory validity and reliability, as shown for example in a total Cronbach's alpha of 0·89. CONCLUSIONS: The TURNIP adds to current literature on person-centred care by presenting a rigorously developed intervention tool based on an explicit conceptual structure that can inform the design, employment and communication of clinical interventions aiming to promote person-centred care. RELEVANCE TO CLINICAL PRACTICE: The TURNIP contains clinically relevant items that are ready to be applied in clinical aged care. The tool can be used as a base for clinical interventions applying discussions in aged care organisations about the quality of current care and how to increase person-centredness of the care provided.

Advance Care Planning Practices in the Nursing Home Setting: A Secondary Analysis.

BACKGROUND AND OBJECTIVES: Advance care planning is intended to support residents' preferences regarding health decisions, even when they can no longer participate. Little is known about the power discourses influencing how residents, family members, and health care workers engage in advance care planning and how advance care directives are used if a conflict arises. A large critical ethnographic study was conducted exploring decision making when a resident's health deteriorates in the nursing home setting. Advance care planning practices were not the focus of the original study, but the richness of the data warranted further exploration. A new research question was developed to inform a secondary analysis: How does advance care planning influence the relationship between resident values and clinical expertise when determining a direction of care at the time of a resident deterioration? RESEARCH DESIGN AND METHODS: A secondary analysis of data from an ethnographic study involving 184 h of participatory observation, 40 semistructured interviews and advance care planning policies, and document review undertaken in two nursing homes in Melbourne, Australia. RESULTS: Advance care planning may result in inaccurate documentation of residents' preferences and devalue clinical decision making and communication with residents and family members at the time of deterioration. DISCUSSION AND IMPLICATIONS: Advance care planning may contribute toward a reductionist approach to decision making. There is an urgent need for the development of evidence-based policy and legislation to support residents, families, and health care workers to make appropriate decisions, including withholding invasive treatment when a resident deteriorates.

Development and initial testing of the Person-centered Care Assessment Tool (P-CAT).

BACKGROUND: Person-centered care is increasingly regarded as being synonymous with best quality care. However, the concept and its precise meaning is a subject of debate and reliable and valid measurement tools are lacking. METHOD: This article describes the development and initial testing of a new self-report assessment scale, the Person-centered Care Assessment Tool (P-CAT), which measures the extent to which long-term aged care staff rate their settings to be person-centered. A preliminary 39-item tool generated from research literature, expert consultations and research interviews with aged care staff (n = 37), people with early onset dementia (n = 11), and family members (n = 19) was distributed to a sample of Australian aged care staff (n = 220) and subjected to item analysis and reduction. RESULTS: Psychometric evaluation of the final 13-item tool was conducted using statistical estimates of validity and reliability. The results showed that the P-CAT was shown to be valid and homogeneous by factor, item and content analyses. Cronbach's alpha was satisfactory for the total scale (0.84), and the three subscales had values of 0.81, 0.77, and 0.31 respectively. Test-retest reliability were evaluated (n = 26) and all analyses indicated satisfactory estimates. CONCLUSION: This study provides preliminary evidence in support of the psychometric properties of the P-CAT when used in an Australian sample of long-term aged care staff. The tool contributes to the literature by making it possible to study person-centered care in relation to health outcomes, organizational models, characteristics and levels of staffing, degrees of care needs among residents, and impact of interventions.

Promoting a continuation of self and normality: person-centred care as described by people with dementia, their family members and aged care staff.

AIMS AND OBJECTIVES: This article aims to describe the content of person-centred care as described by people with dementia, family members and staff in residential aged care. BACKGROUND: Person-centred care is increasingly being regarded as synonymous with best quality aged care; however, studies exploring stakeholders' experiences of person-centred care are few. DESIGN: A qualitative explorative design was employed using conversational research interviews and content analysis. METHOD: Research interviews were conducted in 2007 and 2008 with staff working in aged care (n = 37), people with early onset dementia (n = 11), and family members of patients with dementia (n = 19) and were analysed using content analysis. RESULTS: The findings indicated that the core category of person-centred care was promoting a continuation of self and normality. Five content categories emerged as contributing to promoting a continuation of self and normality: knowing the person; welcoming family; providing meaningful activities; being in a personalised environment; and experiencing flexibility and continuity. CONCLUSIONS: This study describes person-centred care as it is understood by people with dementia, their family members and staff in residential aged care, and as such it contributes with inside perspectives to current understandings of person-centred care, perspectives that have been largely lacking. Relevance to clinical practice. The findings of this study are clinically relevant and ready to be operationalised and applied in clinical aged care. The categories can be used as a topic guide for discussions in aged care organisations on the quality of current care and as elements indicating how to increase the person-centredness of care provided.

Psychometric evaluation of the English language Person-centred Climate Questionnaire--staff version.

AIM: The present study aimed to evaluate psychometric properties of the English language Person-centred Climate Questionnaire--staff version (PCQ-S). BACKGROUND: Person-centred care emphasizes the individual's perspective in the care process. However, the concept is subject to some debate and few measurement tools exist. METHODS: During 2 months in 2007, the Swedish PCQ-S was translated to English and distributed to a sample of Australian hospital staff (n = 52). Psychometric evaluation using statistical estimates of validity and reliability were performed. RESULTS: The 14-item questionnaire showed high reliability as Cronbach's alpha was satisfactory for the total scale (0.89), and for the four subscales: 0.87, 0.79, 0.82 and 0.69. Test-retest reliability were evaluated in a subsample of 40 staff and resulted in P-values >0.05 between mean scores of the PCQ-S at test and retest, r-values between 0.6 and 0.9, and a two-way mixed effects model, single measures intra-class correlations of 0.75 with a confidence interval of 0.58-0.86. Validity of the scale needs further evaluation. CONCLUSIONS AND IMPLICATIONS FOR NURSING MANAGEMENT: The English PCQ-S makes possible studies of associations between person-centredness and different organizational systems, environments, staff characteristics and health and managerial styles. However, scale validity needs further evaluation.

Consumer expectations and experiences of quality in Australian home-based community services.

Australians want to live at home as they age and seek support from health and social care services to achieve this. The consumer driven market-based approach to community services in Australia has resulted in an increases in user's expectations of quality. What constitutes a quality service from the consumer's perspective is an important agenda to understand as the focus of care delivery moves to the domiciliary setting. This paper presents one aspect from a grounded theory PhD study, the aim of which was to understand the lived experience of receiving services in the home and its impact on the meaning of home. Participants were 11 people with dementia and 18 family supporters living in the state of Victoria, Australia. Data were collected between 2015 and 2017 through multiple interviews, photographic images, field notes and memos. NVIVO 10 qualitative analysis software program was used to support constant comparative analysis. Using a grounded theory approach, this study found that the decision to engage with community services was driven by the need to maintain autonomy, self-identity and home life. Participants sought quality services but discovered a dichotomy of positive and negative aspects in the way services were delivered. The most common reaction to the experience of poor-quality care was to reflect on their expectations for care quality; and manage the reality of what was delivered. Team work and service responsiveness were positive characteristics but were offset by service limitations and inefficiencies caused by poor communication and poor staff retention. The interpersonal relationships that participants developed with staff was highlighted; trust was an important factor whereas unreliable, task orientated and poorly trained staff would be rejected. The implications for policy and practice are described.

Pain assessment in older people with dementia: literature review.

AIM: This paper is a report of a literature review conducted to identify barriers to successful pain assessment in older adults with dementia and possible strategies to overcome such barriers. BACKGROUND: Pain is frequently undetected, misinterpreted, or inaccurately assessed in older adults with cognitive impairment. These people are often unable to articulate or convey how they feel and are often perceived as incapable of experiencing or recalling pain. DATA SOURCES: Searches were conducted of CINAHL, Medline and other databases for the period 1993-2007 using the search terms pain, dementia, assess*, barrier* and obstacle*. METHODS: Studies were critically appraised by two independent reviewers. Data were extracted using instruments specifically developed for the review. Studies were categorized according to levels of evidence defined by the Australian National Health and Medical Research Council and Joanna Briggs Institute. RESULTS: Perceived barriers to successful pain assessment in people with dementia included lack of recognition of pain, lack of sufficient education and/or training, misdiagnosis or late diagnosis, and non-use of assessment tools. Barriers related to people with dementia included insufficient evidence, the possibility of a 'no pain' subset of people with dementia, type of pain, and stoical attitudes. Strategies proposed as means of overcoming these barriers included knowing the person, knowing by diversity/intuitive perception, education and training, and use of adequate tools. CONCLUSION: More extensive education and training about the relationship between pain and dementia are urgently needed, as is the development and implementation of an effective pain assessment tool specifically designed to detect and measure pain in older adults with all stages of dementia.