Continuing professional development Conducting sensitive patient interviews Multiple-choice self-assessment 54. Practice profile assessment 55

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1 art&science clinical research education Assessing pain in cognitively impaired older adults Care map 2: diabetes and hyperglycaemia Continuing professional development Conducting sensitive patient interviews Multiple-choice self-assessment 54 Practice profile assessment 55 Author guidelines 56 Guidelines on writing for Nursing Standard s art&science section Assessing pain in cognitively impaired older adults Murdoch J, Larsen D (2004) Assessing pain in cognitively impaired older adults. Nursing Standard. 18, 38, Date of acceptance: September Abstract Background Accurate assessments of pain help healthcare professionals to identify its source and manage it appropriately. Pain in cognitively impaired older adults is difficult to assess and this can result in poor management and outcomes. In response to the vulnerability of this patient group, researchers have produced a variety of tools for pain assessment in cognitively impaired older adults. Conclusion Replication research is recommended to validate further and generalise results, although there is enough evidence to support the use of direct observation of behaviour in identifying pain in this group of patients. OLDER ADULTS form an increasingly large proportion of those seeking medical and nursing care (Tinker 1997). Many of these adults are diagnosed with conditions that result in pain (Ferrell et al 1995). Good pain management can improve function, increase independence and potentially decrease the frequency and length of hospital admission. If the NHS is to deal effectively with the increasing number of older patients, it is crucial that they should occupy hospital beds for the minimum time necessary. The appropriate assessment and management of pain in this group of patients should, therefore, be a priority in their care. It is well recognised that appropriate management of pain is dependent on accurate assessment. Those who are unable to identify their pain are at higher risk of poor pain management; this group includes older people with cognitive impairment. Inability to detect pain in older cognitively impaired patients may mean that painful, even life-threatening, conditions go undetected and untreated. The under-treatment of pain in people with cognitive impairment is of concern given the number of people involved and the serious consequences for functioning and quality of life (Brochet et al 1998, Chatten 1995, Ferrell et al 1995, Parmelee et al 1993). This article reviews the literature on pain assessment in the cognitively impaired older person. Background It is difficult to define when one becomes an older adult. In Western society, and for the general purposes of research, old age tends to be defined from the age of retirement. However, the age at which people retire is changing; the point at which old age actually begins therefore remains arbitrary. It is estimated that 15 per cent of older adults have some form of cognitive impairment and that the risk of this increases with age. Cognitive impairment is characterised by a deterioration of one or more of the following (Ferrell 1996): Memory. Attention. Visual spatial skills. Language. Behaviour. Cognitive impairment may mask the presence of pain and is exacerbated by the presence of pain (Ferrell 1991, Ferrell et al 1990, Forrest 1995, Herr and Mobily 1991, Marzinski 1991, Parke 1998, Roy and Thomas 1986). Pain among people with cognitive impairment can lead to increased care demand. It is associated with the presence of depression and challenging behaviours, including aggression and disruptive vocalisations (Cohen-Mansfield and Marx 1993, Parmelee et al 1991, Ryden et al 1991). Despite the importance of good pain management in this group, practice relating to pain in confused Julie Murdoch RGN, MSc, is clinical nurse specialist in pain management, and Debra Larsen RGN, is acute pain nurse, Royal Devon and Exeter Hospital, Exeter, Devon. Julie.murdoch@ rdehc-tr.swest.nhs.uk Online archive For related articles and author guidelines visit our online archive at: and search using the key words below. Key words Cognitive impairment Older people Pain: measurement These key words are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. june 2/vol18/no38/2004 nursing standard 33

2 older people tends to rely on individual nurses perceptions of pain with often-haphazard methods of pain assessment and little understanding of patients individual problems and requirements, or the consequences of poor pain management. Pain often remains unidentified and is not assessed or documented, thereby resulting in poor management. Assessment and documentation are an essential part of nursing practice. They aid in communication and the planning of care. Since the promotion of patients rights and the empowerment of patients and relatives to be involved in their care through The Patient s Charter (DoH 1991), there has been a shift in attitude towards the importance of record keeping. There has also been an increase in patients and relatives challenging the nursing profession and the care and treatment delivered, in conjunction with an increase in litigation (DoH 2000, Moody 2001). In legal terms, if there is no recorded evidence that assessment has taken place, it is assumed that it was never performed. Until the early 1990s, little information was available to guide practice and subsequent documentation in the assessment of pain in the cognitively impaired older adult. Marzinski (1991) wrote of the difficulties in assessing pain in confused, non-verbal older people, pointing out that most assessment tools rely on verbal reports of pain which are not appropriate for this group. Since then, an increasing amount of literature has become available. The majority of research regarding the assessment of pain in this group of individuals is centred on the use of behavioural observation to identify and document the presence of pain. Literature review The literature review was undertaken using literature obtained from the British Nursing Index, World Information Nursing, OVID Healthstar, CINAHL and Medline, mainly referring to papers from 1988 to 2003, although some earlier key papers were identified. The key words used were pain assessment, older adult/elderly and cognitive impairment. Pain management is dependent on the acknowledgement of a person s pain. Pain in the older adult is poorly assessed and managed (Closs 1994, Ferrell and Ferrell 1996). Confused older adults are even less likely to have their pain identified when compared with those who are cognitively intact. Sengstaken and King (1993) found that physicians attending older patients in a nursing home identified chronic pain in 43 per cent of the communicative group, and only 17 per cent of the non-communicative group. This was despite no significant differences in age, sex and medical diagnoses between the two groups. Fewer members of the non-communicative group received analgesic medication compared with those of the communicative group. More than 50 per cent of nurses in a study by Brockopp et al (1993) agreed with the statement: If confusion exists, an assessment of pain is of minimum value. Those caring for older people may assume that confused individuals are unable to identify appropriately or assess their pain. Patients with shortterm memory loss may not recall recent painful experiences and this can result in healthcare staff discounting complaints of pain. Parmelee et al (1993) examined the association between selfreported pain and cognitive impairment among frail, older institution residents. They concluded that the self-reports of cognitively impaired older residents were no less valid than those of residents with no cognitive deficit. Ferrell et al (1995) corroborated this in their study in which participants underwent a cross-sectional interview and chart review to assess the prevalence of pain complaints, aetiology and pain management. They concluded that pain reports by older individuals with cognitive impairment are reliable and valid. Of those studied, 83 per cent were capable of completing at least one of the available pain assessment tools (Figure 1). Those patients who were unable to complete the pain assessment tool could at least identify the presence of pain in answer to direct questioning. These studies indicate a need for healthcare staff to question patients as to the presence of pain, particularly as unprompted self-reports of pain seem to be uncommon. It appears that many cognitively impaired older adults are capable of reporting the presence of pain, although their capacity to remember painful experiences is yet to be elicited. These individuals need to be given the opportunity to have their pain assessed. This can only be afforded by direct questioning with regular assessment and evaluation. The situation for assessing pain in older adults who are unable to respond verbally and who are also cognitively impaired remains one of the most challenging problems in pain management. Assessment has to incorporate indicators other than verbal report to identify pain in these individuals. Physiological changes, for example, respiratory rate, blood pressure, pulse rate and sweating, cannot be relied on as indicators of painful events as these parameters often remain unchanged in those with chronic pain. They may, however, indicate an acutely painful episode. The difficulty with the sole use of these parameters for the identification of pain lies in the fact that there may be other conditions causing these effects in an individual, for example, full bladder, hunger or emotional distress. To assist in overcoming this problem, changes in the individual s physical signs should be examined in association with his or her medical and nursing history and changes in behaviour. There is a growing body of evidence to demonstrate that there are a number of pain behaviours 34 nursing standard june 2/vol18/no38/2004

3 that can reliably be used to indicate the presence of pain. As early as 1972, McCaffery identified four types of body movement that may accompany pain: Immobilisation. Purposeless movements. Protective movements and rubbing. Rhythmic movements. The immobilisation of a part of the body helps to minimise pain. Purposeless movements such as tossing in bed or kicking are often seen in patients with acute, severe pain. Protective movements are used to prevent the recurrence of pain or its increase. McCaffery (1972) also argues that facial expression may be the first, or only, sign of pain. Common facial expressions identified are: Clenched teeth. Wrinkled forehead. Biting the lower lip. Wide open or tightly shut eyes. Since 1990 more research has been published, the majority of which relates to the introduction and validation of behavioural tools to aid in assessing pain. Hurley et al (1992) produced and tested a discomfort scale for use in non-communicative patients with Alzheimer s disease the DS-DAT (Discomfort Scale for patients diagnosed with advanced Dementia of the Alzheimer Type). The DS-DAT was capable of detecting discomfort in the population sampled, thereby supporting its use in assessing discomfort in these patients in the clinical environment. However, this is a complex scale and is time-consuming to administer. The constraints of working in the day-to-day clinical environment may make this tool difficult to use. In addition, the DS-DAT has been validated for assessing discomfort and not pain in these individuals. The scope of this literature search reveals that this study is often quoted but has not been repeated. Perhaps the complexity of the tool has resulted in its failure to become established in clinical practice. A variety of articles have been published with a number of similar, but easier to administer, tools. All of the following demonstrate that behaviour can be used to identify pain in non-verbal cognitively impaired older adults. However, none of the research has been repeated to further validate and generalise original results. Simons and Malabar (1995) produced and piloted a behavioural pain tool (Box 1). The tool was tested on communicative and non-communicative patients. The ward staff were educated on using the tool. On 96 per cent of occasions when Figure 1. Five unidimensional pain scales McGill pain questionnaire Present pain intensity subscale (Melzack 1975) 0 No pain 1 Mild 2 Discomforting 3 Distressing 4 Horrible 5 Excruciating 100mm Visual Analog scale Make a mark on the line for the severity of your pain No pain Worst possible pain Rand Coop chart (Nelson et al 1987) Memorial pain card subscale (Modified Turskey scale) (Fishman et al 1987) Moderate 4 Strong 5 Just noticeable 1 Mild 3 Excruciating 7 No pain 0 Severe 6 Weak 2 No pain Very mild pain Mild pain Moderate pain Severe pain Verbal scale On a scale of zero to ten, zero meaning no pain and ten meaning the worst pain you can imagine, how much pain are you having now? (Reprinted from Ferrell et al (1995), with permission from the US Cancer Pain Relief Committee) june 2/vol18/no38/2004 nursing standard 35

4 pain behaviour was detected, the pain management intervention was effective. Where this was not so, an alteration in pain management strategy often resulted in the expected behaviour change. The results of this pilot study seem promising yet no further work has been published to corroborate initial findings. Wary et al (1993) constructed the DOLOPLUS 2 scale for the assessment of pain in older people. The inspiration for the scale came from an assessment tool used in young children. The scale is based on ten observations of patient behaviours (Table 1). Pain is confirmed by a score of five or more (maximum score = 30). Lefebvre-Chapiro (2001) studied 500 patients using the DOLOPLUS 2 scale. Some of those studied were able to use a visual analogue scale (VAS) and were considered the control group. Those in the control group showed similar findings when the DOLOPLUS 2 score was applied, further validating the tool. Although the results appear promising, the article does not reveal enough information regarding the study and is descriptive in nature. Accuracy in using this tool not only requires education but also requires the assessor to know the patient s usual level of activity. The tool would seem to have a place in caring for long-term patients with chronic pain but requires further validation; its use in acute settings may be limited. Feldt (2000a) piloted a Checklist of Non-verbal Pain Indicators (CNPI) (Figure 2) in patients following surgery for hip fracture. The CNPI is a tool based on established pain behaviours taken from other research and modified for use in these patients. The aim of the research was to determine if there were differences in observed pain behaviours between cognitively impaired and cognitively intact patients. Observation was carried out on the third post-operative day. Facial gri- Box 1. Observable pain behaviours Verbal response 1 Responsive and alert 2 Responsive on approach by nurses 3 Responsive on approach by significant others 4 Responsive on approach by members of the multidisciplinary team 5 Unresponsive (passive) 6 Crying 7 Verbal expression, for example, ouch 8 Other verbal expression: please identify Facial expression 9 Looks calm, relaxed 10 Looks sad, depressed 11 Looks in pain: please specify Body language 12 Relaxed and awake 13 Relaxed and asleep 14 Not relaxed, with drawn-up knees 15 Not relaxed, touching presumed area of pain 16 Not relaxed and stiff Physiological changes 17 Temperature, pulse, respirations and blood pressure within patients usual parameters 18 Vital signs, as above, changed: please specify 19 Other physiological change: please specify Behavioural changes 20 Behaviours not listed above: please specify Feedback from others (if and when applicable) 21 Not in pain/comfortable 22 In pain/uncomfortable Conscious state 23 Drowsy 24 Disorientated: specify a) time, b) place, c) person 25 Unconscious/asleep (Reprinted from Simons and Malabar (1995), with permission from Blackwell Publishing) 36 nursing standard june 2/vol18/no38/2004

5 Table 1. The DOLOPLUS 2 scale Somatic reactions Score 1. Somatic complaints No complaints 0 Complaints expressed on enquiry only 1 Occasional involuntary complaints 2 Continuous involuntary complaints 3 2. Protective body postures No protective body posture 0 adopted at rest The patient occasionally avoids certain positions 1 Protective postures continuously and effectively sought 2 Protective postures continuously sought without success 3 3. Protection of sore areas No protective action taken 0 Protective actions attempted without interfering against any investigation or nursing 1 Protective actions against any investigation or nursing 2 Protective actions taken at rest, even when not approached 3 4. Expression Usual expression 0 Expression showing pain when approached 1 Expression showing pain even without being approached 2 Permanent and unusually blank look (voiceless, staring, looking blank) 3 5. Sleep pattern Normal sleep 0 Difficult to get to sleep 1 Frequent waking (restlessness) 2 Insomnia affecting waking times 3 Psychomotor reactions 6. Washing and/or dressing Usual abilities unaffected 0 Usual abilities slightly affected (careful but thorough) 1 Usual abilities highly impaired, washing and/or dressing is laborious and incomplete 2 Washing and/or dressing rendered impossible as the patient resists any attempt 3 7. Mobility Usual abilities and activities remain unaffected 0 Usual activities are reduced (the patient avoids certain movements and reduces his or her walking distance) 1 Usual activities and abilities reduced (even with help, the patient cuts down his or her movements) 2 Any movement is impossible, the patient resists all persuasion 3 Psychosocial reactions 8. Communication Unchanged 0 Heightened (the patient demands attention in an unusual manner) 1 Lessened (the patient cuts himself or herself off) 2 Absence or refusal of any form of communication 3 9. Social life Participates normally in every activity (meals, entertainment, therapeutic workshop) 0 Participates in activities only when asked to do so 1 Sometimes refuses to participate in any activity 2 Refuses to participate in anything Behavioural problems Normal behaviour 0 Problems of repetitive reactive behaviour 1 Problems of permanent repetitive reactive behaviour 2 Permanent behavioural problems (without any external stimulus) 3 (Source: maces were the most commonly observed pain behaviour at rest and on movement. The results showed that, although there were no differences in the types of pain behaviour shown, the cognitively intact patients exhibited fewer pain behaviours than the cognitively impaired patients, but had received comparatively more analgesia. The cognitively intact individuals may well have used verbal indicators to identify pain, which could explain the increased use of analgesics. This might not only skew the results but also indicates that the cognitively impaired are less likely to have their pain effectively assessed and managed compared with cognitively intact individuals. Further research june 2/vol18/no38/2004 nursing standard 37

6 is required to assess the reliability of this tool. Kovach et al (2000) determined nurses perceptions of pain management in late-stage dementia patients with particular reference to which behaviours they identified as being indicators of pain. Facial grimacing and restless body movements were most commonly identified as behavioural indicators of pain. The nurses interviewed worked in long-term care facilities and were likely to know patients well and hence recognise changes in behaviour. These nurses had also received pain management education and so may already have had training in recognising behavioural changes in pain. The ADD (Assessment of Discomfort in Dementia) protocol (Kovach et al 2002) was designed to: Aid accurate assessment of discomfort in people who are unable to verbalise a description of their pain. More accurately treat pain. Decrease inappropriate use of psychotropic drugs. It was developed for use in cognitively impaired people in long-term care. The protocol prompts the assessor to look at behavioural symptoms: facial expressions, mood, body language, voice, behaviour, physical assessment and history of current and past pain. The ADD protocol then gives a list of suggested non-pharmacological and pharmacological interventions, and prompts evaluation of any interventions. This study was limited to long-term care residents with end-stage dementia and was conducted in a larger pain management education project. The protocol was initiated if a resident had physical symptoms, behavioural changes, sleep change or a history of pain or terminal illness. The outcome measures included the administration of analgesics and psychotropic drugs as required, the use of non-pharmacological interventions and changes in behaviour. Results showed a small increase in the amount of analgesic drugs administered. The use of non-pharmacological interventions increased significantly and there was some reduction in behavioural symptoms. There was no significant change in the amount of psychotropic drugs given. The researchers concluded that further validation would be necessary (Kovach et al 2002). The participating nurses reported that the main benefits of the protocol were an increased awareness of discomfort and pain in residents and an improved assessment of that discomfort/pain. Conclusion Assessing pain in cognitively impaired older people is a continuing problem but should not be a barrier to improving pain management. Where cognitive impairment is an additional factor for older Figure 2. Checklist of non-verbal pain indicators (CNPI) Write a 0 if the behaviour was not observed and a 1 if the behaviour occurred, even briefly, during activity or rest With movement At rest 1. Vocal complaints (non-verbal): expression of pain not in words moans, groans, grunts, cries, gasps, sighs 2. Facial grimaces/winces: furrowed brow, narrowed eyes tightened lips, dropped jaw, clenched teeth, distorted expressions 3. Bracing: clutching or holding onto side rails, bed, tray table or affected area during movement 4. Restlessness: constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still 5. Rubbing: massaging affected area. In addition, record verbal complaints 6. Vocal complaints (verbal): words expressing discomfort or pain ouch, that hurts, cursing during movement or exclamations of protest stop, that s enough Subtotal score Total score (Feldt 2000b) 38 nursing standard june 2/vol18/no38/2004

7 people with pain, the key to accurate assessment lies in a combination of time, patience and ingenuity (Latham; 1993). Nurses spend more time with patients than any other health professional group and have a key role to play in the assessment and management of pain. As the patients advocate, nurses caring for this vulnerable patient group should continue to strive towards better pain management, ensuring that expressions of pain are considered whether they are verbal or not. Assessing pain in cognitively impaired older adults requires complex clinical assessment and interpretative skills (Ferrell et al 1990, Forrest 1995, Herr and Mobily 1991, Marzinski 1991). For pain to be managed successfully in this patient group, there is a critical need for education and guidance towards best practice. The literature suggests that verbal reports of pain by cognitively impaired older adults should be acknowledged and acted on. The use of behavioural tools is advocated for those patients who are cognitively impaired and unable to report pain verbally. However, there seem to be as many tools as there are research studies, although all the tools demonstrate similar behaviours, which validate the actual behaviours used. There appears to be no single tool that is appropriate for assessing pain in all cognitively impaired older adults; more research is needed to further validate the effectiveness of these assessment tools. Behavioural assessments appear promising but have not yet received widespread use. Nurses require direction regarding when to use an assessment tool and which one is most appropriate. Studies in this field tend to exclude those with severe cognitive impairment and are seldom performed in acute settings. When original studies are small and/or restricted to a particular setting, replication studies help to validate original findings or prevent spurious findings from influencing practice. Replication may offer a way forward in the search for a reliable pain assessment tool for patients who are cognitively impaired. Many small-scale studies would benefit from replication research to support their use in clinical practice Acknowledgement Staff at the postgraduate medical centre library at the Royal Devon and Exeter Healthcare NHS Trust were most helpful in obtaining the articles required. Implications for practice Patients with cognitive impairment have a right to have their pain assessed. Reports of pain by cognitively impaired older adults are valid and should be acted on. The use of behavioural tools in non-verbal cognitively impaired older people should be considered. Appropriate training in the use of behavioural assessment tools should be given to staff working with cognitively impaired older adults. Accurate and legible documentation is important in planning, evaluating and promoting consistency of care. REFERENCES Brochet B et al (1998) Population based study of pain in elderly people: a descriptive survey. Age and Ageing. 27, 3, Brockopp D et al (1993) Nursing knowledge: acute post-operative pain management in the elderly. Journal of Gerontological Nursing. 19, 11, Chatten C (1995) Break up the pain chain. Journal of Dementia Care. 3, 5, Closs S (1994) Pain in elderly patients: a neglected phenomenon? Journal of Advanced Nursing. 19, 6, Cohen-Mansfield J, Marx M (1993) Pain and depression in the nursing home: corroborating results. Journal of Gerontology. 48, 2, Department of Health (2000) An Organisation with a Memory. Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. London, The Stationery Office. Department of Health (1991) The Patient s Charter. London, HMSO. Feldt K (2000a) The checklist of non-verbal pain indicators (CNPI). Pain Management Nursing. 1, 1, Feldt K (2000b) Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annals of Long Term Care. 8, 9, Feldt K (1996) Treatment of Pain in Cognitive Impaired Versus Intact Post-op Fractured Elders. Doctoral dissertation, University of Minnesota. Dissertation Abstracts International B, Ferrell B (1996) Overview of age and pain. In Ferrell B, Ferrell B (Eds) Pain in the Elderly: Task Force on Pain in the Elderly. Seattle WA, IASP Press. Ferrell B (1991) Pain management in elderly people. Journal of the American Geriatrics Society. 39, 1, Ferrell B, Ferrell B (Eds) (1996) Pain in the Elderly: Task Force on Pain in the Elderly. Seattle WA, IASP Press. Ferrell B et al (1995) Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management. 10, 8, Ferrell B et al (1990) Pain in the nursing home. Journal of the American Geriatrics Society. 38, 4, Fishman B et al (1987) The memorial pain assessment card. Cancer. 60, Forrest J (1995) Assessment of acute and chronic pain in older adults. Journal of Gerontological Nursing. 21, 10, Herr K, Mobily P (1991) Complexities of pain assessment in the elderly: clinical considerations. Journal of Gerontological Nursing. 17, 4, Hurley A et al (1992) Assessment of discomfort in advanced Alzheimer patients. Research in Nursing and Health. 15, 5, Kovach C et al (2002) The assessment of discomfort in dementia protocol. Pain Management Nursing. 3, 1, Kovach C et al (2000) Nurses perceptions of pain assessment and treatment in the cognitively impaired elderly. It s not a guessing game. Clinical Nurse Specialist. 14, 5, Latham J (1993) Treatment we can all believe in: pain and its management in later life. Professional Nurse. 8, 4, Lefebvre-Chapiro S (2001) The DOLOPLUS 2 scale: evaluating pain in the elderly. European Journal of Palliative Care. 8, 5, Marzinski L (1991) The tragedy of dementia: clinically assessing pain in the confused non-verbal elderly. Journal of Gerontological Nursing. 17, 6, McCaffery M (1972) Nursing Management of the Patient with Pain. Toronto, Lippincott. Melzack R (1975) The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1, 3, Moody M (2001) Why nurses end up in court. Nursing Times. 97, 8, Nelson E et al (1987) Assessment of function in routine clinical practice: description of the COOP Chart method and preliminary findings. Journal of Chronic Disability. 40, Suppl 1, 55S-69S. Parke B (1998) Gerontological nurses ways of knowing. Realising the presence of pain in cognitively impaired older adults. Journal of Gerontological Nursing. 24, 6, Parmelee P et al (1993) Pain complaints and cognitive status among elderly institution residents. Journal of the American Geriatrics Society. 41, 5, Parmelee P et al (1991) The relation of pain to depression among institutionalised aged. Journal of Gerontology. 46, 1, Roy R, Thomas M (1986) A survey of chronic pain in an elderly population. Canadian Family Physician, 32, Ryden M et al (1991) Aggressive behaviour in cognitively impaired nursing home residents. Research in Nursing and Health. 14, 2, Sengstaken E, King S (1993) The problems of pain and its detection among geriatric nursing home residents. Journal of the American Geriatrics Society. 41, 5, Simons W, Malabar R (1995) Assessing pain in elderly patients who cannot respond verbally. Journal of Advanced Nursing. 22, 4, Tinker A (1997) Older People in Modern Society. Fourth edition. London, Longman. Wary B et al (1993) Ce vieillard a t il mal? In Roy D, Rapin C (Eds) Douleur et antalgie. Les Annales de Soins Palliatifs june 2/vol18/no38/2004 nursing standard 39