Date of Award


Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Christine Kovack

Committee Members

Kim Litwack, Jung Kwak, Julie Ellis


Assessment, Certainty, Dementia, Nursing Home Residents, Pain, Treatment


Despite advances in dementia care Pain in people with dementia is still under recognized, underestimated, and undertreated because of poor assessment, poor treatment, and factors relating to nurses’ critical thinking and decision-making skills. Unrelieved pain leads to many serious negative health outcomes in people with dementia. The purpose of the study was to examine temporally based relationships between change in behavior, the nurses’ level of certainty regarding pain, assessment scope and outcomes of pain and agitation. Relationship between severity of dementia, comorbid burden, ability to verbally self-report symptoms and patient outcomes of pain and agitation was also investigated.

A Convenient sample of 78 nursing home residents with dementia was selected from 5 nursing homes in Amman, Jordan. The average age of the participants was 72. 52 years and 56.0% of them were men. Nurses’ level of certainty regarding suspected pain was examined with one item Likert Scale. Scope of pain assessment was coded and collected directly from change tracking sheets. Pain was measured by Discomfort Scale for Dementia of Alzheimer’s Type. Agitation was measured by Wisconsin Agitation Inventory tool. Severity of dementia was measured by the Mini Mental State Examination. Comorbid burden was measured by Cumulative Illness Rating Scale for Geriatrics and obtained from medical records. Ability to verbally self-report symptoms was measured by Communication of Need – Dementia Alzheimer’s Type tool.

The findings of the original study are consistent with the RCP model, but inconsistent with literature that shows that agitation is caused by multiple factors.

This study found an excessively high percentage of variances accounted for by nurses’ level of certainty due to potential measurement errors, the preliminary nature of this study, and potential unexpected uncontrolled confounding variables. The findings that comorbid burden and ability to verbally self-report symptoms are significant predictors of patient outcomes are consistent with previous studies. The finding that the relationship between comorbid burden and patient outcomes could not be explained by ability to verbally self-report symptoms is consistent with previous studies. The discussion of results and the interpretation of findings should be presented with caution and replicated before being applied to practice or theory derivation. While findings must be replicated with other samples, this study may provide a new understanding of the relationship between nurses’ certainty, assessment scope, and patient outcomes for PWD. Improved understanding of comorbid burden and the ability of PWD to verbally self-report symptoms and how they relate to the problem of unrelieved pain in PWD is crucial.

Arabic MMSE.pdf (648 kB)
Arabic MMSE

arabic version of Nurse consent.pdf (5275 kB)
Arabic Version of Nurse Consent

arabic version of patient consent.pdf (5594 kB)
Arabic Version of patinet Consent

arabic version of proxy consent.pdf (6872 kB)
Arabic Version of Proxy Consent