Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: an ethnographic study.

AIM: The aim of this project was to examine pain management practices with older people admitted to the colorectal unit of an acute hospital trust.

BACKGROUND: Although pain assessment and management are judged to be a priority, little research has examined the care older people receive in the acute surgical setting. Thus, pain in older people (65 years and over) can be under recognized and unrelieved. With the number of older people requiring surgery increasing, it is important to identify factors in the practice context that enhance or inhibit effective pain management.

DESIGN: The project drew upon an in-depth ethnographic approach.

METHOD: Sixty-two hours of around the clock, non-participant observation of nursing practice was completed. Thirty-nine (78%) nurses and forty-six (42%) patients were observed. Seven (6%) additional patients participated in pre- and postoperative interviews and 35 (90%) nurses completed the Nursing Work Index--Revised Questionnaire.

FINDINGS: Holistic pain assessment for older people was found to be deficient in the acute surgical setting. Nurses appeared unaware of the importance of addressing the particular pain needs of older patients. Inflexible analgesic prescriptions provided the mainstay treatment of pain, with minimal consideration given to non-pharmacological strategies. Older people wanted to be active participants in their care. However, existing pain management practices disempowered older patients, making them reluctant or unable to discuss their pain with ward staff.

CONCLUSION: Comprehensive pain assessment, improved documentation and proficient communication, inclusive of older patients, are necessary to improve pain management practices. It is imperative that patients, nurses, doctors and Acute Pain Service work in collaboration to challenge pain management practices and implement change.

RELEVANCE TO CLINICAL PRACTICE: The project demonstrated some of the multiple and complex factors that affect the older persons' pain experience and identified three action research cycles for further development work.