The assessment and management of pain in older people by nurses in acute care: a focused ethnography

Research Doctorate - Doctor of Philosophy (PhD)Introduction: Pain is one of the main reasons why older people (65 years and over) present to hospital. They have the highest rate of admission to hospital involving a multitude of medical and/or surgical procedures and many are associated with acute pain. Older people also often present with histories of existing and multiple pain sources and types. The most common reason for unrelieved pain in acute care settings is the failure of health care providers to systematically assess and treat pain. Pain affects an older person’s health, their ability to function at their optimal capacity both cognitively and physically, and also reduces their quality of life. Older people who are in pain are at risk of sleep disturbances whilst they are an inpatient as well as delayed rehabilitation. Furthermore, it has been shown that an older person who has a higher postoperative pain score, will have a longer stay in hospital and this can lead to chronic functional impairment. Methods: The aims of the study were to explore the culturally mediated practices of registered nurses (RN’s) in acute care settings when assessing and managing pain in older people and to explore the culturally mediated barriers and facilitators to practice. A Qualitative research design was used underpinned by Focused Ethnography. Methods included 1,040 hours in the field with 73 hours of focused observations of nurses (n=9) who cared for older patients (n=42) conducted over a 6 month period. Semi-structured interviews were also held with nurses (n=23) and older patients (n=12). Documents including ward policies, procedures, patient histories and medical notes were also reviewed. The settings for the study were eight wards: medical, surgical, sub-acute and oncology, of two large tertiary referral hospitals in New South Wales Australia. Data were analysed in a range of ways beginning with a qualitative descriptive approach directed by the undertaking of taxonomies, typologies guided by the work of Spradley (1980) and the use of Leininger’s culture care theory (1988), before a content analysis and thematic analysis. Analysis of data showed that when caring for older patients with pain, nurses showed leadership by acting as problem solvers around pain issues and concerns, that they mentored new nurses in relation to pain care, they questioned them about the rationales for their approaches and they provided education to staff, albeit within the limitations of their own knowledge. There were tales of success, how they assessed and rated pain, pain that they acknowledged as real and genuine, and stories of how quality improvement audits shaped what they did. Older patients talked of not being heard by nurses when in pain, of enduring pain, of having to retell their pain histories often, of being moved around from ward to ward, and of being a good patient or an unpopular patient. Observations revealed pain assessment mediated by social rules, rituals and routines for pain care and a range of barriers and facilitators to pain care. There was a lack of continuity of pain care provision from shift to shift, ward to ward, and hospital to hospital and the older people in this study spoke about how difficult it was for them to provide one numerical pain score in the light of their multiple pain sites and types. The older people in this study also spoke of not being heard about their pain, that their pain stories were lost and this meant that at times they experienced frustration. Conclusion: A lack of uptake and use of Evidence Based Practice (EBP) for pain care provision by the acute care RN’s in this study meant that older hospitalised people endured pain. Uptake and use of EBP for pain care provision requires organisational support along with meaningful input from the older people themselves. There is a need for education of RN’s that focuses pain assessment and management in older people and the mechanisms for the uptake of EBP. Clinical supervision that includes external professional input should be mandated to support critical reflection on the care that is provided to older people with pain and how this can be improved