The sustainability of evidence-based pain management practices in aged care

Abstract

Despite there being acknowledgement by the aged care industry of the presence of complex persistent pain in older people living in residential care facilities (RCFs), pain continues to be under-recognised and poorly managed. This is particularly the case for residents from culturally and linguistically diverse (CALD) groups and those living with dementia. Some initiatives in this area include the development of multiple assessment tools, advancement of pharmacological and non-pharmacological strategies, the development of best practice guidelines and increased education. However, little advancement has been made in establishing and sustaining best practice in this area of care. There is also a lack of research examining how knowledge and best practice, on a broader scale, are sustained within RCFs, through ongoing learning.Using a mixed methods approach, this research, conducted in two phases, aimed to identify what factors impact on organisational knowledge and the sustainability of evidence-based (EB) pain management practices in aged care. Phase One was conducted in an RCF that had previously implemented the Australian Pain Society’s (APS) best practice guidelines (Goucke et al., 2005) and it investigated what individual and organisational factors impact on the ability of the direct care staff (registered and enrolled nurse, allied health and care workers) to undertake EB pain management practices. Phase Two was conducted in two Registered Training Organisations (RTOs) in Queensland and it investigated, how current education practices for workers with Certificate III in Aged Care (the primary workforce), influence their ability to conduct EB pain management practices.Organisational learning theory (OLT) was utilised in this research, specifically the organisational learning theoretical framework as proposed by Argote and Miron-Spektor (2011). This framework provided the tool for analysing how factors from the external environmental context (e.g. government policy and legislation) and internal contextual factors (organisational and individual), influence the way in which knowledge about pain management practices is attained, retained and transferred (Argote & Miron-Spektor, 2011).The findings of this research indicate that, two years after implementation of EB pain management strategies, best practice was not sustained and a number of resident, staff, organisational and system factors, influenced the maintenance and utilisation of organisational knowledge. This research also found, that Certificate III care workers obtained only basic knowledge of pain identification and management practices in the course, through one hour of education, primarily provided in the palliative care module. They received limited education or mentoring in these practices and processes, once they were employed in a care worker role. Clinical Facilitators (CFs) involved in care worker training, typically had a Certificate III in care work only and had varying levels of experience and knowledge in pain management practices and processes. The teaching methods utilised in the workers’ education were didactic, with use of workbooks or a power point presentation.The results indicate there are significant individual and organisational factors that impact the sustainability of EB pain management practices in aged care. Inadequate maintenance of best practice, affects the older person’s quality of life and contributes to unnecessary suffering. Whilst many of these factors have previously been documented in the literature as impacting on pain management processes in RCFs, there appears to have been minimal advances in resolving the issues. Knowledge regarding pain identification, assessment and management, may be attained through education and the provision of guidelines. However, the utilisation, retention, and transference of this knowledge within aged care facilities, appears to decline after initial implementation. If best practice is to be sustained, managers and clinical leaders in RCFs, need to utilise a framework or model, such as provided in the organisational learning theoretical framework, to identify potential barriers and facilitators, consider what happens beyond the initial implementation phase and strategically plan how the RCF can sustain knowledge and best practice, given their current human and physical resources. The aged care industry, nursing as a professional body and the public at large, needs to pressure the government to improve staff ratios and skill mix. There also needs to be a pressure placed on the government and training providers, to improve the standard of education offered in the Certificate III/IV aged care training material. Improved education for care workers in pain management (and other clinical areas), would better equip them, for work in the current aged care environment, where care that is more complex is required for older people now being admitted to RCFs.If we do not make some considerable efforts to address the ongoing poor recognition and management of pain in RCFs, then we will continue to fail in our duty of care to one of the most vulnerable groups in our population. Older people have the right to have their pain managed appropriately.