| Summary: | Background: The National Confidential Enquiry into perioperative deaths (NCEPOD, 1999) reported that the majority of older patients (65 years or over), notified to them, underwent surgery in hospitals with established Acute Pain Services (APS). Nevertheless, only a minority had basic pain assessment charts recorded. The Report subsequently recommended that pain teams must work towards addressing pain management issues that are particular to older people. However, research evidence in this field suggests that healthcare professionals experience difficulties in meeting the needs of older people and integrating evidence into daily practice. With the number of older people requiring surgery increasing, it is important to identify and address factors in the practice context that enhance or inhibit effective pain management. Aims: Working as a researcher/facilitator with healthcare staff in two acute surgical wards this project aimed to; (i) implement and evaluate a programme of development that enabled the team to critically analyse practice and put existing research into practice; (ii) develop an understanding of factors in the practice context that enhance or inhibit effective pain management; (iii) and develop effective team working to enhance pain management practices with older people. Methodology: Drawing upon an Emancipatory Action Research approach and utilising the Promoting Action on Research Implementation in Health Services (PARIHS) framework (Kitson et al 1998) to guide the study, nursing staff identified three overarching action cycles that appeared to impact upon pain management practices with older people (communication, interruptions, and pain assessment practices). Working with nursing staff, five focus groups, three workshops, eighteen reflective sessions, twenty-seven critical companionship meetings and twenty-six ad hoc meetings, were completed. To consolidate and affirm the data, nonparticipant observation of nursing practice was completed (46 hours), older patients were invited to participate in semi-structured interviews (n=6) and thirty (83%) registered nurses completed the Nursing Work Index-Revised questionnaire (NWI-R, Aiken and Patrician 2000). Results: Data analysis revealed the complexity of context. Clarification and refinement of the emerging themes resulted in the development of a conceptual framework. Three key themes (psychological safety, leadership, oppression) and four sub-themes (power, horizontal violence, distorted perceptions, autonomy) emerged as significant to nursing practice and context. Conclusion: It is argued that context, effective leadership and the creation of a psychologically safe environment have a significant impact upon all aspects of nursing practice (including pain management practices with older people) in the acute surgical setting. Facilitated reflective sessions and critical companionship created 'spaces' and supported individuals and groups to learn. This resulted in a culture that was more open and willing to work towards a shared vision for effective person-centred nursing practices.
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