Original studies
Nursing home resident barriers to effective pain management: Why nursing home residents may not seek pain medication

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Objectives

Multiple barriers to effective pain management are present in the nursing home setting. The purpose of this analysis was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.

Design

Every 3 months, a 20% sample of residents in 12 nursing homes was administered a short pain interview, then observed for pain indicators. Medical records were reviewed at the same time for documentation about pain and its treatment. All residents were asked if they had pain (or a similar word) now or in the past 24 hours. They were also asked if they had pain but did not request pain medication. If affirmative, the resident was asked to provide up to three reasons for not requesting medication.

Setting

The study was conducted in 12 Colorado nursing homes, located in both urban and rural settings.

Participants

A total of 2033 nursing home residents completed pain interviews and/or were observed for pain indicators by trained research assistants. These interviews took place before, during, and after implementation of an intervention to improve pain practices.

Measurements

A cognitive organizing structure was used to categorize resident responses into a coherent classification. Individual responses were assigned by team members to the appropriate category using a consensus process. The final classification scheme consisted of 10 categories of reasons why residents do not request pain medication.

Results

More than one-half of residents (59.5%) reporting pain in the past 24 hours did not request medication for that pain. Subjects in pain were most likely to state medication concerns or stoicism as the reasons for not requesting pain medication. Concerns about staff reactions to a request or perceptions that the staff was too busy were also mentioned frequently by the residents. Subgroup analyses suggested that residents in pain but not requesting pain medication were significantly more likely to be in rural rather than urban nursing homes (67.9% vs. 52.9%, P ≤ .01), and white as compared to nonwhite ethnicity (60.6% vs. 52.1%, P ≤ .05). They also tended to be older on average (80.4 ± 12.1 years vs. 77.9 ± 12.7 years, P ≤ .01) than residents who did request pain medication. Finally, residents in pain but not requesting pain medication were significantly more likely to report having both continuous (c) and intermittent (i) pain (71.8% [c + i] vs. 61% [c] or 56.5% [i], P ≤ 0.01).

Conclusion

Interventions to reduce pain in nursing home residents need to be responsive to the concerns of the residents. It must be acknowledged that resident preferences and beliefs may lead to declined pain interventions regardless of the staff’s motivation to make the resident more comfortable. Staff nurses also need to make a more concerted effort to systematically assess pain and offer pain medication to residents rather than rely on resident requests.

Section snippets

Methods

We conducted a multifaceted educational and behavioral intervention study to improve nursing home pain practices. A detailed description of the study can be found in the article by Jones et al.22 The setting was 12 rural and urban nursing homes in Colorado, with six selected by the investigators to be intervention sites and six serving as control sites. A 20% random sample of each nursing home’s residents, with over-sampling of Hispanic residents, was interviewed quarterly over the course of

Results

About 10% of the residents approached by the RA declined to participate, due to consent form issues, being too busy, or lack of interest. Some residents were very willing to talk with the RA but were unwilling to sign the consent form. These residents were not included in the study. Slightly more legal guardians refused to allow their relatives to participate than residents themselves. One legal guardian retracted her permission once she received the consent form in the mail. The subject’s data

Discussion

Pain management is a complex problem in nursing homes. More than one-half of residents experience acute pain, persistent pain, or both, of varying etiologies (neuropathic, somatic, and/or visceral) and intensity. Analgesic selection and dosing schedule must consider the intensity and type of pain, other medications the resident may be receiving, and physiologic changes that influence the metabolism and excretion of certain drugs. Physiologic considerations, however, are often overshadowed by

Conclusion

Our categorization of resident barriers is similar to, yet different from, previous categorization schemes. Although we noted concerns about addiction, tolerance, dependence, and side effects, we believe that these reasons all fall under a more general category of concerns about medication. Fatalism or passive reactions to pain did not occur very frequently in this sample of nursing home residents, but “being a good patient” was certainly apparent in the categories reflecting staff concerns and

Acknowledgments

The authors acknowledge the contributions of Jill Scott, Ginny Pepper, Ruby Martinez, Evelyn Casiano, and Lori Jarrell to the nursing home pain project.

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    Supported by Grant U18-HS11093 from the Agency for Healthcare Research and Quality.

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