Exploring the great barrier myth: another look at obstacles to effective pain management.

Pain is a common and treatable condition among nursing home residents, yet evidence consistently shows that pain is underdetected and undertreated in this group. The article by Hoffman and Tarzian in this issue of the Journal presents an in-depth examination of barriers to effective pain management as perceived by Directors of Nursing (DONs) from 113 facilities in Connecticut. A cursory glance at the article suggests that the findings are similar to those reported by others and reflect old news. However, the very fact that the findings persist is a reason for concern and should cause us to look beyond these apparent barriers to the true obstacles that lead to inadequate care for residents with pain. A major finding from this study is that lack of knowledge among nursing home nurses and physicians is the leading barrier to effective pain management. Examined together with other findings from the study, this emphasis on lack of knowledge could be misleading. Take, for example, the fact that arthritis was identified as the most prevalent type of pain among nursing home residents. This is consistent with other reports of the etiology of pain among nursing home residents. Lack of knowledge cannot be justified as a barrier for treating arthritis pain. As the authors note and present in Table 1, multiple clinical practice guidelines are readily available for treatment of arthritis and chronic pain. It is instructive to learn that a majority of the DONs interviewed for the study were unable to name a single pain management guideline. Being in a leadership position carries expectations that the leader is accountable for keeping current with existing standards of practice. Another barrier to effective pain management documented in the survey could be more representative of a true obstacle. Although the authors do not define “facility physicians or staff nurses’ attitudes toward treating pain,” some inferences can be made from other studies. Rather than lack of knowledge being the cause of inadequate pain management, lack of motivation could be the true culprit. In their literature review, the authors document examples of inadequate assessment, lack of physician involvement, and inadequate attention to pain on the part of the nursing home staff. The effects of this indifference could extend beyond the immediate absence of needed treatment. Failure on the part of physicians and nurses to ask residents about pain is likely to reinforce existing attitudes among residents that in turn serve as additional barriers to pain management. A resident who is not asked about pain could infer incorrectly that pain is to be expected and not something worth reporting. Interestingly, when asked about pain in a structured manner, many nursing home residents have significant pain to report and a majority of them want treatment with pain medication, yet less than half of those with chronic pain are being treated. As others have noted, the number one reason for failure to treat the pain is failure to assess it. Clearly, there are resident characteristics that could make assessment more difficult. A commonly identified barrier is the high prevalence of cognitive impairment among nursing home residents. However, a closer look at this issue is warranted. A majority of nursing home residents, even those with moderate cognitive impairment, are able to respond to simple questions about the presence and intensity of pain. Unfortunately, the perceived “barrier” of cognitive impairment prevents these residents from being asked about their pain despite the fact that their responses are likely to be as valid and stable as those of less-impaired residents. Attention to the basics of good clinical care will go a long way toward improving quality of care for a majority of nursing home residents with pain. The time is right for this focus on improving pain management in nursing homes. On a national level, the Centers for Medicare and Medicaid Services (CMS) have invested substantial funding for this endeavor. The CMS quality initiative, rolled out in November 2002, has engaged nursing home participants in the quest for improved pain management. Among the 51 state quality-improvement organizations (QIOs), all 51 are working to improve the quality of care for chronic pain and 23 of the QIOs also have initiated methods to improve pain management for the postacute population. An example of one statewide strategy is the effort implemented in California using the Institute for Healthcare Improvement Collaborative Breakthrough model. Four regional collaboratives have been developed that emphasize testing evidence-based pain assessment and management strategies, as well as methods for overcoming structural and institutional barriers. Successful interventions are disseminated to all other participants with strategies for implementation. Rather than simply providing didactic information about pain, this model represents a paradigm shift in which participants engage in a hands-on approach to recognizing and confronting potential barriers in their facilities. Peer support and reports of success from other collaborative parUCLA School of Nursing, Los Angeles, California.