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Barriers to chronic pain management in community-dwelling low-income older adults: Home-visiting nurses’ perspectives
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Barriers to chronic pain management in community-dwelling low-income older adults: Home-visiting nurses’ perspectives Hyung-Ran Park, PhD, RN, Eunyoung Park, PhD, RN ∗, Jee-Won Park, PhD, RN Ajou University College of Nursing, Suwon, South Korea Received 29 September 2014; received in revised form 30 April 2015; accepted 9 May 2015
KEYWORDS Chronic pain; Pain management; Older adults; Nurses; Community health
Summary This study identified barriers to effective chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives. Four focus group discussions investigated 23 nurses (five to six participants in each focus group) at local homevisiting nursing care centres in Suwon, Korea for data collection. Data were analyzed with inductive thematic analysis. Patient-related, nurse-related, and organizational barriers were identified. Patient-related barriers included limited understanding, lack of success in achieving compliance, continued use of traditional medicines, and financial hardship. Nurse-related barriers were limitations of managing chronic pain, inadequate knowledge and experience, lack of confidence, and uniform interventions. Organizational barriers included inadequate staffing and time constraints, few national support policies, unclear guidance, and limited access to available resources. The nurses’ experiences in caring for older adults with chronic pain provided insights into how nurses perceived barriers to adequate pain management in community-based settings; this may be different from acute care settings. This understanding precedes development of innovative practice strategies for chronic pain management in primary healthcare services. © 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction
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Corresponding author at: Ajou University College of Nursing, Woncheon-dong, Yeongtong-gu, Suwon 443-721, South Korea. Tel.: +82 31 219 7031; fax: +82 31 219 7020. E-mail address: [email protected] (E. Park).
With increased longevity globally, 50—80% of older adults experience chronic pain (Bernhofer & Sorrell, 2012; Ministry of Health & Welfare, 2009). Persistent chronic pain has negative physical and psychosocial influences on daily functioning, including sleep disturbance, depression, anxiety, loneliness, and lack of socialization (American, Geriatrics
http://dx.doi.org/10.1016/j.colegn.2015.05.002 1322-7696/© 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Society Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Dewar, 2006). In particular, low-income older adults in the community report a high prevalence of chronic pain (van Hecke, Torrance, & Smith, 2013). They are unlikely to be treated or managed well due to the high cost burden of pain management (Gaskin & Richard, 2012; Park, Hirz, Manotas, & Hooyman, 2013; Park & Hughes, 2012) and limited resources (Bair et al., 2009). In addition, untreated chronic pain in older adults leads to increasing physical activity difficulties (Gudmannsdottir & Halldorsdottir, 2009; Xu, Descalzi, Ye, Zhuo, & Wang, 2012). Therefore, chronic pain in lowincome older adults is a significant and complex health problem (Dewar, 2006) requiring appropriate management to improve their health and quality of life. Older adults with chronic pain are generally managed in primary care (Henry & Eggly, 2012; Ock et al., 2014). For low-income older adults designated as beneficiaries of the Korean National Basic Livelihood Security System, public health centres provide home-visiting primary care by registered nurses. They perform continuing care after inpatient management or provide preventive care to high-risk groups such as patients with hypertension or diabetes (Ministry of Health & Welfare, 2009; Yang & Lee, 2010). As primary care providers, nurses caring for non-institutionalized older people with low socioeconomic status in particular play a critical role in managing chronic pain in the community (Dewar, 2006). In Korea, home-visiting nurses for low-income older adults conduct educational activities such as exercise, provide information about over-the-counter medication, and coordinate referrals (Ministry of Health & Welfare, 2009; Yang & Lee, 2010). Despite the existence of effective chronic pain management, improving customized assessment and management for older adults and empowering them remains challenging (Karttunen, Turunen, Ahonen, & Hartikainen, 2014). It is therefore essential to identify and overcome major barriers to chronic pain management from the nurses’ perspectives (Egan & Cornally, 2013). Previous studies identified the barriers to optimal chronic pain management in terms of patient-related, healthcare provider-related, and organizational barriers (Dewar, 2006; Egan & Cornally, 2013). There are misconceptions and myths (Weiner & Rudy, 2002), natural consequences of ageing (Bair et al., 2009), and insufficient communication (Matthias et al., 2010) as patient-related barriers. In provider-related barriers, chronic pain knowledge deficits (Kaasalainen et al., 2010) and limited recommendations for future approaches (Park et al., 2013) are included. Organizational-related barriers involve inadequate policies (Kaasalainen et al., 2010), limited resources (Davis, Hiemenz, & White, 2002; Park et al., 2013), few practice guidelines (Smith & Torrance, 2011), and insufficient time and staffing (Wilsey, Fishman, Crandall, Casamalhuapa, & Bertakis, 2008). Most previous studies examined barriers to chronic pain management in institutional settings such as hospitals and nursing homes (Gudmannsdottir & Halldorsdottir, 2009; Teh et al., 2009; Wilsey et al., 2008), and patients’ perspectives (Austrian, Kerns, & Reid, 2005; Davis et al., 2002; Dima et al., 2013; Gudmannsdottir & Halldorsdottir, 2009; Lansbury, 2000; Park et al., 2013; Teh et al., 2009), rather than nurses’ perspectives. There is an urgent need for more investigation of the barriers nurses perceive when caring
for older adults with chronic pain in community settings (Dewar, 2006; Teh et al., 2009). From nurses’ perspectives, a better understanding of the significant barriers to chronic pain management is an initial step towards developing strategies to facilitate primary care nursing practice. Therefore, this study aimed to describe nurses’ experiences and views of barriers influencing chronic pain management during home-visit interventions for low-income older adults living at home.
2. Methods 2.1. Design A qualitative methodology utilizing focus group discussion was employed to collect data. Unlike survey or individual interviews, the focus group method captures group dynamics through interaction and discussion between home-visiting nurses and the individual expression of their views (Kitzinger, 1995). This data collection method obtains a wide range of perspectives from in-depth responses (Barbour & Kitzinger, 1999).
2.2. Setting and participant eligibility The study was conducted at four public health centres (PHC) in Suwon, Korea. Four PHCs were chosen because they reflected nurses’ experiences of chronic pain management in different communities. In Korea, registered nurses from PHCs provide home-visiting care for low-income older adults in the community (Yang & Lee, 2010). The inclusion criteria were registered nurses with direct experience of chronic pain management in home-visiting care for at least three years. Four focus groups were formed with five to six participants in each group. Four to eight informants per group are an optimal size (Kitzinger, 1995).
2.3. Ethical considerations The study was approved by the Institutional Review Board of Ajou University (AJOU-MED-MDB-13-111) and agreed by the home-visiting PHCs in Suwon, Korea. The first author contacted the PHC directors to recruit participation. The directors provided a written advertisement sheet describing the study to home-visiting nurses at regular meeting times. After a week, the first author visited PHC directors, received a list of interested nurses, contacted the nurses, and explained the study. Participants fully understood the issues of confidentiality and anonymity. They were assured that their participation was voluntary and that they could withdraw from the study at any time. Informed consent was obtained before the interview and none of the participants declined participation during focus group interviews.
2.4. Data collection The focus group discussions were held from September through November 2013 in comfortable and convenient PHC conference rooms. The discussions were conducted by a moderator, guiding group dynamics to ensure all
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Barriers to chronic pain management in community-dwelling low-income older adults Table 1
Questions for group discussion guide.
What are the difficulties in managing chronic pain? What led to those difficulties? What are the barriers that disrupt the management? Are there any other barriers? (e.g., aspects of patients, nurses, or organization) What is needed to facilitate chronic pain management?
participants were involved in the discussion. During discussions, two assistant moderators acted as note-takers to observe and capture non-verbal expressions to include this information from the discussion. Each discussion lasted around an hour and a half. The discussion was recorded with digital voice-recorders for transcription and analysis. Data were collected with a semi-structured discussion guide developed based on literature review focused on the aim of this study (Matthias et al., 2010). The suggested guide used health care providers’ (including nurse specialists) experiences about barriers to assessing and managing chronic pain in primary care clinics (Matthias et al., 2010). Participants were asked a broad initial question: ‘What are the difficulties in managing chronic pain?’ Table 1 provides an overview of the other question items.
Table 2
Subthemes and nodes of nurse-related barriers.
Subthemes
Nodes
Limitations of managing chronic pain
Misconceptions about chronic pain: ‘cannot be resolved’ Psychological pressure on the results of pain management Limitations of managing pain: ‘does not seem to improve pain’ Reluctance to administer pain-relieving medications Difficulty in pain assessment due to a variety of individual differences in pain expression Difficulty in objective understanding of chronic pain Difficulty in assessment due to a long period of chronic pain Lack of professional knowledge about chronic pain assessment Inadequate knowledge for individual approaches Inadequate experience about optimal pain management strategies Undermanaging chronic pain due to the unclear cause Limited assurance of pain management for older persons with multiple illnesses Uncertainty about chronic pain resolution Hesitancy in active recommendations or advice for chronic pain management Passive management of chronic pain by referral to hospitals Insufficient evidence-based management for chronic pain Stereotyped strategies
Inadequate knowledge and experience
Lack of confidence
2.5. Data analysis The data were analyzed with inductive thematic analysis. Thematic analysis is a flexible and useful method for understanding rich and detailed meaning within the data (Braun & Clarke, 2006). To prevent bias, authors did not review previous studies until after data analysis except for discussion guide development. The recorded discussions were transcribed verbatim and read by the first author for transcript validation and contextual understanding. She also reviewed notes for nonverbal behavioural connections with transcripts. Each transcript was coded using QSR International’s NVivo 10 qualitative data analysis software. After each author independently elicited initial nodes to enhance reliability, we focused on the level of participants’ consensus within each group of expressed ideas. That was because ideas emerged with natural agreement by the majority of participants, rather than by a single person, through group dynamics, or intensity or frequency of expressed ideas during discussion (Doody, Slevin, & Taggart, 2013). Two authors read once for contextual understanding. They then re-read to elicit 84 initial nodes based on the discussion guide questions. Similar meaning nodes were then sorted into sub-themes. Different coding contents and naming were cross-examined and changed through consensus discussion between two authors. The final 50 nodes and 12 sub-themes were merged into four themes. The examples of subsequent subthemes and nodes in nurserelated barriers to chronic pain management are shown in Table 2. All authors critically reviewed and agreed on the themes. The final themes and subthemes are presented in Table 3. In terms of credibility, a participant from each group was invited by e-mail to check the meaning of preliminary interpretations (Doody et al., 2013).
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Uniform interventions
Table 3
Barriers to chronic pain management.
Themes
Subthemes
Patient-related barriers
Limited understanding Lack of success in achieving compliance Continued use of traditional medicines Financial hardship Limitations of managing chronic pain Inadequate knowledge and experience Lack of confidence Uniform interventions Inadequate staffing and time constraints Few national support policies Unclear guidance Limited access to available resources
Nurse-related barriers
Organizational barriers
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H.-R. Park et al. Table 4
Participant general characteristics N = 23.
Variables Age
Education
Experience as a community nurse Experience as a registered nursea
a
duration, they continuously added the patches without consultation, thereby overdosing on painkillers. (P-12)
N (%) 30—39 40—49 50—59 Associate degree Bachelor’s degree Master’s degree ≤4 5—9 ≥10 ≤4 5—9 10—19 ≥20
2 (8.7) 15 (65.2) 6 (26.1) 15 (65.2) 6 (26.1) 2 (8.7) 13 (56.5) 7 (30.4) 3 (13.1) 8 (34.8) 6 (26.1) 8 (34.8) 1 (4.3)
Excluding experience as a community nurse.
3. Results 3.1. Participant demographic characteristics Twenty-three participants with a median age of 46 years (range 32—53) participated in this study. Community nurse experience was 3—13 years (median = 5.7) and registered nurse experience was 1—23 years (median = 8.0; Table 4). Analysis of the data revealed that concerns could be grouped into three key areas, namely; patient-related, nurse-related, and organizational barriers to chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives (Table 3).
3.2. Patient-related barriers Participants perceived patient-related factors, including limited understanding, poor compliance achievement, continued traditional medicine use, and financial difficulty as barriers to optimal pain management. 3.2.1. Limited understanding Participants stated that older patients often applied pain relief self-management based on inaccurate knowledge. Such inappropriate attempts during exercise or self-care techniques were likely to aggravate rather than reduce their pain. Furthermore, patients’ perceived limited understanding about drug reactions and side effects contributed to taking their medications differently than prescribed. One of the cases where most people lack knowledge is oedema. Even when I tell them to rest, they keep exercising. When I ask them to take a cold pack, they just think, ‘Anything warm will do’, or even ‘I should walk around even if it hurts’. When they are exercising while sick and feel pain growing, they should get some rest and relax. But they think ‘I should be exercising’ regardless of how much pain they are feeling. (P-1) When older patients feel their pain is aggravated, they put medicated patches all over their body, even the forehead. Besides not considering drug administration
3.2.2. Lack of success in achieving compliance The participants reported poor compliance with chronic pain management exercise regimes. Generally, their patients had age-related changes such as poor concentration, reduced stamina, and declining memory. These age-related physical or cognitive changes led to limited desire for active pain management participation. Even if they began to exercise when recommended, they struggled with unrelieved ongoing pain over short periods of time and quit the exercise programme. While complaining about the pain amount. . ., the compliance rate is extremely low. When we teach 100 patients a workout during house visits. . ., 10 patients are the maximum we get who actually show the will. . . They do not believe they can be better with that exercise because they have continuously been in pain. They feel desperate that they will be in pain for good. . . Probably, they can’t be bothered doing anything because of pain and reduced physical strength. (P-2) 3.2.3. Continued use of traditional medicines Older patients trusted and followed unverified experiences from acquaintances rather than utilizing education or advice from healthcare providers. The participants described patients who adhered to personal experiences based on inaccurate knowledge obstructing proper pain management education and intervention. The participants sometimes felt that whatever they taught their patients did not work because of their conviction in their own folk remedies. Older persons often have burns (moxibustion marks) all over the body since they carelessly use moxibustion and apply cupping treatment by themselves at home. The wound festers due to burns. . . but no matter how much I tell them, it doesn’t really work at all. . . They are stubborn and accustomed to doing it their own way, which they think is best rather than going to hospitals, even if I recommend other options. (P-4) 3.2.4. Financial hardship The participants perceived that their patients’ financial difficulties as basic living stipend recipients could interfere with active pain management. Some patients with limited incomes could not receive sufficient pain management due to the high care costs of medical institutions. Additionally, according to the participants’ comments, patients seemed to believe that their families would suffer from the cost burden of the treatment. Because of financial instability, family members’ objections to pain treatment might also prevent patients from seeking proper care. There are older people who reject treatment because of financial difficulties. Their first priority is their living. . . In many cases, those who can’t afford to pay for treatment are not likely to steadily receive medical treatment for chronic pain. (P-15)
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Barriers to chronic pain management in community-dwelling low-income older adults When I visited a low-income older patient with aggravating pain and discussed referral to a hospital for aggressive care with family caregivers, they sometimes said ‘What we do is none of your business’.. . . In such cases, it is difficult to persuade them to take older patients to a hospital for further evaluation. (P-12)
3.3. Nurse-related barriers Home-visiting nurses were aware of their lack of abilities, attitudes, and practices for chronic pain management. 3.3.1. Limitations of managing chronic pain The participants reported that their own previous misconceptions were related to poor pain management. Faced with prolonged patient pain complaints during home visits, they felt ineffective and found pain management difficult. They were likely to passively manage chronic pain because it ‘cannot be fully cured’ or ‘cannot be resolved’. In addition, they often put more value on non-pharmacological interventions such as exercise rather than medications. Their own interpretations of their patients’ pain led to reluctance to administer medications, thus undermanaging the pain. ‘Why does the elderly’s knee pain continue despite my repeated visits? Why is my role like this? What am I missing?’ is what I thought. However, chronic pain doesn’t go away; we prevent it from getting worse, but we thought that the patients should all get better. (P-4) 3.3.2. Inadequate knowledge and experience According to participants, inadequate knowledge and experience interfered with satisfactory pain assessment and management. They had difficulty understanding patients’ pain objectively and professionally due to the subjective nature of pain and individual differences in patients’ expressions. Some patients exaggerated and some underreported the amount of pain they were feeling. Their difficulty hindered proper nursing assessment and intervention. Furthermore, inadequate knowledge about chronic pain management made it difficult to perform individualized interventions. Concerning pain assessment using visual analogue scales, for example, I think a patient is feeling pain at a level 4 or 5, but she tells me it is at a level 8 or 9. It seems like the numbers aren’t very exact. It differs by each individual’s personality. . .so I cannot make decisions considering my lack of professional knowledge. I have not received any intensive education on chronic pain management. (P-4) 3.3.3. Lack of confidence A lack of confidence in providing interventions was a barrier to effective pain management. They lacked confidence because the cause of their patients’ pain was often unclear, particularly for those with multiple illnesses. In such cases, participants expressed that they could not educate patients or provide interventions with confidence. Uncertainty about chronic pain resolution led participants to passive management by referral to hospitals for help or letting their patients select therapeutic options.
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When the cause can’t be found at hospitals, in spite of several diagnostic tests for a lot of chronic pain, I’m not confident in managing chronic pain. . . In particular, it is difficult to care for those with various chronic diseases. (P-18) Questions often arise about how much I have to do for older patients. Sometimes I worry about their worsening conditions heard on the phone from their family members. I was constantly in fear of their complaints because I’m unsure about what I provide. Even though I have been visiting older patients for the last 10 years, I still lack confidence in assessing and managing their persistent pain. Accordingly, I couldn’t insist on what they should do when giving instruction during home visits. (P-6) 3.3.4. Uniform interventions The participants recognized that their own stereotyped strategies obstructed chronic pain management. Because of their own skill and knowledge deficits, they lacked the capacity to make decisions on types of pain management specific to patients’ chronic pain characteristics. Instead of individualized recommendations, they provided their patients with medicated patches, moderate exercises, or stress management methods as standard interventions. Regardless of individual characteristics, I always provide medicated patches and a standardized education about exercise. . . For overweight patients with persistent pain, I educate them with one-size-fits-all approaches, such as weight control, nutrition, and stress management every time I visit. . . We (home-visiting nurses) can’t consider what best fits for each person. Without a specific basis for the pain management offered, our intervention is just a stereotyped set regardless of personal conditions. (P-7)
3.4. Organizational barriers When providing home-visiting nursing care, a number of structural and systematic problems inhibited effective chronic pain management practices. 3.4.1. Inadequate staffing and time constraints Inadequate levels of staffing and time necessary for homevisiting care were significant organizational barriers to sufficient chronic pain management. Each nurse was in charge of 500—600 homes and visited seven homes on average per day. This limited available time had a significant impact on the participants’ ability to undertake individualized assessment and interventions. They also stated that it was difficult to cooperate with other healthcare specialists because there were not enough personnel. It takes up too much time. If it takes over an hour at one home, I can’t visit other homes. I was very willing when I first started home visits, but now I’m tired and I also have to see others. . .We aren’t taking care of a hundred, but hundreds, so it can’t be done. When I’m concentrating on one home, the others complain. That’s what’s most difficult: just too many patients to handle. (P-8)
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H.-R. Park et al. First, what I think is difficult is the lack of cooperation and connection. . . because there are no other employees. Also, we don’t have enough time to stay at one home because of time pressure. We can’t stay at one place for one hour or two. . . (P-6)
3.4.2. Few national support policies The participants thought that the lack of national financial and political support for low-income groups was a significant barrier to adequate chronic pain management. Their patients cannot handle the financial burden of visiting welfare facilities for chronic pain management. In Korean home-visiting nursing care services, chronic pain is not considered a top care priority; concentrated management is difficult. Our patients, recipients of basic living, can’t use a swimming pool if they don’t have the money. . . They have to pay 50% to use it, but they can’t. (P-4) Our major work is related to chronic diseases, such as hypertension and diabetes, not chronic pain. So, we cannot take sensitive care of pain. During home visits, we have no choice but to incompletely care for older patients with chronic pain due to a low proportion of national support policies. . .. For most cases, home-visiting care is associated with hypertension and diabetes. (P-9) 3.4.3. Unclear guidance The participants perceived few detailed assessment and intervention guidelines as a barrier to chronic pain management. If there were consistent and systematic guidelines, they would have effectively managed chronic pain with confidence. Since I have been continuously educated about the hypertension and diabetes guidelines, certainly I can provide information and evidence on those situations with much confidence. But chronic pain’s too comprehensive. Like a manual, intervention guidelines would be helpful to be more familiar with actions to take care of chronic pain. If so, I may feel confident to act upon it when faced with the situation. (P-10) 3.4.4. Limited access to available resources The participants recognized that limited resource accessibility obstructed chronic pain management. They reported that a major reason for limited care access was their patients’ likelihood to decrease their physical activities due to age and persistent pain. In addition to declining functioning in their daily life, limited transportation is an obstacle to free access to community healthcare services. Thus, older patients were not able to access welfare facilities at long distances without other caregivers. First, they can’t go out to take the bus because they are old with damaged joints. . . They also need someone who is by their side to take and bring them back. Actually, it is best if we can be there, but I feel sorry because they live alone. (P-7)
It’s too far (the distance). Old people make very limited use of the facilities. That’s difficult for people who live at quite a distance. (P-11)
4. Discussion This study identified barriers to effective chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives. Patient-related, nurse-related, and organizational barriers to chronic pain management were categorized.
4.1. Patient-related barriers First, limited understanding included misconceptions about drug reactions, side effects, or exercises. Because of the fear of addiction and side effects, older adults who are hesitant to take medications may prefer unverified traditional medicines (Davis et al., 2002; Dewar, 2006; Egan & Cornally, 2013). In addition, older adults lacked success in achieving compliance mainly due to age-related changes such as declining physical and cognitive ability. This finding is consistent with previous studies (Cornally & McCarthy, 2011; Egan & Cornally, 2013). Age-related cognitive problems interfering with pain assessment and management created undertreatment risk (Egan & Cornally, 2013). Moreover, low-income older adults’ financial difficulties were risks for insufficient pain management. This is consistent with previous studies (Davis et al., 2002; Dima et al., 2013; Gudmannsdottir & Halldorsdottir, 2009; Lansbury, 2000) suggesting that family burden from high healthcare service costs contributed to adjusted or discontinued pain management. However, arbitrary treatment adjustment or discontinuation was a major concern for primary care nurses of community elderly since such self-management methods could aggravate persistent pain. Accordingly, nurses should focus on how to easily deliver ‘accurate’ information in education sessions particularly to those with cognitive impairment. It is also important that nurses encourage older patients to express pain in a timely manner during assessment and management (Egan & Cornally, 2013), rather than to tolerate it. Therefore, nurses as primary health care providers should recognize several patient-related barriers to relieving pain. These strategies, which consider individual situations such as financial difficulty, may contribute to motivating older adults with persistent pain to seek proper pain-relieving methods and adhere to recommended management.
4.2. Nurse-related barriers Because the nurses reluctantly gave pain medications to older adults for fear of overmedication, they preferred non-pharmacological interventions such as exercises. These attitudes and beliefs were consistent with previous studies that a significant problem of healthcare providers for older people was excessive caution about giving analgesics (Dewar, 2006; Egan & Cornally, 2013; Jablonski & Ersek, 2009; Kaasalainen et al., 2007).
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Barriers to chronic pain management in community-dwelling low-income older adults In addition to limitations of managing chronic pain, nurses who lacked confidence due to inadequate knowledge and experience likely underestimated their patients’ pain. Because patients’ pain verbalizations often did not match their nonverbal cues, nurses reported difficulty believing pain reports. This discrepancy resulted in inappropriate pain management (Karttunen et al., 2014). Due to cognitive impairment and underlying illnesses, pain assessment is more complex in older adults (Dewar, 2006). To accurately detect pain existence and severity, nurses should use a variety of assessment tools including behavioural ones. Given atypical and complex pain expression characteristics in older people, it is essential to develop well-defined, efficient screening tools and guidelines. Inadequate knowledge and clinical experience is therefore a major barrier leading to uncertainty about pain assessment and management best practices. Considering the study participants’ years of experience, it is surprising that they still felt lacking in nursing knowledge and clinical experience. Tailored ongoing nursing education is necessary based on their specific knowledge needs about chronic pain characteristics, underlying illnesses, and proper educational methods for older adults (Dewar, 2006). Most significantly, uniform intervention strategies were serious pain management problems, potentially leading to older adults’ inadequate motivation. Standardized intervention or non-interactive teaching methods, such as stereotyped exercise printouts or leaflets, did not motivate older adults to practical exercise or other recommended strategies for pain relief (Dima et al., 2013; Park et al., 2013). Thus, for example, a daily exercise programme should be individualized and realistic, considering usual individual lifestyle or implementation difficulties (Lansbury, 2000; Park et al., 2013).
4.3. Organizational barriers This was consistent with suggestions that lack of personnel and time for adequate pain assessment and patient interaction remains a stubborn problem for primary care nurses globally (Egan & Cornally, 2013). In particular, since national support policies do not focus on chronic pain, clear guidance in chronic pain management is lacking in Korea. These are eventual access barriers to low-cost management strategies for older adults living in poor socioeconomic surroundings. This suggests that Korean low-income older adults could be a risk group for chronic pain management, similar to those studies showing that lower socioeconomic level patients experience greater chronic pain intensities (Fisher et al., 2013; van Hecke et al., 2013). In addition to the absence of related policies and practical guidelines, inadequate resources obstruct care continuity (Wilsey et al., 2008) as a critical element of primary nursing care. In Korea, the main reasons for limited resource access, such as community-based exercise programmes for older adults in PHCs, were related to insufficient budget, individual financial difficulty, high care cost, and inconvenient transportation services (Park et al., 2013). Given the limited resource access in Korea, low-income older adults may need easily accessible and inexpensive daily home-based exercise pain relief programmes based
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on individual preferences and lifestyle concerns (Lansbury, 2000). When designing home-based exercise programmes, home-visiting nurses need to focus on patients’ compliance with behavioural changes towards pain relief. Thus, nurses may provide exercise programmes using a pamphlet with big pictures of each body movement for patients to easily learn and practice on a daily basis (Austrian et al., 2005; Park et al., 2013). There are some limitations. Because this study analyzed Korean home-visiting nurses’ perspectives, generalizability of qualitative research should be considered when applying study findings to other cultures and contexts (Horsburgh, 2003). Thus, further studies should be replicated within other cultures and situations where nurses provide similar care but may have different experiences. Further investigation also should consider cultural influences on nurses’ perceived pain management barriers. In addition, data collection mainly depended on focus group interviews, reflecting the nurses’ perspectives, not patients’, on chronic pain management barriers. Further research is needed to compare nurses’ and their patients’ perspectives because understanding the differences is essential for effective pain management.
5. Conclusion Despite these limitations, this study contributes to a better understanding of pain management barriers for low-income community-dwelling older adults. Significant patient-related, nurse-related, and organizational barriers from home-visiting nurses’ perspectives were identified. Nurses’ experiences in caring for older adults with chronic pain provided insights into how nurses perceived barriers to and what they needed for adequate pain management in community-based settings, which may be different from acute care settings. This understanding precedes development of innovative practice strategies for chronic pain management in primary healthcare services, such as individualized educational methods/materials for nurses as well as for patients.
Contributors HRP, EP, and JWP contributed to the study conception and design. HRP collected the data. HRP and EP contributed to data analysis and interpretation, and the draft and critical revision of the manuscript. JWP critically reviewed the draft manuscript. All authors approved the final manuscript for publication.
Funding This research was funded by the Department of Nursing Science, Graduate School of Ajou University (M-2013-C046000007) in Suwon, South Korea.
Conflicts of interest None declared.
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Ethical approval The study was approved by the Institutional Review Board of Ajou University (AJIRB-MED-MDB-13-111).
Acknowledgements We would like to acknowledge Dr. Jungsik Park who proofread the manuscript as well as the home-visiting nurses who participated in this study.
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Collegian (2015) xxx, xxx—xxx
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Barriers to chronic pain management in community-dwelling low-income older adults: Home-visiting nurses’ perspectives Hyung-Ran Park, PhD, RN, Eunyoung Park, PhD, RN ∗, Jee-Won Park, PhD, RN Ajou University College of Nursing, Suwon, South Korea Received 29 September 2014; received in revised form 30 April 2015; accepted 9 May 2015
KEYWORDS Chronic pain; Pain management; Older adults; Nurses; Community health
Summary This study identified barriers to effective chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives. Four focus group discussions investigated 23 nurses (five to six participants in each focus group) at local homevisiting nursing care centres in Suwon, Korea for data collection. Data were analyzed with inductive thematic analysis. Patient-related, nurse-related, and organizational barriers were identified. Patient-related barriers included limited understanding, lack of success in achieving compliance, continued use of traditional medicines, and financial hardship. Nurse-related barriers were limitations of managing chronic pain, inadequate knowledge and experience, lack of confidence, and uniform interventions. Organizational barriers included inadequate staffing and time constraints, few national support policies, unclear guidance, and limited access to available resources. The nurses’ experiences in caring for older adults with chronic pain provided insights into how nurses perceived barriers to adequate pain management in community-based settings; this may be different from acute care settings. This understanding precedes development of innovative practice strategies for chronic pain management in primary healthcare services. © 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction
∗
Corresponding author at: Ajou University College of Nursing, Woncheon-dong, Yeongtong-gu, Suwon 443-721, South Korea. Tel.: +82 31 219 7031; fax: +82 31 219 7020. E-mail address: [email protected] (E. Park).
With increased longevity globally, 50—80% of older adults experience chronic pain (Bernhofer & Sorrell, 2012; Ministry of Health & Welfare, 2009). Persistent chronic pain has negative physical and psychosocial influences on daily functioning, including sleep disturbance, depression, anxiety, loneliness, and lack of socialization (American, Geriatrics
http://dx.doi.org/10.1016/j.colegn.2015.05.002 1322-7696/© 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Society Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Dewar, 2006). In particular, low-income older adults in the community report a high prevalence of chronic pain (van Hecke, Torrance, & Smith, 2013). They are unlikely to be treated or managed well due to the high cost burden of pain management (Gaskin & Richard, 2012; Park, Hirz, Manotas, & Hooyman, 2013; Park & Hughes, 2012) and limited resources (Bair et al., 2009). In addition, untreated chronic pain in older adults leads to increasing physical activity difficulties (Gudmannsdottir & Halldorsdottir, 2009; Xu, Descalzi, Ye, Zhuo, & Wang, 2012). Therefore, chronic pain in lowincome older adults is a significant and complex health problem (Dewar, 2006) requiring appropriate management to improve their health and quality of life. Older adults with chronic pain are generally managed in primary care (Henry & Eggly, 2012; Ock et al., 2014). For low-income older adults designated as beneficiaries of the Korean National Basic Livelihood Security System, public health centres provide home-visiting primary care by registered nurses. They perform continuing care after inpatient management or provide preventive care to high-risk groups such as patients with hypertension or diabetes (Ministry of Health & Welfare, 2009; Yang & Lee, 2010). As primary care providers, nurses caring for non-institutionalized older people with low socioeconomic status in particular play a critical role in managing chronic pain in the community (Dewar, 2006). In Korea, home-visiting nurses for low-income older adults conduct educational activities such as exercise, provide information about over-the-counter medication, and coordinate referrals (Ministry of Health & Welfare, 2009; Yang & Lee, 2010). Despite the existence of effective chronic pain management, improving customized assessment and management for older adults and empowering them remains challenging (Karttunen, Turunen, Ahonen, & Hartikainen, 2014). It is therefore essential to identify and overcome major barriers to chronic pain management from the nurses’ perspectives (Egan & Cornally, 2013). Previous studies identified the barriers to optimal chronic pain management in terms of patient-related, healthcare provider-related, and organizational barriers (Dewar, 2006; Egan & Cornally, 2013). There are misconceptions and myths (Weiner & Rudy, 2002), natural consequences of ageing (Bair et al., 2009), and insufficient communication (Matthias et al., 2010) as patient-related barriers. In provider-related barriers, chronic pain knowledge deficits (Kaasalainen et al., 2010) and limited recommendations for future approaches (Park et al., 2013) are included. Organizational-related barriers involve inadequate policies (Kaasalainen et al., 2010), limited resources (Davis, Hiemenz, & White, 2002; Park et al., 2013), few practice guidelines (Smith & Torrance, 2011), and insufficient time and staffing (Wilsey, Fishman, Crandall, Casamalhuapa, & Bertakis, 2008). Most previous studies examined barriers to chronic pain management in institutional settings such as hospitals and nursing homes (Gudmannsdottir & Halldorsdottir, 2009; Teh et al., 2009; Wilsey et al., 2008), and patients’ perspectives (Austrian, Kerns, & Reid, 2005; Davis et al., 2002; Dima et al., 2013; Gudmannsdottir & Halldorsdottir, 2009; Lansbury, 2000; Park et al., 2013; Teh et al., 2009), rather than nurses’ perspectives. There is an urgent need for more investigation of the barriers nurses perceive when caring
for older adults with chronic pain in community settings (Dewar, 2006; Teh et al., 2009). From nurses’ perspectives, a better understanding of the significant barriers to chronic pain management is an initial step towards developing strategies to facilitate primary care nursing practice. Therefore, this study aimed to describe nurses’ experiences and views of barriers influencing chronic pain management during home-visit interventions for low-income older adults living at home.
2. Methods 2.1. Design A qualitative methodology utilizing focus group discussion was employed to collect data. Unlike survey or individual interviews, the focus group method captures group dynamics through interaction and discussion between home-visiting nurses and the individual expression of their views (Kitzinger, 1995). This data collection method obtains a wide range of perspectives from in-depth responses (Barbour & Kitzinger, 1999).
2.2. Setting and participant eligibility The study was conducted at four public health centres (PHC) in Suwon, Korea. Four PHCs were chosen because they reflected nurses’ experiences of chronic pain management in different communities. In Korea, registered nurses from PHCs provide home-visiting care for low-income older adults in the community (Yang & Lee, 2010). The inclusion criteria were registered nurses with direct experience of chronic pain management in home-visiting care for at least three years. Four focus groups were formed with five to six participants in each group. Four to eight informants per group are an optimal size (Kitzinger, 1995).
2.3. Ethical considerations The study was approved by the Institutional Review Board of Ajou University (AJOU-MED-MDB-13-111) and agreed by the home-visiting PHCs in Suwon, Korea. The first author contacted the PHC directors to recruit participation. The directors provided a written advertisement sheet describing the study to home-visiting nurses at regular meeting times. After a week, the first author visited PHC directors, received a list of interested nurses, contacted the nurses, and explained the study. Participants fully understood the issues of confidentiality and anonymity. They were assured that their participation was voluntary and that they could withdraw from the study at any time. Informed consent was obtained before the interview and none of the participants declined participation during focus group interviews.
2.4. Data collection The focus group discussions were held from September through November 2013 in comfortable and convenient PHC conference rooms. The discussions were conducted by a moderator, guiding group dynamics to ensure all
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Barriers to chronic pain management in community-dwelling low-income older adults Table 1
Questions for group discussion guide.
What are the difficulties in managing chronic pain? What led to those difficulties? What are the barriers that disrupt the management? Are there any other barriers? (e.g., aspects of patients, nurses, or organization) What is needed to facilitate chronic pain management?
participants were involved in the discussion. During discussions, two assistant moderators acted as note-takers to observe and capture non-verbal expressions to include this information from the discussion. Each discussion lasted around an hour and a half. The discussion was recorded with digital voice-recorders for transcription and analysis. Data were collected with a semi-structured discussion guide developed based on literature review focused on the aim of this study (Matthias et al., 2010). The suggested guide used health care providers’ (including nurse specialists) experiences about barriers to assessing and managing chronic pain in primary care clinics (Matthias et al., 2010). Participants were asked a broad initial question: ‘What are the difficulties in managing chronic pain?’ Table 1 provides an overview of the other question items.
Table 2
Subthemes and nodes of nurse-related barriers.
Subthemes
Nodes
Limitations of managing chronic pain
Misconceptions about chronic pain: ‘cannot be resolved’ Psychological pressure on the results of pain management Limitations of managing pain: ‘does not seem to improve pain’ Reluctance to administer pain-relieving medications Difficulty in pain assessment due to a variety of individual differences in pain expression Difficulty in objective understanding of chronic pain Difficulty in assessment due to a long period of chronic pain Lack of professional knowledge about chronic pain assessment Inadequate knowledge for individual approaches Inadequate experience about optimal pain management strategies Undermanaging chronic pain due to the unclear cause Limited assurance of pain management for older persons with multiple illnesses Uncertainty about chronic pain resolution Hesitancy in active recommendations or advice for chronic pain management Passive management of chronic pain by referral to hospitals Insufficient evidence-based management for chronic pain Stereotyped strategies
Inadequate knowledge and experience
Lack of confidence
2.5. Data analysis The data were analyzed with inductive thematic analysis. Thematic analysis is a flexible and useful method for understanding rich and detailed meaning within the data (Braun & Clarke, 2006). To prevent bias, authors did not review previous studies until after data analysis except for discussion guide development. The recorded discussions were transcribed verbatim and read by the first author for transcript validation and contextual understanding. She also reviewed notes for nonverbal behavioural connections with transcripts. Each transcript was coded using QSR International’s NVivo 10 qualitative data analysis software. After each author independently elicited initial nodes to enhance reliability, we focused on the level of participants’ consensus within each group of expressed ideas. That was because ideas emerged with natural agreement by the majority of participants, rather than by a single person, through group dynamics, or intensity or frequency of expressed ideas during discussion (Doody, Slevin, & Taggart, 2013). Two authors read once for contextual understanding. They then re-read to elicit 84 initial nodes based on the discussion guide questions. Similar meaning nodes were then sorted into sub-themes. Different coding contents and naming were cross-examined and changed through consensus discussion between two authors. The final 50 nodes and 12 sub-themes were merged into four themes. The examples of subsequent subthemes and nodes in nurserelated barriers to chronic pain management are shown in Table 2. All authors critically reviewed and agreed on the themes. The final themes and subthemes are presented in Table 3. In terms of credibility, a participant from each group was invited by e-mail to check the meaning of preliminary interpretations (Doody et al., 2013).
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Uniform interventions
Table 3
Barriers to chronic pain management.
Themes
Subthemes
Patient-related barriers
Limited understanding Lack of success in achieving compliance Continued use of traditional medicines Financial hardship Limitations of managing chronic pain Inadequate knowledge and experience Lack of confidence Uniform interventions Inadequate staffing and time constraints Few national support policies Unclear guidance Limited access to available resources
Nurse-related barriers
Organizational barriers
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Participant general characteristics N = 23.
Variables Age
Education
Experience as a community nurse Experience as a registered nursea
a
duration, they continuously added the patches without consultation, thereby overdosing on painkillers. (P-12)
N (%) 30—39 40—49 50—59 Associate degree Bachelor’s degree Master’s degree ≤4 5—9 ≥10 ≤4 5—9 10—19 ≥20
2 (8.7) 15 (65.2) 6 (26.1) 15 (65.2) 6 (26.1) 2 (8.7) 13 (56.5) 7 (30.4) 3 (13.1) 8 (34.8) 6 (26.1) 8 (34.8) 1 (4.3)
Excluding experience as a community nurse.
3. Results 3.1. Participant demographic characteristics Twenty-three participants with a median age of 46 years (range 32—53) participated in this study. Community nurse experience was 3—13 years (median = 5.7) and registered nurse experience was 1—23 years (median = 8.0; Table 4). Analysis of the data revealed that concerns could be grouped into three key areas, namely; patient-related, nurse-related, and organizational barriers to chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives (Table 3).
3.2. Patient-related barriers Participants perceived patient-related factors, including limited understanding, poor compliance achievement, continued traditional medicine use, and financial difficulty as barriers to optimal pain management. 3.2.1. Limited understanding Participants stated that older patients often applied pain relief self-management based on inaccurate knowledge. Such inappropriate attempts during exercise or self-care techniques were likely to aggravate rather than reduce their pain. Furthermore, patients’ perceived limited understanding about drug reactions and side effects contributed to taking their medications differently than prescribed. One of the cases where most people lack knowledge is oedema. Even when I tell them to rest, they keep exercising. When I ask them to take a cold pack, they just think, ‘Anything warm will do’, or even ‘I should walk around even if it hurts’. When they are exercising while sick and feel pain growing, they should get some rest and relax. But they think ‘I should be exercising’ regardless of how much pain they are feeling. (P-1) When older patients feel their pain is aggravated, they put medicated patches all over their body, even the forehead. Besides not considering drug administration
3.2.2. Lack of success in achieving compliance The participants reported poor compliance with chronic pain management exercise regimes. Generally, their patients had age-related changes such as poor concentration, reduced stamina, and declining memory. These age-related physical or cognitive changes led to limited desire for active pain management participation. Even if they began to exercise when recommended, they struggled with unrelieved ongoing pain over short periods of time and quit the exercise programme. While complaining about the pain amount. . ., the compliance rate is extremely low. When we teach 100 patients a workout during house visits. . ., 10 patients are the maximum we get who actually show the will. . . They do not believe they can be better with that exercise because they have continuously been in pain. They feel desperate that they will be in pain for good. . . Probably, they can’t be bothered doing anything because of pain and reduced physical strength. (P-2) 3.2.3. Continued use of traditional medicines Older patients trusted and followed unverified experiences from acquaintances rather than utilizing education or advice from healthcare providers. The participants described patients who adhered to personal experiences based on inaccurate knowledge obstructing proper pain management education and intervention. The participants sometimes felt that whatever they taught their patients did not work because of their conviction in their own folk remedies. Older persons often have burns (moxibustion marks) all over the body since they carelessly use moxibustion and apply cupping treatment by themselves at home. The wound festers due to burns. . . but no matter how much I tell them, it doesn’t really work at all. . . They are stubborn and accustomed to doing it their own way, which they think is best rather than going to hospitals, even if I recommend other options. (P-4) 3.2.4. Financial hardship The participants perceived that their patients’ financial difficulties as basic living stipend recipients could interfere with active pain management. Some patients with limited incomes could not receive sufficient pain management due to the high care costs of medical institutions. Additionally, according to the participants’ comments, patients seemed to believe that their families would suffer from the cost burden of the treatment. Because of financial instability, family members’ objections to pain treatment might also prevent patients from seeking proper care. There are older people who reject treatment because of financial difficulties. Their first priority is their living. . . In many cases, those who can’t afford to pay for treatment are not likely to steadily receive medical treatment for chronic pain. (P-15)
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Barriers to chronic pain management in community-dwelling low-income older adults When I visited a low-income older patient with aggravating pain and discussed referral to a hospital for aggressive care with family caregivers, they sometimes said ‘What we do is none of your business’.. . . In such cases, it is difficult to persuade them to take older patients to a hospital for further evaluation. (P-12)
3.3. Nurse-related barriers Home-visiting nurses were aware of their lack of abilities, attitudes, and practices for chronic pain management. 3.3.1. Limitations of managing chronic pain The participants reported that their own previous misconceptions were related to poor pain management. Faced with prolonged patient pain complaints during home visits, they felt ineffective and found pain management difficult. They were likely to passively manage chronic pain because it ‘cannot be fully cured’ or ‘cannot be resolved’. In addition, they often put more value on non-pharmacological interventions such as exercise rather than medications. Their own interpretations of their patients’ pain led to reluctance to administer medications, thus undermanaging the pain. ‘Why does the elderly’s knee pain continue despite my repeated visits? Why is my role like this? What am I missing?’ is what I thought. However, chronic pain doesn’t go away; we prevent it from getting worse, but we thought that the patients should all get better. (P-4) 3.3.2. Inadequate knowledge and experience According to participants, inadequate knowledge and experience interfered with satisfactory pain assessment and management. They had difficulty understanding patients’ pain objectively and professionally due to the subjective nature of pain and individual differences in patients’ expressions. Some patients exaggerated and some underreported the amount of pain they were feeling. Their difficulty hindered proper nursing assessment and intervention. Furthermore, inadequate knowledge about chronic pain management made it difficult to perform individualized interventions. Concerning pain assessment using visual analogue scales, for example, I think a patient is feeling pain at a level 4 or 5, but she tells me it is at a level 8 or 9. It seems like the numbers aren’t very exact. It differs by each individual’s personality. . .so I cannot make decisions considering my lack of professional knowledge. I have not received any intensive education on chronic pain management. (P-4) 3.3.3. Lack of confidence A lack of confidence in providing interventions was a barrier to effective pain management. They lacked confidence because the cause of their patients’ pain was often unclear, particularly for those with multiple illnesses. In such cases, participants expressed that they could not educate patients or provide interventions with confidence. Uncertainty about chronic pain resolution led participants to passive management by referral to hospitals for help or letting their patients select therapeutic options.
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When the cause can’t be found at hospitals, in spite of several diagnostic tests for a lot of chronic pain, I’m not confident in managing chronic pain. . . In particular, it is difficult to care for those with various chronic diseases. (P-18) Questions often arise about how much I have to do for older patients. Sometimes I worry about their worsening conditions heard on the phone from their family members. I was constantly in fear of their complaints because I’m unsure about what I provide. Even though I have been visiting older patients for the last 10 years, I still lack confidence in assessing and managing their persistent pain. Accordingly, I couldn’t insist on what they should do when giving instruction during home visits. (P-6) 3.3.4. Uniform interventions The participants recognized that their own stereotyped strategies obstructed chronic pain management. Because of their own skill and knowledge deficits, they lacked the capacity to make decisions on types of pain management specific to patients’ chronic pain characteristics. Instead of individualized recommendations, they provided their patients with medicated patches, moderate exercises, or stress management methods as standard interventions. Regardless of individual characteristics, I always provide medicated patches and a standardized education about exercise. . . For overweight patients with persistent pain, I educate them with one-size-fits-all approaches, such as weight control, nutrition, and stress management every time I visit. . . We (home-visiting nurses) can’t consider what best fits for each person. Without a specific basis for the pain management offered, our intervention is just a stereotyped set regardless of personal conditions. (P-7)
3.4. Organizational barriers When providing home-visiting nursing care, a number of structural and systematic problems inhibited effective chronic pain management practices. 3.4.1. Inadequate staffing and time constraints Inadequate levels of staffing and time necessary for homevisiting care were significant organizational barriers to sufficient chronic pain management. Each nurse was in charge of 500—600 homes and visited seven homes on average per day. This limited available time had a significant impact on the participants’ ability to undertake individualized assessment and interventions. They also stated that it was difficult to cooperate with other healthcare specialists because there were not enough personnel. It takes up too much time. If it takes over an hour at one home, I can’t visit other homes. I was very willing when I first started home visits, but now I’m tired and I also have to see others. . .We aren’t taking care of a hundred, but hundreds, so it can’t be done. When I’m concentrating on one home, the others complain. That’s what’s most difficult: just too many patients to handle. (P-8)
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H.-R. Park et al. First, what I think is difficult is the lack of cooperation and connection. . . because there are no other employees. Also, we don’t have enough time to stay at one home because of time pressure. We can’t stay at one place for one hour or two. . . (P-6)
3.4.2. Few national support policies The participants thought that the lack of national financial and political support for low-income groups was a significant barrier to adequate chronic pain management. Their patients cannot handle the financial burden of visiting welfare facilities for chronic pain management. In Korean home-visiting nursing care services, chronic pain is not considered a top care priority; concentrated management is difficult. Our patients, recipients of basic living, can’t use a swimming pool if they don’t have the money. . . They have to pay 50% to use it, but they can’t. (P-4) Our major work is related to chronic diseases, such as hypertension and diabetes, not chronic pain. So, we cannot take sensitive care of pain. During home visits, we have no choice but to incompletely care for older patients with chronic pain due to a low proportion of national support policies. . .. For most cases, home-visiting care is associated with hypertension and diabetes. (P-9) 3.4.3. Unclear guidance The participants perceived few detailed assessment and intervention guidelines as a barrier to chronic pain management. If there were consistent and systematic guidelines, they would have effectively managed chronic pain with confidence. Since I have been continuously educated about the hypertension and diabetes guidelines, certainly I can provide information and evidence on those situations with much confidence. But chronic pain’s too comprehensive. Like a manual, intervention guidelines would be helpful to be more familiar with actions to take care of chronic pain. If so, I may feel confident to act upon it when faced with the situation. (P-10) 3.4.4. Limited access to available resources The participants recognized that limited resource accessibility obstructed chronic pain management. They reported that a major reason for limited care access was their patients’ likelihood to decrease their physical activities due to age and persistent pain. In addition to declining functioning in their daily life, limited transportation is an obstacle to free access to community healthcare services. Thus, older patients were not able to access welfare facilities at long distances without other caregivers. First, they can’t go out to take the bus because they are old with damaged joints. . . They also need someone who is by their side to take and bring them back. Actually, it is best if we can be there, but I feel sorry because they live alone. (P-7)
It’s too far (the distance). Old people make very limited use of the facilities. That’s difficult for people who live at quite a distance. (P-11)
4. Discussion This study identified barriers to effective chronic pain management for low-income community-dwelling older adults from home-visiting nurses’ perspectives. Patient-related, nurse-related, and organizational barriers to chronic pain management were categorized.
4.1. Patient-related barriers First, limited understanding included misconceptions about drug reactions, side effects, or exercises. Because of the fear of addiction and side effects, older adults who are hesitant to take medications may prefer unverified traditional medicines (Davis et al., 2002; Dewar, 2006; Egan & Cornally, 2013). In addition, older adults lacked success in achieving compliance mainly due to age-related changes such as declining physical and cognitive ability. This finding is consistent with previous studies (Cornally & McCarthy, 2011; Egan & Cornally, 2013). Age-related cognitive problems interfering with pain assessment and management created undertreatment risk (Egan & Cornally, 2013). Moreover, low-income older adults’ financial difficulties were risks for insufficient pain management. This is consistent with previous studies (Davis et al., 2002; Dima et al., 2013; Gudmannsdottir & Halldorsdottir, 2009; Lansbury, 2000) suggesting that family burden from high healthcare service costs contributed to adjusted or discontinued pain management. However, arbitrary treatment adjustment or discontinuation was a major concern for primary care nurses of community elderly since such self-management methods could aggravate persistent pain. Accordingly, nurses should focus on how to easily deliver ‘accurate’ information in education sessions particularly to those with cognitive impairment. It is also important that nurses encourage older patients to express pain in a timely manner during assessment and management (Egan & Cornally, 2013), rather than to tolerate it. Therefore, nurses as primary health care providers should recognize several patient-related barriers to relieving pain. These strategies, which consider individual situations such as financial difficulty, may contribute to motivating older adults with persistent pain to seek proper pain-relieving methods and adhere to recommended management.
4.2. Nurse-related barriers Because the nurses reluctantly gave pain medications to older adults for fear of overmedication, they preferred non-pharmacological interventions such as exercises. These attitudes and beliefs were consistent with previous studies that a significant problem of healthcare providers for older people was excessive caution about giving analgesics (Dewar, 2006; Egan & Cornally, 2013; Jablonski & Ersek, 2009; Kaasalainen et al., 2007).
Please cite this article in press as: Park, H. -R., et al. community-dwelling low-income older adults: Home-visiting http://dx.doi.org/10.1016/j.colegn.2015.05.002
Barriers to chronic pain management in nurses’ perspectives. Collegian (2015),
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Barriers to chronic pain management in community-dwelling low-income older adults In addition to limitations of managing chronic pain, nurses who lacked confidence due to inadequate knowledge and experience likely underestimated their patients’ pain. Because patients’ pain verbalizations often did not match their nonverbal cues, nurses reported difficulty believing pain reports. This discrepancy resulted in inappropriate pain management (Karttunen et al., 2014). Due to cognitive impairment and underlying illnesses, pain assessment is more complex in older adults (Dewar, 2006). To accurately detect pain existence and severity, nurses should use a variety of assessment tools including behavioural ones. Given atypical and complex pain expression characteristics in older people, it is essential to develop well-defined, efficient screening tools and guidelines. Inadequate knowledge and clinical experience is therefore a major barrier leading to uncertainty about pain assessment and management best practices. Considering the study participants’ years of experience, it is surprising that they still felt lacking in nursing knowledge and clinical experience. Tailored ongoing nursing education is necessary based on their specific knowledge needs about chronic pain characteristics, underlying illnesses, and proper educational methods for older adults (Dewar, 2006). Most significantly, uniform intervention strategies were serious pain management problems, potentially leading to older adults’ inadequate motivation. Standardized intervention or non-interactive teaching methods, such as stereotyped exercise printouts or leaflets, did not motivate older adults to practical exercise or other recommended strategies for pain relief (Dima et al., 2013; Park et al., 2013). Thus, for example, a daily exercise programme should be individualized and realistic, considering usual individual lifestyle or implementation difficulties (Lansbury, 2000; Park et al., 2013).
4.3. Organizational barriers This was consistent with suggestions that lack of personnel and time for adequate pain assessment and patient interaction remains a stubborn problem for primary care nurses globally (Egan & Cornally, 2013). In particular, since national support policies do not focus on chronic pain, clear guidance in chronic pain management is lacking in Korea. These are eventual access barriers to low-cost management strategies for older adults living in poor socioeconomic surroundings. This suggests that Korean low-income older adults could be a risk group for chronic pain management, similar to those studies showing that lower socioeconomic level patients experience greater chronic pain intensities (Fisher et al., 2013; van Hecke et al., 2013). In addition to the absence of related policies and practical guidelines, inadequate resources obstruct care continuity (Wilsey et al., 2008) as a critical element of primary nursing care. In Korea, the main reasons for limited resource access, such as community-based exercise programmes for older adults in PHCs, were related to insufficient budget, individual financial difficulty, high care cost, and inconvenient transportation services (Park et al., 2013). Given the limited resource access in Korea, low-income older adults may need easily accessible and inexpensive daily home-based exercise pain relief programmes based
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on individual preferences and lifestyle concerns (Lansbury, 2000). When designing home-based exercise programmes, home-visiting nurses need to focus on patients’ compliance with behavioural changes towards pain relief. Thus, nurses may provide exercise programmes using a pamphlet with big pictures of each body movement for patients to easily learn and practice on a daily basis (Austrian et al., 2005; Park et al., 2013). There are some limitations. Because this study analyzed Korean home-visiting nurses’ perspectives, generalizability of qualitative research should be considered when applying study findings to other cultures and contexts (Horsburgh, 2003). Thus, further studies should be replicated within other cultures and situations where nurses provide similar care but may have different experiences. Further investigation also should consider cultural influences on nurses’ perceived pain management barriers. In addition, data collection mainly depended on focus group interviews, reflecting the nurses’ perspectives, not patients’, on chronic pain management barriers. Further research is needed to compare nurses’ and their patients’ perspectives because understanding the differences is essential for effective pain management.
5. Conclusion Despite these limitations, this study contributes to a better understanding of pain management barriers for low-income community-dwelling older adults. Significant patient-related, nurse-related, and organizational barriers from home-visiting nurses’ perspectives were identified. Nurses’ experiences in caring for older adults with chronic pain provided insights into how nurses perceived barriers to and what they needed for adequate pain management in community-based settings, which may be different from acute care settings. This understanding precedes development of innovative practice strategies for chronic pain management in primary healthcare services, such as individualized educational methods/materials for nurses as well as for patients.
Contributors HRP, EP, and JWP contributed to the study conception and design. HRP collected the data. HRP and EP contributed to data analysis and interpretation, and the draft and critical revision of the manuscript. JWP critically reviewed the draft manuscript. All authors approved the final manuscript for publication.
Funding This research was funded by the Department of Nursing Science, Graduate School of Ajou University (M-2013-C046000007) in Suwon, South Korea.
Conflicts of interest None declared.
Please cite this article in press as: Park, H. -R., et al. community-dwelling low-income older adults: Home-visiting http://dx.doi.org/10.1016/j.colegn.2015.05.002
Barriers to chronic pain management in nurses’ perspectives. Collegian (2015),
+Model COLEGN-326; No. of Pages 8
ARTICLE IN PRESS
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H.-R. Park et al.
Ethical approval The study was approved by the Institutional Review Board of Ajou University (AJIRB-MED-MDB-13-111).
Acknowledgements We would like to acknowledge Dr. Jungsik Park who proofread the manuscript as well as the home-visiting nurses who participated in this study.
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Barriers to chronic pain management in nurses’ perspectives. Collegian (2015),