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Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis
JAMDA xxx (2019) 1e9
JAMDA journal homepage: www.jamda.com
Review Article
Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis Jennifer A. Knopp-Sihota PhD a, b, *, Kennedy L. Dirk b, c, Geoffrey S. Rachor BA b a
Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada Translating Research in Elder Care (TREC), University of Alberta, Edmonton, Alberta, Canada c Faculty of Kinesiology, Western University, London, Ontario, Canada b
a b s t r a c t Keywords: Nursing home residents nursing homes systematic review pain assessment barriers and facilitators
Objectives: The burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents. Design: This is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist. Setting and participants: We included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both. Measures: Extracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors. Results: Thirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers’ lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines. Conclusion and implications: Findings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents’ quality of life. Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Prevalence of pain in nursing home residents is high, with an estimated 45% to 80% of residents affected.1 Despite this, pain management in this population is generally less than optimal and pain often goes under recognized and ultimately untreated.2 Consequences
This work was supported by the Alzheimer Society Research Program (Grant 16-12), Alzheimer Society of Canada. The authors declare no conflicts of interest. * Address correspondence to Jennifer A. Knopp-Sihota, PhD, Athabasca University, 1 University Drive, Athabasca, Alberta, Canada. E-mail address: [email protected] (J.A. Knopp-Sihota). https://doi.org/10.1016/j.jamda.2019.01.156 1525-8610/Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
of untreated pain include unnecessary suffering and impaired quality of life,3 functional loss,4 depression,5 and behavioral disturbances including aggression, agitation, and wandering.6 Pain not only affects residents but also impacts formal and informal caregivers, resulting in burnout,7 decreased quality of life, and substantial burden.8 Better pain management can improve quality of life for both residents and their caregivers. However, successful pain management depends first on accurate pain assessment. Approaches to pain assessment are complex but ought to be resident centered and take into account individual resident characteristics, including cognitive function. In residents with intact
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cognition, pain self-report is the gold standard,9 but this becomes less reliable and valid as cognitive function declines.10 For residents with intact cognition, multiple bedside pain assessment tools (eg, visual analog scales) are validated for use. For residents with moderate to severe dementia, observing and detecting their pain-related behaviors is a valid approach to identifying pain.10,11 Scales for this purpose are typically checklists scored as number of behaviors observed.12 Despite use of these tools, pain assessment in nursing home residents remains inadequate.13 In this review, we identify and summarize available evidence to improve understanding of barriers and facilitators to pain assessment for nursing home residents. Similar literature reviews have been carried out, but these reviews are either outdated, not systematic in their design, limited specifically to nursing home residents with dementias,14 or are limited to acute care settings.2,15 This study provides the first systematic review, following Cochrane’s guidelines, to identify primary barriers and facilitators to pain assessment for nursing home residents. Although work has focused on improving pain assessment for nursing home residents,16e18 best practices have not been consistently identified across residents with varying levels of physical or cognitive function.19 Factors attributed to pain assessment for nursing home residents can be categorized at the level of the resident, health care provider, or health care system (organizational).20e22 These factors are often post hoc considerations rather than targeted outcomes of research studies. In this review, we sought to synthesize and critically appraise literature about factors (barriers and facilitators) associated with pain assessment for nursing home residents. Methods We followed procedures for conducting systematic reviews as described in the Cochrane Handbook of Systematic Reviews of Interventions23 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.24 Our review protocol with detailed methodology and design is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42018105007). Criteria for Considering Studies for This Review Types of studies As it would be difficult to comprehensively quantify the multiple barriers and facilitators to pain assessment in nursing home residents, we identified our topic as more amenable to a qualitative approach. For this reason, we planned to include all primary (original) qualitative studies published in any language and any year that used a recognized data collection method (eg, focus groups, interviews) and qualitative analyses. Studies must have evaluated and reported barriers or facilitators to pain assessment that were resident based (eg, cognitive impairment), health care provider based (eg, knowledge deficit), or at the health system level (eg, organizational communication). After extensive preliminary review of the literature, we chose categories that represented the most prevalent themes across available literature. We excluded unpublished/gray literature and secondary analysis studies. Types of participants in studies To meet inclusion criteria, studies must have focused on either nursing home residents, nursing home health care providers, or both. Studies focusing on residents were included if residents were identified as 65 years and older or referred to as elderly or aged, and were not limited by sex or cognitive status. Additionally, residents must have had either acute or chronic pain and permanently resided in an institutional setting, such as a nursing home, long-term care, or
residential care setting. Studies with health care providers as participants were also not limited by sex. Health care providers must have identified as working within an institutional setting (eg, nurses, health care aides, physicians). Studies were excluded if they were conducted within hospital settings, short-term care facilities, health care clinics, assisted living, and all other health care settings not within the scope of nursing homes or long-term care.
Search Strategy Database searches, including databases, key words, and limiters, were selected in consultation with academic librarians. Database searches included studies published from database inception to June 7, 2018, and were not limited to English language. Our search strategies are reported in Appendix 1. Searched databases included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and Web of Science. One reviewer (K.D.) independently screened titles and abstracts from the initial database searches. Full text of studies passing initial screening were retrieved and reviewed independently by 2 reviewers (K.D., G.R.) and verified by a third reviewer (J.K.S.). We resolved discrepancies in final inclusion decisions by consensus. Study selection and screening processes are presented in Supplemental Figure 1.
Data Extraction and Synthesis Using a pretested data collection Excel spreadsheet, we extracted data in 2 phases. In phase 1, 1 reviewer (K.D.) extracted study information: author and year of publication, setting, participant characteristics, study objectives, and data collection and analysis procedures. Two reviewers (K.D., G.R.) reviewed extracted data for accuracy and consistency, and resolved any discrepancies by discussion. In phase 2, 2 reviewers (K.D., G.R.) extracted and clustered data into 3 primary groups: resident, health care provider, and health systemelevel factors that influence pain assessment for nursing home residents. Extracted data were subjected to thematic analysis, a systematic, qualitative process to identify, collate, and summarize emergent themes related to the 3 factors.25 Adhering to recommendations for systematically reviewing qualitative research,25,26 2 reviewers (K.D., G.R.) independently coded themes (reviewed by J.K.S.) in a cyclical manner in light of emergent themes until no further new themes emerged. On completion of thematic analyses, we conducted narrative syntheses of results.27
Quality Appraisal: Risk of Bias in Individual Studies We assessed included articles for bias and methodological quality using the Critical Appraisal Skills Programme’s (CASP) Checklist for Qualitative Research.28 CASP’s Checklist for qualitative appraisal broadly assesses the validity of results and methodological rigor. The checklist consists of 10 questions grouped into 3 broad categories: (1) Are the results valid? (clear aims; appropriate methodology; research design, recruitment strategy, and data collection procedures address the aims; appropriate researcher-participant relationship). (2) What are the results? (ethical consideration, data analysis sufficiently rigorous, and a clear findings). (3) Will the results help locally? (the overall value of the research).28 Two reviewers (K.D., G.R.) constructed a risk of bias table and assessed each question as low risk of bias (answered “yes”), high risk of bias (answered “no”), or unclear or unknown risk of bias (answered as “can’t tell”). Discrepancies were resolved by discussion.
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Results Study Selection Our initial database search identified 2079 records for review (see Supplemental Figure 1). Upon initial screening, 809 duplicate records were removed, with an additional 1179 records excluded based on title and abstract (n ¼ 1158) and availability (n ¼ 21), resulting in a total of 112 records for full-text review. Of the remaining 91 records, 60 were eliminated based on outcomes measured, study setting, or study design. Thirty-one full-text studies met our inclusion criteria and were included in our qualitative synthesis.17,19e22,29e54 Study Characteristics Characteristics of included studies are in Table 1. Thirty-one studies with 3297 unique participants were included: 2281 nursing home staff and 1016 nursing home residents. Nursing home staff included physicians, nurse practitioners, registered nurses, licensed practical nurses, certified nursing aides, nursing home managers, and other administrators. One study did not report sample size; however, available data were still extracted and included in our results.33 Studies were conducted in the United States (n ¼ 12),19,29,32,33,35,38,43,45,47,49,51,52 Canada (n ¼ 7),17,21,22,37,40,41,44 Australia (n ¼ 6),36,42,46,48,50,53 United Kingdom (n ¼ 2),30,34 Ireland (n ¼ 1),20 Japan (n ¼ 1),54 Iceland (n ¼ 1),39 and Israel (n ¼ 1).31 Included studies ranged in year of publication from 1995 to 2018. All studies were observational, with the majority (n ¼ 16) using either focus groups or interviews for data collection.17,19,21,22,32,33,35,37e39,41,42,46,47,50,53 The remainder used either surveys or questionnaires (n ¼ 12)20,29e31,36,40,44,45,49,51,52,54 or a combination of both (n ¼ 3).34,43,48 Quality Appraisal With the exception of 1 study,34 we considered the overall risk of bias of included studies to be low (see Supplemental Figure 2). All studies had a clear statement of aims and used appropriate qualitative methodology. Three studies31,34,52 had a high risk of bias attributed to research design, whereas 9 studies20,29e31,34,35,42,43,48 were labeled high risk of bias based on recruitment. One study29 had a high risk of data collection bias, and 6 studies20,29,31,34,46,48 did not explicitly consider conflicting interests. Four studies41,43,51,53 had an unclear risk of bias based on consideration of ethical issues. Three studies31,34,43 were at risk of bias because they did not meet the criteria for rigorous data analysis, and 1 study34 did not meet the criterion for clearly stating their findings. Despite these methodologic issues, we considered these concerns as not sufficient to exclude these studies from the review. Emergent Themes Of the 31 included studies, 28 reported resident factors,17,19e22,29,30,32e40,43e54 28 reported health care provider factors,17,19e22,29e38,40e50,52,54 and 29 reported on health system factors17,19e22,29e33,35e38,40e52,54 associated with pain assessment. Our meta-synthesis revealed several constructs related to barriers and facilitators in assessing pain in nursing home residents (see Table 2). At the resident level, we identified the 3 subthemes of physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic factors, where cognitive impairment emerged as the most prominent subtheme at the resident level. At the health care provider level, we identified the 3 subthemes of knowledge and skills, attitudes and beliefs, and social/cultural/demographic background factors, where knowledge and skills emerged as the most prominent subtheme. Lastly, at the health system level, we identified the 3
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subthemes of interpersonal factors, resources, and policy, where interpersonal factors within organizational hierarchies emerged as the most prominent subtheme. Resident factors Physical or cognitive impairments. The most prominent subtheme related to factors of pain assessment at the resident level was cognitive impairment, where 22 studies identified the presence, and severity, of dementia as a primary barrier to pain assessment.17,19e22,29,30,32e35,37,38,40,44,46e51,54 For example, nurses expressed difficulties in assessing pain in residents with more advanced dementia, as residents’ ability to self-report pain was often impaired.17,19e22,29,30,33,35,37,40,47e51,54 Resident behaviors were identified as both a barrier17,19,21,22,32,33,41,46,48,50,51 and the most prominent facilitator17,19,21,22,29,30,33,35,46e48,50,51 to adequate pain assessment, regardless of resident cognitive status. For example, observing pain-related behaviors such as facial expressions and body movements facilitated pain assessment in noncommunicative residents with cognitive impairment.17,19,32,33,35,48 Conversely, some residents expressed challenging behaviors as an exaggeration or tolerance of pain, where exaggerated challenging behaviors were sometimes viewed by health care providers as manipulative and indicative of attention- or medication-seeking behavior rather than pain.17,20e22,32,33,35,38,45,47,48,50,51 Additionally, the presence of multiple comorbid chronic conditions such as depression or other illnesses were associated with exacerbating and overlapping symptoms, making it difficult to discern painrelated symptoms.19e21,32,33,38 Attitudes and beliefs. Residents’ attitudes and beliefs were found to influence pain assessment across 12 studies.20,21,32,33,35,38,39,48,50,52e54 In these studies, residents were reluctant to report pain because of stoicism, pride, or denial of their pain, and feared the loss of independence.20,21,32,33,35,38,39,48,50,53 Many residents believed that pain was a normal part of aging, resulting in desensitization and acceptance of their pain.20,21,32,33,39,52,53 Some residents were hesitant to report pain because they did not want to be seen as a difficult patient, bother busy staff, or be perceived as a medication seeker.20,21,33,35,39,41,45,50,52e54 Social, cultural, and demographic. Social, cultural, and demographic variables affected resident pain assessment in 5 studies.20,32,33,35,50 For example, rural-based residents were less likely to report pain.32,33 Residents’ social (eg, previous drug abuse history)33 and cultural33,35,49 backgrounds affected their concept of pain and likelihood of reporting. Sex or ethnicity of the health care provider at times predicted residents’ willingness to report pain; this was thought to stem from residents’ cultural values of not discussing sensitive matters with the opposite sex.35 Further, if residents and health care providers spoke different primary languages, pain assessments by self-report often could not be used.20,50 Health care provider factors Knowledge and skills. The most prominent subtheme at the health care provider level related to knowledge and skills, where lack of knowledge about pain assessment was identified as a primary barrier to pain assessment in 22 studies.19e22,29e33,35,36,38,40,42e46,49e51,54 Accordingly, 7 studies reported that greater staff knowledge and education facilitated pain assessment for nursing home residents.30e32,36,38,47,48 Some staff also sought external education and supports to facilitate pain assessment.38,46,49 Across 16 studies, health care providers identified specific skills required to improve pain assessment.17,19,20,29e31,33e36,42,43,46e48,50 For example, having a relationship with the resident and knowing how they express pain improved pain identification, especially in
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Table 1 Characteristics of Included Studies Author and Year
Location
Participants
Allcock et al29 (2002)
USA
NH managers (n ¼ 68)
Barry et al30 (2012)
Ireland
NH managers (n ¼ 96)
Ben-Natan et al31 (2013)
Israel
Nurses (n ¼ 104)
Clark et al33 (2004)
USA
Professional and unlicensed NH staff (n ¼ N/A)*
Clark et al32 (2006)
USA
Administrators (n ¼ 9), RNs (n ¼ 38), LPNs (n ¼ 26)
Closs et al34 (2006)
United Kingdom
Residents (n ¼ 113), NH staff (n ¼ 65)
Dobbs et al35 (2014)
USA
CNAs (n ¼ 28)
Douglas et al36 (2016)
Australia
Residents (n ¼ 636), NH staff (n ¼ 434)
Egan and Cornally20 (2013)
Ireland
RNs (n ¼ 62), clinical nurse managers (n ¼ 18)
Fox et al22 (2004)
Canada
Ghandehari et al37 (2013)
Canada
Physicians (n ¼ 6), RNs (n ¼ 19), RPNs (n ¼ 8), health care aides (n ¼ 13), occupational/ physiotherapists (n ¼ 8) RNs (n ¼ 70), health care aids (n ¼ 61)
Gropelli and Sharer38 (2013)
USA
RNs (n ¼ 9), LPNs (n ¼ 7)
Gudmannsdottir and Halldorsdottir39 (2009)
Iceland
Residents (n ¼ 12)
Study Objectives
To identify barriers in assessment and management of chronic pain in residents To explore knowledge/ beliefs of NH managers regarding pain assessment in residents with dementia To identify factors predicting nurses’ performance of pain assessment for residents To describe pain assessment measures used in NH, as well as staff judgments of residents’ pain complaints Explore perceptions of NH staff to inform the development of a pain management intervention Compare staff and resident reports of pain; and to explore staffs experiences with pain assessment To examine cultural context and communication of pain between CNAs and residents To examine pain assessment tools implementation and use and associated outcomes To identify barriers to pain assessment and management from the perspectives of nurses To provide an understanding of pain practices in NH, and to identify barriers to pain management To investigate the effects of a continuing education program for pain assessment in NH To determine nurse’s perceptions of pain management in NH To describe the experiences of, and essential considerations of, chronic pain in residents
Methodology
Factors
Data Collection
Data Analysis
Questionnaire (closed and open ended)
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Qualitative data analysis; content/ thematic analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ correlational
HCP, health care system
Focus group interviews
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Semistructured interviews
Content/thematic analysis
Resident, HCP, health care system
Semistructured and structured interviews
Descriptive; qualitative data analysis
Resident, HCP
Focus group interviews
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Self-report questionnaires; chart audits
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident, HCP, health care system
Structured (focused) interviews
Content/thematic analysis
Resident, HCP, health care system
Unstructured interviews
Interpretive phenomenology
Resident
(continued on next page)
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Table 1 (continued ) Author and Year
Location
Participants
RN (n ¼ 70), administrators (n ¼ 46), health care aides (n ¼ 25), physicians (n ¼ 11), other (n ¼ 15) Residents (n ¼ 65), RNs (n ¼ 2), RPNs (n ¼ 6), personal support workers (n ¼ 7), physicians (n ¼ 2), kinesiologist (n ¼ 1), manager (n ¼ 1)
Hadjistavropoulos et al40 (2011)
Canada
Hadjistavropoulos et al17 (2014)
Canada
Hadjistavropoulos et al41 (2016)
Canada
Nurses (n ¼ 19), CNAs (n ¼ 19), clinical nurse specialist (n ¼ 1), director of care (n ¼ 1)
Holloway and McConigley42 (2009)
Australia
Nursing assistants (n ¼ 6)
Jones et al43 (2004)
USA
NH staff (n ¼ 60), residents (n ¼ 60)
Kaasalainen et al44 (2007)
Canada
Nurse practitioners (n ¼ 16)
Kaasalainen et al21 (2010)
Canada
Long45 (2013)
USA
RNs (n ¼ 15), RPNs (n ¼ 6), unified caring providers (n ¼ 20), physicians (n ¼ 4), administrators (n ¼ 4), physiotherapists (n ¼ 2), pharmacists (n ¼ 2) Professional staff (n ¼ 14), CNAs (n ¼ 10)
McConigley et al46 (2008)
Australia
Mentes et al47 (2004)
USA
Physicians (n ¼ 7), RNs (n ¼ 11), enrolled nurses (n ¼ 4), allied health professionals (n ¼ 8), care managers (n ¼ 4) Family members (n ¼ 16), CNAs (n ¼ 11), cognitively impaired residents (n ¼ 20)
Study Objectives
To examine the opinions of key stakeholders in implementing pain assessment guidelines into NH To evaluate whether regular pain assessments alongside communication to physicians affect prescription of psychotropic medications To evaluate whether the implementation of a pain protocol results in greater performance on a variety of quality indicators To describe the experiences of nursing assistants who care for older residents in pain To develop and test a culturally competent intervention for NHs and to assess staff and residents’ knowledge of pain. To examine the role of nurse practitioners in a pain management model, and to identify factors affecting implementation To identify barriers to pain management, as well as barriers to implementing a pain protocol, in NH
To survey NH staff before and after an educational pain intervention on outcomes of knowledge, attitudes, and barriers To develop recommendations for pain management in residential aged care facilities. To evaluate information from CNAs, residents, and family/friends caregivers on residents’ pain experiences
Methodology
Factors
Data Collection
Data Analysis
Questionnaire (closed and open ended)
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Focus group interviews; semistructured interviews
Descriptive and qualitative/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews; semistructured interviews
Descriptive; content/ thematic analysis
HCP, health care system
Semistructured interviews
Thematic analysis
HCP, health care system
Focus group interviews; structured individual interviews
Descriptive and qualitative/ quantitative data analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Descriptive and qualitative/content analysis
Resident, HCP, health care system
Focus group interviews; individual interviews
Descriptive and qualitative/thematic analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus groups; individual interviews
Qualitative/thematic analysis
Resident, HCP, health care system
Semistructured interviews
Content/thematic analysis
Resident, HCP, health care system
(continued on next page)
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Table 1 (continued ) Author and Year
Location
Participants
Monroe et al19 (2015)
USA
RNs and LPNs (n ¼ 29)
Peisah et al48 (2014)
Australia
Directors of care (n ¼ 4), RNs (n ¼ 10), patient care assistants (n ¼ 6)
Tanaka and Momose54 (2012)
Japan
Nurses (n ¼ 443)
Tarzian and Hoffman49 (2004)
USA
Directors of nursing (n ¼ 113)
Veal et al50 (2018)
Australia
RNs (n ¼ 18), facility managers (n ¼ 5)
Wagner et al51 (1997)
USA
Residents (n ¼ 461)
Weiner and Rudy52 (2002)
USA
Residents (n ¼ 75), RNs (n ¼ 75), CNAs (n ¼ 75)
Yates et al53 (1995)
Australia
Residents (n ¼ 42)
Study Objectives
Methodology
To examine nurses’ cues and practices used in identifying pain in residents with dementia To explore attitudes and processes relating to pain management for residents with dementia in residential aged care facilities To examine problems associated with pain assessment in elderly residents To identify pain management demographics, perceived resources and barriers to manage pain in NHs To characterize and identify barriers of pain management in residential aged care facilities To describe trends relating to pain management in NH’s, and to identify ways to improve residents pain management To explore attitudes of resident and staff acting as barriers to pain assessment and management To describe the beliefs, attitudes, and perceptions about pain and pain management held by residents
Factors
Data Collection
Data Analysis
Focus group interviews
Thematic analysis/ scissor-and-sort technique
Resident, HCP, health care system
Survey with semistructured interviews
Descriptive/content analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Descriptive and qualitative/ quantitative data analysis Descriptive/ quantitative data analysis
Resident, HCP, health care system
Semistructured interviews
Thematic analysis
Resident, HCP, health care system
Chart audits, observational surveys
Descriptive/ quantitative data analysis
Resident, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident
Self-report questionnaires
Resident, HCP, health care system
CNA, certified nursing assistant; HCP, health care provider; LPN, licensed practical nurse; NH, nursing home; RN, registered nurse; RPN, registered practical nurse. *Sample size not reported.
observing pain-related behaviors in residents with cognitive impairment.19e22,29,33,35,41e43,47,48,51 Staff experience was a facilitator in pain assessment, along with staff confidence and sense of control in performing assessments.17,20,31,34,36,50 Further, skills such as the use of touch or observation of patient behavior facilitated pain assessment and improved residents’ level of comfort with staff.35 Attitudes and beliefs. In 19 studies, health care providers’ attitudes and views toward pain were found to affect pain assessment.20e22,30e33,35e38,40,43e45,48e50,52 For example, staff believed pain to be a normal part of aging, resulting in biased assessments and failure to acknowledge pain.20,22,30,31,33,35,36,49,52 If staff demonstrated positive views toward pain and aging, staff were more likely to express the intent to and to conduct an assessment.31,36 Nursing home staff were at times reluctant to complete assessments as they feared overmedicating residents.20,21,38,44,49,50 Toward overcoming these barriers, multiple studies indicated experience, and efforts toward increasing the knowledge of pain assessment in nursing home staff resulted in more positive
attitudes and beliefs of pain and aging, and a greater likelihood of conducting pain assessments.32,35e37,40,43,45,48 Social, cultural, and demographic. Three studies referred to social, cultural, and demographic factors affecting pain assessment at the health care provider level.35,49,50 Care providers’ cultural and religious backgrounds were identified as barriers to pain assessment and were thought to affect attitudes and beliefs toward pain.49 Conversely, many care providers recognized that regardless of their and residents’ cultural backgrounds, pain is universal, highlighting the need for assessing pain regardless of individuals’ backgrounds.35 To facilitate pain assessments, care providers assessed pain in the primary language of the residents, where possible.50 Health care system and organizational-level factors Interpersonal. Interpersonal communication was the most prominent subtheme at the health care system level. The primary barrier at this level related to the breakdown of communication across
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Table 2 Meta-synthesis Results Factors
Subthemes
Pain Constructs and Definitions
Resident
Attitudes and beliefs
Physical or cognitive impairments Social/cultural/demographic
Health Care Provider
Knowledge/skills
Attitudes and beliefs
Health care system
Social/cultural/demographic Policy Resources
Interpersonal
Beliefs and assumptions that pain is a normal part of aging Denial that pain is present Desensitization or resignation to pain Experiencing pain without displaying feelings or complaining (stoicism) Sensory or cognitive impairments may affect the ability to effectively communicate pain in typical ways Residents with multimorbidity (eg, depression) and overlapping symptoms complicate assessment Reluctance to report pain based on cultural/ethnic preferences of the assessor (ie, sex, race, and language of the assessor is different from the resident’s) Religion, geographic area (rural vs urban), and cultural views affect a resident’s self-perception of pain Lacking the necessary pain knowledge or geriatric training to perform an adequate pain assessment Lack of familiarity/training with pain assessment tools and scales HCP having a relationship with/knowing the resident in order to provide resident-centered pain assessment Using touch or other techniques to facilitate pain assessment Having the experience and confidence/control to complete pain assessments Belief that pain is a normal part of aging and being insensitive or biased in assessment Fear of overmedicating resident Intention/agency to complete assessment Culture, religion, and ethical beliefs affecting view on pain and ability to legitimize pain complaints Lack of standardized and routine assessments or policies/procedures The documentation required and the report type (verbal vs nonverbal) affect assessment Lack of available training opportunities for staff Lack of access to pain specialists (eg, clinical nurse educator) Insufficient facility funding with high staff turnover and workload; leading to inadequate time (pain assessment is time consuming) Communication, collaboration, and respect in interdisciplinary teams Lack of resident family involvement affects assessment
organizational hierarchies, which influenced resident pain assessment in 22 studies.17,19e22,30,32,33,35e38,40e44,46e50 Breakdown of communication included a perceived lack of respect by unregulated health care providers, as well as a lack of acknowledgement, or feeling ignored in their communication toward other professionals.20e22,30,33,37,38,40e44,48e50 Furthermore, poor physician communication and lack of involvement was a barrier to interdisciplinary teamwork.20e22,30,33,37,38,40,43,44,46,48e50 Interdisciplinary teams with respect and trust between members resulted in greater teamwork and communication, which facilitated pain assessment.17,19,22,32,36,40e42,44,46 Additionally, interpersonal pain assessment was facilitated when family members or residents were involved, as this allowed a deeper understanding of the resident and their behavior.19,22,35,36,38,47 Resources. In 22 studies, resources (eg, pain assessment tools, staff training) were discussed as either barriers or facilitators to pain assessment.17,20e22,29e33,36,37,40,41,43e46,48e50,52,54 Lack of pain assessment specialists,29,40,43,46,48 such as geriatricians and palliative care specialists,46 as well as deficient staff training,21,30,31,40,44 low staffing levels,17,21,40,48 high staff turnover,43,50 insufficient time,17,20e22,30,33,37,40,41,44e46,49,52,54 and low funding for staff resources and training40,49 were identified as barriers to pain assessment. Identified as the primary facilitator to pain assessment at the health care system level were interventions aimed toward promoting routine assessment policies. In addition, providing and implementing standardized assessments and staff training facilitated pain assessment practices.17,21,29,30,32,36,37,40,41,43,46,48 Policy. Eighteen studies cited nursing home policies as both a barrier and facilitator to pain assessment.17,20e22,29,30,33,35e38,40,41,44,46,48e50,54 Lack of pain assessment policies or lack of procedures for standardized or routine pain assessment were a barrier to pain assessment,20,21,29,30,33,38,40,41,44,49,50,54 where multiple studies noted that implementing policies and guidelines concerning pain assessment made staff more aware of, and facilitated the assessment of, pain in residents.17,37,41,44,50 However, excessive documentation required by nursing home policies in assessing and reporting pain often made it
impractical for staff to address residents’ pain on a regular basis.20,22,40,46 Verbal reports, including direct questioning and residents’ self-reports of pain were indicated as inappropriate for use in residents with cognitive impairment,29,33,35,50 where health care providers noted the limited efficacy of verbal pain scales as a barrier to pain assessment in these residents,50 and expressed the need for policy and resources related to nonverbal assessments of pain in residents with cognitive impairment.29,48,50 These resources included nonverbal pain assessment tools,48 and the use of behavior charts, picture boards, and written forms of communication to assess pain.29,48 Discussion Given the difficulties associated with assessing pain in nursing home residents, it is important to identify factors that influence the effective and accurate assessment of pain in this vulnerable population. This is, to our knowledge, the first systematic review and metasynthesis identifying and reporting barriers and facilitators to pain assessment in the nursing home setting at the nursing home resident, health care provider, and health care system levels. Across the 9 identified subthemes, cognitive impairment was the most common barrier to pain assessment at the nursing home resident level. At the health care provider level, lack of knowledge and skills were identified as the most common barrier to pain assessment. In contrast, at the health care system level, interpersonal factors within organizational hierarchies, such as the breakdown of communication, was identified as the most common barrier to pain assessment. The most common facilitators that were identified at the resident, health care provider, and health care system level included, respectively, the identification of resident pain-related behaviors in relation to cognitive impairment, health care providers’ previous experiences in, and knowledge of, pain assessment, and having policies and procedures in place to facilitate routine pain assessment practices within the nursing home. Additional barriers to pain assessment emerged across all identified subthemes at the resident, health care provider, and health care system-level. Barriers were thought to have affected the accuracy of pain assessments, as well as whether pain assessments were completed. Barriers included residents’ attitudes and beliefs about
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pain, highlighting stoic attitudes and the belief that pain is a normal part of aging as important factors affecting whether residents reported their pain. Additionally, residents’ social and cultural backgrounds were found to affect their attitudes and beliefs about pain, as well as present language barrier considerations affecting whether self-reports of pain could be obtained by health care providers. Additional health care providererelated barriers to pain assessment similarly included attitudes and beliefs, as well as social, cultural, and demographic factors. Beyond interpersonal communication at the health care system level, a lack of resources, as well as the absence of having documented pain assessment policies and procedures, were highlighted as important barriers to pain assessment. However, it is important to note that where policies and procedures did exist, health care providers expressed that excessive documentation was required, which ultimately made regular pain assessment impractical. Toward overcoming the identified barriers to pain assessment, we were able to identify multiple facilitators to pain assessment across many, but not all, of the identified subthemes at the resident, health care provider, and health care system levels. At the resident level, observable pain-related behaviors facilitated the identification of pain and offered a means of overcoming barriers related to cognitive impairment, such as limited ability to verbalize the experience of pain. At the health care provider level, previous education and experiences in pain assessment, as well as related skills, facilitated the identification of pain in residents. The involvement of family caregivers was an important means of identifying pain in residents, and allowed for an understanding of how individual residents expressed their pain. Additionally, where previous education and experiences had not been obtained, staff often expressed that they had utilized resources available for education within, and external to, the facility. Importantly, where health care providers had noted previous education and experiences with pain assessment, they were less likely to hold negative or biased attitudes and beliefs toward pain, which improved their pain assessment practices. Lastly, although the lack of any standardized assessment policies and procedures within nursing homes was noted as a substantial barrier to pain assessment, efforts toward implementing pain assessment policies and procedures, as well as toward promoting regular pain assessment, showed significant and lasting differences in improving pain assessment practices within nursing homes. Overall, findings from our study have strong external validity, with most studies including numerous nursing home settings and large sample sizes. This strengthens the generalizability of our results. All studies passed our quality appraisal, indicating acceptable methodology. Included studies were diverse and did not discriminate on country of origin, year published, or language of publication, also increasing the generalizability of our findings. Although we are confident in our findings, this review has limitations. First, most studies did not identify barriers or facilitators to pain assessment specifically. Rather, barriers and facilitators were discussed more broadly as pain management, which also includes pain treatment. However, the barriers and facilitators outlined in this review are consistent with previous research,14,20e22 although our study is the first to explore these factors strictly in nursing home settings. Secondly, reviewers were not blind to trial author, journal, or institution information. Potential bias from nonblinded quality assessment was expected to be low because review authors had no conflict of interest (financial or other). While barriers and facilitators to pain assessment have been identified across the literature,14,20e22 research to date has not yet provided a comprehensive account and synthesis of these factors at the resident, and health care provider levels in a systematic review. Taking this into account, our review highlights key considerations for stakeholders, including health care providers, administrators, and policy decision makers, when it comes to assessing pain in nursing
home residents. Being cognizant of the multiple barriers to pain assessment in nursing home residents is an important means of improving the identification of pain in this population, and has important implications for the development of policies and procedures related to pain assessment in nursing homes. Further, the identification of strategies to overcome these barriers provides important avenues for further research in this area, and informs stakeholders of strategies that may help to improve pain assessment, and ultimately pain management in nursing homes.
Acknowledgments We would like to acknowledge librarians Dagmara Chojecki MLIS and Linda Slater BEd, BA(Hon), MLIS, from the John W. Scott Health Sciences Library at the University of Alberta for their help with database searching.
Supplementary Data Supplementary data related to this article can be found online at https://doi.org/10.1016/j.jamda.2019.01.156.
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39. Gudmannsdottir GD, Halldorsdottir S. Primacy of existential pain and suffering in residents in chronic pain in nursing homes: A phenomenological study. Scand J Caring Sci 2009;23:317e327. 40. Hadjistavropoulos T, Janzen Claude JA, Hadjistavropoulos H, et al. Stakeholder opinions on a transformational model of pain management in long-term care. J Gerontol Nurs 2011;37:40e51. 41. Hadjistavropoulos T, Williams J, Kaasalainen S, et al. Increasing the frequency and timeliness of pain assessment and management in long-term care: Knowledge transfer and sustained implementation. Pain Res Manag 2016;2016: 6493463. 42. Holloway K, McConigley R. Understanding nursing assistants’ experiences of caring for older people in pain: The Australian experience. Pain Manag Nurs 2009;10:99e106. 43. Jones KR, Fink R, Vojir C, et al. Translation research in long-term care: Improving pain management in nursing homes. Worldviews Evid Based Nurs 2004;1:S13eS20. 44. Kaasalainen S, DiCenso A, Donald FC, Staples E. Optimizing the role of the nurse practitioner to improve pain management in long-term care. Can J Nurs Res 2007;39:14e31. 45. Long CO. Pain management education in long-term care: It can make a difference. Pain Manag Nurs 2013;14:220e227. 46. McConigley R, Toye C, Goucke R, Kristjanson LJ. Developing recommendations for implementing the Australian Pain Society’s pain management strategies in residential aged care. Australas J Ageing 2008;27:45e49. 47. Mentes JC, Teer J, Cadogan MP. The pain experience of cognitively impaired nursing home residents: Perceptions of family members and certified nursing assistants. Pain Manag Nurs 2004;5:118e125. 48. Peisah C, Weaver J, Wong L, Strukovski JA. Silent and suffering: A pilot study exploring gaps between theory and practice in pain management for people with severe dementia in residential aged care facilities. Clin Interv Aging 2014; 9:1767e1774. 49. Tarzian AJ, Hoffmann DE. Barriers to managing pain in the nursing home: Findings from a statewide survey. J Am Med Dir Assoc 2004;5:82e88. 50. Veal F, Williams M, Bereznicki L, et al. Barriers to optimal pain management in aged care facilities: An Australian qualitative study. Pain Manag Nurs 2018;19: 177e185. 51. Wagner AM, Goodwin M, Campbell B, et al. Pain prevalence and pain treatments for residents in Oregon nursing homes. Geriatr Nurs 1997;18: 268e272. 52. Weiner DK, Rudy TE. Attitudinal barriers to effective treatment of persistent pain in nursing home residents. J Am Geriatr Soc 2002;50:2035e2040. 53. Yates P, Dewar A, Fentiman B. Pain: The views of elderly people living in longterm residential care settings. J Adv Nurs 1995;21:667e674. 54. Tanaka H, Momose Y. Investigation of pain assessment trends among residents in Japanese long-term care facilities [in Japanese]. Nippon Ronen Igakkai Zasshi 2012;49:99e106.
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Appendix 1. Supplemental Information File, Study Selection 1. MEDLINE Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> 1 exp Nursing Homes/ or residential facilities/ or assisted living facilities/ or homes for the aged/ 2 (((extended or "long term" or intermediate or skilled) adj3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") adj3 (facilit* or institution*)) or "residential care").mp. 3 1 or 2 4 Pain Measurement/ 5 (pain adj3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)).mp. or pain.ti. 6 4 or 5 7 3 and 6 8 (aged or elder* or seniors or (old* adj2 (people or person* or patient* or men or women))).mp. 9 7 and 8 2. Embase Embase <1974 to 2018 June 01> 1 *nursing home/ or *residential care/ or (((extended or long term or intermediate or skilled) adj3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") adj3 (facilit* or institution*)) or residential care).ti,ab,kw. 2 exp *pain assessment/ or (pain adj3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)).ti,ab,kw. or pain.ti. 3 1 and 2 4 (aged or elder* or seniors or (old* adj2 (people or person* or patient* or men or women))).mp. 5 3 and 4 6 limit 5 to (conference abstract or conference review) 7 5 not 6
3. Cochrane Central Register of Controlled Trials #1 [mh Nursing Homes] or [mh residential facilities] or [mh assisted living facilities] or [mh homes for the aged] or (((extended or "long term" or intermediate or skilled) near/3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") near/3 (facilit* or institution*)) or "residential care"):ti,ab,kw #2 #1 or #2 #3 [mh "Pain Measurement"] or (pain near/3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)):ti,ab,kw or (pain):ti #4 #2 AND #3 4. CINAHL (MH "Residential Facilitiesþ") OR (MH "Nursing Homesþ") OR (MH "Skilled Nursing Facilities") OR (extended or "long term" or intermediate or skilled) w3 (care or facilit*) or "rest home*" or "convalescen* home*" or ("assisted care" or "assisted living" or "continuing care") w3 (facilit* or institution*)) or "residential care" AND (MH "Pain Measurement") OR pain n3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*) ) OR TI pain AND aged or elder* or seniors or old* w2 (people or person* or patient* or men or women) 5. Web of Science Core TS¼( ( extended OR "long term" OR intermediate OR skilled ) near/3 ( care OR facilit* ) OR "rest home*" OR "convalescen* home*" OR ( ( "assisted care" OR "assisted living" OR "continuing care" ) near/3 ( facilit* OR institution* ) ) OR "residential care" ) AND ( TS¼( pain near/3 ( assess* OR evaluat* OR diagnos* OR screen* OR measur* OR score* OR scale* ) ) OR TI¼( pain ) ) AND TS¼( aged OR elder* OR seniors OR ( old* near/2 ( people OR person* OR patient* OR men OR women ) ) )
Identification
J.A. Knopp-Sihota et al. / JAMDA xxx (2019) 1e9
Records identified through database searching (n = 2,067)
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Additional records identified through other sources (n = 12)
Eligibility
Screening
Duplicates removed (n = 809)
Records screened on basis of title and abstract (n = 1,270)
Records excluded based on title, abstract, and availability* (n = 1,179) *Full-text not available despite efforts to locate.
Articles (full text) retrieved, based on title and abstract, for eligibility (n = 91)
Articles excluded (n = 60) Paper type* (n = 29) Outcomes** (n = 27) Setting (n = 4)
Included
*Primary (original) research studies only. **General relevance of article to our review.
Studies included in qualitative synthesis (n = 31)
Supplemental Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram: Study selection process.
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Supplemental Figure 2. Risk of bias summary: reviewers’ judgments about each risk of bias item for each of the included studies.
JAMDA journal homepage: www.jamda.com
Review Article
Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis Jennifer A. Knopp-Sihota PhD a, b, *, Kennedy L. Dirk b, c, Geoffrey S. Rachor BA b a
Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada Translating Research in Elder Care (TREC), University of Alberta, Edmonton, Alberta, Canada c Faculty of Kinesiology, Western University, London, Ontario, Canada b
a b s t r a c t Keywords: Nursing home residents nursing homes systematic review pain assessment barriers and facilitators
Objectives: The burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents. Design: This is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist. Setting and participants: We included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both. Measures: Extracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors. Results: Thirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers’ lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines. Conclusion and implications: Findings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents’ quality of life. Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
Prevalence of pain in nursing home residents is high, with an estimated 45% to 80% of residents affected.1 Despite this, pain management in this population is generally less than optimal and pain often goes under recognized and ultimately untreated.2 Consequences
This work was supported by the Alzheimer Society Research Program (Grant 16-12), Alzheimer Society of Canada. The authors declare no conflicts of interest. * Address correspondence to Jennifer A. Knopp-Sihota, PhD, Athabasca University, 1 University Drive, Athabasca, Alberta, Canada. E-mail address: [email protected] (J.A. Knopp-Sihota). https://doi.org/10.1016/j.jamda.2019.01.156 1525-8610/Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
of untreated pain include unnecessary suffering and impaired quality of life,3 functional loss,4 depression,5 and behavioral disturbances including aggression, agitation, and wandering.6 Pain not only affects residents but also impacts formal and informal caregivers, resulting in burnout,7 decreased quality of life, and substantial burden.8 Better pain management can improve quality of life for both residents and their caregivers. However, successful pain management depends first on accurate pain assessment. Approaches to pain assessment are complex but ought to be resident centered and take into account individual resident characteristics, including cognitive function. In residents with intact
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cognition, pain self-report is the gold standard,9 but this becomes less reliable and valid as cognitive function declines.10 For residents with intact cognition, multiple bedside pain assessment tools (eg, visual analog scales) are validated for use. For residents with moderate to severe dementia, observing and detecting their pain-related behaviors is a valid approach to identifying pain.10,11 Scales for this purpose are typically checklists scored as number of behaviors observed.12 Despite use of these tools, pain assessment in nursing home residents remains inadequate.13 In this review, we identify and summarize available evidence to improve understanding of barriers and facilitators to pain assessment for nursing home residents. Similar literature reviews have been carried out, but these reviews are either outdated, not systematic in their design, limited specifically to nursing home residents with dementias,14 or are limited to acute care settings.2,15 This study provides the first systematic review, following Cochrane’s guidelines, to identify primary barriers and facilitators to pain assessment for nursing home residents. Although work has focused on improving pain assessment for nursing home residents,16e18 best practices have not been consistently identified across residents with varying levels of physical or cognitive function.19 Factors attributed to pain assessment for nursing home residents can be categorized at the level of the resident, health care provider, or health care system (organizational).20e22 These factors are often post hoc considerations rather than targeted outcomes of research studies. In this review, we sought to synthesize and critically appraise literature about factors (barriers and facilitators) associated with pain assessment for nursing home residents. Methods We followed procedures for conducting systematic reviews as described in the Cochrane Handbook of Systematic Reviews of Interventions23 and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.24 Our review protocol with detailed methodology and design is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42018105007). Criteria for Considering Studies for This Review Types of studies As it would be difficult to comprehensively quantify the multiple barriers and facilitators to pain assessment in nursing home residents, we identified our topic as more amenable to a qualitative approach. For this reason, we planned to include all primary (original) qualitative studies published in any language and any year that used a recognized data collection method (eg, focus groups, interviews) and qualitative analyses. Studies must have evaluated and reported barriers or facilitators to pain assessment that were resident based (eg, cognitive impairment), health care provider based (eg, knowledge deficit), or at the health system level (eg, organizational communication). After extensive preliminary review of the literature, we chose categories that represented the most prevalent themes across available literature. We excluded unpublished/gray literature and secondary analysis studies. Types of participants in studies To meet inclusion criteria, studies must have focused on either nursing home residents, nursing home health care providers, or both. Studies focusing on residents were included if residents were identified as 65 years and older or referred to as elderly or aged, and were not limited by sex or cognitive status. Additionally, residents must have had either acute or chronic pain and permanently resided in an institutional setting, such as a nursing home, long-term care, or
residential care setting. Studies with health care providers as participants were also not limited by sex. Health care providers must have identified as working within an institutional setting (eg, nurses, health care aides, physicians). Studies were excluded if they were conducted within hospital settings, short-term care facilities, health care clinics, assisted living, and all other health care settings not within the scope of nursing homes or long-term care.
Search Strategy Database searches, including databases, key words, and limiters, were selected in consultation with academic librarians. Database searches included studies published from database inception to June 7, 2018, and were not limited to English language. Our search strategies are reported in Appendix 1. Searched databases included the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and Web of Science. One reviewer (K.D.) independently screened titles and abstracts from the initial database searches. Full text of studies passing initial screening were retrieved and reviewed independently by 2 reviewers (K.D., G.R.) and verified by a third reviewer (J.K.S.). We resolved discrepancies in final inclusion decisions by consensus. Study selection and screening processes are presented in Supplemental Figure 1.
Data Extraction and Synthesis Using a pretested data collection Excel spreadsheet, we extracted data in 2 phases. In phase 1, 1 reviewer (K.D.) extracted study information: author and year of publication, setting, participant characteristics, study objectives, and data collection and analysis procedures. Two reviewers (K.D., G.R.) reviewed extracted data for accuracy and consistency, and resolved any discrepancies by discussion. In phase 2, 2 reviewers (K.D., G.R.) extracted and clustered data into 3 primary groups: resident, health care provider, and health systemelevel factors that influence pain assessment for nursing home residents. Extracted data were subjected to thematic analysis, a systematic, qualitative process to identify, collate, and summarize emergent themes related to the 3 factors.25 Adhering to recommendations for systematically reviewing qualitative research,25,26 2 reviewers (K.D., G.R.) independently coded themes (reviewed by J.K.S.) in a cyclical manner in light of emergent themes until no further new themes emerged. On completion of thematic analyses, we conducted narrative syntheses of results.27
Quality Appraisal: Risk of Bias in Individual Studies We assessed included articles for bias and methodological quality using the Critical Appraisal Skills Programme’s (CASP) Checklist for Qualitative Research.28 CASP’s Checklist for qualitative appraisal broadly assesses the validity of results and methodological rigor. The checklist consists of 10 questions grouped into 3 broad categories: (1) Are the results valid? (clear aims; appropriate methodology; research design, recruitment strategy, and data collection procedures address the aims; appropriate researcher-participant relationship). (2) What are the results? (ethical consideration, data analysis sufficiently rigorous, and a clear findings). (3) Will the results help locally? (the overall value of the research).28 Two reviewers (K.D., G.R.) constructed a risk of bias table and assessed each question as low risk of bias (answered “yes”), high risk of bias (answered “no”), or unclear or unknown risk of bias (answered as “can’t tell”). Discrepancies were resolved by discussion.
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Results Study Selection Our initial database search identified 2079 records for review (see Supplemental Figure 1). Upon initial screening, 809 duplicate records were removed, with an additional 1179 records excluded based on title and abstract (n ¼ 1158) and availability (n ¼ 21), resulting in a total of 112 records for full-text review. Of the remaining 91 records, 60 were eliminated based on outcomes measured, study setting, or study design. Thirty-one full-text studies met our inclusion criteria and were included in our qualitative synthesis.17,19e22,29e54 Study Characteristics Characteristics of included studies are in Table 1. Thirty-one studies with 3297 unique participants were included: 2281 nursing home staff and 1016 nursing home residents. Nursing home staff included physicians, nurse practitioners, registered nurses, licensed practical nurses, certified nursing aides, nursing home managers, and other administrators. One study did not report sample size; however, available data were still extracted and included in our results.33 Studies were conducted in the United States (n ¼ 12),19,29,32,33,35,38,43,45,47,49,51,52 Canada (n ¼ 7),17,21,22,37,40,41,44 Australia (n ¼ 6),36,42,46,48,50,53 United Kingdom (n ¼ 2),30,34 Ireland (n ¼ 1),20 Japan (n ¼ 1),54 Iceland (n ¼ 1),39 and Israel (n ¼ 1).31 Included studies ranged in year of publication from 1995 to 2018. All studies were observational, with the majority (n ¼ 16) using either focus groups or interviews for data collection.17,19,21,22,32,33,35,37e39,41,42,46,47,50,53 The remainder used either surveys or questionnaires (n ¼ 12)20,29e31,36,40,44,45,49,51,52,54 or a combination of both (n ¼ 3).34,43,48 Quality Appraisal With the exception of 1 study,34 we considered the overall risk of bias of included studies to be low (see Supplemental Figure 2). All studies had a clear statement of aims and used appropriate qualitative methodology. Three studies31,34,52 had a high risk of bias attributed to research design, whereas 9 studies20,29e31,34,35,42,43,48 were labeled high risk of bias based on recruitment. One study29 had a high risk of data collection bias, and 6 studies20,29,31,34,46,48 did not explicitly consider conflicting interests. Four studies41,43,51,53 had an unclear risk of bias based on consideration of ethical issues. Three studies31,34,43 were at risk of bias because they did not meet the criteria for rigorous data analysis, and 1 study34 did not meet the criterion for clearly stating their findings. Despite these methodologic issues, we considered these concerns as not sufficient to exclude these studies from the review. Emergent Themes Of the 31 included studies, 28 reported resident factors,17,19e22,29,30,32e40,43e54 28 reported health care provider factors,17,19e22,29e38,40e50,52,54 and 29 reported on health system factors17,19e22,29e33,35e38,40e52,54 associated with pain assessment. Our meta-synthesis revealed several constructs related to barriers and facilitators in assessing pain in nursing home residents (see Table 2). At the resident level, we identified the 3 subthemes of physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic factors, where cognitive impairment emerged as the most prominent subtheme at the resident level. At the health care provider level, we identified the 3 subthemes of knowledge and skills, attitudes and beliefs, and social/cultural/demographic background factors, where knowledge and skills emerged as the most prominent subtheme. Lastly, at the health system level, we identified the 3
3
subthemes of interpersonal factors, resources, and policy, where interpersonal factors within organizational hierarchies emerged as the most prominent subtheme. Resident factors Physical or cognitive impairments. The most prominent subtheme related to factors of pain assessment at the resident level was cognitive impairment, where 22 studies identified the presence, and severity, of dementia as a primary barrier to pain assessment.17,19e22,29,30,32e35,37,38,40,44,46e51,54 For example, nurses expressed difficulties in assessing pain in residents with more advanced dementia, as residents’ ability to self-report pain was often impaired.17,19e22,29,30,33,35,37,40,47e51,54 Resident behaviors were identified as both a barrier17,19,21,22,32,33,41,46,48,50,51 and the most prominent facilitator17,19,21,22,29,30,33,35,46e48,50,51 to adequate pain assessment, regardless of resident cognitive status. For example, observing pain-related behaviors such as facial expressions and body movements facilitated pain assessment in noncommunicative residents with cognitive impairment.17,19,32,33,35,48 Conversely, some residents expressed challenging behaviors as an exaggeration or tolerance of pain, where exaggerated challenging behaviors were sometimes viewed by health care providers as manipulative and indicative of attention- or medication-seeking behavior rather than pain.17,20e22,32,33,35,38,45,47,48,50,51 Additionally, the presence of multiple comorbid chronic conditions such as depression or other illnesses were associated with exacerbating and overlapping symptoms, making it difficult to discern painrelated symptoms.19e21,32,33,38 Attitudes and beliefs. Residents’ attitudes and beliefs were found to influence pain assessment across 12 studies.20,21,32,33,35,38,39,48,50,52e54 In these studies, residents were reluctant to report pain because of stoicism, pride, or denial of their pain, and feared the loss of independence.20,21,32,33,35,38,39,48,50,53 Many residents believed that pain was a normal part of aging, resulting in desensitization and acceptance of their pain.20,21,32,33,39,52,53 Some residents were hesitant to report pain because they did not want to be seen as a difficult patient, bother busy staff, or be perceived as a medication seeker.20,21,33,35,39,41,45,50,52e54 Social, cultural, and demographic. Social, cultural, and demographic variables affected resident pain assessment in 5 studies.20,32,33,35,50 For example, rural-based residents were less likely to report pain.32,33 Residents’ social (eg, previous drug abuse history)33 and cultural33,35,49 backgrounds affected their concept of pain and likelihood of reporting. Sex or ethnicity of the health care provider at times predicted residents’ willingness to report pain; this was thought to stem from residents’ cultural values of not discussing sensitive matters with the opposite sex.35 Further, if residents and health care providers spoke different primary languages, pain assessments by self-report often could not be used.20,50 Health care provider factors Knowledge and skills. The most prominent subtheme at the health care provider level related to knowledge and skills, where lack of knowledge about pain assessment was identified as a primary barrier to pain assessment in 22 studies.19e22,29e33,35,36,38,40,42e46,49e51,54 Accordingly, 7 studies reported that greater staff knowledge and education facilitated pain assessment for nursing home residents.30e32,36,38,47,48 Some staff also sought external education and supports to facilitate pain assessment.38,46,49 Across 16 studies, health care providers identified specific skills required to improve pain assessment.17,19,20,29e31,33e36,42,43,46e48,50 For example, having a relationship with the resident and knowing how they express pain improved pain identification, especially in
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Table 1 Characteristics of Included Studies Author and Year
Location
Participants
Allcock et al29 (2002)
USA
NH managers (n ¼ 68)
Barry et al30 (2012)
Ireland
NH managers (n ¼ 96)
Ben-Natan et al31 (2013)
Israel
Nurses (n ¼ 104)
Clark et al33 (2004)
USA
Professional and unlicensed NH staff (n ¼ N/A)*
Clark et al32 (2006)
USA
Administrators (n ¼ 9), RNs (n ¼ 38), LPNs (n ¼ 26)
Closs et al34 (2006)
United Kingdom
Residents (n ¼ 113), NH staff (n ¼ 65)
Dobbs et al35 (2014)
USA
CNAs (n ¼ 28)
Douglas et al36 (2016)
Australia
Residents (n ¼ 636), NH staff (n ¼ 434)
Egan and Cornally20 (2013)
Ireland
RNs (n ¼ 62), clinical nurse managers (n ¼ 18)
Fox et al22 (2004)
Canada
Ghandehari et al37 (2013)
Canada
Physicians (n ¼ 6), RNs (n ¼ 19), RPNs (n ¼ 8), health care aides (n ¼ 13), occupational/ physiotherapists (n ¼ 8) RNs (n ¼ 70), health care aids (n ¼ 61)
Gropelli and Sharer38 (2013)
USA
RNs (n ¼ 9), LPNs (n ¼ 7)
Gudmannsdottir and Halldorsdottir39 (2009)
Iceland
Residents (n ¼ 12)
Study Objectives
To identify barriers in assessment and management of chronic pain in residents To explore knowledge/ beliefs of NH managers regarding pain assessment in residents with dementia To identify factors predicting nurses’ performance of pain assessment for residents To describe pain assessment measures used in NH, as well as staff judgments of residents’ pain complaints Explore perceptions of NH staff to inform the development of a pain management intervention Compare staff and resident reports of pain; and to explore staffs experiences with pain assessment To examine cultural context and communication of pain between CNAs and residents To examine pain assessment tools implementation and use and associated outcomes To identify barriers to pain assessment and management from the perspectives of nurses To provide an understanding of pain practices in NH, and to identify barriers to pain management To investigate the effects of a continuing education program for pain assessment in NH To determine nurse’s perceptions of pain management in NH To describe the experiences of, and essential considerations of, chronic pain in residents
Methodology
Factors
Data Collection
Data Analysis
Questionnaire (closed and open ended)
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Qualitative data analysis; content/ thematic analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ correlational
HCP, health care system
Focus group interviews
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Semistructured interviews
Content/thematic analysis
Resident, HCP, health care system
Semistructured and structured interviews
Descriptive; qualitative data analysis
Resident, HCP
Focus group interviews
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Self-report questionnaires; chart audits
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident, HCP, health care system
Structured (focused) interviews
Content/thematic analysis
Resident, HCP, health care system
Unstructured interviews
Interpretive phenomenology
Resident
(continued on next page)
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Table 1 (continued ) Author and Year
Location
Participants
RN (n ¼ 70), administrators (n ¼ 46), health care aides (n ¼ 25), physicians (n ¼ 11), other (n ¼ 15) Residents (n ¼ 65), RNs (n ¼ 2), RPNs (n ¼ 6), personal support workers (n ¼ 7), physicians (n ¼ 2), kinesiologist (n ¼ 1), manager (n ¼ 1)
Hadjistavropoulos et al40 (2011)
Canada
Hadjistavropoulos et al17 (2014)
Canada
Hadjistavropoulos et al41 (2016)
Canada
Nurses (n ¼ 19), CNAs (n ¼ 19), clinical nurse specialist (n ¼ 1), director of care (n ¼ 1)
Holloway and McConigley42 (2009)
Australia
Nursing assistants (n ¼ 6)
Jones et al43 (2004)
USA
NH staff (n ¼ 60), residents (n ¼ 60)
Kaasalainen et al44 (2007)
Canada
Nurse practitioners (n ¼ 16)
Kaasalainen et al21 (2010)
Canada
Long45 (2013)
USA
RNs (n ¼ 15), RPNs (n ¼ 6), unified caring providers (n ¼ 20), physicians (n ¼ 4), administrators (n ¼ 4), physiotherapists (n ¼ 2), pharmacists (n ¼ 2) Professional staff (n ¼ 14), CNAs (n ¼ 10)
McConigley et al46 (2008)
Australia
Mentes et al47 (2004)
USA
Physicians (n ¼ 7), RNs (n ¼ 11), enrolled nurses (n ¼ 4), allied health professionals (n ¼ 8), care managers (n ¼ 4) Family members (n ¼ 16), CNAs (n ¼ 11), cognitively impaired residents (n ¼ 20)
Study Objectives
To examine the opinions of key stakeholders in implementing pain assessment guidelines into NH To evaluate whether regular pain assessments alongside communication to physicians affect prescription of psychotropic medications To evaluate whether the implementation of a pain protocol results in greater performance on a variety of quality indicators To describe the experiences of nursing assistants who care for older residents in pain To develop and test a culturally competent intervention for NHs and to assess staff and residents’ knowledge of pain. To examine the role of nurse practitioners in a pain management model, and to identify factors affecting implementation To identify barriers to pain management, as well as barriers to implementing a pain protocol, in NH
To survey NH staff before and after an educational pain intervention on outcomes of knowledge, attitudes, and barriers To develop recommendations for pain management in residential aged care facilities. To evaluate information from CNAs, residents, and family/friends caregivers on residents’ pain experiences
Methodology
Factors
Data Collection
Data Analysis
Questionnaire (closed and open ended)
Descriptive; content/ thematic analysis
Resident, HCP, health care system
Focus group interviews; semistructured interviews
Descriptive and qualitative/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews; semistructured interviews
Descriptive; content/ thematic analysis
HCP, health care system
Semistructured interviews
Thematic analysis
HCP, health care system
Focus group interviews; structured individual interviews
Descriptive and qualitative/ quantitative data analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Descriptive and qualitative/content analysis
Resident, HCP, health care system
Focus group interviews; individual interviews
Descriptive and qualitative/thematic analysis
Resident, HCP, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus groups; individual interviews
Qualitative/thematic analysis
Resident, HCP, health care system
Semistructured interviews
Content/thematic analysis
Resident, HCP, health care system
(continued on next page)
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Table 1 (continued ) Author and Year
Location
Participants
Monroe et al19 (2015)
USA
RNs and LPNs (n ¼ 29)
Peisah et al48 (2014)
Australia
Directors of care (n ¼ 4), RNs (n ¼ 10), patient care assistants (n ¼ 6)
Tanaka and Momose54 (2012)
Japan
Nurses (n ¼ 443)
Tarzian and Hoffman49 (2004)
USA
Directors of nursing (n ¼ 113)
Veal et al50 (2018)
Australia
RNs (n ¼ 18), facility managers (n ¼ 5)
Wagner et al51 (1997)
USA
Residents (n ¼ 461)
Weiner and Rudy52 (2002)
USA
Residents (n ¼ 75), RNs (n ¼ 75), CNAs (n ¼ 75)
Yates et al53 (1995)
Australia
Residents (n ¼ 42)
Study Objectives
Methodology
To examine nurses’ cues and practices used in identifying pain in residents with dementia To explore attitudes and processes relating to pain management for residents with dementia in residential aged care facilities To examine problems associated with pain assessment in elderly residents To identify pain management demographics, perceived resources and barriers to manage pain in NHs To characterize and identify barriers of pain management in residential aged care facilities To describe trends relating to pain management in NH’s, and to identify ways to improve residents pain management To explore attitudes of resident and staff acting as barriers to pain assessment and management To describe the beliefs, attitudes, and perceptions about pain and pain management held by residents
Factors
Data Collection
Data Analysis
Focus group interviews
Thematic analysis/ scissor-and-sort technique
Resident, HCP, health care system
Survey with semistructured interviews
Descriptive/content analysis
Resident, HCP, health care system
Questionnaire (closed and open ended)
Descriptive and qualitative/ quantitative data analysis Descriptive/ quantitative data analysis
Resident, HCP, health care system
Semistructured interviews
Thematic analysis
Resident, HCP, health care system
Chart audits, observational surveys
Descriptive/ quantitative data analysis
Resident, health care system
Self-report questionnaires
Descriptive/ quantitative data analysis
Resident, HCP, health care system
Focus group interviews
Content/thematic analysis
Resident
Self-report questionnaires
Resident, HCP, health care system
CNA, certified nursing assistant; HCP, health care provider; LPN, licensed practical nurse; NH, nursing home; RN, registered nurse; RPN, registered practical nurse. *Sample size not reported.
observing pain-related behaviors in residents with cognitive impairment.19e22,29,33,35,41e43,47,48,51 Staff experience was a facilitator in pain assessment, along with staff confidence and sense of control in performing assessments.17,20,31,34,36,50 Further, skills such as the use of touch or observation of patient behavior facilitated pain assessment and improved residents’ level of comfort with staff.35 Attitudes and beliefs. In 19 studies, health care providers’ attitudes and views toward pain were found to affect pain assessment.20e22,30e33,35e38,40,43e45,48e50,52 For example, staff believed pain to be a normal part of aging, resulting in biased assessments and failure to acknowledge pain.20,22,30,31,33,35,36,49,52 If staff demonstrated positive views toward pain and aging, staff were more likely to express the intent to and to conduct an assessment.31,36 Nursing home staff were at times reluctant to complete assessments as they feared overmedicating residents.20,21,38,44,49,50 Toward overcoming these barriers, multiple studies indicated experience, and efforts toward increasing the knowledge of pain assessment in nursing home staff resulted in more positive
attitudes and beliefs of pain and aging, and a greater likelihood of conducting pain assessments.32,35e37,40,43,45,48 Social, cultural, and demographic. Three studies referred to social, cultural, and demographic factors affecting pain assessment at the health care provider level.35,49,50 Care providers’ cultural and religious backgrounds were identified as barriers to pain assessment and were thought to affect attitudes and beliefs toward pain.49 Conversely, many care providers recognized that regardless of their and residents’ cultural backgrounds, pain is universal, highlighting the need for assessing pain regardless of individuals’ backgrounds.35 To facilitate pain assessments, care providers assessed pain in the primary language of the residents, where possible.50 Health care system and organizational-level factors Interpersonal. Interpersonal communication was the most prominent subtheme at the health care system level. The primary barrier at this level related to the breakdown of communication across
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Table 2 Meta-synthesis Results Factors
Subthemes
Pain Constructs and Definitions
Resident
Attitudes and beliefs
Physical or cognitive impairments Social/cultural/demographic
Health Care Provider
Knowledge/skills
Attitudes and beliefs
Health care system
Social/cultural/demographic Policy Resources
Interpersonal
Beliefs and assumptions that pain is a normal part of aging Denial that pain is present Desensitization or resignation to pain Experiencing pain without displaying feelings or complaining (stoicism) Sensory or cognitive impairments may affect the ability to effectively communicate pain in typical ways Residents with multimorbidity (eg, depression) and overlapping symptoms complicate assessment Reluctance to report pain based on cultural/ethnic preferences of the assessor (ie, sex, race, and language of the assessor is different from the resident’s) Religion, geographic area (rural vs urban), and cultural views affect a resident’s self-perception of pain Lacking the necessary pain knowledge or geriatric training to perform an adequate pain assessment Lack of familiarity/training with pain assessment tools and scales HCP having a relationship with/knowing the resident in order to provide resident-centered pain assessment Using touch or other techniques to facilitate pain assessment Having the experience and confidence/control to complete pain assessments Belief that pain is a normal part of aging and being insensitive or biased in assessment Fear of overmedicating resident Intention/agency to complete assessment Culture, religion, and ethical beliefs affecting view on pain and ability to legitimize pain complaints Lack of standardized and routine assessments or policies/procedures The documentation required and the report type (verbal vs nonverbal) affect assessment Lack of available training opportunities for staff Lack of access to pain specialists (eg, clinical nurse educator) Insufficient facility funding with high staff turnover and workload; leading to inadequate time (pain assessment is time consuming) Communication, collaboration, and respect in interdisciplinary teams Lack of resident family involvement affects assessment
organizational hierarchies, which influenced resident pain assessment in 22 studies.17,19e22,30,32,33,35e38,40e44,46e50 Breakdown of communication included a perceived lack of respect by unregulated health care providers, as well as a lack of acknowledgement, or feeling ignored in their communication toward other professionals.20e22,30,33,37,38,40e44,48e50 Furthermore, poor physician communication and lack of involvement was a barrier to interdisciplinary teamwork.20e22,30,33,37,38,40,43,44,46,48e50 Interdisciplinary teams with respect and trust between members resulted in greater teamwork and communication, which facilitated pain assessment.17,19,22,32,36,40e42,44,46 Additionally, interpersonal pain assessment was facilitated when family members or residents were involved, as this allowed a deeper understanding of the resident and their behavior.19,22,35,36,38,47 Resources. In 22 studies, resources (eg, pain assessment tools, staff training) were discussed as either barriers or facilitators to pain assessment.17,20e22,29e33,36,37,40,41,43e46,48e50,52,54 Lack of pain assessment specialists,29,40,43,46,48 such as geriatricians and palliative care specialists,46 as well as deficient staff training,21,30,31,40,44 low staffing levels,17,21,40,48 high staff turnover,43,50 insufficient time,17,20e22,30,33,37,40,41,44e46,49,52,54 and low funding for staff resources and training40,49 were identified as barriers to pain assessment. Identified as the primary facilitator to pain assessment at the health care system level were interventions aimed toward promoting routine assessment policies. In addition, providing and implementing standardized assessments and staff training facilitated pain assessment practices.17,21,29,30,32,36,37,40,41,43,46,48 Policy. Eighteen studies cited nursing home policies as both a barrier and facilitator to pain assessment.17,20e22,29,30,33,35e38,40,41,44,46,48e50,54 Lack of pain assessment policies or lack of procedures for standardized or routine pain assessment were a barrier to pain assessment,20,21,29,30,33,38,40,41,44,49,50,54 where multiple studies noted that implementing policies and guidelines concerning pain assessment made staff more aware of, and facilitated the assessment of, pain in residents.17,37,41,44,50 However, excessive documentation required by nursing home policies in assessing and reporting pain often made it
impractical for staff to address residents’ pain on a regular basis.20,22,40,46 Verbal reports, including direct questioning and residents’ self-reports of pain were indicated as inappropriate for use in residents with cognitive impairment,29,33,35,50 where health care providers noted the limited efficacy of verbal pain scales as a barrier to pain assessment in these residents,50 and expressed the need for policy and resources related to nonverbal assessments of pain in residents with cognitive impairment.29,48,50 These resources included nonverbal pain assessment tools,48 and the use of behavior charts, picture boards, and written forms of communication to assess pain.29,48 Discussion Given the difficulties associated with assessing pain in nursing home residents, it is important to identify factors that influence the effective and accurate assessment of pain in this vulnerable population. This is, to our knowledge, the first systematic review and metasynthesis identifying and reporting barriers and facilitators to pain assessment in the nursing home setting at the nursing home resident, health care provider, and health care system levels. Across the 9 identified subthemes, cognitive impairment was the most common barrier to pain assessment at the nursing home resident level. At the health care provider level, lack of knowledge and skills were identified as the most common barrier to pain assessment. In contrast, at the health care system level, interpersonal factors within organizational hierarchies, such as the breakdown of communication, was identified as the most common barrier to pain assessment. The most common facilitators that were identified at the resident, health care provider, and health care system level included, respectively, the identification of resident pain-related behaviors in relation to cognitive impairment, health care providers’ previous experiences in, and knowledge of, pain assessment, and having policies and procedures in place to facilitate routine pain assessment practices within the nursing home. Additional barriers to pain assessment emerged across all identified subthemes at the resident, health care provider, and health care system-level. Barriers were thought to have affected the accuracy of pain assessments, as well as whether pain assessments were completed. Barriers included residents’ attitudes and beliefs about
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pain, highlighting stoic attitudes and the belief that pain is a normal part of aging as important factors affecting whether residents reported their pain. Additionally, residents’ social and cultural backgrounds were found to affect their attitudes and beliefs about pain, as well as present language barrier considerations affecting whether self-reports of pain could be obtained by health care providers. Additional health care providererelated barriers to pain assessment similarly included attitudes and beliefs, as well as social, cultural, and demographic factors. Beyond interpersonal communication at the health care system level, a lack of resources, as well as the absence of having documented pain assessment policies and procedures, were highlighted as important barriers to pain assessment. However, it is important to note that where policies and procedures did exist, health care providers expressed that excessive documentation was required, which ultimately made regular pain assessment impractical. Toward overcoming the identified barriers to pain assessment, we were able to identify multiple facilitators to pain assessment across many, but not all, of the identified subthemes at the resident, health care provider, and health care system levels. At the resident level, observable pain-related behaviors facilitated the identification of pain and offered a means of overcoming barriers related to cognitive impairment, such as limited ability to verbalize the experience of pain. At the health care provider level, previous education and experiences in pain assessment, as well as related skills, facilitated the identification of pain in residents. The involvement of family caregivers was an important means of identifying pain in residents, and allowed for an understanding of how individual residents expressed their pain. Additionally, where previous education and experiences had not been obtained, staff often expressed that they had utilized resources available for education within, and external to, the facility. Importantly, where health care providers had noted previous education and experiences with pain assessment, they were less likely to hold negative or biased attitudes and beliefs toward pain, which improved their pain assessment practices. Lastly, although the lack of any standardized assessment policies and procedures within nursing homes was noted as a substantial barrier to pain assessment, efforts toward implementing pain assessment policies and procedures, as well as toward promoting regular pain assessment, showed significant and lasting differences in improving pain assessment practices within nursing homes. Overall, findings from our study have strong external validity, with most studies including numerous nursing home settings and large sample sizes. This strengthens the generalizability of our results. All studies passed our quality appraisal, indicating acceptable methodology. Included studies were diverse and did not discriminate on country of origin, year published, or language of publication, also increasing the generalizability of our findings. Although we are confident in our findings, this review has limitations. First, most studies did not identify barriers or facilitators to pain assessment specifically. Rather, barriers and facilitators were discussed more broadly as pain management, which also includes pain treatment. However, the barriers and facilitators outlined in this review are consistent with previous research,14,20e22 although our study is the first to explore these factors strictly in nursing home settings. Secondly, reviewers were not blind to trial author, journal, or institution information. Potential bias from nonblinded quality assessment was expected to be low because review authors had no conflict of interest (financial or other). While barriers and facilitators to pain assessment have been identified across the literature,14,20e22 research to date has not yet provided a comprehensive account and synthesis of these factors at the resident, and health care provider levels in a systematic review. Taking this into account, our review highlights key considerations for stakeholders, including health care providers, administrators, and policy decision makers, when it comes to assessing pain in nursing
home residents. Being cognizant of the multiple barriers to pain assessment in nursing home residents is an important means of improving the identification of pain in this population, and has important implications for the development of policies and procedures related to pain assessment in nursing homes. Further, the identification of strategies to overcome these barriers provides important avenues for further research in this area, and informs stakeholders of strategies that may help to improve pain assessment, and ultimately pain management in nursing homes.
Acknowledgments We would like to acknowledge librarians Dagmara Chojecki MLIS and Linda Slater BEd, BA(Hon), MLIS, from the John W. Scott Health Sciences Library at the University of Alberta for their help with database searching.
Supplementary Data Supplementary data related to this article can be found online at https://doi.org/10.1016/j.jamda.2019.01.156.
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Appendix 1. Supplemental Information File, Study Selection 1. MEDLINE Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to Present> 1 exp Nursing Homes/ or residential facilities/ or assisted living facilities/ or homes for the aged/ 2 (((extended or "long term" or intermediate or skilled) adj3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") adj3 (facilit* or institution*)) or "residential care").mp. 3 1 or 2 4 Pain Measurement/ 5 (pain adj3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)).mp. or pain.ti. 6 4 or 5 7 3 and 6 8 (aged or elder* or seniors or (old* adj2 (people or person* or patient* or men or women))).mp. 9 7 and 8 2. Embase Embase <1974 to 2018 June 01> 1 *nursing home/ or *residential care/ or (((extended or long term or intermediate or skilled) adj3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") adj3 (facilit* or institution*)) or residential care).ti,ab,kw. 2 exp *pain assessment/ or (pain adj3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)).ti,ab,kw. or pain.ti. 3 1 and 2 4 (aged or elder* or seniors or (old* adj2 (people or person* or patient* or men or women))).mp. 5 3 and 4 6 limit 5 to (conference abstract or conference review) 7 5 not 6
3. Cochrane Central Register of Controlled Trials #1 [mh Nursing Homes] or [mh residential facilities] or [mh assisted living facilities] or [mh homes for the aged] or (((extended or "long term" or intermediate or skilled) near/3 (care or facilit*)) or ((rest or convalescen*) adj home*) or (("assisted care" or "assisted living" or "continuing care") near/3 (facilit* or institution*)) or "residential care"):ti,ab,kw #2 #1 or #2 #3 [mh "Pain Measurement"] or (pain near/3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*)):ti,ab,kw or (pain):ti #4 #2 AND #3 4. CINAHL (MH "Residential Facilitiesþ") OR (MH "Nursing Homesþ") OR (MH "Skilled Nursing Facilities") OR (extended or "long term" or intermediate or skilled) w3 (care or facilit*) or "rest home*" or "convalescen* home*" or ("assisted care" or "assisted living" or "continuing care") w3 (facilit* or institution*)) or "residential care" AND (MH "Pain Measurement") OR pain n3 (assess* or evaluat* or diagnos* or screen* or measur* or score* or scale*) ) OR TI pain AND aged or elder* or seniors or old* w2 (people or person* or patient* or men or women) 5. Web of Science Core TS¼( ( extended OR "long term" OR intermediate OR skilled ) near/3 ( care OR facilit* ) OR "rest home*" OR "convalescen* home*" OR ( ( "assisted care" OR "assisted living" OR "continuing care" ) near/3 ( facilit* OR institution* ) ) OR "residential care" ) AND ( TS¼( pain near/3 ( assess* OR evaluat* OR diagnos* OR screen* OR measur* OR score* OR scale* ) ) OR TI¼( pain ) ) AND TS¼( aged OR elder* OR seniors OR ( old* near/2 ( people OR person* OR patient* OR men OR women ) ) )
Identification
J.A. Knopp-Sihota et al. / JAMDA xxx (2019) 1e9
Records identified through database searching (n = 2,067)
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Additional records identified through other sources (n = 12)
Eligibility
Screening
Duplicates removed (n = 809)
Records screened on basis of title and abstract (n = 1,270)
Records excluded based on title, abstract, and availability* (n = 1,179) *Full-text not available despite efforts to locate.
Articles (full text) retrieved, based on title and abstract, for eligibility (n = 91)
Articles excluded (n = 60) Paper type* (n = 29) Outcomes** (n = 27) Setting (n = 4)
Included
*Primary (original) research studies only. **General relevance of article to our review.
Studies included in qualitative synthesis (n = 31)
Supplemental Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram: Study selection process.
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Supplemental Figure 2. Risk of bias summary: reviewers’ judgments about each risk of bias item for each of the included studies.