Interventions to overcome clinician- and patient-related barriers to pain management

Sigridur Gunnarsdottir*, Heidi S. Donovan, Sandra Ward

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

31 Citations (Scopus)

Abstract

There are many barriers to the optimal management of cancer pain. This article has addressed clinician- and patient-related barriers, inadequate knowledge and beliefs or attitudes that lead to behaviors that are incongruent with effective pain management. For health care providers, these behaviors include inadequate or inconsistent assessment of pain and inadequate prescribing habits. For patients, these behaviors include a reluctance to communicate about pain with health care providers and reluctance to use pain medication as prescribed. Because these behaviors seem to have lack of knowledge or misconceptions as their root cause, it would seem obvious that providing education to improve knowledge and counter misconceptions ultimately would lead to better outcomes for patients. Unfortunately, the solution appears more complex. More often than not, educational interventions - whether directed at health care providers or patients - do not have their hypothesized effect on knowledge and attitudes. Even when an effect on knowledge is shown, the effect generally is short-lived and rarely is translated into behavior change. Effects on patients' pain-related outcomes are even rarer. Why is this case? Several possibilities have implications for research and practice. The first issue is related to outcome measures. In the face of several well-designed comprehensive educational programs that show minimal impact on patients' pain-related outcomes, perhaps if it is time to re-evaluate the extent to which current outcome measures are sensitive to the effects of educational interventions and whether the timing of measurements is optimal for detecting effects. Secondly, there is a need to look at the interventions themselves. Because optimal pain management is threatened by barriers from many different angles - health care providers, patients, procedures within institutions - it is likely that efforts to improve barriers in one area will be muted by barriers in the other areas. The study by Du Pen et al [26] is a good example of this situation. In this study focusing on clinician barriers, patient adherence to prescribed opioids was only 62% to 72%. For patients in the intervention group (whose physicians followed established guidelines for pain management), those who had greater adherence to their prescribed medications reported lower worst and usual pain scores. This relationship between patient adherence and pain outcomes was not seen in the control group. Conversely, in many educational interventions aimed at patients, the educational program takes place outside of normal patient care. That is, there is a disconnect between what is encouraged in the educational programs (importance of communication and benefits of taking medications that have been prescribed based on established guidelines) and what the patient may encounter in the normal health care setting. Although they may be prepared to make optimal use of their prescribed analgesics, what is prescribed may be suboptimal. Careful evaluation of the relationships that are believed to exist between knowledge, behavior, and patient outcomes is required. Clinicians and researchers must collaborate to design careful, controlled trials that test the relationship between specific educational interventions and patient outcomes. When targeting patient-related barriers, one should ensure that patients in the studies have access to optimal pain management. One possibility would be to take components of interventions shown to be effective in studies directed at clinician-related barriers and combine them with effective components from patient-focused studies and test them in carefully designed, controlled studies. Based on this review, one could consider testing a pain management algorithm for clinicians combined with a nurse-led educational program for patients, including information about pain management regimens and information to counter common misconceptions. Although conducting such an intervention study would be complicated and require many resources, it potentially could provide answers about the necessary and sufficient components of effective pain management interventions.

Original languageEnglish
Pages (from-to)419-434
Number of pages16
JournalNursing Clinics of North America
Volume38
Issue number3
DOIs
Publication statusPublished - Sept 2003

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