Table 1.
Barriers Impeding Provider Relations and Hospice Medication Delivery with Examples in Nursing Homes and Private Homes
| Barriers | Examples in nursing homes | Examples in private homes |
|---|---|---|
| 1. Attitudinal Barriers | ||
| Nursing Home Providers … | Family Caregivers … | |
| “Owning” the setting | Guarded their nursing home as their “turf” and saw hospice providers as “an intrusion” | Viewed their home as a “sacred” space and resisted hospice guidance, raising concerns about medication safety |
| “Knowing what's best for the patient” | Thought they knew patients' needs but seemed complacent about their care, dismissing hospice's clinical advice | Were overprotective of the patient's care and did not want to lose control of medications |
| Distrust toward hospice | Had professional distrust toward hospice and did not cooperate with hospice providers during visits | Had distrust toward hospice due to prior negative experience with health care and did not involve hospice in family meetings |
| Emotional state | Feared giving opioids and therefore did not adhere to hospice prescribing instructions | Feared being viewed as incompetent and avoided asking questions |
| Were overwhelmed with grief, which impaired learning and caregiving | ||
| 2. Site-Readiness Barriers | ||
| Nursing Homes … | Private Homes … | |
| Ill-Defined Hierarchy/Poor Communication | Had hierarchy but poor communications existed, making coordination with hospice difficult | Had poorly-defined hierarchy with no primary caregiver in charge, making communication with hospice confusing |
| Disagreements among Care Providers | Had a lack of teamwork among nursing home providers, resulting in hospice orders being overturned | Had poor cohesion among family caregivers, which often resulted from deep-seated conflict |
| Responsibility Overload | Had high patient load that limited communication opportunities and hindered around-the-clock monitoring of patient | Had responsibility overload among family caregivers that increased burn-out and hampered communication |
| 3. Alignment Barriers | ||
| Nursing Home Providers … | Family Caregivers … | |
| Differences in care priority | Did not prioritize pain management, contradicting hospice priority in comfort care | Gave less than necessary dosage of pain medicines by favoring alertness with patient |
| Differences in education/training | Did not possess basic pain management skills that hospice providers expected of them | Questioned hospice clinical advice when they used unreliable sources to self-educate |