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Nurses’ attitudes toward pain treatment with opioids: a survey in a Belgian university hospital
ARTICLE IN PRESS
International Journal of Nursing Studies 41 (2004) 183–189
Nurses’ attitudes toward pain treatment with opioids: a survey in a Belgian university hospital S. Broekmansa,b,*, S. Vanderschuerena, B. Morliona, A. Kumara, G. Eversa,b b
a Multidisciplinary Pain Centre, University Hospital, Leuven, Belgium Centre for Health Services and Nursing Research, Catholic University, Kapucijnenvoer 35, Leuven, Belgium
Received 12 December 2002; received in revised form 16 May 2003; accepted 29 May 2003
Abstract Aim: To investigate nurses’ attitudes toward pain treatment with opioids in a Belgian university hospital. Method: A cross-sectional, descriptive study design was used. The randomised sample included 350 nurses working in the University Hospital Leuven, Belgium. Non-response was 10.9%. Nurses’ attitudes were explored by a structured questionnaire. The score on the opioid attitude scale (OAS) varied between 9 and 45. Results: Despite a neutral to positive score on the OAS (mean=69.4%), nurses had clearly negative attitudes towards the use of opioids during a diagnostic phase and the risk of possible addiction. These negative attitudes can hinder adequate pain treatment. r 2003 Elsevier Ltd. All rights reserved. Keywords: Attitudes; Pain; Opioid; Nurse
1. Introduction Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Merskey and Bogduk, 1994). Therefore, acute pain has an important function. It is a warning of tissue damage and plays an important role during the diagnostic process. When pain has fulfilled its warning function it should not be allowed to persist. Adequate pain control facilitates accurate diagnosis, e.g. the patient can cooperate better during required examinations. For example, undertreatment of acute postoperative pain can postpone and extend the recovery period by impairment of lung function and mobility of the patient (Brown, 1989; Vandermeulen and Van Aken, 1994). In *Corresponding author. Tel.: +32-16-33-69-79; fax: +32-16-33-69-70. E-mail address: [email protected] (S. Broekmans).
addition, pain has also an important psychosocial function. Pain influences sleeping patterns, concentration and provokes fear, uncertainty and fatigue (Dorrepaal et al., 1988; Yates et al., 1998). Pain is also correlated to depression and irritation (Cleeland, 1984). These physical, psychological and social effects require that pain has to be controlled effectively. Opioids can be effective in pain treatment, especially for patients with nociceptive pain. However, studies show that many hospitalised patients still have relatively severe pain. Pain prevalence among surgical patients varies between 22% and 67% (Oates et al., 1994; Vallano et al., 1999). Rates among cancer patients with modest or severe pain vary between 40% and 80% (Daut and Cleeland, 1982; Cleeland, 1984; Dorrepaal et al., 1988; Portenoy and Lesage, 1999). These figures suggest that physicians and nurses still prescribe and administer opioids insufficiently. Many barriers can hinder effective pain control. Patient-related factors include ineffective pain reporting and non-compliance, fear of side effects of opioids and inadequate knowledge
0020-7489/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00129-9
ARTICLE IN PRESS 184
S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
of dosage (Portenoy, 1993; Evers, 1997). Factors related to health care providers can also influence pain treatment. These factors may be classified into three areas: influence of drug regulatory agencies, lack of knowledge and cultural attitudes (Hill, 1993).
2. Aim The aim of this study was to investigate the attitudes of nurses toward pain treatment with opioids in a Belgian university hospital. An attitude is a favourable or unfavourable view towards something or someone because of one’s beliefs, opinions, or intentions (Meyers, 1996). An attitude can be predictive for certain behaviour (Meyers, 1996). Negative attitudes towards pain treatment with opioids can hinder adequate pain management. Cleeland et al. introduced the concept of ‘liberalness’ to describe attitudes toward pain treatment with opioids. Liberal attitudes toward pain management are characterised by the opinion that during the course of the disease (1) the patient should have control over pain management; (2) that early intervention should be available with a maximum of tolerated analgesics; (3) that professionals should be increasingly willing to prescribe more potent analgesics enhanced by the belief that patients with cancer generally receive inadequate analgesics (Cleeland et al., 1986; O’Brien et al., 1996). Studies reveal that some nurses are reluctant to administer opioids based on negative attitudes. Chapman et al. found that one out of four nurses would wait to administer opioids until the patient had severe pain. Fear of addiction or side-effects can promote a negative attitude (Chapman et al., 1987; McGaffery and Ferrell, 1997).
3. Method
sample of 350 nurses was drawn out of the 1131 nurses who fulfilled these criteria. Three hundred and twelve nurses completed the data collection. Non-response was 10.9%. The sample consisted of 49 (16%) males and 263 (84%) females. The mean age of the respondents was 37 years ranging from 21 to 57 years. One hundred and four nurses worked on a surgical unit, 86 nurses on intensive care, 85 on a general medicine unit and 37 on an oncological unit. 3.3. Variables and instrument A structured questionnaire was used to measure the attitudes of nurses. Two questions were derived from the ‘Wisconsin Cancer Pain Initiative nurses’ Survey’ (Vortherms et al., 1992). The first question measured self-appraisal of ‘liberalness’ in comparison with other nurses. After agreement to participate, nurses were asked to position themselves in one of five categories, ranging from very conservative to very liberal. The second question explored what the nurses thought about pain treatment of cancer patients in Belgium. There were three possible answers: patients received too many analgesics, adequate treatment or too few analgesics. The questionnaire also included the opioid attitude scale (OAS). This scale is an adopted version of the Brydon attitude scale (Brydon and Asbury, 1995; Willems et al., 2000). The scale consists of nine statements with five answering categories, ranging from totally agree to totally disagree. The statements express attitudes toward addiction, side effects and use of opioids during a diagnostic phase. Theoretical scores can vary between 5 and 45. A higher score corresponds with more positive attitudes. The internal consistency reliability of the OAS in this study was acceptable (a ¼ 0:70). Age was measured in years and the type of unit as general medicine, surgery, intensive care or oncology. Experience with cancer patients or patients using opioids were measured as the number of patients treated yearly.
3.1. Design 3.4. Data collection A cross-sectional, descriptive design was used. Attitudes of nurses towards pain treatment with opioids were the dependent variables. Independent variables were age, gender, type of unit (surgery, general medicine, oncology and intensive care) and experience with cancer patients and patients taking opioids.
During a 7-week period, the investigator contacted all nurses who were included in the random sample. After permission to participate, a short questionnaire was handed over to the nurses by the investigator. The questionnaire was immediately completed and returned to the investigator.
3.2. Sample 3.5. Statistics Data were collected in a random sample of nurses working in the University Hospital Leuven, Belgium. Nurses had to be fully registered and had to currently work in one of the following departments: surgery, general medicine, oncology or intensive care. A random
Data were coded in Microsoft Excel. The programme SPSS was used for the statistical testing. For comparison of continuous variables with a normal distribution, a T-test and ANOVA was used. A Mann–Whitney
ARTICLE IN PRESS S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
U test and a Kruskal–Wallis test were used for continuous variables without normal distribution. The Mann–Whitney U test was also used for comparison of ordinal variables. A w2 -test was used for comparison of nominal variables. Level of statistical significance was set at po0:05:
4. Results The majority of the nurses (59.1%) considered themselves neither conservative nor liberal in comparison with their colleagues (Fig. 1). About 36.7% considered themselves liberal to very liberal and 4.2% conservative to very conservative. Surgical nurses perceived themselves as more liberal than nurses on other wards (w2 ¼ 10305; p ¼ 0:036). There was no statistical difference between the scores of nurses younger than 35 (median age) and nurses older than 35 (z=1:917; p ¼ 0:055). There was a tendency that older nurses considered themselves more liberal (41.3%) than younger nurses (29.2%). Neither gender nor experience with cancer patients were significantly related to the self-appraisal of liberalness. Three out of four nurses thought that cancer patients received too little pain medication (Fig. 2). None of the nurses thought that they received too much. There were no significant differences between the nurses of the different speciality areas (w2 ¼ 1:960; p ¼ 0:581). Age, gender and experience with cancer patients were not significantly related to the scores. In general, nurses scored neutral to positive on the OAS. Empirical scores ranged between 23 and 45. The
Surgery (n=104)
General medicine (n=85)
185
total score was normally distributed, with a mean of 34 and a standard deviation of 4.34. Nurses working in oncology scored significantly higher than their colleagues in general medicine (z=2:705; p ¼ 0:007), surgical units (z=2:378; p ¼ 0:017) and intensive care units (z=2:129; p ¼ 0:033) (Fig. 3). There were significant differences in relation to experience with cancer patients (w2 ¼ 15:228; p ¼ 0:004) (Fig. 4). Nurses who took care of more than 100 cancer patients a year scored higher (mean=34.96) than nurses caring for fewer than 50 cancer patients a year. Neither age nor gender had a significant influence on the total score. Despite the neutral to positive score in general, nurses had clearly negative attitudes towards specific items. Half of the nurses considered addiction as an important side effect of long-term use of morphine (Table 1). The type of unit was clearly related to this attitude. Surgical or general medicine nurses scored significantly more negatively than nurses of other units. They considered addiction more often as an important side effect of morphine (w2 ¼ 13:786; p ¼ 0:003). Nurses who cared for more than 100 cancer patients a year had the least negative attitudes towards addiction. (w2 ¼ 20:236; po0:001). There were no differences according to age and gender. Only one out of three of the nurses had a positive attitude towards use of morphine during a diagnostic phase of acute pain. About 35.9% were convinced that the use of morphine in these circumstances was not acceptable (Table 1). Age, gender, type of unit and experience with cancer patients were not related to this attitude.
Intensive care (n=86)
Oncology (n=37)
Total
70
60
Percentage (%)
50
40
30
20
10
0
Very conservative
Conservative
Neutral
Liberal
Very liberal
Fig. 1. Are you more conservative or more liberal than your colleagues towards pain treatment with opioids?
ARTICLE IN PRESS S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
186
75.9 80 70
Percentage (%)
60 50 40
24.1 30 20
0 10 0
Too much
Adequate
Too little
Analgesics
Fig. 2. What do you think about pain treatment of cancer patients in Belgium?
35.8 36
35.5
35
Total score
34.5
34
34
34 33.5
33.5
33
32.5
32
Surgery
General medicine
Intensive care
oncology
Fig. 3. The mean score on the OAS of nurses on surgical (n ¼ 104), general medicine (n ¼ 85), intensive care (n ¼ 86) and oncology units (n ¼ 37).
5. Discussion Nurses seem to be well aware of inadequate pain treatment as 76% expressed the opinion that cancer patients in Belgium receive inadequate medication. Most nurses had neutral to liberal attitudes towards pain treatment with opioids. No nurse scored extremely negatively. The mean score of the nurses on the OAS was 34 (69.4%). Research concerning attitudes of oncological nurses shows that, in general, they possess
quite liberal attitudes toward the treatment of cancer pain (Vortherms et al., 1992; Ryan et al., 1994; O’Brien et al., 1996; Hollen et al., 2000). In the study of Hollen et al. (2000) the mean on the attitude scale was 77%. This corresponds well with the score of oncological nurses in our study (74.4%). Results of studies on nurses’ attitudes towards postoperative pain were less positive (Weis et al., 1983; Chapman et al., 1987). This study did not focus on one particular type of pain. Nevertheless, our study also shows a significant
ARTICLE IN PRESS S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
35.5
187
35 34.7
35
Total score
34.5
34
33.2 33.5
33.1
33
32.5
32
31.5
1 - 10 (n=79)
11 - 50 (n=61) 51 - 100 (n=50) Number of cancer patients treated yearly
101 - 1000 (n=92)
Fig. 4. Total score on the OAS of nurses who take care of cancer patients. Table 1 Answers of nurses on the OAS Percentage agree Addiction is a substantial side effect of the long-term use of morphine During the diagnostic phase of an acute pain syndrome the use of morphine is not acceptable Long-term use of morphine causes drowsiness Morphine should be reserved to treat pain in terminally ill patients In pain treatment it is not necessary to remove all pain Patients should not ask for morphine before the pain is unbearable It is better to accept the pain than to treat it with morphine The side effects of morphine are worse than the pain itself Physicians prescribe too easily morphine for patients with severe pain
difference in the scores of nurses on oncology (74.4%) and surgical wards (69.4%). Despite this significance, statistics show only weak a correlation (Table 2). Other variables, which were not measured in this study, may be more strongly associated with nurses’ attitudes toward the use of opioids in pain treatment. Despite the positive attitudes in general towards the use of opioids, nurses seem to have negative attitudes towards specific items, possibly reflecting persistent misconceptions. Half of the nurses thought that addiction was an important problem when opioids are used for long-term treatment. This was more pronounced in nurses on surgical or general medicine units. Oncological nurses had a less negative attitude about this. Currently, there is scientific evidence that addiction rarely arises when opioids are correctly used (Portenoy, 2000; Porter and Jick, 1980). The trend of increasing medical use of opioids to treat pain does not appear to contribute to more addiction (Joranson et al., 2000).
49.4 35.9 32.0 13.1 9.6 7.1 1.3 0.9 0.6
Fear of addiction among health care providers is an important topic in many studies. The proportion of healthcare providers who incorrectly believe that the use of opioids cause addiction varies depending on the way the topic is studied. In a study on attitudes of nurses toward postoperative pain, 64% was concerned about the risk for addiction (Chapman et al., 1987). Furstenberg et al. (1998) however reported that 90% of the physicians and nurses were convinced that addiction was not an important problem in the treatment of cancer patients. On the contrary, Hollen et al. (2000) reported that 74% of oncological nurses incorrectly thought that the risk for psychological dependence was more than 1%. Overestimation of the risk of addiction seems to persist among nurses. Addiction can be a problem when opioids are used for non-opioid sensitive pain. It is important that the indication for use of opioids in pain management is correct. Strict follow-up by one prescribing physician
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6. Conclusion
Table 2 Correlations with the total score on the OAS
Age Gender Experience with patients using opioids Experience with cancer patients Self-appraisal of liberalness Appraisal of pain treatment in Belgium a
Kendall’s tau
Sig. (two-tailed)
0.013 0.087 0.119a
0.742 0.071 0.008
0.132a
0.002
0.127a
0.006
0.080
0.099
In this study nurses working in a university hospital had neutral to positive attitudes towards the use of opioids in pain treatment in general. However, particularly negative attitudes towards the use of opioids during a diagnostic phase and the risk of addiction after opioid therapy persist. These negative attitudes can hinder adequate pain treatment of specific patient groups and require more attention in clinical practice. Replication of this study in other health care settings and countries is urgently needed.
Correlation is significant at the 0.01 level (two-tailed).
References and one pharmacist can minimise the abusive risk. The percentage of nurses in the current study stating that addiction is an important problem is high. This may be due to misconceptions about real addiction risks or to misunderstanding of the difference between addiction, tolerance and dependence (Hill, 1993). A second negative attitude which this study reveals, is about use of opioids during a diagnostic phase. Only one out of three nurses thought opioids could be used during the diagnostic phase. For many years it has been assumed that analgesics should not be provided during a diagnostic phase as it was thought that analgesics could affect clinical signs and delay diagnosis and therapy (Silen, 1994). A randomised, placebo-controlled study showed that early administration of opioids to patients with an acute abdomen significantly reduced the pain. However, the diagnostic examination was not delayed. On the contrary administration of opioids facilitated an accurate diagnoses (Attard et al., 1992). Research by Zoltie and Cust (1992) confirmed these results. It is likely that knowledge deficit influences this negative attitude toward the use of opioids during the diagnostic phase. Education is needed to correct this misconception so nurses will no longer be reluctant to ask physicians for adequate control of severe pain and administer prescribed opioids at this time. This study has some methodological limitations. Due to the use of a cross-sectional design, no causal relationships can be inferred. Does working on oncology wards induce positive attitudes or are nurses with positive attitudes attracted to these wards? This study only investigated attitudes of nurses working on surgical, general medicine, oncology or intensive care units of a University Hospital in Belgium. Results of this study should not therefore be generalised to nurses in other specialities, hospitals or countries. Nevertheless, the results highlight specific problems in pain management which may need more attention in other specialities, hospitals and countries.
Attard, A.R., Corlett, M.J., Kidner, N.J., Leslie, A.P, Fraser, I.A., 1992. Safety of early pain relief for acute abdominal pain. British Medical Journal 305, 556–561. Brown, J.G., 1989. Systemic opioid analgesia for postoperative pain management. Anesthetic Clinics of North America 7, 51. Brydon, C.W., Asbury, A.J., 1995. Attitudes to pain and pain relief in adult surgical patients. Anaesthesia 51, 279–281. Chapman, P.J., Ganendran, A., Scott, R.J., Basford, K.E., 1987. Attitudes and knowledge of nursing staff in relation to management of postoperative pain. The Australian and New Zealand Journal of Surgery 57, 447–450. Cleeland, C.S., 1984. The impact of pain on the patient with cancer. Cancer 54, 2641–2653. Cleeland, C.S., Cleeland, L.M., Dar, R., Rinehardt, L.C., 1986. Factors influencing physician management of cancer pain. Cancer 58, 796–800. Daut, R.L., Cleeland, C.S., 1982. The prevalence and severity of pain in cancer. Cancer 50, 1913–1918. Dorrepaal, K.L., Aaronson, N.K., van Dam, F.S.A.M., 1988. Pain experience and pain management among hospitalised cancer patients. Cancer 63 (3), 593–598. Evers, G.C.M., 1997. Pseudo-opioid-resistant pain. Support Cancer Care 5, 457–460. Furstenberg, C.T., Ahles, T.A., Whedon, M.B., Pierce, K.L., Dolan, M., Roberts, L., Silberfarb, P.M., 1998. Knowledge and attitudes of health care providers toward cancer pain management. Journal of Pain and Symptom Management 15 (6), 335–349. Hill, S.C., 1993. The barriers to adequate pain management with opioid analgesics. Seminars in Oncology 20 (2, Suppl 1), 1–5. Hollen, C.J., Hollen, C.W., Stolte, K., 2000. Hospice and hospital oncology unit nurses: a comparative survey of knowledge and attitudes about cancer pain. Oncology Nursing Forum 27 (10), 1593–1599. Joranson, D.E., Ryan, K.M., Gilson, A.M., Dahl, J.L., 2000. Trends in medical use and abuse of opioid analgesics. Journal of the American Medical Association 283 (3), 1710–1714. McGaffery, M., Ferrell, B., 1997. Nurses’ knowledge of pain assessment and management: how much progress have we made? Journal of Pain and Symptom Management 14 (3), 175–188.
ARTICLE IN PRESS S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189 Merskey, H., Bogduk, N., 1994. Classification of Chronic Pain, 2nd Edition, IAPS Task Force on Taxonomy. IASP Press, Seattle, pp. 209–214. Meyers, D.G., 1996. Social Psychology. McGraw-Hill, New York, pp. 123–161. Oates, J.D.L., Snowdon, S.L., Jayson, D.W.H., 1994. Failure of pain relief after surgery. Anaesthesia 49, 755–758. O’Brien, S., Dalton, J.A., Konsler, G., Carlson, J., 1996. The knowledge and attitudes of experienced oncology nurses regarding the management of cancer-related pain. Oncology Nursing Forum 23 (3), 515–521. Portenoy, R.K., 1993. Inadequate outcome of opioid therapy for cancer pain: influences on practitioners and patients. In: Patt, R.B. (Ed.), Cancer Pain. J.B. Lippincott Co, Philadelphia, pp. 119–128. Portenoy, R.K., 2000. Current pharmacotherapy of chronic pain. Journal of Pain Symptom Management 19 (1 suppl), S16–20. Portenoy, R.K., Lesage, P., 1999. Management of cancer pain. The Lancet 353, 1695–1700. Porter, J., Jick, H., 1980. Addiction rare in-patients treated with narcotics. The New England Journal of Medicine 302 (2), 123. Ryan, P., Vortherms, R., Ward, S., 1994. Cancer pain: knowledge, attitudes of pharmacologic management. Journal of Gerontological Nursing 20 (1), 7–16. Silen, W., 1994. Abdominal pain. In: Fauci, A.S., Braunwald, E., Isselbacher, K.J., Wilson, J.D., Martin, J.B., Kasper, D.L., Hauser, S.L., Longo, D.L. (Eds.), Harrison’s Principles of
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Internal Medicine, 14th Edition.. McGraw-Hill, New York, pp. 61–64. Vallano, A., Aguilera, C., Arnau, J.M., Ban˜os, J.E., Laporte, J.R., 1999. Management of postoperative pain in abdominal surgery in Spain. A multicentre drug utilisation study. British Journal of Clinical Pharmacology 47, 667–673. Vandermeulen, E., Van Aken, H., 1994. Acute postoperatieve pijntherapie. Tijdschrift voor Geneeskunde 50 (13), 1067–1078. Vortherms, R., Ryan, P., Ward, S., 1992. Knowledge of, attitudes toward, and barriers to pharmacologic management of cancer pain in a state-wide random sample of nurses. Research in Nursing & Health 15, 459–466. Weis, O.F., Sriwatanakul, K., Alloza, J.L., Weintraub, M., Lasagna, L., 1983. Attitudes of patients, housestaff, and nurses toward postoperative analgesic care. Anesthesia and Analgesia 62, 70–74. Willems, K., Evers, G.C.M., Vermaut, G., 2000. Misvattingen en negatieve attitudes inzake pijnbestrijding met opiaten bij pati.enten. Projectthesis aangeboden tot het verkrijgen van de graad van Licentiaat in de Medisch-sociale wetenschappen. Yates, P., Dewar, A., Edwards, H., Fentiman, B., Najman, J., Nash, R., Richardson, V., Fraser, J., 1998. The prevalence and perception of pain amongst hospital in-patients. Journal of Clinical Nursing 7, 521–530. Zoltie, N., Cust, M.P., 1992. Analgesia in the acute abdomen. Annals of the Royal College of Surgeons of England 68, 209–210.
International Journal of Nursing Studies 41 (2004) 183–189
Nurses’ attitudes toward pain treatment with opioids: a survey in a Belgian university hospital S. Broekmansa,b,*, S. Vanderschuerena, B. Morliona, A. Kumara, G. Eversa,b b
a Multidisciplinary Pain Centre, University Hospital, Leuven, Belgium Centre for Health Services and Nursing Research, Catholic University, Kapucijnenvoer 35, Leuven, Belgium
Received 12 December 2002; received in revised form 16 May 2003; accepted 29 May 2003
Abstract Aim: To investigate nurses’ attitudes toward pain treatment with opioids in a Belgian university hospital. Method: A cross-sectional, descriptive study design was used. The randomised sample included 350 nurses working in the University Hospital Leuven, Belgium. Non-response was 10.9%. Nurses’ attitudes were explored by a structured questionnaire. The score on the opioid attitude scale (OAS) varied between 9 and 45. Results: Despite a neutral to positive score on the OAS (mean=69.4%), nurses had clearly negative attitudes towards the use of opioids during a diagnostic phase and the risk of possible addiction. These negative attitudes can hinder adequate pain treatment. r 2003 Elsevier Ltd. All rights reserved. Keywords: Attitudes; Pain; Opioid; Nurse
1. Introduction Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Merskey and Bogduk, 1994). Therefore, acute pain has an important function. It is a warning of tissue damage and plays an important role during the diagnostic process. When pain has fulfilled its warning function it should not be allowed to persist. Adequate pain control facilitates accurate diagnosis, e.g. the patient can cooperate better during required examinations. For example, undertreatment of acute postoperative pain can postpone and extend the recovery period by impairment of lung function and mobility of the patient (Brown, 1989; Vandermeulen and Van Aken, 1994). In *Corresponding author. Tel.: +32-16-33-69-79; fax: +32-16-33-69-70. E-mail address: [email protected] (S. Broekmans).
addition, pain has also an important psychosocial function. Pain influences sleeping patterns, concentration and provokes fear, uncertainty and fatigue (Dorrepaal et al., 1988; Yates et al., 1998). Pain is also correlated to depression and irritation (Cleeland, 1984). These physical, psychological and social effects require that pain has to be controlled effectively. Opioids can be effective in pain treatment, especially for patients with nociceptive pain. However, studies show that many hospitalised patients still have relatively severe pain. Pain prevalence among surgical patients varies between 22% and 67% (Oates et al., 1994; Vallano et al., 1999). Rates among cancer patients with modest or severe pain vary between 40% and 80% (Daut and Cleeland, 1982; Cleeland, 1984; Dorrepaal et al., 1988; Portenoy and Lesage, 1999). These figures suggest that physicians and nurses still prescribe and administer opioids insufficiently. Many barriers can hinder effective pain control. Patient-related factors include ineffective pain reporting and non-compliance, fear of side effects of opioids and inadequate knowledge
0020-7489/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0020-7489(03)00129-9
ARTICLE IN PRESS 184
S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
of dosage (Portenoy, 1993; Evers, 1997). Factors related to health care providers can also influence pain treatment. These factors may be classified into three areas: influence of drug regulatory agencies, lack of knowledge and cultural attitudes (Hill, 1993).
2. Aim The aim of this study was to investigate the attitudes of nurses toward pain treatment with opioids in a Belgian university hospital. An attitude is a favourable or unfavourable view towards something or someone because of one’s beliefs, opinions, or intentions (Meyers, 1996). An attitude can be predictive for certain behaviour (Meyers, 1996). Negative attitudes towards pain treatment with opioids can hinder adequate pain management. Cleeland et al. introduced the concept of ‘liberalness’ to describe attitudes toward pain treatment with opioids. Liberal attitudes toward pain management are characterised by the opinion that during the course of the disease (1) the patient should have control over pain management; (2) that early intervention should be available with a maximum of tolerated analgesics; (3) that professionals should be increasingly willing to prescribe more potent analgesics enhanced by the belief that patients with cancer generally receive inadequate analgesics (Cleeland et al., 1986; O’Brien et al., 1996). Studies reveal that some nurses are reluctant to administer opioids based on negative attitudes. Chapman et al. found that one out of four nurses would wait to administer opioids until the patient had severe pain. Fear of addiction or side-effects can promote a negative attitude (Chapman et al., 1987; McGaffery and Ferrell, 1997).
3. Method
sample of 350 nurses was drawn out of the 1131 nurses who fulfilled these criteria. Three hundred and twelve nurses completed the data collection. Non-response was 10.9%. The sample consisted of 49 (16%) males and 263 (84%) females. The mean age of the respondents was 37 years ranging from 21 to 57 years. One hundred and four nurses worked on a surgical unit, 86 nurses on intensive care, 85 on a general medicine unit and 37 on an oncological unit. 3.3. Variables and instrument A structured questionnaire was used to measure the attitudes of nurses. Two questions were derived from the ‘Wisconsin Cancer Pain Initiative nurses’ Survey’ (Vortherms et al., 1992). The first question measured self-appraisal of ‘liberalness’ in comparison with other nurses. After agreement to participate, nurses were asked to position themselves in one of five categories, ranging from very conservative to very liberal. The second question explored what the nurses thought about pain treatment of cancer patients in Belgium. There were three possible answers: patients received too many analgesics, adequate treatment or too few analgesics. The questionnaire also included the opioid attitude scale (OAS). This scale is an adopted version of the Brydon attitude scale (Brydon and Asbury, 1995; Willems et al., 2000). The scale consists of nine statements with five answering categories, ranging from totally agree to totally disagree. The statements express attitudes toward addiction, side effects and use of opioids during a diagnostic phase. Theoretical scores can vary between 5 and 45. A higher score corresponds with more positive attitudes. The internal consistency reliability of the OAS in this study was acceptable (a ¼ 0:70). Age was measured in years and the type of unit as general medicine, surgery, intensive care or oncology. Experience with cancer patients or patients using opioids were measured as the number of patients treated yearly.
3.1. Design 3.4. Data collection A cross-sectional, descriptive design was used. Attitudes of nurses towards pain treatment with opioids were the dependent variables. Independent variables were age, gender, type of unit (surgery, general medicine, oncology and intensive care) and experience with cancer patients and patients taking opioids.
During a 7-week period, the investigator contacted all nurses who were included in the random sample. After permission to participate, a short questionnaire was handed over to the nurses by the investigator. The questionnaire was immediately completed and returned to the investigator.
3.2. Sample 3.5. Statistics Data were collected in a random sample of nurses working in the University Hospital Leuven, Belgium. Nurses had to be fully registered and had to currently work in one of the following departments: surgery, general medicine, oncology or intensive care. A random
Data were coded in Microsoft Excel. The programme SPSS was used for the statistical testing. For comparison of continuous variables with a normal distribution, a T-test and ANOVA was used. A Mann–Whitney
ARTICLE IN PRESS S. Broekmans et al. / International Journal of Nursing Studies 41 (2004) 183–189
U test and a Kruskal–Wallis test were used for continuous variables without normal distribution. The Mann–Whitney U test was also used for comparison of ordinal variables. A w2 -test was used for comparison of nominal variables. Level of statistical significance was set at po0:05:
4. Results The majority of the nurses (59.1%) considered themselves neither conservative nor liberal in comparison with their colleagues (Fig. 1). About 36.7% considered themselves liberal to very liberal and 4.2% conservative to very conservative. Surgical nurses perceived themselves as more liberal than nurses on other wards (w2 ¼ 10305; p ¼ 0:036). There was no statistical difference between the scores of nurses younger than 35 (median age) and nurses older than 35 (z=1:917; p ¼ 0:055). There was a tendency that older nurses considered themselves more liberal (41.3%) than younger nurses (29.2%). Neither gender nor experience with cancer patients were significantly related to the self-appraisal of liberalness. Three out of four nurses thought that cancer patients received too little pain medication (Fig. 2). None of the nurses thought that they received too much. There were no significant differences between the nurses of the different speciality areas (w2 ¼ 1:960; p ¼ 0:581). Age, gender and experience with cancer patients were not significantly related to the scores. In general, nurses scored neutral to positive on the OAS. Empirical scores ranged between 23 and 45. The
Surgery (n=104)
General medicine (n=85)
185
total score was normally distributed, with a mean of 34 and a standard deviation of 4.34. Nurses working in oncology scored significantly higher than their colleagues in general medicine (z=2:705; p ¼ 0:007), surgical units (z=2:378; p ¼ 0:017) and intensive care units (z=2:129; p ¼ 0:033) (Fig. 3). There were significant differences in relation to experience with cancer patients (w2 ¼ 15:228; p ¼ 0:004) (Fig. 4). Nurses who took care of more than 100 cancer patients a year scored higher (mean=34.96) than nurses caring for fewer than 50 cancer patients a year. Neither age nor gender had a significant influence on the total score. Despite the neutral to positive score in general, nurses had clearly negative attitudes towards specific items. Half of the nurses considered addiction as an important side effect of long-term use of morphine (Table 1). The type of unit was clearly related to this attitude. Surgical or general medicine nurses scored significantly more negatively than nurses of other units. They considered addiction more often as an important side effect of morphine (w2 ¼ 13:786; p ¼ 0:003). Nurses who cared for more than 100 cancer patients a year had the least negative attitudes towards addiction. (w2 ¼ 20:236; po0:001). There were no differences according to age and gender. Only one out of three of the nurses had a positive attitude towards use of morphine during a diagnostic phase of acute pain. About 35.9% were convinced that the use of morphine in these circumstances was not acceptable (Table 1). Age, gender, type of unit and experience with cancer patients were not related to this attitude.
Intensive care (n=86)
Oncology (n=37)
Total
70
60
Percentage (%)
50
40
30
20
10
0
Very conservative
Conservative
Neutral
Liberal
Very liberal
Fig. 1. Are you more conservative or more liberal than your colleagues towards pain treatment with opioids?
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75.9 80 70
Percentage (%)
60 50 40
24.1 30 20
0 10 0
Too much
Adequate
Too little
Analgesics
Fig. 2. What do you think about pain treatment of cancer patients in Belgium?
35.8 36
35.5
35
Total score
34.5
34
34
34 33.5
33.5
33
32.5
32
Surgery
General medicine
Intensive care
oncology
Fig. 3. The mean score on the OAS of nurses on surgical (n ¼ 104), general medicine (n ¼ 85), intensive care (n ¼ 86) and oncology units (n ¼ 37).
5. Discussion Nurses seem to be well aware of inadequate pain treatment as 76% expressed the opinion that cancer patients in Belgium receive inadequate medication. Most nurses had neutral to liberal attitudes towards pain treatment with opioids. No nurse scored extremely negatively. The mean score of the nurses on the OAS was 34 (69.4%). Research concerning attitudes of oncological nurses shows that, in general, they possess
quite liberal attitudes toward the treatment of cancer pain (Vortherms et al., 1992; Ryan et al., 1994; O’Brien et al., 1996; Hollen et al., 2000). In the study of Hollen et al. (2000) the mean on the attitude scale was 77%. This corresponds well with the score of oncological nurses in our study (74.4%). Results of studies on nurses’ attitudes towards postoperative pain were less positive (Weis et al., 1983; Chapman et al., 1987). This study did not focus on one particular type of pain. Nevertheless, our study also shows a significant
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35.5
187
35 34.7
35
Total score
34.5
34
33.2 33.5
33.1
33
32.5
32
31.5
1 - 10 (n=79)
11 - 50 (n=61) 51 - 100 (n=50) Number of cancer patients treated yearly
101 - 1000 (n=92)
Fig. 4. Total score on the OAS of nurses who take care of cancer patients. Table 1 Answers of nurses on the OAS Percentage agree Addiction is a substantial side effect of the long-term use of morphine During the diagnostic phase of an acute pain syndrome the use of morphine is not acceptable Long-term use of morphine causes drowsiness Morphine should be reserved to treat pain in terminally ill patients In pain treatment it is not necessary to remove all pain Patients should not ask for morphine before the pain is unbearable It is better to accept the pain than to treat it with morphine The side effects of morphine are worse than the pain itself Physicians prescribe too easily morphine for patients with severe pain
difference in the scores of nurses on oncology (74.4%) and surgical wards (69.4%). Despite this significance, statistics show only weak a correlation (Table 2). Other variables, which were not measured in this study, may be more strongly associated with nurses’ attitudes toward the use of opioids in pain treatment. Despite the positive attitudes in general towards the use of opioids, nurses seem to have negative attitudes towards specific items, possibly reflecting persistent misconceptions. Half of the nurses thought that addiction was an important problem when opioids are used for long-term treatment. This was more pronounced in nurses on surgical or general medicine units. Oncological nurses had a less negative attitude about this. Currently, there is scientific evidence that addiction rarely arises when opioids are correctly used (Portenoy, 2000; Porter and Jick, 1980). The trend of increasing medical use of opioids to treat pain does not appear to contribute to more addiction (Joranson et al., 2000).
49.4 35.9 32.0 13.1 9.6 7.1 1.3 0.9 0.6
Fear of addiction among health care providers is an important topic in many studies. The proportion of healthcare providers who incorrectly believe that the use of opioids cause addiction varies depending on the way the topic is studied. In a study on attitudes of nurses toward postoperative pain, 64% was concerned about the risk for addiction (Chapman et al., 1987). Furstenberg et al. (1998) however reported that 90% of the physicians and nurses were convinced that addiction was not an important problem in the treatment of cancer patients. On the contrary, Hollen et al. (2000) reported that 74% of oncological nurses incorrectly thought that the risk for psychological dependence was more than 1%. Overestimation of the risk of addiction seems to persist among nurses. Addiction can be a problem when opioids are used for non-opioid sensitive pain. It is important that the indication for use of opioids in pain management is correct. Strict follow-up by one prescribing physician
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6. Conclusion
Table 2 Correlations with the total score on the OAS
Age Gender Experience with patients using opioids Experience with cancer patients Self-appraisal of liberalness Appraisal of pain treatment in Belgium a
Kendall’s tau
Sig. (two-tailed)
0.013 0.087 0.119a
0.742 0.071 0.008
0.132a
0.002
0.127a
0.006
0.080
0.099
In this study nurses working in a university hospital had neutral to positive attitudes towards the use of opioids in pain treatment in general. However, particularly negative attitudes towards the use of opioids during a diagnostic phase and the risk of addiction after opioid therapy persist. These negative attitudes can hinder adequate pain treatment of specific patient groups and require more attention in clinical practice. Replication of this study in other health care settings and countries is urgently needed.
Correlation is significant at the 0.01 level (two-tailed).
References and one pharmacist can minimise the abusive risk. The percentage of nurses in the current study stating that addiction is an important problem is high. This may be due to misconceptions about real addiction risks or to misunderstanding of the difference between addiction, tolerance and dependence (Hill, 1993). A second negative attitude which this study reveals, is about use of opioids during a diagnostic phase. Only one out of three nurses thought opioids could be used during the diagnostic phase. For many years it has been assumed that analgesics should not be provided during a diagnostic phase as it was thought that analgesics could affect clinical signs and delay diagnosis and therapy (Silen, 1994). A randomised, placebo-controlled study showed that early administration of opioids to patients with an acute abdomen significantly reduced the pain. However, the diagnostic examination was not delayed. On the contrary administration of opioids facilitated an accurate diagnoses (Attard et al., 1992). Research by Zoltie and Cust (1992) confirmed these results. It is likely that knowledge deficit influences this negative attitude toward the use of opioids during the diagnostic phase. Education is needed to correct this misconception so nurses will no longer be reluctant to ask physicians for adequate control of severe pain and administer prescribed opioids at this time. This study has some methodological limitations. Due to the use of a cross-sectional design, no causal relationships can be inferred. Does working on oncology wards induce positive attitudes or are nurses with positive attitudes attracted to these wards? This study only investigated attitudes of nurses working on surgical, general medicine, oncology or intensive care units of a University Hospital in Belgium. Results of this study should not therefore be generalised to nurses in other specialities, hospitals or countries. Nevertheless, the results highlight specific problems in pain management which may need more attention in other specialities, hospitals and countries.
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