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The impact of the nurse-physician relationship on barriers encountered by nurses during pain management
The Impact of the NursePhysician Relationship on Barriers Encountered by Nurses During Pain Management yyy Leesa Micole Van Niekerk, BA Hons., and Frances Martin, PhD
y
From the School of Psychology, University of Tasmania, Hobart, Tasmania, Australia This research was supported by a scholarship to the first author from the Australian Commonwealth Department of Health and Aged Care (QUM). Address correspondence and reprint requests to Leesa Micole Van Niekerk, BA Hons., School of Psychology, University of Tasmania, GPO Box 252-30, Hobart, Tasmania, 7001 © 2003 by the American Society of Pain Management Nurses 1524-9042/03/0401-0000$30.00/0 doi: 10.1053/jpmn.2003.4
ABSTRACT
The aim of the current investigation was to examine the barriers encountered by Tasmanian registered nurses when attempting to provide optimal pain management. The impact of nurse satisfaction with their professional relationship with physicians during pain management on the types of barriers encountered was also examined. A total of 1,015 registered nurses completed a 21-item survey that examined the types of barriers encountered during pain management. In addition, data were gathered on nurses’ satisfaction with their professional relationship with physicians during pain management. More than one-third of the respondents indicated that they had encountered at least one type of barrier to providing optimal pain relief, including insufficient cooperation by physicians and inadequate prescriptions of analgesic medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to encounter barriers such as insufficient cooperation by patient’s physicians and inadequate prescription of analgesic medications. The barriers to effective pain management encountered by nurses were affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that nurses encounter fewer barriers during pain management. Optimal pain management practice will result if guidelines for dealing effectively with barriers are tailored to the specific type of institution and the unit within those institutions. © 2003 by the American Society of Pain Management Nurses
The role of the nurse is vital for the assessment and management of patients’ pain. In addition, effective patient pain management is inextricably linked to decisions nurses are required to make. These decisions include the scheduling of medications, the route of administration, and the dose that is administered. Nurses are required to make decisions about pain management, and optimal Pain Management Nursing, Vol 4, No 1 (March), 2003: pp 3-10
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pain management requires the dissemination of adequate information between the patient’s nurse and physician. The process of effective decision making can place nurses in a position in which they have to overcome a number of barriers. Cadogan, Franzi, Osterweil, and Hill (1999) compared the potential communication barriers between nurses and physicians in four Californian nursing homes. Five categories of barriers to communication were identified including nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Significant differences in perceived communication barriers between physicians and nurses were identified. Physicians, unlike nurses, perceived the competence of nurses as a significant barrier. Nurses, on the other hand, perceived physicians to be unpleasant, and both groups agreed that physicians did not value nurses’ opinions. In a study that investigated nurse-physician telephone communication, Kayser-Jones, Weiner, and Barbaccia (1989) found that nurses felt that physicians were difficult to reach, failed to return phone calls promptly, and became irritated by phone calls they perceived as insignificant. The appropriate assessment and treatment of pain is highly dependent upon collegial working relationships between physicians and nurses. The role of the physician is to assess and provide pharmacologic interventions, whereas the role of the nurse is to assess the patient’s status and serve as an advocate for the patient by promoting understanding of existing problems among the members of the health care team. Therefore, optimal management of the patient’s pain is dependent on adequate and accurate communication between the two parties regarding their respective assessments (Fife, Irick, & Painter, 1993; Keenan, Cooke, & Hillis, 1998; McMahan, Hoffman, & McGee, 1994). Whereas the role of the nurse may vary in the choice and type of treatment, the responsiveness and sensitivity of the nurse to treatment goals could effectively facilitate or block pain management (Archer Copp, 1987). To fulfill their role as a liaison officer between the patient and their physician, the nurse needs to have an up-to-date knowledge about pain diagnosis and management. Unfortunately, current studies have documented a lack of knowledge in nursing staff regarding pain management (Ferrell, McGuire, & Donovan, 1993; Hamilton & Edgar, 1992; Lebovits et al., 1997; Van Niekerk & Martin, 2001). A poor knowledge base can create a barrier for nurses to be able to provide optimal pain management. Barriers to optimal pain management exist at many levels of the health care system and can include patient-related barriers, provider-related barriers, and systems barriers.
The recent and increasing popularity of managed care systems of health care delivery, with an emphasis on cost reduction through decreased health care utilization, may pose serious obstacles to the multidisciplinary and long-term medical and psychosocial needs of pain patients (Roth & DeRosayro, 1999). Patients may express concerns about distracting care providers, about addiction and drug tolerance, or complying with treatment regimes. Providers, on the other hand, may have little formal training in pain management, may express concerns about addiction, and may fail to pursue pain related issues aggressively or appropriately (Furstenberg et al., 1998; Von Gunten & Von Roenn, 1994). Ferrell, Eberts, McCaffery, and Grant (1991) examined the way in which nurses make clinical decisions regarding pain, and the barriers nurses may encounter when making decisions about pain management. Surveys were administered to registered nurses at lectures presented by McCaffery. More than onethird of the nurses reported that the most frequent barrier to pain relief was knowledge of the patient or family. Issues such as cooperation by physicians, inadequate analgesic prescriptions, and nursing staff time were cited as barriers to pain management by less than one-third of the participants. More than half of the nurses indicated that they had experienced a conflict with a patient regarding pain management. Ferrell, McCaffery, and Ropchan (1992) surveyed nurses in attendance at a National Oncology Nursing Conference regarding their perceived barriers to providing adequate pain management. Issues such as physician knowledge, inadequate medication orders, and physician cooperation were rated as the top three impediments to pain management. Other barriers included knowledge of the patient and family, patient cooperation, knowledge of nursing colleagues, and nursing staff time. These barriers highlight the complex nature of providing a strategy conducive to optimal pain management and the necessity of intervening with physicians and nurses, as well as with patients and their family members. The nurses frequently voiced frustration at having attended pain conferences and gained knowledge about advances in pain treatment only to return to a work setting where their suggestions were not given equal weight and where physicians prescribed inadequate medications. The authors concluded that nurses’ success in pain management depended on a team effort involving nurses, physicians, and other disciplines. Brunier, Carson, and Harrison (1995) examined nurses’ knowledge and attitudes regarding pain in the acute and long-term care settings of a Canadian teaching hospital. The respondents were asked to rate eight
The Impact of the Nurse-Physician Relationship
potential barriers to optimal cancer pain management in their work setting. Fifty percent or more of the sample rated inadequate assessment of pain, pain relief, and patient’s reluctance to take opioids as major barriers to effective pain management practices. Less than one-third of the respondents identified nursing staff reluctance to administer opioids as a barrier of major importance. According to the authors, the failure to acknowledge these as significant barriers to pain management illustrated a lack of awareness of the impediments to pain management. Clarke et al. (1996), in a study that examined the knowledge, attitudes, and clinical practice of registered nurses regarding pain management, investigated the barriers that nurses faced in providing optimal pain relief. More than 70% of the nurses surveyed viewed patients’ reluctance to report pain and patients’ reluctance to take opioids as significant barriers to effective pain management. In contrast, less than 50% of the respondents viewed staff-related barriers such as inadequate knowledge of pain management or nursing staff reluctance to administer opioids as important barriers to pain management. Although previous research has documented a number of barriers that nurses encounter in pain management, these issues have not been studied in a sample of Australian nurses. Furthermore, these studies focused on issues related to the management of cancer pain or pain management in long-term care. No studies have investigated the differences in barriers experienced by nurses across different employment settings and clinical units. Previous research has focused on the actual barriers perceived by nurses rather than on the frequency with which nurses experience these barriers. Because pain management needs to be varied to suit the individual and his or her diagnosis, it would be inappropriate to assume that all areas of nursing are affected by the same barriers as those faced by nurses in the areas of oncology or palliative care. If nurses see their relationship with physicians as a barrier, then the likelihood that this barrier will affect their level of involvement in the pain management process is high. However, very little research has addressed this issue. Therefore, using a sample of Tasmanian nurses, this study aimed to address the following research questions: ●
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Do Tasmanian nurses experience similar barriers when providing pain management as documented in other international studies? Do the barriers experienced differ in relation to various demographic variables such as the nurse’s age, length of employment, and time spent with patients in pain? Do the barriers experienced by nurses differ across various clinical units?
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Do the barriers experienced by nurses differ across different hospital or nursing home settings? Does the nurse-physician relationship have an impact on the types of barriers encountered by nurses during pain management?
METHODS Instruments A questionnaire was developed based on a review of the questionnaires used in similar studies (Ferrell et al., 1991, 1992). The questionnaire contained three sections: (1) demographic and background information of the respondent, (2) respondents’ involvement in pain management within their clinical settings, and (3) barriers the respondents faced in providing optimal pain relief. The first section obtained data on: age, sex, employment setting, term of employment, clinical unit, duration of employment, position on the unit, and level of nursing education. Information was obtained on the nurses’ experience in working with patients and the proportion of the work week spent attending to patients. In the second section, nurses were asked to indicate their involvement in pain management, such as assessment and the use of analgesics, and to indicate the frequency with which they consulted their patient’s primary physician. Nurses were asked to indicate their level of involvement in pain management and their satisfaction with this level of involvement. The third section consisted of a list of nine barriers to optimal pain relief. Nurses were asked to indicate whether they had experienced any of these barriers. Procedures To survey a representative sample of the state’s nursing population, the state was divided into three regions (i.e., south, north, and northwest). These areas in Tasmania contain the major population centers and hospitals. The total number of nurses employed in each region was calculated and a proportional number of surveys was mailed to nurses in that region. Within each region, nurses were randomly selected from the Tasmanian Nursing Registrar. A total of 2,768 surveys were mailed to the residential address of Tasmanian nurses registered with the Tasmanian Nursing Registration Board. Nurses surveyed were employed in public settings (e.g., hospitals and nursing homes funded by the government), private settings (e.g., hospitals and nursing homes funded by private groups), and community settings (including government funded, community-based health-care institutions such as mother-care units and private settings such as doctors’ surgeries).
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Nurses were supplied with a reply-paid envelope and were given 3 weeks to complete and return the survey. Fifty-eight surveys were returned from nurses who were not currently working, had retired, or no longer resided at that address, leaving 2,710 valid surveys. Of this number, 1,015 surveys were returned, giving an overall return rate of 38%. No follow-up requests were made for the return of the surveys. Although the response rate for this survey was relatively low (38% overall; 52% from the southern area of the state), it compares favorably with previous studies (Clarke et al., 1996; Furstenberg et al., 1998). Ethics approval to conduct the study was obtained from the University of Tasmania Ethics Committee (Human). Data Analysis The data from the questionnaire were scored and a series of two- and three-way analyses of variance were conducted on the dependent variables (e.g., barriers, satisfaction with the level of involvement, satisfaction with nurse-physician relationship). Where appropriate, post hoc analyses were done using the Student Newman-Keuls test. For all tests, significance was set at ␣ ⫽ .05.
RESULTS Sample Characteristics The largest proportion of surveys were returned by nurses from the Southern region of the state of Tasmania (52%), followed by nurses residing in the Northern (30%), and Northwest (18%) regions of the state. The majority of the nurses who responded was between 40 and 49 years of age (37%), followed by nurses between 20 and 29 years (13%), 30 and 39 years (30%), and 50 plus years (20%). Given the small number of surveys returned by male nurses (6%), who do not represent a large proportion of nurses employed in Tasmania, sex differences were not analyzed. Table 1 shows the employment characteristics of the respondents. The majority of respondents was employed on a part-time basis (50%) and were employed in public (46.1%) or private (21.5%) hospitals. The largest proportion of surveys was returned by geriatric, community, and surgical nurses. Seventy-seven percent of the respondents had spent 25 months or more in their current clinical unit. The level of nurse involvement in pain management is listed in Table 2. A total of 410 (40%) nurses indicated that they had more than 21 years of experience working with patients in pain compared to 8% of the nurses who indicated that they had less than 5 years of experience in patient pain management. The majority of nurses (67%) indicated that approximately
TABLE 1. Employment Characteristics of the Respondents (N ⴝ 1,015)
Term of Employment Full-time Part-time Casual Employment Setting Public hospital Private hospital Private nursing home Public nursing home Community setting Current Clinical Unit Rehabilitation Midwifery Pediatrics Community nursing Casualty/emergency Oncology Palliative care Respiratory Geriatric/gerontology Medical Surgical Perioperative Critical/intensive care Psychiatric Duration of Employment in Clinical Unit 1–6 months 7–12 months 13–18 months 19–24 months ⬎25 months
No.
%
400 507 108
39.4 50.0 10.6
468 218 121 48 160
46.1 21.5 11.9 4.7 15.7
37 86 60 133 46 45 45 19 149 84 138 76 60 37
3.7 8.5 5.9 13.1 4.5 4.4 4.4 1.9 14.7 8.3 13.6 7.5 5.9 3.7
59 75 50 50 781
5.8 7.4 4.9 4.9 77.0
66% to 100% of their work week was spent attending to patients in pain and that 38% of them were involved in pain management more than once each day. Barriers to Providing Optimal Pain Management Table 3 lists the barriers that nurses experienced when attempting to provide optimal pain management. A large percentage of the respondents indicated that their ability to provide pain relief was adversely affected by physician-related barriers. For example, nurses reported insufficient cooperation by physicians in relationship to their suggestions (63.6%), inadequate prescription of analgesic medications (69.9%), and physician’s knowledge and perceptions of pain (66.0%). On the other hand, only 35% of the respondents indicated that their ability to provide pain relief was adversely affected by a personal lack of knowledge about pain management. Sixty-eight percent of the respondents indicated that the patient to nurse
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The Impact of the Nurse-Physician Relationship
TABLE 2. Respondent’s Level of Involvement in Pain Management
Years of Experience in Pain Management 0–5 yr 6–10 yr 11–15 yr 16–20 yr ⬎21 years Involvement in Pain Management Almost never Less than once per week Several times each week Daily More than once each day Proportion of Time Attending to Patients ⬍33% 33–66% 66–100%
No.
%
81 171 160 193 410
7.9 16.9 15.8 19.0 40.4
78 87 241 226 383
7.7 8.6 23.7 22.3 37.7
168 172 675
16.6 17.0 66.5
ratio (i.e., insufficient time to spend with individual patients) created a barrier to providing optimal pain management. The Impact of Respondent Characteristics on Barriers Encountered A series of two-way analyses of variance were conducted to investigate the effect of nurse employment characteristics on the type of barriers nurses encountered during pain management. A significant interaction was found between employment setting and barrier type (F(32,8088) ⫽ 1.95, p ⬍ .001) with post hoc Student Newman-Keuls comparisons revealing that nurses employed in private hospitals and private nurs-
ing homes were significantly more likely to view patient to nurse ratio as a barrier to providing effective pain relief than nurses employed in government or community settings. A significant interaction was found between nurse clinical unit and type of barrier (F(13,1001) ⫽ 3.83, p ⬍ .001) with nurses working in critical care units significantly less likely to perceive that their ability to provide pain relief was affected by patient to nurse ratio than nurses working in medical or surgical units. Nurses working in perioperative units were significantly less likely to encounter difficulties in relation to patient cooperation in taking medications than were nurses in oncology or palliative care units. Rehabilitation nurses expressed significantly less concern regarding insufficient knowledge of other nursing staff than did nurses working in the areas of palliative care, pediatrics, or psychiatry. Respondent age affected the types of barriers encountered (F(24,8088) ⫽ 3.07, p ⬍ .001). Student Newman-Keuls post hoc comparisons revealed that respondents 40 years of age and older were significantly less likely to view insufficient knowledge of the patient’s physician as a barrier to pain management than nurses in the lowest age category (20 to 29 years). Nurses in the oldest age category (50 years or more) were also significantly less likely to view insufficient cooperation by the patient’s physician and inadequate prescriptions of analgesic medications as barriers to optimal pain relief compared to their younger counterparts. The interaction between frequency of involvement in pain management and type of barrier was significant (F(32,8080) ⫽ 1.88, p ⬍ .001). Nurses who were never or rarely involved in pain management were significantly more likely to feel that their own
TABLE 3. Nurse Experience of Barriers to Providing Optimal Pain Relief Barrier to Pain Relief Patient-related Barriers 1. Insufficient knowledge about patient/family 2. Patient cooperation in taking medication Provider-related Barriers 1. Insufficient knowledge of the patient’s physician 2. Insufficient knowledge of other nursing staff 3. Insufficient cooperation by physician to nurse suggestions 4. Inadequate prescribing of pain relief medications 5. Personal lack of pain knowledge 6. Physician knowledge and perception of pain System-related Barrier 1. Patient to nurse ratio
% Agree
% Disagree
55.07 49.16
44.93 50.84
40.29 34.97 63.64 69.85 34.75 66.01
59.71 65.03 36.36 30.15 63.25 33.99
67.68
32.32
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personal lack of pain knowledge was a barrier than were nurses involved in pain management several times each week or daily. The interaction between experience and the type of barrier encountered was also significant (F(32,8080) ⫽ 1.56, p ⬍ .01). Post hoc Student Newman-Keuls indicated that nurses with less than 10 years of experience were significantly more likely to have difficulty with insufficient cooperation from physicians to their suggestions than nurses with 21 years or more experience. Barrier type did not vary according to employment term (F(16,8069) ⫽ 1.42, p ⫽ .124), employment duration (F(32,8080) ⫽ .794, p ⫽ .788), or proportion of work week spent attending to patients (F(16,8096) ⫽ .886, p ⫽ .586). Nurse-Physician Relationships and Barriers to Pain Management In order to investigate the relationship between the level of consultation between nurses and physicians and perceived barriers to optimal pain management, a two-way analysis of variance was performed (i.e., adequately consulted by perceived barrier). A significant interaction was found between feeling adequately consulted by physicians and the perceived barrier to pain management (F(8,8088) ⫽ 5.30, p ⬍ .0001). Student Newman-Keuls post hoc analyses showed that nurses who did not feel adequately consulted by physicians were significantly more likely to perceive insufficient knowledge of the patient’s physician, insufficient cooperation by the patient’s physician, inadequate prescription of analgesic medications, and lack of physician’s knowledge and inappropriate perceptions of pain as barriers to optimal pain management than nurses who felt adequately consulted by physicians.
DISCUSSION The results of the current study indicate that nurses encounter a variety of barriers when attempting to provide optimal pain management. The three main types of barriers were patient-related barriers, provider-related barriers, and system-related barriers. Although the frequency with which the nurses surveyed encountered various barriers to pain management differed across institutions and clinical units, it is important to note that more than one-third of the respondents had encountered each type of barrier at least once. The most frequently cited system-related barrier was patient to nurse ratio. This barrier can also be seen as a provider-related barrier. The most frequently cited provider-related barriers included insufficient cooperation by physicians in relation to nurse suggestions, inadequate prescription of analgesic medications, and the physician’s lack of knowledge and inappropriate percep-
tions of pain. The most frequently cited patient-related barrier was an insufficient knowledge about the patient. Given that the nurses surveyed reported that they did not know enough about the patient to provide an optimal level of pain management, the data provided on patient charts may need to be increased. If nurses were provided with sufficient information about the patient’s background, including variables such as ethnicity, religious beliefs, previous pain treatments, and pain beliefs, they would be better able to formulate the most appropriate and effective pain management regimen for their patients. Patients who are experiencing pain have their own beliefs about pain and its treatment and these beliefs reflect past experiences and advice from family or friends. Thus it is important that nurses have an understanding of the beliefs of the patient that may be either therapeutic or detrimental to the patient’s pain management program (Diekmann & Wassem, 1991). This information could be gathered during the initial intake when possible and made readily available to the treating nurses. The gathering of data related to patient background may be especially important in clinical settings such as oncology or palliative care as the results of the current study found that nurses from these areas were significantly more likely to express concerns about patient reluctance to take analgesic medications. Provider-related barriers can be either nurse-related or physician-related. The perception of nurserelated barriers varied, with nurses expressing more concern about patient to nurse ratio than about their lack of knowledge about pain and its management or about the knowledge of other nursing staff. Although patient to nurse ratio can also be classified as a systemrelated barrier, it will be discussed under the general rubric of provider/nurse-related barriers. The finding that nurses felt that the patient to nurse ratio created a barrier to effective pain management is consistent with the findings of previous research (Ferrell et al., 1991, 1992). In these studies, nurses expressed concerns regarding the amount of time that they could spend with individual patients (i.e., patient to nurse ratio). In the current study, concern about the patient to nurse ratio was linked to a number of nurse employment characteristics. Nurses working in critical care units reported that their ability to provide optimal pain management was impeded less by the issue of patient to nurse ratio than did nurses working in medical or surgical units. Nurses employed in the private sector were more concerned with the issue of patient to nurse ratio than nurses employed in the government sector. Nurses in the private sector felt that their ability to provide optimal pain relief was impeded by a lack of time to spend with individual patients which
The Impact of the Nurse-Physician Relationship
resulted in the nurse feeling that they did not know enough about the patient to implement the most effective individualized pain management program. Given the findings of previous research with regard to nurses’ knowledge of pain management, it is of some concern that the respondents in the current study and those who participated in previous research expressed less concern about their own personal level of knowledge in providing optimal pain management than they did for other barriers (Ferrell et al., 1991, 1992). Van Niekerk and Martin (2001) examined the knowledge of Tasmanian registered nurses regarding pain management issues such as addiction, use of analgesics, and the assessment of pain. They found that nurses specifically lacked up-to-date knowledge concerning the pharmacologic management of pain, but displayed a more up-to-date knowledge concerning the effects of patient variables on pain perception. Similarly, previous studies have found that nurses lacked up-to-date knowledge regarding the pharmacologic management of pain (Hamilton & Edgar, 1992; Vortherms, Ryan, & Ward, 1992; Watt-Watson, 1992). This finding highlights the importance of providing continuous workplace education programs so nurses can maintain a high level of knowledge about pain management, especially related to pharmacologic management. The most frequently cited physician-related barriers to providing optimal pain relief included insufficient cooperation by physicians in relation to nurses’ suggestions, inadequate prescription of analgesic medications, and the physician’s lack of knowledge and inappropriate perceptions of pain. These findings are commensurate with previous studies that reported that the ability of nurses to provide optimal patient pain management is hindered by physician-related barriers (Ferrell et al., 1991, 1992). The results of the current study indicated that a number of nurse employment characteristics (e.g., nurse age, years of experience with pain management) influence the likelihood of encountering physician-related barriers to pain management. The younger respondents to the current survey (20 to 29 years) were more likely to encounter difficulties regarding insufficient cooperation by physicians, to express concerns about inadequate prescrip-
REFERENCES Archer Copp, L. (1987). The role of the nurse in chronic pain management. In G.D. Burrows, D. Elton, & G.V. Stanley (Eds.), Handbook of chronic pain management (pp. 227-239). Amsterdam: Elsevier Science.
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tion of analgesic medications, or to admit to not knowing enough about the patient’s treating physician than their older counterparts. This result is surprising given that younger nurses were found to have a more up-to-date knowledge of pain management principles, particularly in relation to addiction and patient variables (Van Niekerk & Martin, 2001). Similarly, nurses with less than 10 years’ experience in pain management were more likely to report difficulties in relation to physician cooperation than nurses who had been involved in pain management for 21 years or more. This result could reflect physicians’ perceptions of younger and less experienced nurses as less capable than their older and more experienced counterparts. Nurses who were satisfied with their professional relationship with physicians were less likely to express concerns regarding physician-related barriers such as insufficient cooperation by physicians and inadequate prescription of analgesic medications than nurses who expressed dissatisfaction with their professional relationships.
CONCLUSION The results of this study demonstrate the importance of the professional relationship between nurses and physicians in that it can have a significant effect on barriers to optimal pain management. A collaborative relationship between the two professions would ensure that the barriers experienced by nurses could be resolved in a supportive team approach. More effective pain management practice will result if guidelines for dealing with barriers are tailored to the specific type of institution and the clinical units within these institutions. Education concerning barriers is vital so that nurses can deal with them quickly and competently if they are encountered during pain management. If education programs included coverage of the types of barriers that are common in the different clinical units and methods for overcoming these obstacles to effective pain management, better nursing practice would result.
ACKNOWLEDGMENT The authors would like to thank the nurses who participated in this study.
Brunier, G., Carson, M.G., & Harrison, D.E. (1995). What do nurses know and believe about patients with pain? Results of a hospital survey. Journal of Pain and Symptom Management, 10, 436-445. Cadogan, M.P., Franzi, C., Osterweil, D., & Hill, T. (1999). Barriers to effective communication in skilled nurs-
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ing facilities: differences between the perception of nurses and physicians. Journal of the American Geriatric Society, 47, 71-75. Clarke, E.B., French, B., Bilodeau, M., Capasso, V.C., Edwards, A., & Empoliti, J. (1996). Pain management knowledge, attitudes, and clinical practice: the impact of nurses’ characteristics and education. Journal of Pain and Symptom Management, 11, 18-31. Diekmann, J.M., & Wassem, R.A. (1991). A survey of nursing students’ knowledge of cancer pain control. Cancer Nursing, 14, 314-320. Ferrell, B., Eberts, M., McCaffery, M., & Grant, M. (1991). Clinical decision making and pain. Cancer Nursing, 14, 289-297. Ferrell, B., McCaffery, M., & Ropchan, R. (1992). Pain management as a clinical challenge for nursing administration. Nursing Outlook, 40, 263-268. Ferrell, B.R., McGuire, D.B., & Donovan, M.I. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing, 9, 79-88. Fife, B., Irick, N., & Painter, J. (1993). A comparative study of the attitudes of physicians and nurses towards the management of cancer pain. Journal of Pain and Symptom Management, 8, 132-139. Furstenberg, C.T., Ahles, T., Whedon, M.B., Pierce, K.L., Dolan, M., Roberts, L., & Silberfarb, P.M. (1998). Knowledge and attitudes of healthcare provides toward cancer pain management: a comparison of physicians, nurses, and pharmacists in the state of New Hampshire. Journal of Pain and Symptom Management, 15, 335-349. Hamilton, J., & Edgar, L. (1992). A survey examining nurses’ knowledge of pain control. Journal of Pain and Symptom Management, 7, 18-26.
Kayser-Jones, J., Weiner, C., & Barbaccia, J. (1989). Factors contributing to the hospitalisation of nursing home residents. Gerontologist, 29, 502-510. Keenan, G.M., Cooke, R., & Hillis, S.L. (1998). Norms and nurse management of conflicts: keys to understanding nurse-physician collaboration. Research Nursing Health, 21, 59-72. Lebovits, A.H., Florence, I., Bathina, R., Hunko, V., Fox, M.T., & Bramble, C.Y. (1997). Pain knowledge and attitudes of health care providers: practice characteristic differences. Clinical Journal of Pain, 13, 237-243. McMahan, E.M., Hoffman, K., & McGee, G.W. (1994). Physician-nurse relationships in clinical settings: a review and critique of the literature, 1966 –1992. Medical Care Review, 51, 83-112. Roth, R.S., & DeRosayro, A.M. (1999). Cancer pain. In A.R. Block & E.F. Kremer (Eds.), Handbook of Pain Syndromes: Biopsychosocial Perspective’s (pp. 499-527). Lawrence Erlbaum Associates. Van Niekerk, L.M., & Martin, F. (2001). Tasmanian nurses’ knowledge of pain management. International Journal of Nursing Studies, 38, 141-152. Von Gunten, C.F., & Von Roenn, J.H. (1994). Barriers to pain control: ethics and Knowledge. Journal of Palliative Care, 10, 52-54. Vortherms, R., Ryan, P., & Ward, S. (1992). Knowledge of, attitudes toward, and barriers to pharmacological management of cancer pain in statewide random sample of nurses. Research Nursing Health, 15, 459-466. Watt-Watson, J.H. (1992). Misbeliefs about pain. In J.H. Watt-Watson & M.I. Donovan (Eds.), Pain management: nursing perspective (pp. 36-58). St Louis: Mosby Year Book.
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From the School of Psychology, University of Tasmania, Hobart, Tasmania, Australia This research was supported by a scholarship to the first author from the Australian Commonwealth Department of Health and Aged Care (QUM). Address correspondence and reprint requests to Leesa Micole Van Niekerk, BA Hons., School of Psychology, University of Tasmania, GPO Box 252-30, Hobart, Tasmania, 7001 © 2003 by the American Society of Pain Management Nurses 1524-9042/03/0401-0000$30.00/0 doi: 10.1053/jpmn.2003.4
ABSTRACT
The aim of the current investigation was to examine the barriers encountered by Tasmanian registered nurses when attempting to provide optimal pain management. The impact of nurse satisfaction with their professional relationship with physicians during pain management on the types of barriers encountered was also examined. A total of 1,015 registered nurses completed a 21-item survey that examined the types of barriers encountered during pain management. In addition, data were gathered on nurses’ satisfaction with their professional relationship with physicians during pain management. More than one-third of the respondents indicated that they had encountered at least one type of barrier to providing optimal pain relief, including insufficient cooperation by physicians and inadequate prescriptions of analgesic medications. Nurses who did not feel adequately consulted by physicians were significantly more likely to encounter barriers such as insufficient cooperation by patient’s physicians and inadequate prescription of analgesic medications. The barriers to effective pain management encountered by nurses were affected by their relationship with physicians. Education, for both nurses and physicians, concerning the role of the nurse in the workplace will help to ensure that nurses encounter fewer barriers during pain management. Optimal pain management practice will result if guidelines for dealing effectively with barriers are tailored to the specific type of institution and the unit within those institutions. © 2003 by the American Society of Pain Management Nurses
The role of the nurse is vital for the assessment and management of patients’ pain. In addition, effective patient pain management is inextricably linked to decisions nurses are required to make. These decisions include the scheduling of medications, the route of administration, and the dose that is administered. Nurses are required to make decisions about pain management, and optimal Pain Management Nursing, Vol 4, No 1 (March), 2003: pp 3-10
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pain management requires the dissemination of adequate information between the patient’s nurse and physician. The process of effective decision making can place nurses in a position in which they have to overcome a number of barriers. Cadogan, Franzi, Osterweil, and Hill (1999) compared the potential communication barriers between nurses and physicians in four Californian nursing homes. Five categories of barriers to communication were identified including nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Significant differences in perceived communication barriers between physicians and nurses were identified. Physicians, unlike nurses, perceived the competence of nurses as a significant barrier. Nurses, on the other hand, perceived physicians to be unpleasant, and both groups agreed that physicians did not value nurses’ opinions. In a study that investigated nurse-physician telephone communication, Kayser-Jones, Weiner, and Barbaccia (1989) found that nurses felt that physicians were difficult to reach, failed to return phone calls promptly, and became irritated by phone calls they perceived as insignificant. The appropriate assessment and treatment of pain is highly dependent upon collegial working relationships between physicians and nurses. The role of the physician is to assess and provide pharmacologic interventions, whereas the role of the nurse is to assess the patient’s status and serve as an advocate for the patient by promoting understanding of existing problems among the members of the health care team. Therefore, optimal management of the patient’s pain is dependent on adequate and accurate communication between the two parties regarding their respective assessments (Fife, Irick, & Painter, 1993; Keenan, Cooke, & Hillis, 1998; McMahan, Hoffman, & McGee, 1994). Whereas the role of the nurse may vary in the choice and type of treatment, the responsiveness and sensitivity of the nurse to treatment goals could effectively facilitate or block pain management (Archer Copp, 1987). To fulfill their role as a liaison officer between the patient and their physician, the nurse needs to have an up-to-date knowledge about pain diagnosis and management. Unfortunately, current studies have documented a lack of knowledge in nursing staff regarding pain management (Ferrell, McGuire, & Donovan, 1993; Hamilton & Edgar, 1992; Lebovits et al., 1997; Van Niekerk & Martin, 2001). A poor knowledge base can create a barrier for nurses to be able to provide optimal pain management. Barriers to optimal pain management exist at many levels of the health care system and can include patient-related barriers, provider-related barriers, and systems barriers.
The recent and increasing popularity of managed care systems of health care delivery, with an emphasis on cost reduction through decreased health care utilization, may pose serious obstacles to the multidisciplinary and long-term medical and psychosocial needs of pain patients (Roth & DeRosayro, 1999). Patients may express concerns about distracting care providers, about addiction and drug tolerance, or complying with treatment regimes. Providers, on the other hand, may have little formal training in pain management, may express concerns about addiction, and may fail to pursue pain related issues aggressively or appropriately (Furstenberg et al., 1998; Von Gunten & Von Roenn, 1994). Ferrell, Eberts, McCaffery, and Grant (1991) examined the way in which nurses make clinical decisions regarding pain, and the barriers nurses may encounter when making decisions about pain management. Surveys were administered to registered nurses at lectures presented by McCaffery. More than onethird of the nurses reported that the most frequent barrier to pain relief was knowledge of the patient or family. Issues such as cooperation by physicians, inadequate analgesic prescriptions, and nursing staff time were cited as barriers to pain management by less than one-third of the participants. More than half of the nurses indicated that they had experienced a conflict with a patient regarding pain management. Ferrell, McCaffery, and Ropchan (1992) surveyed nurses in attendance at a National Oncology Nursing Conference regarding their perceived barriers to providing adequate pain management. Issues such as physician knowledge, inadequate medication orders, and physician cooperation were rated as the top three impediments to pain management. Other barriers included knowledge of the patient and family, patient cooperation, knowledge of nursing colleagues, and nursing staff time. These barriers highlight the complex nature of providing a strategy conducive to optimal pain management and the necessity of intervening with physicians and nurses, as well as with patients and their family members. The nurses frequently voiced frustration at having attended pain conferences and gained knowledge about advances in pain treatment only to return to a work setting where their suggestions were not given equal weight and where physicians prescribed inadequate medications. The authors concluded that nurses’ success in pain management depended on a team effort involving nurses, physicians, and other disciplines. Brunier, Carson, and Harrison (1995) examined nurses’ knowledge and attitudes regarding pain in the acute and long-term care settings of a Canadian teaching hospital. The respondents were asked to rate eight
The Impact of the Nurse-Physician Relationship
potential barriers to optimal cancer pain management in their work setting. Fifty percent or more of the sample rated inadequate assessment of pain, pain relief, and patient’s reluctance to take opioids as major barriers to effective pain management practices. Less than one-third of the respondents identified nursing staff reluctance to administer opioids as a barrier of major importance. According to the authors, the failure to acknowledge these as significant barriers to pain management illustrated a lack of awareness of the impediments to pain management. Clarke et al. (1996), in a study that examined the knowledge, attitudes, and clinical practice of registered nurses regarding pain management, investigated the barriers that nurses faced in providing optimal pain relief. More than 70% of the nurses surveyed viewed patients’ reluctance to report pain and patients’ reluctance to take opioids as significant barriers to effective pain management. In contrast, less than 50% of the respondents viewed staff-related barriers such as inadequate knowledge of pain management or nursing staff reluctance to administer opioids as important barriers to pain management. Although previous research has documented a number of barriers that nurses encounter in pain management, these issues have not been studied in a sample of Australian nurses. Furthermore, these studies focused on issues related to the management of cancer pain or pain management in long-term care. No studies have investigated the differences in barriers experienced by nurses across different employment settings and clinical units. Previous research has focused on the actual barriers perceived by nurses rather than on the frequency with which nurses experience these barriers. Because pain management needs to be varied to suit the individual and his or her diagnosis, it would be inappropriate to assume that all areas of nursing are affected by the same barriers as those faced by nurses in the areas of oncology or palliative care. If nurses see their relationship with physicians as a barrier, then the likelihood that this barrier will affect their level of involvement in the pain management process is high. However, very little research has addressed this issue. Therefore, using a sample of Tasmanian nurses, this study aimed to address the following research questions: ●
●
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Do Tasmanian nurses experience similar barriers when providing pain management as documented in other international studies? Do the barriers experienced differ in relation to various demographic variables such as the nurse’s age, length of employment, and time spent with patients in pain? Do the barriers experienced by nurses differ across various clinical units?
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Do the barriers experienced by nurses differ across different hospital or nursing home settings? Does the nurse-physician relationship have an impact on the types of barriers encountered by nurses during pain management?
METHODS Instruments A questionnaire was developed based on a review of the questionnaires used in similar studies (Ferrell et al., 1991, 1992). The questionnaire contained three sections: (1) demographic and background information of the respondent, (2) respondents’ involvement in pain management within their clinical settings, and (3) barriers the respondents faced in providing optimal pain relief. The first section obtained data on: age, sex, employment setting, term of employment, clinical unit, duration of employment, position on the unit, and level of nursing education. Information was obtained on the nurses’ experience in working with patients and the proportion of the work week spent attending to patients. In the second section, nurses were asked to indicate their involvement in pain management, such as assessment and the use of analgesics, and to indicate the frequency with which they consulted their patient’s primary physician. Nurses were asked to indicate their level of involvement in pain management and their satisfaction with this level of involvement. The third section consisted of a list of nine barriers to optimal pain relief. Nurses were asked to indicate whether they had experienced any of these barriers. Procedures To survey a representative sample of the state’s nursing population, the state was divided into three regions (i.e., south, north, and northwest). These areas in Tasmania contain the major population centers and hospitals. The total number of nurses employed in each region was calculated and a proportional number of surveys was mailed to nurses in that region. Within each region, nurses were randomly selected from the Tasmanian Nursing Registrar. A total of 2,768 surveys were mailed to the residential address of Tasmanian nurses registered with the Tasmanian Nursing Registration Board. Nurses surveyed were employed in public settings (e.g., hospitals and nursing homes funded by the government), private settings (e.g., hospitals and nursing homes funded by private groups), and community settings (including government funded, community-based health-care institutions such as mother-care units and private settings such as doctors’ surgeries).
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Nurses were supplied with a reply-paid envelope and were given 3 weeks to complete and return the survey. Fifty-eight surveys were returned from nurses who were not currently working, had retired, or no longer resided at that address, leaving 2,710 valid surveys. Of this number, 1,015 surveys were returned, giving an overall return rate of 38%. No follow-up requests were made for the return of the surveys. Although the response rate for this survey was relatively low (38% overall; 52% from the southern area of the state), it compares favorably with previous studies (Clarke et al., 1996; Furstenberg et al., 1998). Ethics approval to conduct the study was obtained from the University of Tasmania Ethics Committee (Human). Data Analysis The data from the questionnaire were scored and a series of two- and three-way analyses of variance were conducted on the dependent variables (e.g., barriers, satisfaction with the level of involvement, satisfaction with nurse-physician relationship). Where appropriate, post hoc analyses were done using the Student Newman-Keuls test. For all tests, significance was set at ␣ ⫽ .05.
RESULTS Sample Characteristics The largest proportion of surveys were returned by nurses from the Southern region of the state of Tasmania (52%), followed by nurses residing in the Northern (30%), and Northwest (18%) regions of the state. The majority of the nurses who responded was between 40 and 49 years of age (37%), followed by nurses between 20 and 29 years (13%), 30 and 39 years (30%), and 50 plus years (20%). Given the small number of surveys returned by male nurses (6%), who do not represent a large proportion of nurses employed in Tasmania, sex differences were not analyzed. Table 1 shows the employment characteristics of the respondents. The majority of respondents was employed on a part-time basis (50%) and were employed in public (46.1%) or private (21.5%) hospitals. The largest proportion of surveys was returned by geriatric, community, and surgical nurses. Seventy-seven percent of the respondents had spent 25 months or more in their current clinical unit. The level of nurse involvement in pain management is listed in Table 2. A total of 410 (40%) nurses indicated that they had more than 21 years of experience working with patients in pain compared to 8% of the nurses who indicated that they had less than 5 years of experience in patient pain management. The majority of nurses (67%) indicated that approximately
TABLE 1. Employment Characteristics of the Respondents (N ⴝ 1,015)
Term of Employment Full-time Part-time Casual Employment Setting Public hospital Private hospital Private nursing home Public nursing home Community setting Current Clinical Unit Rehabilitation Midwifery Pediatrics Community nursing Casualty/emergency Oncology Palliative care Respiratory Geriatric/gerontology Medical Surgical Perioperative Critical/intensive care Psychiatric Duration of Employment in Clinical Unit 1–6 months 7–12 months 13–18 months 19–24 months ⬎25 months
No.
%
400 507 108
39.4 50.0 10.6
468 218 121 48 160
46.1 21.5 11.9 4.7 15.7
37 86 60 133 46 45 45 19 149 84 138 76 60 37
3.7 8.5 5.9 13.1 4.5 4.4 4.4 1.9 14.7 8.3 13.6 7.5 5.9 3.7
59 75 50 50 781
5.8 7.4 4.9 4.9 77.0
66% to 100% of their work week was spent attending to patients in pain and that 38% of them were involved in pain management more than once each day. Barriers to Providing Optimal Pain Management Table 3 lists the barriers that nurses experienced when attempting to provide optimal pain management. A large percentage of the respondents indicated that their ability to provide pain relief was adversely affected by physician-related barriers. For example, nurses reported insufficient cooperation by physicians in relationship to their suggestions (63.6%), inadequate prescription of analgesic medications (69.9%), and physician’s knowledge and perceptions of pain (66.0%). On the other hand, only 35% of the respondents indicated that their ability to provide pain relief was adversely affected by a personal lack of knowledge about pain management. Sixty-eight percent of the respondents indicated that the patient to nurse
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The Impact of the Nurse-Physician Relationship
TABLE 2. Respondent’s Level of Involvement in Pain Management
Years of Experience in Pain Management 0–5 yr 6–10 yr 11–15 yr 16–20 yr ⬎21 years Involvement in Pain Management Almost never Less than once per week Several times each week Daily More than once each day Proportion of Time Attending to Patients ⬍33% 33–66% 66–100%
No.
%
81 171 160 193 410
7.9 16.9 15.8 19.0 40.4
78 87 241 226 383
7.7 8.6 23.7 22.3 37.7
168 172 675
16.6 17.0 66.5
ratio (i.e., insufficient time to spend with individual patients) created a barrier to providing optimal pain management. The Impact of Respondent Characteristics on Barriers Encountered A series of two-way analyses of variance were conducted to investigate the effect of nurse employment characteristics on the type of barriers nurses encountered during pain management. A significant interaction was found between employment setting and barrier type (F(32,8088) ⫽ 1.95, p ⬍ .001) with post hoc Student Newman-Keuls comparisons revealing that nurses employed in private hospitals and private nurs-
ing homes were significantly more likely to view patient to nurse ratio as a barrier to providing effective pain relief than nurses employed in government or community settings. A significant interaction was found between nurse clinical unit and type of barrier (F(13,1001) ⫽ 3.83, p ⬍ .001) with nurses working in critical care units significantly less likely to perceive that their ability to provide pain relief was affected by patient to nurse ratio than nurses working in medical or surgical units. Nurses working in perioperative units were significantly less likely to encounter difficulties in relation to patient cooperation in taking medications than were nurses in oncology or palliative care units. Rehabilitation nurses expressed significantly less concern regarding insufficient knowledge of other nursing staff than did nurses working in the areas of palliative care, pediatrics, or psychiatry. Respondent age affected the types of barriers encountered (F(24,8088) ⫽ 3.07, p ⬍ .001). Student Newman-Keuls post hoc comparisons revealed that respondents 40 years of age and older were significantly less likely to view insufficient knowledge of the patient’s physician as a barrier to pain management than nurses in the lowest age category (20 to 29 years). Nurses in the oldest age category (50 years or more) were also significantly less likely to view insufficient cooperation by the patient’s physician and inadequate prescriptions of analgesic medications as barriers to optimal pain relief compared to their younger counterparts. The interaction between frequency of involvement in pain management and type of barrier was significant (F(32,8080) ⫽ 1.88, p ⬍ .001). Nurses who were never or rarely involved in pain management were significantly more likely to feel that their own
TABLE 3. Nurse Experience of Barriers to Providing Optimal Pain Relief Barrier to Pain Relief Patient-related Barriers 1. Insufficient knowledge about patient/family 2. Patient cooperation in taking medication Provider-related Barriers 1. Insufficient knowledge of the patient’s physician 2. Insufficient knowledge of other nursing staff 3. Insufficient cooperation by physician to nurse suggestions 4. Inadequate prescribing of pain relief medications 5. Personal lack of pain knowledge 6. Physician knowledge and perception of pain System-related Barrier 1. Patient to nurse ratio
% Agree
% Disagree
55.07 49.16
44.93 50.84
40.29 34.97 63.64 69.85 34.75 66.01
59.71 65.03 36.36 30.15 63.25 33.99
67.68
32.32
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personal lack of pain knowledge was a barrier than were nurses involved in pain management several times each week or daily. The interaction between experience and the type of barrier encountered was also significant (F(32,8080) ⫽ 1.56, p ⬍ .01). Post hoc Student Newman-Keuls indicated that nurses with less than 10 years of experience were significantly more likely to have difficulty with insufficient cooperation from physicians to their suggestions than nurses with 21 years or more experience. Barrier type did not vary according to employment term (F(16,8069) ⫽ 1.42, p ⫽ .124), employment duration (F(32,8080) ⫽ .794, p ⫽ .788), or proportion of work week spent attending to patients (F(16,8096) ⫽ .886, p ⫽ .586). Nurse-Physician Relationships and Barriers to Pain Management In order to investigate the relationship between the level of consultation between nurses and physicians and perceived barriers to optimal pain management, a two-way analysis of variance was performed (i.e., adequately consulted by perceived barrier). A significant interaction was found between feeling adequately consulted by physicians and the perceived barrier to pain management (F(8,8088) ⫽ 5.30, p ⬍ .0001). Student Newman-Keuls post hoc analyses showed that nurses who did not feel adequately consulted by physicians were significantly more likely to perceive insufficient knowledge of the patient’s physician, insufficient cooperation by the patient’s physician, inadequate prescription of analgesic medications, and lack of physician’s knowledge and inappropriate perceptions of pain as barriers to optimal pain management than nurses who felt adequately consulted by physicians.
DISCUSSION The results of the current study indicate that nurses encounter a variety of barriers when attempting to provide optimal pain management. The three main types of barriers were patient-related barriers, provider-related barriers, and system-related barriers. Although the frequency with which the nurses surveyed encountered various barriers to pain management differed across institutions and clinical units, it is important to note that more than one-third of the respondents had encountered each type of barrier at least once. The most frequently cited system-related barrier was patient to nurse ratio. This barrier can also be seen as a provider-related barrier. The most frequently cited provider-related barriers included insufficient cooperation by physicians in relation to nurse suggestions, inadequate prescription of analgesic medications, and the physician’s lack of knowledge and inappropriate percep-
tions of pain. The most frequently cited patient-related barrier was an insufficient knowledge about the patient. Given that the nurses surveyed reported that they did not know enough about the patient to provide an optimal level of pain management, the data provided on patient charts may need to be increased. If nurses were provided with sufficient information about the patient’s background, including variables such as ethnicity, religious beliefs, previous pain treatments, and pain beliefs, they would be better able to formulate the most appropriate and effective pain management regimen for their patients. Patients who are experiencing pain have their own beliefs about pain and its treatment and these beliefs reflect past experiences and advice from family or friends. Thus it is important that nurses have an understanding of the beliefs of the patient that may be either therapeutic or detrimental to the patient’s pain management program (Diekmann & Wassem, 1991). This information could be gathered during the initial intake when possible and made readily available to the treating nurses. The gathering of data related to patient background may be especially important in clinical settings such as oncology or palliative care as the results of the current study found that nurses from these areas were significantly more likely to express concerns about patient reluctance to take analgesic medications. Provider-related barriers can be either nurse-related or physician-related. The perception of nurserelated barriers varied, with nurses expressing more concern about patient to nurse ratio than about their lack of knowledge about pain and its management or about the knowledge of other nursing staff. Although patient to nurse ratio can also be classified as a systemrelated barrier, it will be discussed under the general rubric of provider/nurse-related barriers. The finding that nurses felt that the patient to nurse ratio created a barrier to effective pain management is consistent with the findings of previous research (Ferrell et al., 1991, 1992). In these studies, nurses expressed concerns regarding the amount of time that they could spend with individual patients (i.e., patient to nurse ratio). In the current study, concern about the patient to nurse ratio was linked to a number of nurse employment characteristics. Nurses working in critical care units reported that their ability to provide optimal pain management was impeded less by the issue of patient to nurse ratio than did nurses working in medical or surgical units. Nurses employed in the private sector were more concerned with the issue of patient to nurse ratio than nurses employed in the government sector. Nurses in the private sector felt that their ability to provide optimal pain relief was impeded by a lack of time to spend with individual patients which
The Impact of the Nurse-Physician Relationship
resulted in the nurse feeling that they did not know enough about the patient to implement the most effective individualized pain management program. Given the findings of previous research with regard to nurses’ knowledge of pain management, it is of some concern that the respondents in the current study and those who participated in previous research expressed less concern about their own personal level of knowledge in providing optimal pain management than they did for other barriers (Ferrell et al., 1991, 1992). Van Niekerk and Martin (2001) examined the knowledge of Tasmanian registered nurses regarding pain management issues such as addiction, use of analgesics, and the assessment of pain. They found that nurses specifically lacked up-to-date knowledge concerning the pharmacologic management of pain, but displayed a more up-to-date knowledge concerning the effects of patient variables on pain perception. Similarly, previous studies have found that nurses lacked up-to-date knowledge regarding the pharmacologic management of pain (Hamilton & Edgar, 1992; Vortherms, Ryan, & Ward, 1992; Watt-Watson, 1992). This finding highlights the importance of providing continuous workplace education programs so nurses can maintain a high level of knowledge about pain management, especially related to pharmacologic management. The most frequently cited physician-related barriers to providing optimal pain relief included insufficient cooperation by physicians in relation to nurses’ suggestions, inadequate prescription of analgesic medications, and the physician’s lack of knowledge and inappropriate perceptions of pain. These findings are commensurate with previous studies that reported that the ability of nurses to provide optimal patient pain management is hindered by physician-related barriers (Ferrell et al., 1991, 1992). The results of the current study indicated that a number of nurse employment characteristics (e.g., nurse age, years of experience with pain management) influence the likelihood of encountering physician-related barriers to pain management. The younger respondents to the current survey (20 to 29 years) were more likely to encounter difficulties regarding insufficient cooperation by physicians, to express concerns about inadequate prescrip-
REFERENCES Archer Copp, L. (1987). The role of the nurse in chronic pain management. In G.D. Burrows, D. Elton, & G.V. Stanley (Eds.), Handbook of chronic pain management (pp. 227-239). Amsterdam: Elsevier Science.
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tion of analgesic medications, or to admit to not knowing enough about the patient’s treating physician than their older counterparts. This result is surprising given that younger nurses were found to have a more up-to-date knowledge of pain management principles, particularly in relation to addiction and patient variables (Van Niekerk & Martin, 2001). Similarly, nurses with less than 10 years’ experience in pain management were more likely to report difficulties in relation to physician cooperation than nurses who had been involved in pain management for 21 years or more. This result could reflect physicians’ perceptions of younger and less experienced nurses as less capable than their older and more experienced counterparts. Nurses who were satisfied with their professional relationship with physicians were less likely to express concerns regarding physician-related barriers such as insufficient cooperation by physicians and inadequate prescription of analgesic medications than nurses who expressed dissatisfaction with their professional relationships.
CONCLUSION The results of this study demonstrate the importance of the professional relationship between nurses and physicians in that it can have a significant effect on barriers to optimal pain management. A collaborative relationship between the two professions would ensure that the barriers experienced by nurses could be resolved in a supportive team approach. More effective pain management practice will result if guidelines for dealing with barriers are tailored to the specific type of institution and the clinical units within these institutions. Education concerning barriers is vital so that nurses can deal with them quickly and competently if they are encountered during pain management. If education programs included coverage of the types of barriers that are common in the different clinical units and methods for overcoming these obstacles to effective pain management, better nursing practice would result.
ACKNOWLEDGMENT The authors would like to thank the nurses who participated in this study.
Brunier, G., Carson, M.G., & Harrison, D.E. (1995). What do nurses know and believe about patients with pain? Results of a hospital survey. Journal of Pain and Symptom Management, 10, 436-445. Cadogan, M.P., Franzi, C., Osterweil, D., & Hill, T. (1999). Barriers to effective communication in skilled nurs-
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ing facilities: differences between the perception of nurses and physicians. Journal of the American Geriatric Society, 47, 71-75. Clarke, E.B., French, B., Bilodeau, M., Capasso, V.C., Edwards, A., & Empoliti, J. (1996). Pain management knowledge, attitudes, and clinical practice: the impact of nurses’ characteristics and education. Journal of Pain and Symptom Management, 11, 18-31. Diekmann, J.M., & Wassem, R.A. (1991). A survey of nursing students’ knowledge of cancer pain control. Cancer Nursing, 14, 314-320. Ferrell, B., Eberts, M., McCaffery, M., & Grant, M. (1991). Clinical decision making and pain. Cancer Nursing, 14, 289-297. Ferrell, B., McCaffery, M., & Ropchan, R. (1992). Pain management as a clinical challenge for nursing administration. Nursing Outlook, 40, 263-268. Ferrell, B.R., McGuire, D.B., & Donovan, M.I. (1993). Knowledge and beliefs regarding pain in a sample of nursing faculty. Journal of Professional Nursing, 9, 79-88. Fife, B., Irick, N., & Painter, J. (1993). A comparative study of the attitudes of physicians and nurses towards the management of cancer pain. Journal of Pain and Symptom Management, 8, 132-139. Furstenberg, C.T., Ahles, T., Whedon, M.B., Pierce, K.L., Dolan, M., Roberts, L., & Silberfarb, P.M. (1998). Knowledge and attitudes of healthcare provides toward cancer pain management: a comparison of physicians, nurses, and pharmacists in the state of New Hampshire. Journal of Pain and Symptom Management, 15, 335-349. Hamilton, J., & Edgar, L. (1992). A survey examining nurses’ knowledge of pain control. Journal of Pain and Symptom Management, 7, 18-26.
Kayser-Jones, J., Weiner, C., & Barbaccia, J. (1989). Factors contributing to the hospitalisation of nursing home residents. Gerontologist, 29, 502-510. Keenan, G.M., Cooke, R., & Hillis, S.L. (1998). Norms and nurse management of conflicts: keys to understanding nurse-physician collaboration. Research Nursing Health, 21, 59-72. Lebovits, A.H., Florence, I., Bathina, R., Hunko, V., Fox, M.T., & Bramble, C.Y. (1997). Pain knowledge and attitudes of health care providers: practice characteristic differences. Clinical Journal of Pain, 13, 237-243. McMahan, E.M., Hoffman, K., & McGee, G.W. (1994). Physician-nurse relationships in clinical settings: a review and critique of the literature, 1966 –1992. Medical Care Review, 51, 83-112. Roth, R.S., & DeRosayro, A.M. (1999). Cancer pain. In A.R. Block & E.F. Kremer (Eds.), Handbook of Pain Syndromes: Biopsychosocial Perspective’s (pp. 499-527). Lawrence Erlbaum Associates. Van Niekerk, L.M., & Martin, F. (2001). Tasmanian nurses’ knowledge of pain management. International Journal of Nursing Studies, 38, 141-152. Von Gunten, C.F., & Von Roenn, J.H. (1994). Barriers to pain control: ethics and Knowledge. Journal of Palliative Care, 10, 52-54. Vortherms, R., Ryan, P., & Ward, S. (1992). Knowledge of, attitudes toward, and barriers to pharmacological management of cancer pain in statewide random sample of nurses. Research Nursing Health, 15, 459-466. Watt-Watson, J.H. (1992). Misbeliefs about pain. In J.H. Watt-Watson & M.I. Donovan (Eds.), Pain management: nursing perspective (pp. 36-58). St Louis: Mosby Year Book.