The influence of personal values and patient intoxication on nurses concerns about opioids: results of a prospective cross-sectional multi-centre study.

BACKGROUND: Nurses are the main administrators of opioids in hospitals and enjoy some autonomy when using them to manage pain. Nevertheless evidence suggests they exercise this freedom restrictively with the reasons for this self-limitation remaining unclear. Nurses are influenced by personal and professional values and by patients' attributes. Intoxicated patients pose a particular challenge. This study therefore investigated whether cautious attitudes towards opioids were aggravated in intoxicated patients and influenced by personal values. METHODS: A two-version questionnaire was developed. Each presented a case vignette describing a patient in acute pain who was either intoxicated or not intoxicated. Questionnaires contained identical case statements inquiring about concerns regarding opioids, preferred analgesics and statements about opioids and personal values. They were distributed prospectively in a cross-sectional, multi-centre design. Equal distribution of both questionnaires was achieved through randomization of wards. Regression analysis was employed to determine predictors for responses to the case statements. RESULTS: In total, n = 374 (26%) nurses returned questionnaires, 85% were female, 39% worked in surgery and 64% had >10 years experience. A total of 78% were concerned using opioids in the intoxicated patient and 70% preferred non-opioids instead. Most nurses agreed familiarity with an opioid gives them more confidence and they were more concerned in patients with a history of drug abuse. They neither associated opioids with helping patients to die nor with drug abuse. The majority endorsed value statements representing 'universalism', 'hedonism' and 'benevolence' while disagreeing with 'power' and 'stimulation'. Nurses concerns were predicted by values indicating 'conformity' and 'achievement'. CONCLUSION: Nurses were concerned giving opioids to intoxicated patients and preferred non-opioids instead. These concerns were predicted by personal values representing 'Conservation' ('conformity') and 'Self-Enhancement' ('achievement'). Therefore, stigmatizing mental models likely contribute to nurses' reluctance to use opioids. Interestingly, personal ambition might protect nurses from discriminatory thoughts and practice.

Practice and bias in intraoperative pain management: results of a cross-sectional patient study and a survey of anesthesiologists.

BACKGROUND: Perioperative pain carries a considerable risk of becoming persistent; hence aggressive preventive approaches are advocated. Persistently high prevalence of postoperative pain, however, suggests anesthesiologists underuse these strategies. A prospective cross-sectional study of patients in the postanesthetic care unit (PACU) and a survey of anesthesiologists were thus conducted to evaluate practice and uncover bias in intraoperative pain management. METHODS: Notes of PACU patients were reviewed and information regarding surgical context, comorbidities, and analgesic administration was retrieved. Variables were analyzed for their predictive properties on pain and intraoperative analgesic management. Furthermore, clinical dose-effect estimates for intraoperative morphine were determined. Finally, anesthesiologists completed a questionnaire comprising statements regarding pain relating to surgical context and morphine administration. RESULTS: Data of 200 patients and 55 anesthesiologists were analyzed. Prevalence of pain in PACU was 28% and was predicted by local anesthetic (LA) and low-dose morphine administration. Additionally, when LA was used, little coanalgesics were employed. These results suggest a restrained approach by anesthesiologists toward intraoperative pain management. It is supported by their reluctance to administer more than 10 mg morphine, despite these individuals regarding this practice as insufficient. The hesitancy toward morphine also transpired in the dose-effect estimates with the average applied dose operating on an ED63 instead of an ED95 level. CONCLUSION: This study confirmed a high prevalence of pain in PACU. It also indicated conservative intraoperative analgesic administration by anesthesiologists. The modest morphine usage and overreliance on LA application, which are not supported by published evidence, additionally suggest bias in current intraoperative pain management.

Nurses and opioids: results of a bi-national survey on mental models regarding opioid administration in hospitals.

OBJECTIVE: Pain remains insufficiently treated in hospitals. Increasing evidence suggests human factors contribute to this, due to nurses failing to administer opioids. This behavior might be the consequence of nurses' mental models about opioids. As personal experience and conceptions shape these models, the aim of this prospective survey was to identify model-influencing factors. MATERIAL AND METHODS: A questionnaire was developed comprising of 14 statements concerning ideations about opioids and seven questions concerning demographics, indicators of adult learning, and strength of religious beliefs. Latent variables that may underlie nurses' mental models were identified using undirected graphical dependence models. Representative items of latent variables were employed for ordinal regression analysis. Questionnaires were distributed to 1,379 nurses in two London, UK, hospitals (n=580) and one German (n=799) hospital between September 2014 and February 2015. RESULTS: A total of 511 (37.1%) questionnaires were returned. Mean (standard deviation) age of participants were 37 (11) years; 83.5% participants were female; 45.2% worked in critical care; and 51.5% had more than 10 years experience. Of the nurses, 84% were not scared of opioids, 87% did not regard opioids as drugs to help patients die, and 72% did not view them as drugs of abuse. More English (41%) than German (28%) nurses were afraid of criminal investigations and were constantly aware of side effects (UK, 94%; Germany, 38%) when using opioids. Four latent variables were identified which likely influence nurses' mental models: "conscious decision-making"; "medication-related fears"; "practice-based observations"; and "risk assessment". They were predicted by strength of religious beliefs and indicators of informal learning such as experience but not by indicators of formal learning such as conference attendance. CONCLUSION: Nurses in both countries employ analytical and affective mental models when administering the opioids and seem to learn from experience rather than from formal teaching. Additionally, some attitudes and emotions towards opioids are likely the result of nurses' cultural background.

Clinical benefits, referral practice and cost implications of an in-hospital pain service: results of a service evaluation in a London teaching hospital.

BACKGROUND: In-hospital pain services (IPS) are commonplace, but evidence of efficacy is inadequate, and patients' pain management in any hospital ward remains problematic. This service evaluation aimed to measure the effect of a contemporary IPS, its appropriate use and cost-efficacy. METHODS: Records of 249 adults reviewed by the IPS in an inner London Teaching Hospital over an 8-month period were analysed for demographic data, interventions, workload and change in pain intensity measured by numerical rating scale (NRS). Non-parametric tests were used to evaluate differences between initial and final NRS. Spearman's rank correlation analysis was used to create a correlation matrix to evaluate associations between all identified independent variables with the change in NRS. All strongly correlated variables (ρ > 0.5) were subsequently included in a binary logistic regression analysis to identify predictors of pain resolution greater than 50% NRS and improvement rather than deterioration or no change in NRS. Finally, referral practice and cost of inappropriate referrals were estimated. Referrals were thought to be inappropriate when pain was not optimised by the referring team; they were identified using a set algorithm. RESULTS: Initial median NRS and final median NRS were significantly different when a Wilcoxon signed-rank test was applied to the whole cohort; Z = -5.5 (p = 0.000). Subgroup analysis demonstrated no significant difference in the 'mild' pain group; z = -1.1 (p = 0.253). Regression analysis showed that for every unit increase in initial NRS, there was a 62% chance of general and a 33% chance of >50% improvement in final NRS. An estimated annual cost-saving potential of £1546 to £4558 was found in inappropriate referrals and patients experiencing no benefit from the service. DISCUSSION: Results suggest that patients with moderate to severe pain benefit most from IPS input. Also pain management resources are often distributed inefficiently. Future research is required to develop algorithms for easy identification of potential treatment responders.