Evaluation of nurses’ beliefs, values and learning needs regarding pain management of veterans

Introduction

The Canadian Guide to End-of-Life Care for Seniors (2000) defines pain as an unpleasant sensory or emotional experience that is derived from sensory stimuli and modified by individual memory, expectations and emotions. McCaffery (1989) emphasized the subjective aspect of pain, stating that pain is what the person says it is, existing whenever the person says it does. Although pain is not related to age, painful chronic illnesses are prevalent in the elderly (Marzinski, 1991). Indeed, a recent study (Fox et al., 1999) indicated that 49 - 83% of patients in long-term care experience pain. These results are comparable to those of other studies (Bowling & Braune, 1991; Ferrell et al., 1990; Gibson et al., 2005; Kerns et al., 2003), which estimated that 45 - 80% of long-term care patients suffered pain. Chronic untreated pain can have numerous consequences on the health of the elderly: difficulty in activities of daily living, insomnia, depression, decreased social activity, malnutrition, altered mental function, polypharmacy and falls (Closs, 1994; Ferrell et al., 1990; Ferrell, 1991; Marzinski, 1991). All of these consequences can seriously alter the quality of life of the elderly.

Furthermore, Closs (1994) found that management of pain in the elderly is commonly neglected. Ferrell et al. (1990) found that 71% of patients in long-term care facilities experienced pain on an intermittent or continuous basis. Of these individuals, only 15% had received an analgesic in the preceding 24 hours. Although most patients had been prescribed acetaminophen, only 10% of the prescribed analgesics were administered regularly. These data demonstrate the poor quality of clinical practices with respect to pain management in the elderly (Herr, 2002; Ryan et al., 1994)

In an editorial written in 1987 for the journal Pain, Melzack & Liebeskind expressed their dismay at the under-treatment of pain in those who are most vulnerable: children and the elderly. The editorial was written 18 years ago. Since that time, pain management in the elderly still remains a secondary consideration (Gibson, 1998), particularly with respect to elderly individuals suffering from cognitive impairments who have difficulty verbalizing pain (Malloy & Hadjistavropoulos, 2004). Indeed, the incidence of pain in the cognitively impaired elderly is difficult to establish. A single study, that of Ferrell, Ferrell & Rivera (1995), conducted on 217 elderly patients with cognitive impairments, found the prevalence of pain to be 62%. Moreover, Marzinski (1991) believes that elderly individuals with dementia experience pain, but since they cannot verbalize it, their pain often goes unnoticed. Horgas & Tsais (1998) conducted a correlational study on 339 elderly individuals which showed that where patients had similar conditions, the cognitively impaired received significantly less analgesia, both in terms of dosage and frequency of doses, than did the cognitively intact patients.

Although it would seem reasonable to believe that hospital resources would ensure optimum pain management, reality demonstrates differently. Indeed, several studies have shown that pain is generally poorly managed in the hospital environment (Carr, 1990; Closs, 1994; Melzack & Liebeskind, 1987).

Following the review of eight geriatric nursing textbooks, thus a total of over 5,000 pages of text, Ferrell & Ferrell (1990) found only 18 pages dealing with pain management. This suggests the lack of interest and knowledge with respect to pain in the elderly. Further, in a study involving 208 nurses, Closs (1996) showed that nurses on surgical wards had a better understanding of pain in the elderly than did nurses in geriatric wards. Also, nurses had misconceptions regarding pharmaceutical pain management and exaggerated the risk of respiratory distress caused by opioids. Moreover, one-third (69/208) of participants stated that pain and discomfort were part of normal aging. Finally, the author found no disparity in the nurses’ knowledge based on their level of education, number of years of experience or shift work.

The purpose of this study was to evaluate nurses’ learning needs, values, and beliefs regarding pain management of the elderly in order to develop a customized training program. The data collected will eventually be used to develop a nursing training program on pain assessment and management in the elderly. The identification of values, beliefs and needs is important, as it will enable us to determine teaching strategies and theoretical content.

The conceptual framework of this study is one proposed by Loeser & Egan (1989) and modified by Parke (1998), which describes the pain experience from four perspectives: nociceptors, pain, suffering and pain-related behaviour, and which integrates nurses’ pain assessment (Figure 1).

According to this model, the nurse initiates his or her assessment once the patient shows any signs or symptoms of pain. The assessment by the nurse is influenced by many factors: training, theoretical knowledge, professional and personal experiences, culture, values and beliefs. These factors can both positively and negatively influence his or her interactions with the suffering patient and, consequently, affect his or her clinical judgment and interventions. This study is based on the researchers’ belief that changes to nurses’ theoretical knowledge, values and beliefs will lead to positive changes in their clinical judgment and ensuing interventions. This should result in the improvement of pain management practices for suffering patients.

Methods

Setting

The study was conducted at Ste. Anne’s Hospital, (Québec). This long-term care facility is a federally run establishment offering care and shelter to 551 veterans of World War I and II and the Korean War. The veterans hospitalized are semi-autonomous to totally dependent on the staff for their care. This hospital also offers ambulatory care services to veterans still autonomous and living in the community.

Design of the study

A mixed approach was utilized which included an initial exploratory study to sample nurses’ learning needs, values and beliefs in order to obtain factual data and a quantitative survey on pain knowledge. Qualitative research is particularly useful for studying phenomenon or events about which little is known (Appleton, 1995; Field & Morse, 1985). This approach focuses on individuals’ experiences and can provide rich and detailed descriptions of previously unexplored phenomena (Appleton, 1985). It therefore seemed a useful approach for the researchers.

Sample

A sample of 45 primary care nurses was selected randomly among all of the nursing staff of the hospital. Primary care nursing is an organizational mode of care delivery which implies that each nurse is assigned a group of patients and provides care to these patients during all their hospital stay. Eight nurse managers were also invited to participate in the study. Nurse managers were interviewed separately and were not included in the primary care nurses focus groups. The sample of primary care nurses represented approximately 30% of the total number of primary care nurses at Ste. Anne’s Hospital. The primary care nurses were divided into two groups, one made up of nurses with fewer than ten years of experience and the other composed of nurses with more than ten years of experience. Each focus group was composed of an average of six nurses in order to promote discussion.

Questionnaires

A structured questionnaire was developed according to suggestions from the following authors Closs (1996), Parke (1998), Ryan (1994) and the clinical expertise of one of the investigators (MS). The questionnaire (Annex 1) was composed of 10 openended questions covering the three major variables: Learning Needs (4 questions), Values (2 questions) and Beliefs (4 questions).

The learning needs were also measured using the Pain Management Questionnaire (PMQ) by McCaffery & Pasero (1999). The PMQ is a 20-item dichotomized (True-False) questionnaire measuring basic knowledge on pain management. Scores on the PMQ vary from 0 to 20, where a score close to 20 indicates best pain management practices. A Kuder-Richardson of 0.62 was obtained, in the present study, for the internal consistency of that scale.

Data collection procedure (focus groups)

Firstly, ethical clearance for this study was obtained through the Ethical and Research Committee for Health Sciences of the University of Montréal. All of the participants were sent a letter outlining the objectives of the study and soliciting their participation with a date and hour scheduled for attending the focus group.

Group meetings were facilitated by the principal investigator and the co-principal investigator. Each meeting lasted no more than 60 minutes in the same setting. Nurses took part in the meetings during their work hours. A questionnaire with open-ended questions was used to structure discussion and eliminate bias in focus groups. By using open-ended questions subjects are encouraged to expand on their own experiences (Appleton, 1985). Discussions were tape-recorded and then transcribed to typed format for analysis. Before the end of each session, one of the investigators asked the participants to fill out the PMQ. All data remained confidential although respondents within each focus group were not able to maintain their anonymity. Nevertheless, their names were never mentioned on the tapes or on the PMQ. Finally, we facilitated the focus groups until we obtained data saturation, meaning that the verbatim of the interviews did not render any new information.

Research Phases

The current study is the first phase of a three-phase research project (Table 1). In this phase of the study, focus groups were used to identify nurses’ knowledge and needs with respect to pain management in the elderly. Nurses’ values and beliefs regarding pain and pain management of the elderly were also identified. Phase 2 focuses mainly on the development and implementation of a training program on pain management of the elderly, including an evaluation of baseline knowledge and posteducational sessions knowledge of nurses. In phase 3, we plan to evaluate the impact of the educational sessions through a posttest and chart review of nurses’ notes on pain management.

Data analyses

The data obtained with the PMQ were analyzed with the SAS release 6.12 software (SAS Institute, Cary, North Carolina).

The content of the interviews were subjected to the analysis method described by Miles & Huberman (1984) which includes data reduction and data display.

Data reduction

Data reduction refers to the process of selecting, focusing, simplifying, abstracting and transforming the data (Miles & Huberman, 1994), as the researchers elicit meanings and insights from the words of the respondents (Marshall & Rossman, 1989).

A secretary with experience in tape transcriptions listened to each tape and transcribed each tape herself, numbering each line of the content of the interviews. In the initial stages of data reduction each line or group of lines was coded as an emerging theme. The two investigators coded (assigned themes) separately the same transcripts of the first three interviews and then compared their coding results. An agreement of 90% was obtained between both investigators. Once coded, all of the interviews’ transcripts were entered into the N’VIVO software for analysis. All of the lines or group of lines related to each theme were then assembled together. This establishment and labelling of categories is known as latent content analysis (Field & Morse, 1985). The data were analysed and eight descriptive themes emerged. The eight themes were as follows: Learning needs, Beliefs, Values, Communication with families, Work organization, Communication with patients, Communication with medical doctors, Professional relationships among nurses. Finally, two nurses who participated in the focus groups reviewed independently the reduced data and both agreed with the final results obtained.

Data display

In this study, qualitative data are presented in the form of quotes reflecting all the elements related to each principal emergent theme.

Results

Characteristics of the participants

Thirty-one (69%) of the primary care nurses and six nurse managers (75%) participated to the focus groups. The majority of nurses (N = 28) had more than 10 years of experience in nursing. Only nine nurses had less than 10 years of experience in nursing. Fourteen nurses including two nurse managers did not show up to the focus group. Since participation was voluntary, we did not solicit these persons a second time.

Results with the focus groups

Many themes emerged from the analyses of the content of the interviews. However, it was decided to present only the data related to the three main themes of interest for this study, thus learning needs, beliefs and values of nurses. This decision was based on the fact that the questions submitted to the participants focused entirely on the learning needs, beliefs and values of nurses. Furthermore, the content related to the other emergent themes overlapped with the information presented in Tables 2 and 3.

Beliefs

Beliefs are defined as cognitive configurations formed by an individual or shared by a culture. In the evaluation process of an event, the beliefs construct the significance of the event (Lazarus & Folkman, 1984).

The data generated five general categories under the heading of beliefs: beliefs regarding drugs, beliefs regarding pain management, beliefs of families perceived by nurses, beliefs of patients perceived by nurses and beliefs of doctors perceived by nurses. The following represents some quotes from the data regarding issues related to beliefs.

Among the respondents, many nurses feared giving the last dose to a dying patient suffering from pain. One of the nurses said: “..we do not want to completely relieve a patient’s pain because we’re afraid of giving the last dose. We do not want to be identified as the nurse who killed the patient.” Yet, one other nurse mentions: “..and I can tell you, I have been here ten years and I have never seen anybody die because of the last dose of morphine.” Another nurse adds:

..nurses tend to panic when they see a dose of 15 or 20 mg of morphine prescribed for a patient. It is not a question of dosage! It is a question of getting the proper dosage to relieve the patient’s pain. When a patient has bone cancer, it really hurts and he needs a higher dosage. This is a strong belief that needs to be changed.

Another nurse feels that the elderly tend to exaggerate their pain: “…they are complainers. Their pain is superficial. I had this kind of pain before and it does not hurt that much. All they want by complaining is our attention.”

Another nurse mentioned that many times they had a proper analgesic order available and they were motivated to relieve a patient’s pain but the patient himself would refuse for various reasons: “..and the patient would tell me that he refuses the analgesic because he believes that he has to suffer to win himself a place in Heaven.” He (patient) would add: “you have to leave me suffering.” In the same vein, a different nurse states that some patients would say: “..if you are a good Catholic, you have to endure pain.” A patient told a nurse: “When I was younger I used to take street drugs. I got rid of that addiction and I am afraid that if you give me any pain medication I might get addicted again.”

Table 2 summarizes the major beliefs regarding pain management, mentioned by nurses during the interviews.

Values

Values are defined as social principles, goals or standards held or accepted by an individual, class, or society (Merriam- Webster’s Dictionary, 1994). The three principal values reported by the nurses during the interviews were: 1) to provide comfort to the patient, 2) to respect the patients’ wishes and 3) to promote the quality of life. Most of the nurses mentioned that they deemed important that their patients be comfortable but not at the detriment of their quality of life.

A nurse mentioned:

That drives me nuts when there is a patient that I know who is in pain. I had a very bad experience of pain in my life a year ago, so…It’s very important not to see someone else suffering. I mean that’s a personal experience, but I suffered and I went through people not believing me just like some of our patients.

One nurse’s values were also confronted by the beliefs of certain families regarding end-of-life care:

One evening I was caring for a dying patient. He was lucid, in pain and asking for relief of his pain. I could not give him anything for his pain because the religious beliefs of some of the members of this family prohibited a painless death. How could the family have the right to impose their beliefs upon the patient and the nurses caring for him?

Ethical issues were also raised by a nurse regarding care provided by medical doctors especially regarding patients suffering from cancer in the terminal phase:

Doctors do not prescribe enough analgesics to patients suffering with cancer. We (nurses) often have to wait until the evening shift or the weekend to get the doctor on call to increase the dosage or modify the prescription for a more effective analgesic. There is a difference between euthanasia and proper relief of pain. I think that for some staff doctors, they’re both considered the same thing.

Learning needs

The data generated six general categories of learning needs: Information on pharmacology, evaluation of pain, pathophysiology of pain, non-pharmacological methods to relieve pain, communication and evaluation of pain with the cognitively impaired patients. These results are reflected in many comments best summed up by this nurse: “…it is pharmacology. For me, it is really pharmacology. All the different analgesics, the side effects…”

One nurse agrees but would also add more specific learning needs regarding pharmacology:

..It concerns more the pharmacology of analgesics with the elderly. What is the proper medication, the proper dosages with this population of patients? I would need to know more about coanalgesics that are safe for the elderly. …Know how to manage the side effects of analgesics with the elderly, work in collaboration with medical doctors’ decision making related to prescribing of analgesic regimens.

One nurse reported issues with measurement of pain as being a major learning need especially with cognitively impaired patients:

..I would really need to know which questionnaire or instrument to use to be able to find out if the patient is in pain. We once had a patient who was screaming all day long “My house is on fire.” We just could not figure out what was going on with this patient. One of the nurses, who knew the patient well, found out that he was in pain. The patient was given an analgesic and he stopped screaming. I would have liked to be able to help this patient earlier.

Table 3 outlines the major learning needs identified by nurses from the focus groups.

Results on the Pain Management Questionnaire (PMQ)

All of the participants of the focus groups answered the PMQ, thus 37 nurses. A mean of 9.35 + 1.69 was obtained for the global score of the PMQ. Questions related to pharmacological knowledge contributed to the lower score obtained with that scale. The lack of knowledge on pharmacology was also reported as a source of frustration when communicating with physicians. Nurses often mentioned not being in agreement with the analgesics prescribed but they were unable to discuss the issues with the physician because of insufficient knowledge. This latter situation explains why nurses felt they needed to build trust and develop better communication strategies with physicians. It was also suggested that sharing pain education sessions with the physicians and the multidisciplinary team members would promote cohesiveness in the pain management of patients. The other learning needs identified were lack of knowledge of the different types of pain and the assessment of pain, especially with the cognitively impaired which remains a clinical challenge as frequently mentioned in the literature.

Discussion

The findings from this study support prior research (Ersek et al., 2000; Herr, 2002) which indicated a strong need for nurses to acquire knowledge on pharmacology. In our study, nurses almost unanimously identified a lack of knowledge in pharmacology. This lack of knowledge was corroborated by some of the misconceptions entertained by nurses regarding pain management with the elderly such as: misconceptions related to the use of PRN, the fear of giving the last dose and misconceptions related to the use of narcotics with the elderly. The utilization of PRN analgesics represents a particular challenge to nurses. There seems to be no consensus on how PRN analgesics be administered. Should they be offered regularly, given upon request only or given on a regular basis.

Overall, nurses reported strong values as a framework for the care they provide to elderly patients. However, these values seem contradictory to some of the beliefs (misconceptions) the nurses mentioned. The most predominant one is their disbelief of some patients’ evocation of pain; especially the psychiatric patients that were often labeled manipulative or attention seekers.

The authors were quite impressed by the fact that when interviewed about their values, nurses did not limit their responses to the physical aspect of the care but mentioned much wider and multifactorial concepts such as: providing comfort, respecting patients’ wishes and promoting the quality of life.

Regarding the nurses’ beliefs, fear of giving the last dose is still considered to be a strong concern despite the multiple educational efforts to clarify this false belief. This again proves that the application of pure theoretical knowledge is not sufficient when trying to modify clinical practices. Nurses are also quite divided on opinions regarding the feasibility of totally relieving pain. Some say it is possible and some say it is not a realistic objective. Some say it is more important to keep the patient alert and functional than totally relieved of pain.

On the other hand, the most important belief of the families is in fact a misconception and it concerns the fear of the use of morphine. According to nurses, families commonly associate morphine with imminent death and are sometimes reluctant to use this drug, believing that it will precipitate the death of their relative.

As for the patients, it seems that their main concern, according to nurses, is the fear of addiction to narcotics. Indeed, many refused to take any medication by fear of becoming addicted. Furthermore, some patients, according to nurses, are reluctant to complain of pain because they believe that suffering is a way to expiate their sins and gain a place in Heaven.

Given the nurses’ fears and misconceptions regarding the use of narcotics, it is not surprising that families and patients who depend on the professionals for information and care also have fears and misconceptions regarding narcotics in particular the use of Morphine. One may suspect that the information given to the patients and their families might be altered by the misconceptions and fears of the professionals involved in their care.

Conclusion

The findings of this study indicate a strong need for nursing education on pharmacology in relation to pain management. The study has also brought to evidence the need for patients and families to receive adequate information regarding the use of drugs especially narcotics and its prototype morphine. Finally, this study has shown that there is more to education than pure theoretical content. In order to change pain management clinical practices, one needs to consider the beliefs and the values of the nurses involved in caring for the patient with pain.

Acknowledgements

The authors would like to acknowledge FRESIQ (Québec Foundation for Nursing Research) and the Canadian Pain Society for grants supporting this research. Moreover, we would like to thank the editor of the journal for his support and the two anonymous reviewers for their judicious comments. Finally, we would like to show our appreciation towards all the nurses, the nurse managers and the medical doctors of St. Anne’s Hospital who generously volunteered to participate in the focus groups.