Addressing Patients' Concerns About Pain Management and Addiction Risks
Addressing Patients' Concerns About Pain Management and Addiction Risks
Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p = .004). Nursing staff with more years' experience (OR 1.070; p = .005) and higher levels of self-efficacy/confidence (OR 1.380; p = .001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.
Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management (McCaffery and Pasero, 1999, Randall–David et al., 2003, Sullivan and Ferrell, 2005). The prevalence of substance abuse may be as high as 10% in outpatient settings where many patients in late life receive their care, and both providers and patients may fear that opioid medications could exacerbate an underlying substance abuse disorder or even initiate one (Fleming, Balousek, Klessig, Mundt, & Brown, 2007). This risk, while real, is generally associated with selected patient characteristics, including a diagnosis of nonopioid substance abuse, male gender, younger age, and mental health disorders (Edlund et al., 2007, Ives et al., 2006, Manchikanti et al., 2007).
Clinical experts regard addressing patient concerns as an important attribute of high quality pain management practice (National Consensus Project for Quality Palliative Care, 2009). Indeed, clarification, inquiry, and education are important ways for providers to respond when patients express fears about addiction related to treatment (Fishman, 2005). These issues are particularly germane to efforts to improve palliative care delivery in outpatient settings, for which pain management is a major focus (Higginson et al., 2007). Because nursing staff may provide the first contact with patients and pain assessment is a key nursing role, it is important to understand what influences this crucial service for patients.
To examine these clinical issues, we used social cognitive theory (SCT), which provides certain advantages over past investigations of provider pain management, which have not emphasized explicit behavioral frameworks. SCT is a theory previously used to examine provider performance for depression management, antibiotic prescribing, and other behaviors (Eccles et al., 2007, Meredith et al., 2000). SCT identifies important environmental/contextual and personal (cognitive and affective) domains that might be associated with pain management practices (Bandura, 1994).
Accordingly, we evaluated the influence of environmental/contextual factors (peer attitudes toward pain management) and personal variables (negative pain beliefs and perceived self-efficacy, or confidence, in managing pain) as well as professional characteristics (experience, education, and credentials) on nursing staff predisposition to address patient concerns about addiction risk and opioid therapy. We hypothesized that these variables might be associated with nursing practices for a number of reasons.
First, evidence from earlier studies suggests that contextual/environmental variables influence provider performance (Dudley and Holm, 1984, Manias et al., 2005). Values such as willingness to expend time and energy managing pain in specific patient groups (oncology or substance abuse populations) may be acquired during acculturation into professional practice (Brockopp, Ryan, & Warden, 2003). These values may influence nurses' inferences of physical pain and psychologic suffering (Brockopp et al., 2003, Wilson and McSherry, 2006) and proclivity to address addiction concerns with patients. Second, professional attitudes, such as negative regard for patients' pain, may be an obstacle to achieving optimal pain management (Brockopp et al., 2003, Glajchen, 2001, McCaffery and Pasero, 1999, Morgan, 2006, Wilson and McSherry, 2006). Treatment efforts may be lacking in nurses who doubt the validity of pain in substance abusers (Morgan, 2006). Other nurses may struggle with treating patients with chronic nonmalignant pain which frequently is disproportional to objective disease severity (Sullivan & Ferrell, 2005) Studies of provider education suggest heightened awareness of and motivation for pain management after participation in pain and palliative care education (Brockopp et al., 2004, McCaffrey and Ferrell, 1997). Additionally, clinically confident nurses may be more likely to serve as strong patient advocates (Glajchen & Bookbinder, 2001). Finally, these issues are relevant in light of the nursing shortage and the shrinking pool of experienced nurses (Hatcher et al., 2006).
Assessing interpersonal interactions poses special methodologic challenges. Like other providers, nurses do not always completely document such activities, making chart reviews potentially infeasible. Clinical vignettes are brief scenarios related to a realistic clinical situation that have been found to be more accurate than chart abstraction in measuring certain aspects of clinician performance. The vignette approach is especially helpful in studying interpersonal and similar aspects of care that are less likely to be documented (Peabody et al., 2000, Peabody et al., 2004). Therefore, a clinical vignette was used to evaluate proclivity to respond to a patient whose addiction concerns impeded effective pain management.
Abstract and Introduction
Abstract
Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management. In this study, a clinical scenario ascertained nursing staff members' usual practice in addressing addiction fears for patients with concerns about the addictive potential of pain medication. One hundred forty-five Veterans Health Administration nursing staff members from eight ambulatory care sites were queried to identify variables associated with proclivity to address patient fears about addiction risks in a population where pain is prevalent and the risk for substance abuse is high. Regarding addressing addiction concerns, 66% of nursing staff were very likely, 16% somewhat likely, 9% unsure, 6% somewhat unlikely, and 2% very unlikely to take action. Health technicians were less likely to address addiction concerns than registered or licensed vocational nurses (odds ratio [OR] 0.116; p = .004). Nursing staff with more years' experience (OR 1.070; p = .005) and higher levels of self-efficacy/confidence (OR 1.380; p = .001) were more likely to engage in discussions related to addiction risks. Targeted efforts to improve pain management activities should focus on retaining experienced nursing staff in initial assessment positions and improving the skills and confidence of less experienced and less skilled staff.
Introduction
Fear of engendering addiction is frequently reported as both a provider and a patient barrier to effective pain management (McCaffery and Pasero, 1999, Randall–David et al., 2003, Sullivan and Ferrell, 2005). The prevalence of substance abuse may be as high as 10% in outpatient settings where many patients in late life receive their care, and both providers and patients may fear that opioid medications could exacerbate an underlying substance abuse disorder or even initiate one (Fleming, Balousek, Klessig, Mundt, & Brown, 2007). This risk, while real, is generally associated with selected patient characteristics, including a diagnosis of nonopioid substance abuse, male gender, younger age, and mental health disorders (Edlund et al., 2007, Ives et al., 2006, Manchikanti et al., 2007).
Clinical experts regard addressing patient concerns as an important attribute of high quality pain management practice (National Consensus Project for Quality Palliative Care, 2009). Indeed, clarification, inquiry, and education are important ways for providers to respond when patients express fears about addiction related to treatment (Fishman, 2005). These issues are particularly germane to efforts to improve palliative care delivery in outpatient settings, for which pain management is a major focus (Higginson et al., 2007). Because nursing staff may provide the first contact with patients and pain assessment is a key nursing role, it is important to understand what influences this crucial service for patients.
To examine these clinical issues, we used social cognitive theory (SCT), which provides certain advantages over past investigations of provider pain management, which have not emphasized explicit behavioral frameworks. SCT is a theory previously used to examine provider performance for depression management, antibiotic prescribing, and other behaviors (Eccles et al., 2007, Meredith et al., 2000). SCT identifies important environmental/contextual and personal (cognitive and affective) domains that might be associated with pain management practices (Bandura, 1994).
Accordingly, we evaluated the influence of environmental/contextual factors (peer attitudes toward pain management) and personal variables (negative pain beliefs and perceived self-efficacy, or confidence, in managing pain) as well as professional characteristics (experience, education, and credentials) on nursing staff predisposition to address patient concerns about addiction risk and opioid therapy. We hypothesized that these variables might be associated with nursing practices for a number of reasons.
First, evidence from earlier studies suggests that contextual/environmental variables influence provider performance (Dudley and Holm, 1984, Manias et al., 2005). Values such as willingness to expend time and energy managing pain in specific patient groups (oncology or substance abuse populations) may be acquired during acculturation into professional practice (Brockopp, Ryan, & Warden, 2003). These values may influence nurses' inferences of physical pain and psychologic suffering (Brockopp et al., 2003, Wilson and McSherry, 2006) and proclivity to address addiction concerns with patients. Second, professional attitudes, such as negative regard for patients' pain, may be an obstacle to achieving optimal pain management (Brockopp et al., 2003, Glajchen, 2001, McCaffery and Pasero, 1999, Morgan, 2006, Wilson and McSherry, 2006). Treatment efforts may be lacking in nurses who doubt the validity of pain in substance abusers (Morgan, 2006). Other nurses may struggle with treating patients with chronic nonmalignant pain which frequently is disproportional to objective disease severity (Sullivan & Ferrell, 2005) Studies of provider education suggest heightened awareness of and motivation for pain management after participation in pain and palliative care education (Brockopp et al., 2004, McCaffrey and Ferrell, 1997). Additionally, clinically confident nurses may be more likely to serve as strong patient advocates (Glajchen & Bookbinder, 2001). Finally, these issues are relevant in light of the nursing shortage and the shrinking pool of experienced nurses (Hatcher et al., 2006).
Assessing interpersonal interactions poses special methodologic challenges. Like other providers, nurses do not always completely document such activities, making chart reviews potentially infeasible. Clinical vignettes are brief scenarios related to a realistic clinical situation that have been found to be more accurate than chart abstraction in measuring certain aspects of clinician performance. The vignette approach is especially helpful in studying interpersonal and similar aspects of care that are less likely to be documented (Peabody et al., 2000, Peabody et al., 2004). Therefore, a clinical vignette was used to evaluate proclivity to respond to a patient whose addiction concerns impeded effective pain management.
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