Nurses’ Attitudes and Practices in Sickle Cell Management

Ardie Pack-Mabien, E. Labbe, D. Herbert, and J. Haynes, Jr.

Professional objectivity should be the primary focus of patient care. Health care professionals are at times reluctant to give opioids out of fear that patients may become addicted, which would result in the undertreatment of pain. The influence of nurses’ attitudes on the management of sickle cell pain was studied. The variables of age, education, area of practice, and years of active experience were considered. Of the respondents, 63% believed addiction was prevalent, and 30% were hesitant to administer high-dose opioids. Study findings suggest that nurses would benefit from additional education on , pain assessment and management, and addiction. Educational recommendations are discussed. Copyright © 2001 by W.B. Saunders Company

ICKLE CELL DISEASE (SCD) is a chronic he- the patient, family, community, and health care S matological disorder that is characterized by the professionals (Shapiro, Benjamin, Payne, & Heid- production of hemoglobin S in the erythrocyte, vaso- rich, 1997). It is important to understand that an occlusion, and hemolytic anemia. Hemoglobin S dif- individual’s perception and appreciation of pain fers from normal hemoglobin A by a single amino acid are complex phenomena influenced by numerous substitution of valine for glutamic acid at the number 6 variables such as coping mechanisms, chronicity, position of the beta chain on chromosome 11. Chronic accessibility to health care, support structure, cul- hemolytic anemia, recurrent vaso-occlusive pain epi- ture, age, and gender. sodes, acute and chronic organ damage, and increased Additionally, an individual’s perception of pain susceptibility to infection characterize SCD. Periodic, involves psychological as well as emotional pro- self-limited episodes of excruciating pain that involves cesses that may also activate pain pathways (Ed- the long bones, abdomen, chest, and back consume the wards, 1998). Although individualized pain man- lives of patients with SCD (Platt et al., 1991). Of sickle agement is an important aspect of patient care, the cell anemia patients, approximately 60% of individuals need for relief of pain, an acceptable level of will have an episode of severe pain each year, and a functioning, the ability to live a normal lifestyle, small minority have severe pain almost constantly and reassurance from their health care providers (Steinberg, 1999). Some patients have frequent (Katz, 1998) is common to all patients who are in vaso-occlusive pain episodes and require multiple hos- pain. For the health care provider to be most ef- pital admissions, whereas other patients infrequently fective at meeting these needs, he or she must experience pain and rarely require hospitalization (Martin & Moore, 1997; Platt et al., 1991). Variability is the hallmark of sickle cell pain episodes. Ardie Pack-Mabien, RNC, MSN, C RNP, University of South In SCD, recurring pain episodes are the most Alabama Comprehensive Sickle Cell Center, Mobile, AL; E. Labbe, Department of Psychology, University of South Alabama common reason for medical evaluation. The num- College of Medicine, Mobile, AL; D. Herbert, Department of ber of pain episodes per year in SCD has been Radiology, University of South Alabama College of Medicine, shown to be an indicator of clinical severity and to Mobile, AL; and J. Haynes, Jr., University of South Alabama correlate with early death in patients over 20 years Comprehensive Sickle Cell Center, Mobile, AL. of age (Platt et al., 1991). Although more than 75 This work was supported by the Comprehensive Sickle Cell Program Grant P60HL-3839 from the National Heart, Lung, million people present to practicing physicians and Blood Institute. each year with some form of persistent or recurrent Address reprint requests to Ardie Pack-Mabien, RNC, MSN, pain (Caudill, Holman, & Turk, 1996), it is often C RNP, Clinical Nurse Practitioner and Clinical Nurse Man- difficult to assess, define, describe, and manage. ager, USA Springhill Pediatrics-5216, 1504 Springhill Avenue, Patients with SCD-related pain receive care Mobile, AL 36604. Copyright © 2001 by W.B. Saunders Company within a complicated and extensive sociocultural 0897-1897/01/1404-0003$35.00/0 system that is shaped by the beliefs and attitudes of doi:10.1053/apnr.2001.26783

Applied Nursing Research, Vol. 14, No. 4 (November), 2001: pp 187-192 187 188 PACK-MABIEN ET AL. respect the patient’s right, believe the patient’s pain SCD is only between 0.2% and 2% (Martin & history, and implement early and aggressive treat- Moore, 1997). Addiction is a compulsive disorder ment. For conditions such as SCD where pain is in which an individual becomes preoccupied with often frequent and/or chronic, employment of a obtaining and using a substance, and which, if multidisciplinary approach is often needed and continued, results in a decreased quality of life beneficial to the patient. (American Academy of Pain Medicine & Ameri- can Pain Society, 1997). The lack of understanding of the true incidence and definition of addiction and the fear of creating addicts in the management Periodic, self-limited episodes of ex- of sickle cell pain may lead to the mislabeling of cruciating pain that involves the long patients as “addicts” and the unnecessary with- bones, abdomen, chest, and back con- holding of opioid analgesics (American Academy of Pain Medicine & American Pain Society, 1997; sume the lives of patients with SCD Schug, Merry, & Acland, 1991). (Platt et al., 1991).

Factors that are recognized in the management of The lack of understanding of the true pain include an array of interpersonal, educational, and incidence and definition of addiction social issues that affect the patient, family, and health and the fear of creating addicts in the care professional. These issues can be significant bar- riers to adequate assessment of pain and to effective management of sickle cell pain may . Attitude is an example of an inter- lead to the mislabeling of patients as personal factor. Many nurses develop their attitudes “addicts” and the unnecessary with- and beliefs about pain and the use of opioids in pain holding of opioid analgesics (Ameri- management from within their families, churches, communities, ethnic background, and values before can Academy of Pain Medicine & they enter nursing school. Attitudes, beliefs, learned American Pain Society, 1997; Schug, behaviors, and coping mechanisms may be entirely Merry, & Acland, 1991). different for patients and health care providers, which results in inaccurate pain scores and undertreatment of pain (Beyer, Platt, Kinney, & Treadwell, 1999). The purposes of this study were to determine whether nurses’ attitudes influence their practice Attitude is an example of an interper- when caring for patients with sickle cell pain epi- sodes and determine whether and/or describe how sonal factor. Many nurses develop age, education, years of active nursing experience, their attitudes and beliefs about pain and area of practice influence nurses’ attitudes and and the use of opioids in pain man- practices in sickle cell pain management.

agement from within their families, METHODS churches, communities, ethnic back- The study was conducted at a southern univer- ground, and values before they enter sity teaching hospital. The study population con- nursing school. sisted of student nurses, licensed practical nurses, registered nurses, advanced practice nurses, and adult and pediatric health nurses. The study did not control for gender, scheduled shifts, or level of Concern regarding addiction in the management education. Adult and pediatric emergency depart- of sickle cell pain episodes is frequent (Shapiro et ments and medical-surgical units were of primary al., 1997); however, the incidence of addiction in interest because of the frequency and number of SICKLE CELL PAIN/ATTITUDES AND PRACTICES 189 sickle cell patients who were triaged and admitted area of practice. Somer’s D and Spearman rank to these units. correlation coefficient statistics were used to ex- A written 31-item multiple choice survey was amine the associations between the several pairs of developed to obtain information on nurses’ atti- ordinal variables of interest. Only the associations tudes and perceived barriers to pain management of age, educational level, and years of active nurs- with opioids when caring for patients with sickle ing experience were significant (two-tailed test), cell pain episodes. The survey was divided into using exact methods. Somer’s D was used because three components: (1) attitudes, practices, and the associations of interest were asymmetrical: one knowledge level; (2) perceived barriers to sickle variable (attitude) is dependent, and the second cell pain management; and (3) demographic infor- variable (demographic) is independent (Siegel & mation. Some of the items in the first and second Castellan, 1988). components of the survey were adapted from a physician survey that addressed attitudes and prac- RESULTS tices in the management of cancer pain (Von The number of returned surveys in which every Roenn, Cleeland, Gonin, Hatfield, & Pandya, question was answered was 77 (34%). The major- 1993). The number of items in each section was 14, ity of the respondents were in the age ranges of 20 9, and 8, respectively. Responses to the questions to 29 and 30 to 39 years (41% and 31%, respec- on the surveys were recorded as either (a) disagree, tively) and had either a bachelor’s or associate’s no opinion,oragree; (b) never to rarely, often to degree in nursing (50% and 23%, respectively). always; and (c) most likely to least likely on a scale Seventy-four (70%) of the respondents had less of nine to one. The survey was favorably reviewed than 10 years of active nursing experience. Eighty- by the Nursing Research Committee (composed of three (78%) of the respondents were employed on advanced practice nurses, unit managers, and staff a full-time basis, and the remaining participants nurses) for content validity before distribution. The were employed part-time. study was approved by the Institutional Review The majority (63%) of the surveyed nurses be- Board, and permission was obtained from nursing lieved that drug addiction frequently develops in administration to collect data. The survey was dis- the treatment of sickle cell pain episodes. One cussed with each participating unit manager, clin- hundred and three (97%) of the surveyed respon- ical nurse specialists, and resource nurses to obtain dents believed that individuals with SCD who are support to conduct the survey. addicted to opioids can also have pain episodes. Two hundred surveys were distributed into the Ninety-four (87%) of the respondents believed individual mailboxes of the nursing staff on each drug addiction should not be a primary nursing participating unit. The completed surveys were concern when caring for a patient with sickle cell placed in a labeled collection box located at the pain episodes. The belief that drug addiction fre- nurses’ station on each participating unit. One hun- quently develops in the management of sickle cell dred and six (52%) of the surveys were completed pain episodes was inversely related to age, years of and collected over a period of four weeks. Partici- active nursing experience, and level of education. pation was voluntary, and confidentiality of re- Area of practice was not significantly related to sponses was assured. this belief. Using age as the independent variable, the belief that drug addiction frequently develops STATISTICAL ANALYSIS in the management of sickle cell pain episodes The correlation between the responses to two decreased with increasing age of the nurses (D ϭ questions that addressed attitudes and four demo- Ϫ0.18, p ϭ .02). Fifty-two (49%) of the respon- graphic variables were examined. The two survey dents who believed addiction was prevalent in the questions were: (1) Does drug addiction frequently management of sickle cell pain episodes had be- develop in patients who are treated for sickle cell tween zero and five years of active nursing expe- pain episodes? and (2) Should drug addiction be rience. Nursing education at the master’s level the nurses’ primary concern when caring for a inversely correlated with the belief that addiction is patient with sickle cell pain episodes? The vari- prevalent in SCD. Fifty-one (49%) of the respon- ables considered in this survey were age, level of dents reported not having broad knowledge of education, years of active nursing experience, and SCD. Spearman correlation identified a significant 190 PACK-MABIEN ET AL. association between nurses’ belief that drug addic- and years of active nursing experience. Area of tion frequently develops in patients who are treated practice had no influence on the belief that drug for pain episodes and that most sickle cell patients addiction should be a primary nursing concern in are drug addicts (r ϭ 0.57, p ϭ .002). the management of sickle cell pain episodes.

The majority (63%) of the surveyed The belief that drug addiction should nurses believed that drug addiction be a primary nursing concern de- frequently develops in the treatment creased significantly as the years of of sickle cell pain episodes. Ninety- active nursing experience increased .(؊0.1308, p < .01؍ four (87%) of the respondents be- (D lieved drug addiction should not be a primary nursing concern when car- ing for a patient with sickle cell pain In regard to nursing practice, the concern for episodes. addiction was “rarely to never” a factor that re- sulted in hesitancy to administer high doses of opioids for 70% of the respondents, whereas 30% were hesistant to administer high doses of opioids. The belief that drug addiction should be a pri- Forty (39%) of the respondents who were “always mary nursing concern in the management of sickle to often” hesitant to administer high dose opioid cell pain episodes was influenced by age, years of analgesics believed there was not a true indication active nursing experience, and education. None of for opioid analgesics. Of the nurses surveyed, 50% the respondents older than 39 years of age believed did not think drug addiction was a barrier in the that drug addiction should be a primary nursing management of sickle cell pain episodes, whereas concern in the management of sickle cell pain. 33% did, and 17% had no opinion. It is noteworthy that 61 (59%) of the respondents reported that an inadequate pain assessment tool was the greatest barrier in the management of sickle cell pain epi- The belief that drug addiction should be sodes. The next most common barriers in the man- a primary nursing concern in the man- agement of sickle cell pain were: lack of time to agement of sickle cell pain episodes was provide psychological support (58%), nurse reluc- influenced by age, years of active nurs- tance to give opioids (37%), narrow range of avail- able analgesics (37%), physicians’ reluctance to ing experience, and education. prescribe opioids (33%), and belief that most sickle cell patients are drug addicts (32%).

Overall, the concern about addiction in SCD ϭ decreased as the age of the nurses increased (D 61 (59%) of the respondents reported Ϫ0.0931, p ϭ .0564). None of the respondents with more than 10 years of active nursing experi- that an inadequate pain assessment tool ence believed that drug addiction should be a was the greatest barrier in the manage- primary nursing concern. The belief that drug ad- ment of sickle cell pain episodes. diction should be a primary nursing concern de- creased significantly as the years of active nursing experience increased (D ϭϪ0.1308, p Ͻ .01). The belief that drug addiction should be a primary The least likely barriers identified in the man- nursing concern decreased as the level of education agement of sickle cell pain included: excessive increased (D ϭϪ0.15, p Ͻ 0.01), similar to age state regulations of analgesics (27%), patient’s re- SICKLE CELL PAIN/ATTITUDES AND PRACTICES 191 luctance to take opioids (16%), and patient’s reluc- tance to report pain (10%). Generally speaking, there is an enor-

DISCUSSION mous amount of sympathy for pa- The overall objective of this study was to assess tients with cancer pain, postoperative whether and/or how nurses’ attitudes impact nurs- pain, or pain due to trauma. In con- ing practice in the management of sickle cell pain trast, health care providers often have episodes. Age, education, and years of active nurs- difficulty relating to or understanding ing experience were found to influence attitude and practice in the management of sickle cell pain the pain of SCD. episodes. Area of practice, however, had no influ- ence on nurses’ attitudes or practice. In this study, nurses believed drug addiction was prevalent in clients who were treated for sickle cell pain epi- individuals with SCD (Shapiro et al., 1997). Sixty- sodes but also recognized that addicted individuals six (63%) of the nurses in this study believed drug with SCD could also experience a sickle cell pain addiction was prevalent in individuals with SCD. episode. These findings are similar to those ob- Such beliefs are not supported by data. In fact, the served in a physician’s attitude survey that as- incidence of addiction is believed to be less than sessed physicians’ belief regarding the prevalence 1%; generally stated as between 0.2% and 2% of drug dependency in SCD (Waldrop & Mandry, (Martin & Moore, 1997). Opioid addiction as a 1995). result of acute pain management is extremely low, Most health care providers view the pain of SCD and this concern should not be used as a reason to as only a series of acute painful episodes separated undertreat patients who are experiencing a sickle by periods of being pain-free (Nichols, 1996). Al- cell pain episode (Perry & Heidrich, 1982; Porter though the pain of SCD does not represent an & Jick, 1980). immediate life-threatening event, the degree of Regarding pain management, data from this pain may be comparable to that of a myocardial study support similar observations made in a sur- infarction (Nichols, 1996). Generally speaking, vey that addressed physician’s attitudes and prac- there is an enormous amount of sympathy for tices in cancer pain management (Von Roenn et al., patients with cancer pain, postoperative pain, or 1993). In both studies, inadequate pain assessment pain due to trauma. In contrast, health care provid- tools were thought to be the greatest barrier. Inter- ers often have difficulty relating to or understand- estingly, patient reluctance to report pain and to ing the pain of SCD. Alleyne and Thomas (1994) take opioids was found to be the second most found that nurses have difficulty dealing with common barrier in the cancer pain management chronic illness such as SCD because patients do study, whereas patient reluctance to report pain and not “fit” the concept of the “sick role” in the way to take opioids was the least common barrier re- that patients with an acute illness might. This may ported in this study. Concerns about excessive state explain why many of the nurses in this survey regulations of opioids, which contributed to the (62%) expressed frustration when caring for pa- reluctance to administer opioid analgesics, were tients who experienced sickle cell pain episodes. also identified as a barrier. This suggests the need Nurses may be more likely to take the report of for more comprehensive physician and nursing ed- pain by patients with SCD less seriously than that ucation that addresses the legal ramifications of of patients without SCD because of attitudes and opioid administration. In addition, more education beliefs about lifestyles and addiction (Vourakis, is needed to address the lack of understanding 1998). Nurses are obligated to acknowledge and about the pharmacology of opioids and pain man- respect the patient’s health beliefs and practices agement. even when their own personal values and beliefs Health care professionals cannot allow these ob- are different (Fielo & Degazon, 1997). Health care stacles and barriers to lead to skeptical attitudes or professionals generally overestimate the risk of opinions regarding true pain as compared with opioid addiction in the pharmacological manage- drug abuse behavior. When critically evaluating ment of pain and believe addiction is prevalent in uninformed physician and nursing bias, it stands to 192 PACK-MABIEN ET AL. reason that attitudes may impact negatively on To provide patients with the best possible care, patient care and create barriers to adequate and health care professionals must examine their atti- effective health care delivery. Such attitudes also tudes, perceptions, values, and knowledge level in explain in part why patients become resentful over order to discover internal barriers in the manage- time when they feel they must convince others that ment of pain. The challenge to health care profes- their pain is real. sionals is to provide compassionate care and com- fort in a changing and varied clinical, social, and IMPLICATIONS AND RECOMMENDATIONS financial setting. Although this study addressed The findings of this study have important impli- age, education, area of practice, and years of active cations for the management of patients with sickle nursing experience, there must be an understanding cell pain episodes and indicate that nurses and that there are multiple other variables including student nurses would benefit from further educa- issues of race, creed, and gender that can influ- tion in SCD, specifically related to the assessment ence the decision-making process (Edwards, of pain, pain management, and the incidence of 1998). Only then can the most effective pain man- addiction. Survey findings also suggest that con- agement intervention be employed. Patients with tinuing nursing education is imperative in order for SCD are dependent on nurses and other health care nurses to be equipped to face the challenges of the professionals for education, counseling, and pain future in dealing with health care issues as they management. Patient surveys that address health relate to patient care, particularly in pain manage- care professionals’ attitudes and the patients’ per- ment. Educational opportunities such as unit-spe- ception of pain management would be beneficial. cific hospital orientation programs would be a Professional objectivity, not personal values, atti- prime mechanism to educate new staff nurses tudes, and beliefs, should be the primary focus of about SCD and its complications. patient care.

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