Nurses’ Attitudes and Practices in Sickle Cell Pain 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 sickle cell disease, 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 pain management. 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.