Acute pain is designed as a warning function, which may require medical attention if not adequately addressed and allowed to persist. This unpleasant sensory and emotional experience, if not efficiently treated, impairs the lung function and mobility of patients, postponing and extending their recovery period (Morales-Fernandez, Morales-Asencio, Canca-Sanchez, Moreno-Martin, & Vergara-Romero, 2016 ; Singh, Saikia, & Lahakar, 2016). Given their close therapeutic relationships with patients, hospital nurses are urged to have a pivotal role in pain management and must, therefore, possess a strong foundation and positive attitude toward pain care (Bayuo & Agbenorku, 2015 ; Drew, Gordon, Morgan, & Manworren, 2018). A growing body of literature has provided several guidelines and protocols for the use of opioids with patients in pain, but substantial reluctance among nurses remains to appropriately utilize this drug class in pain management (Bayuo & Agbenorku, 2015 ; Kahan, Mailis-Gagnon, Wilson, & Srivastava, 2011).
In particular, morphine prescription is often rejected by health care professionals such as nurses, which has led to an attitude termed as “morphinophobia” (Chatchumni, Namvongprom, Eriksson, & Mazaheri, 2016b ; Coulthard, Patel, Bailey, & Armstrong, 2014). Recent studies indicate that the fear of inducing addiction in patients treated with opioids persists among health care providers (Chatchumni, Namvongprom, Eriksson, & Mazaheri, 2016a ; Chatchumni et al., 2016b). Other scholars argue that many health care providers, in particular hospital nurses, still associate morphine with palliative care, end of life, significant adverse effects, or even euthanasia and many also fear the risk of legal prosecution (Barnett, Mulvenon, Dalrymple, & Connelly, 2010 ; Grant, Ugalde, Vafiadis, & Philip, 2015). Although patient-related factors include ineffective pain reporting and noncompliance, fear of side effects of opioids and misconceptions among patients can be reinforced by health practitioners who lack up-to-date education (Coulthard et al., 2014 ; Schroeder et al., 2016).
Much of the research associated with opioid therapy and the risks associated with it has been primarily conducted on younger populations or on cancer and critically ill patients (Grant et al., 2015 ; Gupta, Sahi, Bhargava, & Talwar, 2015), with lesser attention given to the postoperative context. For example, a recent study indicated that nurses' perception of morphine was mixed as they were uncertain about some aspects of importance to morphine and consequently would favor other analgesics (Bayuo & Agbenorku, 2015).
However, the current literature continues to offer us repeated challenges related to inadequate pain management and the reluctance to use opioids. This situation is inconsistent with the liberal attitudes toward pain management, which stresses that the patient should have control over pain management through the use of an interdisciplinary team of nurses and other related health care professionals (Drew et al., 2018 ; Jukiewicz, Alhofaian, Thompson, & Gary, 2017).
In Jordan, although much research has been conducted on pain management in recent years (D'emeh, Yacoub, Darawad, Al-Badawi, & Shahwan, 2016 ; Shoqirat, 2015), nurses' attitudes toward opioids and morphine, in particular, have not yet been examined in qualitative or quantitative terms. It is therefore in light of this, by using a mixed methodology, the study sets out to explore the attitudes and experiences of nurses relating to the use of opioids, in general, and morphine, in particular, within the surgical context. A more coherent understanding of these attitudes and related experiences may contribute to more effective pain control, a better therapeutic relationship, and maximize patients' satisfaction and quality of life.
The purpose of this study was to explore the attitudes and experiences relating to opioids, in general, and morphine, in particular, among Jordanian nurses within the surgical context.
Study Design, Sample, and Setting
A triangulated research design, including structured questionnaires and focus group discussions (FGDs; n = 4), was used. The aim was not only to validate the results and elicit more consistent evidence but, more importantly, also to deepen the understanding of the use of opioids, particularly morphine, by nurses (Yeasmin & Rahman, 2012). The data for this study were collected from a 200-bed capacity teaching hospital, located in the southern province of Jordan. A total of four surgical units were targeted. The accessible population for this study was a convenience sample of all nurses working in the identified surgical units (n = 4). The study included all registered nurses who were working in the identified surgical units and were willing to participate voluntarily in the study. In the target surgical units, pain is managed using pethidine (meperidine), tramadol, and morphine. Analgesia in general is prescribed by the surgeons on the units.
The Study Instrument
The Opioids Attitude Scale (OAS) developed by Brydon was used to measure nurses' attitudes toward opioids, in general, and morphine, in particular (Brydon & Asbury, 1996). The first part elicits demographic data, such as gender, work experiences, and their level of education in nursing. The second part consists of nine statements with five answers ranging from strongly agree to strongly disagree using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). These statements express attitudes toward addiction, side effects, and use of opioids. The total score can range from 5 to 45. The higher the score, the more negative the attitude. The internal consistency reliability of the OAS was acceptable (α = 0.70; Ferreira, Verloo, Mabire, Vieira, & Marques-Vidal, 2014). Content validity was established by a panel of pain experts (n = 10) from Jordanian hospitals and nursing faculties. These included a pharmacist, seven nursing supervisors with a PhD degree, a doctor, and a clinical nurse specialist in pain management. To ensure the clarity of the scale, a pilot study was carried out at the target hospital with eight registered nurses who were excluded from the main study. No changes were made to the questionnaire after the expert review and the pilot study. The scale was not translated to Arabic because nursing is taught formally in English in Jordan and is used for documentation in hospitals.
Focus Group Discussions
Four FGDs were conducted with surgical nurses. The sample was selected conveniently from those who completed the questionnaires. Two FGDs—one with seven and another with eight participants—were conducted with surgical nurses in a male unit. To encourage participants to verbalize their opinions and experiences freely in a group without reservations, the first FGD was conducted with senior nurses and the second with junior nurses. Another two FGDs were held with surgical nurses in a female unit, involving nine senior and 10 junior participants, respectively. The number of participants in each group was manageable to achieve the study purpose (Hennink, 2013). The total sample included 34 surgical nurses. Focus groups were preferred to individual interviews to benefit from group dynamics regarding debating, sharing, and comparing experiences regarding opioids and morphine among members (Tveito, Shaw, Huang, Nicholas, & Wagner, 2010).
The study was approved by the Research and Ethics Committee at Mutah University and the Jordanian Ministry of Health. During this study, ethical issues concerned the participants' autonomy, confidentiality, and anonymity. All participants were informed about the purpose of the study and the voluntary nature of their participation. Informed consent was obtained from the participants in writing and signed by them at all stages of the study. Names in the transcripts were replaced by codes. All participants were assured that lack of participation or withdrawal from the study would not affect them in any way.
Over the period of 1 month, the research assistant, who was a nurse but unknown to participants, contacted all surgical nurses (n = 123). After obtaining permission to participate, a short questionnaire and an information sheet were handed over to the nurses. The questionnaire was immediately completed and returned to the research assistant. This was considered as an expression of giving the consent.
The first author (N.S.) conducted all the FGDs to ensure the consistency of the data collected. The first two discussions were arranged with junior nurses in surgical units, and the other two discussions were arranged with senior nurses. Before conducting the discussions, the participants' demographic data (e.g., age, experience) were obtained. The FGDs used a semistructured format. However, the questions were mostly open-ended and exploratory, enabling participants to offer more in-depth data about their attitudes toward and experiences of using opioids in pain management. These included the following: What are your attitudes and beliefs toward opioids in general, and, morphine, in particular? How do they affect pain management of surgical patients? What are the barriers to the use of opioids in your area? Example? These questions were developed in light of relevant international literature (Bayuo & Agbenorku, 2015 ; Shoqirat, 2015 ; Spitz et al., 2011). Group interactions and contributions were observed by the first researcher at the time of each discussion to aid in data analysis. Each FGD lasted between 35 and 90 min. All FGDs were conducted in a relaxing and well-ventilated hall located in the hospital.
Quantitative data were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 21. Item-by-item analysis for the OAS was carried out. Statistics, including means and standard deviations of continuous variables and frequencies and percentages of categorical variables, were calculated to describe the sample. To examine the relationships between demographic variables, Pearson's correlation, Kruskal–Wallis tests, and one-sample t tests were used. The p value less than .05 was defined to be statistically significant.
Qualitative data were analyzed using NVivo 9. All transcripts were translated into English by two bilingual nursing professionals. The transcripts were coded and grouped into categories to explore the original themes. The discussions were transcribed verbatim, cross-checked for authenticity, and then thematically analyzed by the researchers. Data were initially analyzed by (N.S.) and then reanalyzed in conjunction with the other qualitative researcher (D.M.). Concepts related to opioids were organized by literal and interpretive meanings and grouped thematically into categories. Themes were collectively discussed, refined, and further discussed between the researchers until an agreement was reached. The analysis was conducted simultaneously with data collection, with discussions examining the emerging themes as they became apparent. When no new themes were found, it was considered that saturation had been achieved. A brief narrative summary was generated for each transcript.
The trustworthiness of the qualitative data was considered. A member-checking method with randomly selected transcripts (n = 15) was used to accomplish validity regarding the accuracy of the participants' description of their opinions and experiences. The involvement of a bilingual professional PhD holder in nursing contributed to the validity of translation and thus of the data obtained. The credibility of the data was ensured by involving an independent researcher who carried out some coding and analysis. Finally, the use of triangulation design in this study strengthens the overall validity of conclusions.
A total of 123 questionnaires were distributed, and 120 questionnaires were valid and completed, giving a response rate of 96%. The frequent follow-up visits by the researchers to surgical units might have contributed to this excellent response rate. About 61 participants were male (51%), and 72 (60%) participants were younger than 30 years. The sample was dominated by bachelor's prepared registered nurses (n = 115; 96%), and about two thirds of participants (n = 75; 63%) had experience of 5 years or fewer in surgical nursing (Table 1).
Attitudes Toward Opioids
Participants were asked to identify their attitudes toward opioids and morphine. The sample agreed the least with the statement “Physicians prescribe morphine too easily for patients with severe pain” (mean: 2.27 of 5; SD = 0.98). On the contrary, they most strongly agreed with the statement “Addiction is a substantial side effect of the long-term use of morphine” (mean: 3.67 of 5; SD = 0.91). The mean scores of all items were 3.19 of 5, indicating moderate agreement (see Table 2). Further analyses revealed that negative attitudes toward pain management were associated with the age of the respondents (p = .001 and p ≤ .003, respectively), with those 30 years and older scoring higher on the scale. There was also an association between negative attitudes toward opioids and the years of experience in the nursing profession (p = .020 and p ≤ .005, respectively), with participants having experience of 5 years or more scoring higher. No significant correlation was found with the type of nursing program.
General Characteristics of the Participants
The participants' (n = 34) age ranged from 23 to 43 years, with an average age of 31.1 years. The years of experience in surgical units ranged from 2 to 16 years, with a mean of 10.6 years. All participants had a bachelor's degree in nursing. Twenty participants were female and 14 were male. Two major themes emerged that illuminated the context and perceived attitudes toward the use of opioids with surgical patients. The first was referred to as “not being in the same boat” and comprised two subthemes: blame culture and physicians versus nurses. The second major theme “morphine as the last on the list” again was made up of two subthemes: lack of confidence and fear of legal persecution (see Table 3).
Theme 1: “Not Being in the Same Boat”. This theme explains how the overall unit environment influences the use of opioids. The theme of “not being in the same boat” highlights a lack of teamwork and a fragmented pain management philosophy, as opposed to supportive and holistic care. It is made up of two related subthemes, namely, blame culture and physicians versus nurses.
Subtheme 1: Blame Culture. When all participants (n = 34) were asked about their intention and experiences to use opioids with surgical patients, a frequently occurring statement was the fear of “blame.” Participants felt that using opioids is often coupled with the sense of being blamed for two reasons. First, when surgical patients insist on opioids—in particular, morphine—as a painkiller, and if they are not given it, the nurse in charge will be blamed. Second, some participants (n = 15) pointed out that when morphine is given as the doctor's order, patients start blaming them and complaining about its side effects, such as nausea and vomiting. This subtheme and related concepts are illuminated as follows:
....last night we had a surgical patient who was suffering from severe pain..... I gave him the morphine but then all other patients and blamed me for not giving them some strong painkiller.... I was blamed badly! (laughing). (Participant 4)
It is true, and sometimes if you give morphine, the patient will keep blaming you for nausea and vomiting even if you offer anti-emetic medicine ... sometimes avoiding [opioids] is better. (Participant 10)
The aforementioned evidence reveals not only the fear of being blamed but also the lack of patients' understanding of pain management and how poorly it is dealt with. It would also appear that nursing care was not based on a partnership and negotiation approach, which is an essential part of effective pain management. That is to say, nurses and patients were not in the same boat regarding cooperation and exploration of needs. These disparities in treating the pain of patients after surgery might have led to a lack of satisfaction, in particular, when coupled with avoidance of opioids.
Subtheme 2: Physicians Versus Nurses. According to participants, the relationship between physicians and nurses plays a vital role in managing patients' pain using opioids. In particular, nurses in Jordan are not allowed to prescribe painkillers, such as morphine, and relying on busy physicians is problematic. Although nurses frequently inform the doctor on duty about the need for opioids for some patients, there is always a delay in responding. This often leads to communication problems between nurses and physicians on one side and nurses and patients on the other.
...we often inform the physicians on duty about the need for morphine for a certain patient, but the order is written late due to busy shifts ... we end up blaming each other it is like we are not in the same boat in offering effective pain management. (Participant 18)
...yes ... it is problematic as we cannot give morphine without a medical order ... the patient gets so annoyed ... teamwork is limited.... (Participant 14)
In light of aforementioned evidence, it seems that physicians' and nurses' role in prescribing and giving opioids is largely affected by the busy shifts and job description. This might create a gap between patients' expressed needs for painkillers and the medical team's response, thus contributing to a poor treatment regimen. The “the order is written late” is a common expression found in the analysis and raises questions about not only the efficiency of the documentation system but also the mechanism used to monitor patients' pain.
Theme 2: “Morphine as the Last on the List”. In this theme, the majority of participants (n = 25/34) expressed their concern about using morphine within the surgical context and referred to it as the final option to think about for various reasons explained in the subthemes, namely, a lack of confidence and the fear of legal persecution.
Subtheme 1: Lack of Confidence. The analysis of participants' narratives suggested that a lack of confidence, in terms of knowledge and skills, is a vital barrier to the use of opioids with surgical patients. This is why nurses, particularly senior nurses in this study, prefer to use alternatives such as paracetamol (acetaminophen) or Voltaren (diclofenac sodium).
...I been working here for five years and using opioids to control pain is not as common as using paracetamol in this ward ... frankly it is scarce to give morphine, and I lack knowledge and skills. (Participant 10)
...yeah ... I feel that giving morphine needs a lot of observation and care to avoid serious side effects, especially addiction. (Participant 14)
It would appear that the use of opioids is not a top priority for those surgical nurses who lack confidence and fear perceived side effects, such as addiction. Likewise, it seems that giving opioids is limited inwards and thus few opportunities to learn how to administer them to patients are created. The misconception about morphine as a source of addiction raises concerns about the quality of pain management delivered to surgical patients.
Subtheme 2: Fear of Legal Persecution. In addition to the concern of addiction, a close examination of participants' stories revealed a complicated issue. Participants believed that dealing with opioids is risky for different reasons. The risk is explained by itself in the following extracts:
...I prefer to use paracetamol with surgical patients ... they are not [suffering from] cancer ... if a morphine ampoule went missing you will be referred to a strict committee and then a disciplinary action might be taken against you! (Participant 9)
...indeed an .ose means death, autopsy and prison ... [laughing]. (Participant 16)
These findings do not only confirm the previous subtheme “lack of confidence” but also deepen our understanding about the lack of hospital policy driven by patient's rights to opioids and nurses' rights to competency-based training. This enabled them to freely administer morphine as prescribed without fear of being punished and persecuted if something goes wrong. The statement “they are not [suffering from] cancer” indicates the misconception among participants regarding not only how to use opioids but also when and for what type of patients.
To the best of our knowledge, this is the first mixed-methods study that examined attitudes and experiences of surgical nurses toward the use of opioids and morphine. The results showed that most nurses had negative attitudes toward pain treatment with opioids and in particular morphine (mean: 3.19 of 5). However, these results are similar to the previous international literature, suggesting that misconceptions regarding the side effects and administration of morphine are still a barrier to pain management (Bayuo & Agbenorku, 2015 ; Ferreira, Verloo, Vieira, & Marques-Vidal, 2013 ; Yin, Tse, & Wong, 2015). However, unlike previous studies, these concerns have been validated by the quantitative data that emerged from this research, confirming the lack of intention to use opioids and specifically morphine. Alarmingly, this study found that about 73% (n = 87) of the participants agreed that “addiction is a substantial side effect of the long-term use of morphine.” Thus, it is not surprising that participants believe that “it is better to accept the pain than to treat it with morphine” (n = 79; 66%; mean: 3.28 of 5). Statistically speaking, nurses who were 30 years or older and those with surgical experience of 5 years or more expressed more negative attitudes toward the use of opioids than their counterparts (p = .001 and p = .020, respectively). This evidence is substantiated by qualitative data from the FGDs, adding further credibility. Participants referred to the use of morphine as “the last on the list,” raising questions about their intentions to use it and how pain relief is prioritized. To add to the problem, it seems that nurses in surgical areas are more interested in using pethidine and paracetamol than morphine. On this basis, it could be argued that the perceived fear of potential side effects related to morphine use, mainly by senior nurses, might prevent caregivers from prescribing and administering this drug and consequently could compromise the pain management of patients with severe postoperative pain. Similar to other studies, these results suggest that surgical nurses have a less-than-adequate knowledge regarding the prescription of morphine and how it should be involved in pain management (Bayuo & Agbenorku, 2015 ; Ferreira et al., 2013 ; Yin et al., 2015). However, further analysis of qualitative data would propose that the problem goes deeper than merely a lack of knowledge and confidence and revolves around the fear of legal persuasion in the case of misuse of morphine. In this context, one would wonder how severe pain is managed among surgical patients when morphine is a source of fear for nurses themselves.
Although education and training in the use of opioids and pain management are largely emphasized in the literature (Jones, 2015 ; Yin et al., 2015), much still needs to be done to correct fears and misconceptions that might contribute to poor quality of life for surgical patients. Innovative education strategies are needed to familiarize nurses with the use of opioids at an early stage of their undergraduate education, taking into account that pain relief is a responsibility of all health care professionals. That is, the training programs and curriculum need to be evaluated, developed, and executed to maximize nurses' knowledge base, which, in turn, might contribute to attitudinal changes. However, caution must be exercised here. For the mechanisms to be effective, the culture of opioid administration and use is in need of adjustment. These mechanisms will not be effective unless the culture of using opioids is reformed within the unit and hospitals as a whole. In relation to this, it seems that the culture of the surgical unit is largely based on blame and poor job description. Also, “not being in the same boat” is a much more complicated issue than the fear of addiction.
An interdisciplinary team guided by mutual communication between the patient, nurses, and physicians following surgery lies at the heart of needs-based interventions for the use of opioids (Chatchumni et al., 2016b ; Jukiewicz et al., 2017). Therefore, the qualitative and quantitative evidence calls for programs aimed at changing both physicians' and nurses' behavior to acknowledge the complexity involved in using opioids, especially morphine, from the stage of pain assessment through to the administration and evaluation stages.
To date, this is the only international and Jordanian study that used both quantitative and qualitative methods to explore and understand nurses' attitudes and experiences toward the use of opioids and morphine among surgical patients. The study therefore offers more coherent evidence that might better guide practice and future research. The health care system in many countries is multifaceted and shaped by health policies, culture, and education. On this basis, caution must be exercised against extrapolating this study's findings to other countries where the protocols of using opioids are different. However, given that the use of opioids in the postoperative context is an international issue, the current findings might be used for cross-cultural comparison, application, and thus stimulate further debate and research in this largely unexplored area. That is, the findings might be seen as a benchmark against which future studies with a larger sample size of nurses—and perhaps physicians—could be developed.
The study findings offer insights into the world of surgical nurses' attitudes, experiences, and challenges involved when opioids and morphine are to be communicated about and administered. The findings highlight not only the lack of knowledge and negative attitudes toward the use of morphine but, more importantly, also the missed ethical responsibility of treating pain in the postoperative context. If health care professionals and nurses are to be “in the same boat” in the area of pain management, overall hospital organization and unit culture should be developed and reformed toward a more holistic, team-driven, and evidence-based approach of care. Serious endeavors must also be made to create and sustain an effective communication path from patient to nurse and doctor, thus enhancing the opportunity of pain-free status for surgical patients. Not doing so may mean that morphine will continue to be, as referred to in this study, “the last on the list.”
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